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Pen STAT!—A Writing Guide for Future NursesBy: Lauren Harper

“Code Blue ICU! Code Blue ICU!” You hear a code called. You know someone is on the verge of life and death. The patient’s heart has stopped. He is not breathing. He could die any second. The code tells you to spring into action. You immediately grab a pen and rush to his room....wait, that’s not right. You grab paddles, an ambu-bag, and the crash cart with all your emergency drugs. You rush to save the patient’s life. Writing is not exactly the first thing on your mind. As a nurse, your job is to save lives and take care of patients. That is what you got into nursing for. However, you have to write as a nurse. After that patient is resuscitated and the code is cleared, you will have to write down the details of the code, including the time it happened, what medications were given, who responded, and his vital signs upon regaining consciousness. Tomorrow, you will assess his progress on a written chart or you may type your findings into an electronic health record. You may write down adjustments on his care plan and discharge instructions when he leaves the hospital three weeks later. If you enter the field of research, you may study the effectiveness of defibrillators, and publish the findings of your clinical trials into a scientific journal. Though writing is not your primary job as a nurse, it is one of the many factors in providing adequate care for your patients. This guide will give you instructions on how to write as a nurse.

Table of Contents

I. What do Nurses Write? (2)II. Records (2)

Purpose What Types of Nurses Write

Records? Style Medical Terminology Handwritten Notes Electronic Health Records

III. Care Plans (7) Purpose What Types of Nurses Write Care

Plans? Nursing Diagnoses Generalized Care Plans Individualized Care Plans Style

IV. Patient Education (12) Purpose Assessment Style

V. Research (12) Purpose Style Literature Reviews Clinical Trials Contents APA Citations

VI. Legal, Political, and Ethical Considerations (16)

Liability Privacy Scope of Practice Legal Documents Political Involvement

VII. Conclusion (18)VIII. References (19)

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I. What Do Nurses Write?What you write as a nurse will depend on your position, your level of education, your certifications, and the setting in which you work. For instance, registered nurses (RNs) who work on the medical surgical floor are likely to write mostly records. Licensed Practical Nurses (LPNs) have much less writing tasks, while Certified Registered Nurse Anesthetists (CRNAs) and Nurse Practitioners (NPs) can write orders and prescriptions. Following is a list of some of the documents you may write at some point in your nursing career.

Resumes Written records Letters to management Care plans Algorithms Computerized charts Letters to politicians Policies and procedures Case studies Memos Journal articles Patient education

Birth certificate information Literature reviews Discharge instructions Notes to coworkers Cards for patients and their families Editorials Prescriptions E-mails Ethical papers Assessments Incident reports Referrals

It is unlikely that any one nurse would write all these things, even over the span of his or her whole career. This guide focuses on what RNs are likely to be writing. The most important and most frequently written documents that nurses write are discussed in further detail in the following sections.

II. RecordsPurposeThe purpose of writing records is to document what happened. They are used to communicate with other healthcare professionals and protect the nurse legally if a malpractice suit is filed. Keeping records on patients helps to document trends. For instance, a patient’s blood pressure may still be in the normal range, but you can see that it has been steadily decreasing over the last few hours if you record it periodically. When nurses change shifts, they will need to see the records of the patient that they are responsible for to provide consistent care. Doctors may request to see a patient’s records to see what has been done for the patient and make sure interventions are appropriate and tests are not repeated. A general practitioner may send records to a specialist to share information. Records include items like a medical history, prescriptions, allergies, vital signs, interventions, test results and everything else pertinent to patient care.

What types of Nurses Write Records?As a nurse, most of your writing will probably be records. All nurses write records in some way, shape, or form. Nurses on the medical/surgical floor would be documenting vital signs on a chart. A scrub nurse in the operating room gives an oral report, as someone else records it. The scrub nurse then reviews the document and signs off for accuracy. A community health nurse may keep a log of clients he or she comes in contact with. An emergency room nurse will document his or her assessment of a trauma victim. A triage nurse is likely to write down the patient’s demographics and personal information. Most records are written in a similar style, though.

