Why Writing Works

Disciplinary Approaches to Composing Texts

Documentation in Nursing

by Dr. Nancyruth Leibold

In nursing, a great deal of documentation is required. Patient documentation is important to establish a story of the patient’s situation and provide a record of communication for others. Each facility that employs nurses has a policy and procedure about health care documentation that includes the when, what, and how. Common examples of documentation in clinical nursing include patient assessments, vital signs, weight, height, medication administration, intravenous and blood product therapy, nurse’s notes, physician/provider orders and notes, laboratory values, radiology reports, surgery reports, and therapy notes. The healthcare facility determines the writing format and policies.  Most clinical documentation is in a computerized records system or Electronic Health Record (EHR) (Androwich, 2013), but a rare handwritten documentation system exists or may be used in the event of a computer system failure. Writing styles for health records include using an objective format. “Just the facts” is a common phrase to prompt nurses on how to document.

Since a major aspect of the nursing discipline is to provide patient, family, community, and society nursing care, the documentation of this act is important. It is a record of the nursing care provided and so it is important to be in detail. Nurses tend to write in incomplete sentences and other than paragraph format in clinical patient records. The fewest amount of words is preferred. Grammar is less important in patient records; for example, a sentence fragment is acceptable. This is in contrast to other disciplines or scholarly writing and may be a leap for nurses who return to school for further education.  

Documentation style for scholarly work

The American Psychological Association (APA), 6th edition is used in most nursing writings. The format is chosen by the school in nursing programs, and by publishers in published works. Some publishers may use the American Medicine Association (AMA) format. Items that should be included in APA format are headings to organize the paper sections, in-text citations with matching references, Times New Roman or Arial 12 point font, double-spacing, and placement of page numbers in the upper right corner of the page. There are other more detailed APA format rules in the APA 6th edition manual. Probably the most critical aspect of APA format is the way to cite and reference sources, so that credit is given to the originator of the idea.  


View a video on documentation in the field of nursing here

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