Friday, November 9, 2012

The Art of Writing Nursing Notes

I feel I am learning a new language, and learning how to write, both at the same time! 

I already speak five languages, and can muddle my way through a couple others, that are very similar to the ones I know.   I love languages, and was lucky enough to live in several countries where I got to truly learn the languages.  Now I'm learning a new language from a textbook in simulation lab...certainly a new experience!

I also already have a MA in Communications, and spent the vast majority of my government career writing and in strategic communications.  Writing was one of my core strengths in my job...I wrote, planned and project managed for a living.  Writing was so easy, so natural. I knew all the governmentese lingo.  I was fluent in it.  Not anymore!  Now I read my nursing notes and feel like they were written by a five year old.

What a learning curve it is for me to write succinct, yet descriptive medical notes that touch on all the important points that need to be addressed with each patient. The sentences are so intricate.  Medical writing fascinates me, as to how a simple sentence can convery so much information. 

The medical lingo in itself is mostly new. And learning what to include, what is "note worthy" and what is secondary, is currently the biggest hurdle.  Further, today I learned that something as simple as a carelessly written number could make or break a court case, as my nursing notes could be considered invalid evidence. The pressure!

What makes it particularly daunting, is that somebody's life may be on the line.  That was NEVER a factor in any of my previous writing.  Ever.  Now, if I miss documenting something that was, in hindsight, a vital clue for that person's diagnosis, or even if I don't ask the right questions in an interview, the results truly could be life and death. 

I'm not trying to sound melodramatic here.  It's simply coming to realize the full implications of writing in my new career reality.  I never before fully appreciated just how important the writing component is.

That's a lot of responsibility.  I'm up for the challenge, and am reading and practicing as much as I can (yes, I've mentioned before I am somewhat of a 'keener' -- but all joking aside, this is really very important to me to learn to do as best as I can, as quickly as I can.)

I'm hoping it will come more naturally over time and from practice, and most importantly, from experience.  That last factor is probably 'the' most important piece of the puzzle.  We are still only in simulation lab.  Lots of practice and real-life experience, where I can read 'real' nursing notes is bound to help with the learning process.

Any suggestions of books or website that people have found useful in learning this craft would be greatly appreciated.

Have I mentioned recently just how much I'm LOVIN' this career change!?!?!

Happy Future Nurse Kate!!!

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