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StyleRecords are written in a highly technical manner, since they are primarily used to communicate with other healthcare professionals. In a way, records are written collaboratively, because a patient’s record is constantly being added to by various members of the healthcare team. Nurses write records using medical terminology, symbols, and abbreviations. Medical terminology is discussed in the next section. This specialized vocabulary makes records precise and concise. Records are very to-the-point. Nurses use the acronym SOAP to make sure the necessary information is included in their records:

S – Subjective O – Objective A – Assessment P – Plan

The subjective includes the reason they are seeking medical attention, such as symptoms and complaints. The objective part is what you see as a nurse—the signs. Assessment is a deeper level of questioning and examining the patient. The plan is what you intend to do to help the patient, including patient teaching, which is discussed in a later section (Harper, 2011). Following is a sample of a record a nurse might write for a head injury patient:

What the nurse writes: Patient claims he fell out of a tree, striking his head on a branch. Denies LOC. Denies any other injury. Denies neck pain. Full ROM w/o pain. Ambulatory into the ED with steady gait. PERL. Denies blurry vision. A&Ox3. Denies N/V. Neg. battle sign. Neg. raccoon eyes. Denies epistaxis or otorrhea. Active bleeding right forehead from 10 cm gaping wound. Bleeding controlled w/direct pressure x 2 min. VS normal w/BP of 122/70, radial pulse 72 and regular w/o ectopics, respirations unlabored @ 22/min. Cleaned wound w/betadine & gauze. Dr. Tomas in to suture wound. Dressing applied. Visual acuity 20/20 OD, 20/25 OS w/o corrective lenses using Snellen chart @ 20 ft. Went over wound care & neuro signs. No ETOH. May take Acetaminophen for discomfort q 4-6 h PRN. Discharged ambulatory with SO.

What it means: A man fell out of a tree and hit his head on a branch. He says he did not have loss of consciousness, meaning he was not knocked out. He said the only thing he hurt was his head. His neck does not hurt and he has full range of motion, meaning he can move it without pain. He walked into the Emergency Department under his own power. His pupils are equal and reactive to a light shone in his eyes, and he feels he can see clearly. He is alert and oriented times three, meaning he knows who he is, where he is, and when it is. He says he does not feel nauseous, nor has he vomited. He does not have bruising or discoloration behind his ears, a phenomenon called battle sign. He does not have darkness or bruising around his eyes. He says he did not have a nosebleed nor fluid coming out of his ears. He has a cut on his right forehead that is bleeding, 10 centimeters long, with edges spread far apart. The nurse held pressure on the wound for two minutes with gauze, and the bleeding stopped. His vital signs are normal. His blood pressure is normal, because his systolic pressure is 122 mmHg and his diastolic pressure is 70 mmHg. His pulse is normal. The nurse checked it at his wrist. His heart was beating 72 times a minute, with a regular pattern without any skipped or missed beats. It was not hard for him to breathe, and he was breathing 22 times a minute, which is normal. The nurse then cleaned the wound, using gauze and an iodine-based cleaning agent. The doctor came in and stitched the wound. (The details for this process would be in the doctor’s records. Dr. Tomas would include his own assessment, the number of stitches, medications used, instructions, etc.) The nurse then cleaned up the remaining blood and betadine from the patient’s face and hair before applying the bandage. She checked his vision from 20 feet away with a standard eye chart. His vision in his oculus dexter, right eye, was 20/20, meaning he can see at twenty feet what he should be able to see at 20 feet. His vision in his oculus sinister, left eye, was 20/25, meaning he can see at 20 feet

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what most people could see from 25 feet away. He does not wear contact lenses or glasses. His vision is clear enough. The nurse then taught the patient how to clean and care for his wound, signs of infection, and what to do if he is concerned. She told him to make an appointment to get his stitches out in 7-10 days. She also gave him a sheet with warning signs for brain injury, because these can occur even days later. The nurse told him to abstain from alcohol, because this could mask brain injury signs. She told him he could take Tylenol every 4 to 6 hours if he needs it for pain. She made sure he was not driving himself and that he had someone with him for the next 24 hours to watch him for brain injury signs. His significant other drove him home from the emergency department.

Notice that this record uses a lot of abbreviations, and it is very blunt. It does not include the entire story of how he hit his head but just the necessary information. For instance, the record only says the nurse “went over wound care and neuro signs,” but a healthcare professional knows this implies she told him not to drink alcohol and he has to make an appointment in 7-10 days. Nurses write almost the bare minimum to communicate, but reading between the lines, a lot more happened.

