Communication
8 Professional writing for nurses
Laurie E Paugel
One of the areas that new students struggle is the writing aspect. It seems to be a struggle when you have to switch types of writing from a text you may send to a friend to a professional communication with your instructor or potential employer. As a student nurse, you want to be taken seriously and keep your writing professional and factual (unless it is an opinion type of piece you are writing.)
When you are documenting in a client record, you will use professional language and approved abbreviations and acronyms. This varies by institution policy and the record matrix. Most of the documentation done in a client record is now electronic, this allows for more transparency and easier readability.
Remember that the client record or chart is a communication tool for the healthcare team but it is also a legal record. The information in the record needs to be factual, objective and professional. The information that you enter in the client record will be used for insurance purposes , to bill for services rendered. The information that you enter will also stand as your “part ” as the nurse in the care of that client and may be used as evidence in litigation.
The other part of the documentation is what you use to write in emails to colleagues, or documentation for publication and things of that nature.
As a nursing student, adopting professional practices that indicate your reliability, character and position as a nursing professional in the community will help you succeed in the role. Try to learn to write as required for your classes and for the institution or facility you are working in; You will use discussion boards, papers, journaling and emails to your instructor and peers in this program. APA format will be used to reference sources used in these writings and you will be held to a different standard than someone who is in a different program.
You will need to learn how to use nursing diagnosis and proper terminology in order to write as a professional nurse as well.