Medical TerminologyWhen you are writing records, you will be using medical terminology. These are specialized vocabulary words used in healthcare. Medical terminology must be very specific so that there is no question as to what you are talking about. For instance, most people would say, “He had a heart attack,” but as a medical professional, you might say, “An embolus lodged in the left anterior descending coronary artery, leading to ischemia and a myocardial infarction.”

Many medical terms can be assembled with a prefix, root word, and/or a suffix. A prefix comes at the beginning of the word and a suffix comes at the end of the word. The root word is often a part of the body, and its combining form is the root word with another vowel, usually an o, added. When the suffix starts with a vowel, you drop the last vowel from the combining form, but when the suffix starts with a consonant, you leave the combining vowel on the end. Oddly enough, medical terminology should be deciphered suffix then prefix then root word. For example, in the word “subcutaneous,” “-ous” is the suffix, “sub-” is the prefix, and “cutane/o” is the root word (Gylys & Wedding, 2009). Subcutaneous means pertaining to (-ous) beneath (sub-) the skin (cutane/o). Subcutaneous, or sub-q, injections are shots given right below the surface of the skin. Many root words sound just like the word they represent, like “arteri/o” for artery. Others, like “aden/o” for gland, are more obscure. Learning your Latin stems is crucial in deciphering and writing medical terms. Below are some of the medical word elements you are most likely to use as a nurse:

Prefixes Root Words Suffixesa- without/not abdomin/o abdomen -ac pertaining toab- away from acous/o hearing -acusis hearingad- toward acr/o extremity -ad towardaf- toward aden/o gland -al pertaining toallo- other/different adip/o fat -algesia painan- without/not aer/o air -algia painana- against albin/o white -ation processante- before angi/o vessel -blast embryonic cellanti- against anter/o front -centesis surgical punctureauto- self aque/o water -cide killingbi- two arteri/o artery -clasis surgical fracturebracy- short arthr/o joint -cusia hearingbrady- slow ather/o plaque -cyte cell

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Prefixes (cont.) Root Words (cont.) Suffixes (cont.)circum- around audi/o hearing -derma skincontra- against aur/o ear -desis binding/fixationde- cessation bacteri/o bacteria -dipsia thirstdi- double brachi/o arm -dynia paindia- through/across bucc/o cheek -eal pertaining todipl- double carcin/o cancer -ectomy excisiondys- bad/painful cardi/o heart -edema swellingecto- outisde caud/o tail -emesis vomitingen- in/within cephal/o head -emia blood conditionendo- in/within cervic/o neck -esis conidtionepi- above/upon chonr/o cartilage -esthesia feelingeu- good/normal chrom/o color -ferent to carryex- out cirrh/o yellow -gen originexo- outside/outward corp/o body -globin proteinextra- outside cost/o ribs -gnosis knowinghemi- half cutane/o skin -gram record/writinghetero- different cyan/o blue -ia conditionhomo- same cyst/o bladder -iac pertaining tohyper- excessive/above dent/o teeth -iasis abnormal conditionhypo- under/deficient encephal/o brain -iatry medicine/treatmentim- not enter/o intestine -ic pertaining toin- in/not erythr/o red -ician specialistinfra- below/under gastr/o stomach -ism conidtioninter- between gloss/o tongue -itis inflammationintra- within glyc/o sugar -kinesia movementiso- same/equal hem/o blood -lepsy seizuremacro- large hepat/o liver -lith stonemal- bad hist/o tissue -logy study ofmedi- middle hydr/o water -lysis destructionmega- enlargement kary/o nucleus -malacia softeningmicro- small labi/o lip -oid resemblingmono- one lact/o milk -ole small/minutemulti- many/much later/o side -oma tumorneo- new leuk/o white -opia visionpan- all lip/o fat -osis abnormal conditionpara- near/beside ment/o mind -osmia smellper- through my/o mind -ous pertaining toperi- around nas/o nose -pathy diseasepoly- many/much nat/o birth -penia deficiencypost- after/behind necr/o death -phagia swallowingpre- before/front nephr/o kidney -phasia speechpro- before/front neur/o nerve -philia attractionpseudo- false noct/o night -phylaxis protectionquadric- four ocul/o eye -plasm growthretro- backward/behind or/o mouth -plasty surgical repairsemi- half oste/o bone -plegia paralysissub- under/below ot/o ear -pnea breathingsupra- excessive/above ped/i foot/child -poiesis formationsyn- together pil/o hair -rrhage bursting forthtachy- rapid pneum/o air/lung -rrhaphy suturetrans- across/through psych/o mind -rrhea flow

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Prefixes (cont.) Root Words (cont.) Suffixes (cont.)tri- three py/o pus -rrhexis ruptureultra- excess/beyond ren/o kidney -scopy visual examinationuni- one rhin/o nose -sis condition

somat/o body -sphyxia pulsespir/o breathe -stasis stillsteth/o chest -stenosis narrowingtherm/o heat -tomy incisionthorac/o chest -toxic poisonthromb/o blood clot -tripsy crushingvas/o vessel -ule small/minuteven/o vein -uria urine

(Gylys & Wedding, 2009)

This is not an extensive list of all the medical word elements. Notice that many of them have overlapping definitions. You will need to know many more specialized terms as a nurse, but if you learn these stems first, then it will make learning medical terminology much easier. Plenty of medical terms cannot be assembled using these Latin bases. Diseases are often named after people or places and procedures and medicines are often named by companies, so you will have to memorize many other terms. Your nursing program will probably offer medical terminology imbedded in another course or as its own class. Pathophysiology and pharmacology are likely to be separate classes.

Handwritten NotesAs a nurse, you are likely to write down a lot of your records. Neat and clear handwriting is crucial in a healthcare, because you have to communicate accurately. The abbreviation for four times a day is q.i.d., while the abbreviation for every other day is q.o.d. If a nurse wrote in her records that a patient was supposed to have the corticosteroid Prednisone every other day, but the nurse on the next shift thought it said four times a day, the patient would get eight times the recommended dose. This could jeopardize the patient’s wellbeing and even his or her life. It also puts both nurses at risk for a malpractice suit.

Many hospitals put allergy labels on the outside of a patient’s chart, so that it is the first thing the nurse or another healthcare provider sees. The label in Figure 1 could say Amaryl, which is a diabetes medication, or it could say Reminyl, which is prescribed for Alzheimer’s. A doctor might prescribe one of these medicines, and the patient could be allergic to the other. The patient may or may not be conscious or mentally competent enough to tell the nurse which medicine he is allergic to. If the patient is diabetic, and she does not give him is medicine, then he might not have adequate control of his blood sugar, which can be life-threatening. If the patient has Alzheimer’s and she does not give him the prescribed medicine, his mental state may continue to decline. If she gives him the medicine he is allergic to, he could experience an anaphylactic reaction and die. When in doubt about someone else’s writing, always ask. As a nurse, you must practice your penmanship, and you must write slowly to make

Figure 1 This poorly written allergy label demonstrates how important good handwriting is as a nurse.

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sure it is legible. If you need to, check with another nurse and make sure others can read your handwriting. Always write in print, because it is easier to read than cursive.

Electronic Health RecordsMessy handwriting is one of the problems that electronic health records, also called electronic medical records, intend to solve. Electronic health records, more commonly referred to as EHRs, are relatively new technology, but they are being used more and more in healthcare. EHRs put all of a patient’s information into a computer, so that everything is all in one place. An EHR will provide you with an electronic form of sorts with spots for information to fill in. There are many different forms of EHRs being used today, but they aim to provide quality, efficient, and consistent patient care. These EHRs are also used in various settings, from pediatrician’s offices to the Intensive Care Unit at the hospital. Sometimes, an entire hospital system will have the EHRs of all its constituents linked. This means that the orthopedist can take an X-ray of a patient’s broken leg, and his physical therapist can later pull up the same image on his or her computer across town. This is a lot more efficient than patients having to make copies of their records at one doctor’s office and bring it to their other doctor’s office. EHRs reduce redundancy and improve efficiency. This also gives each and every healthcare provider access to all the important information (Bell & Thorton, 2011). In the case of the example from the last section and Figure 1, an alert would probably come up every time you opened that patient’s chart on an EHR that said he was allergic to Amaryl. His history would be consistent with a diagnosis of Alzheimer’s, and you would see that the patient takes Reminyl to improve his cognitive functioning. Beverly Bell, a nurse who specializes in EHR implementation, and her coworker, Kelly Thorton, say that EHRs reduce medication errors, help to standardize data, observe population trends, and improve disease management (2011). Positive attitudes like these and continuing research will mean EHRs are used more and more in the future. You will need to become familiar with writing in them as a nurse.

EHRs allow writing to be clearer, because you are often typing. This means you will have to be very careful about typographical errors. Typos on an EHR can be just as devastating as poor handwriting on an allergy label. EHRs do not get you off the hook for penmanship either. Many healthcare facilities enter patient information into the EHR by writing on tablets. You may have a COW, or computer on wheels, to take to each patient. Sometimes, you might take down vitals on a sticky note in the patient’s room then take the information to a computer down the hall.

III. Care PlansPurposeCare plans are what they sound like, a plan for care. Care plans are used to guide decision-making and address anticipated problems in association with a medical diagnosis (Harper, 2011). For instance, a medical diagnosis might be type 1 diabetes. The care plan will outline an acceptable range for the patient’s blood sugar and actions to keep it in that range.

What Types of Nurses Write Care Plans?All registered nurses may, at some point, be called on to write a care plan. LPNs cannot write care plans. Nurses who care for patients with chronic or long-term problems will need to know how to write care plans. This includes, but is not limited to, school nurses, med-surg nurses, home health nurses, community health nurses, and nurses who work in rehabilitation or long-term care settings, like nursing homes. Nurses who work only in acute care, such as in the emergency room or operating room, are unlikely to write care plans.

Nursing Diagnoses

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RNs can write nursing diagnoses, which are included in care plans. These are different from a medical diagnosis. A doctor may make a medical diagnosis of an ischemic ulcer, while a nurse is concerned with the diagnoses of compromised skin integrity, impaired mobility, and inability to perform independent activities of daily living (Harper, 2011). A nursing diagnosis should include a label, a definition, defining characteristics, risk factors, and related factors (North American Nursing Diagnosis Association, 2011). Following are examples of possible nursing diagnoses you might write:

Risk for infection Acute confusion Risk for imbalanced nutrition Impaired physical mobility Acute pain Fatigue Risk for decreased cardiac output Disturbed body image Deficient knowledge of condition Grieving Anxiety Deficient fluid volume Insomnia Impaired swallowing

Compromised family coping Ineffective tissue perfusion Risk for caregiver role strain Risk for sedentary lifestyle Disturbed thought processes Activity intolerance Impaired social interaction Ineffective coping Post-trauma syndrome Disturbed sensory/perception Impaired skin integrity Hyperthermia Self-care deficit

(Taber’s Cyclopedic Medical Dictionary [Taber’s] , 2009)

The description and risk factors will depend on the disorder it is linked with. For instance, the risk factors for decreased cardiac output with acute respiratory distress syndrome are “hypovolemia, vascular pooling, diuretic therapy, and increased intrathoracic pressure/use of ventilator/positive end-expiratory pressure,” but for Addison’s disease, the risk factors are “hypovelemia and altered electrical conduction, and/or diminished cardiac muscle mass, possible evidenced by alterations in vital signs, changes in mentation, and irregular pulse or pulse deficit” (Taber’s, 2009). When you write your nursing diagnoses, you must be specific to distinguish the same nursing diagnoses in relation to separate medical diagnoses. As a nurse, you will be responsible for writing down justification for your nursing diagnoses and detailed plans to fix the anticipated problem.

Generalized Care PlansA generalized care plan is based on a specific medical diagnosis applied to a general population. This includes protocol or algorithms for treating a specific disorder. You will need to write generalized care plans with the entire population in mind. The nursing database CINAHL offers a variety of generalized care plans that it calls Evidence Based Care Sheets. These can be found on many topics from alopecia to urinary catheters. On the next two pages is an Evidence Based Care Sheet on lice, labeled Figure 2:

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(cont.)

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Figure 2 This evidence based care sheet is an example of a generalized care plan.

(Grose, 2010).

Some nurses will write these generalized care plans, but, as a nurse, your ability to write individualized care plans will be much more important.

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Individualized Care PlansAn individualized care plan is based on a specific medical diagnosis for a specific patient. As a nurse, you will need to take the patient’s age, education level, ethnicity, availability of services, family, work environment, home environment, and compliance into consideration when writing an individualized care plan (Harper, 2011). You will have different concerns for a newly diagnosed juvenile diabetic in an elementary school than a geriatric diabetic in a nursing home. Following is a fictional sample care plan, written by a school nurse for a 2nd grade newly diagnosed diabetic.

Patient Name: Jack Kellers

Age: 7

Medical Diagnosis: Type 1 Diabetes Mellitus, diagnosed Feb, 2011 by George Pickens, MD.

Assessment: Jack has developed age appropriate self management skills. He has good problem solving abilities & effective coping skills. He is good at communicating needs.

Nursing Diagnosis 1: Risk for unstable blood glucoseJack’s blood sugar will stay in the range of 80-150 during the school day. This will be measured by his One-Touch glucometer before lunch and before gym class. The nurse will assist with finger stick, monitor use, recording of blood glucose, and insulin injections. Jack uses Novolog insulin, and his dosage is based on carbohydrate counting plus sliding scale. Jack’s mom will pack lunch and record in his personal daily log the number of carbs in his lunch. He is currently on a ratio of 1 unit of insulin per 28 grams of carbohydrates. Additional units may be given if blood sugar is above 200 on a sliding scale. Jack has apple juice in the nurse’s office if his blood sugar is below 80.

Nursing Diagnosis 2: Deficient knowledge regarding disease processJack is not old enough to be fully independent in his care nor recognize that his blood sugar is out of range. His mother and older sister are both very supportive and have been included in all patient teaching. His mother will help him make informed choices for lunch menus. Each of his teachers has been informed about his condition and posters have been hung up to help recognize the signs and symptoms of hypoglycemia and hyperglycemia. Jack has been assigned a buddy that accompanies him to the health room and watches Jack for abnormal behaviors, drowsiness, sweating, excessive trips to the water fountain or bathroom, and other signs of hypoglycemia or hyperglycemia. His buddy is to report any suspicions to the teacher or nurse.

Nursing Diagnosis 3: Risk of social exclusionJack’s classmates may not understand his diabetes and treat him differently because of it. They may be jealous of the fact that he gets to eat snacks in class, unrestricted bathroom breaks, and extra attention. Jack may also feel self-conscious about being different from his classmates. The nurses have made an age-appropriate presentation in Jack’s class to explain diabetes with his and his parents’ permission. Jack’s mother is informed about class parties beforehand so that she may accommodate extra carbohydrate intake so that insulin may be adjusted properly. Jack may eat sweets that are brought into class, as long as his mother approves it beforehand.

Individualized care plans can be in many formats, but a common layout is to present the nursing diagnoses as problems and the plan of care as a solution, as in the example above. Different disorders will require different formatting for your individualized care plans. Learn what your employer expects to be included, so that you can write the best care plan possible.

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StyleYour workplace is likely to have a specific outline for care plans. Individualized care plans will include more narrative than generalized care plans. Care plans are written in a semi-technical style. Some medical terminology will be included, but care plans do include personal, subjective language. Your care plans will include more explanations than your records will. Care plans may be written collaboratively with other nurses.

IV. Patient EducationPurposeThe purpose of patient education is to empower and enable people to care for themselves as independently as possible. When you write patient education documents, they must be as a complement to face-to-face teaching. Teach people as much as possible in person, so that patient education documents only have to serve as a reminder.

AssessmentMost nurses will see a wide range of patients. You will treat old people, young people, Hispanics, African Americans, mentally challenged people, and college graduates. You must tailor patient education to the individual patient that is the intended audience. You must asses any language barriers, your patient’s education level, age, maturity, and current knowledge of the subject.

StyleYou will probably be provided with a general sheet or pamphlet with the topic your patient needs to be educated on. As a nurse, you will use what you have learned in your assessment to edit that generalized document to meet the needs of an individual patient (Harper, 2011). If the patient speaks Spanish, you may need the help of your hospital’s language services department to translate the information accurately. Never use an online translator to switch from English to Spanish, as these do not interpret precise meanings, accurate grammar, and appropriate syntax. Only a human can do that. If the patient is very young, you may want to give the generalized version to his or her parent, and add illustrations to a child’s version. If your patient is well-educated about medical matters, you may only need to give them a little information. Always ask your patients if they understand the document you gave them and tell them not to be embarrassed if they do not. Offer your patients more information and instruction if they want or need it, and refer them to other sources that may be able to help them more than you can as their nurse. Write a patient education document as if it will need to stand alone, even though you will be teaching them in person. Always put a contact phone number on a patient education document, because patients are likely to think of questions or encounter problems after they have left your care and supervision.

V. ResearchPurpose Nurses operate on the principle of evidence based practice (EBP). This means we make our decisions based off of research. According to the Oncology Nursing Society, “The goal of EBP is to use this evidence to guide interventions that will benefit the patient, enhance the quality and outcomes of care, and be cost effective” (Mast, 2000). You would not just give a patient a drug if you did not think that it would help them. There must be significant evidence that this particular medicine is effective at treating this particular problem. You also have to have evidence that you are treating a patient effectively. Barbara Harper, RN, says, “Evidence based practice means nurses have to show that specific results came out of specific acts working toward a specific goal” (2011). Nurses must be able to justify why they

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are doing what they are doing, and that what they are doing is working. For example, you cannot just say Mr. Jacob’s hypertension is getting better with medication just because he looks alright. You must record his blood pressure over a period of time and use that as evidence that his pills are truly lowering his blood pressure. This is why nurses are often involved in the research process. As a nurse involved in research, you may write literature reviews and/or articles on clinical trials.

StyleNurses who write in the research field must do so in a scientific manner. Nurses must not seem biased or uninformed. You can still voice your opinion and sound professional. You must be accurate in your spelling and grammar or risk sounding ignorant. Your research will be written in a highly technical manner. Be precise and clear. You do not need to add flowery or emotionally- charged language to a scientific paper. Make sure you are not offensive to any population (American Psychological Association, 2010). Your job as a researcher is to present the facts and analyze them. As a research nurse, you may also write collaboratively with other researchers.

Literature ReviewWhen nurses write a literature review, they are writing a summary and analysis of already published information on a topic (American Psychological Association, 2010). A nurse might be interested in studying bone marrow transplants as a treatment for patients with sickle cell anemia. He would probably perform a literature review first. The nurse would have to research information on the genetics of sickle cell anemia, its pathophysiology, current treatments and their effectiveness, bone marrow transplants for other diseases, and previous studies on bone marrow transplants for sickle cell patients. He would analyze all these sources for their credibility and usefulness. For instance, a genetics textbook may have great information on how sickle cell anemia is transferred from generation to generation, and a peer-reviewed journal may have an article about an experiment with a sickle cell medication developed last year. Different sources have their strengths and weaknesses. Textbooks are typically well-organized and easy to access. However, it may be ten years before the most recent experiments are put into textbooks (LaRochelle, King, Tanas, Day, Marshall, & Tyler, 2011). This makes textbooks good for researching information that has stayed relatively stable over time, such as anatomy of a normal red blood cell.

Peer-reviewed journal articles are seen as the epitome of credibility, but finding these often requires specialized searching skills and many journals will charge you money for access to their articles. Your school library will probably have access to databases you can use to search for journal articles. Here are some hints for searching for useful sources:

Use the Boolean operators AND, OR, and NOT to refine your search (Pulley, 2011). The nurse researching bone marrow transplants for sickle cell patients might search “bone marrow transplants AND sickle cell anemia” to include both topics in his search. He might try “bone marrow transplants NOT leukemia” to weed out the many articles that are discussing blood cancers not sickle cell anemia. He might try “bone marrow transplant OR hematopoietic stem cell transplant” because these stem cells are the active part of the bone marrow.

Use an asterisk (*) to search for different forms of the same root word. If the nurse searches for “bone marrow transplant*,” he will come up with results for bone marrow transplant, transplants, transplantation, transplantations, etc. This will help the nurse come up with a variety of pertinent articles.

Use quotes around a phrase if you want the exact phrase in that order. The nurse could search “bone marrow transplant” to find that exact term. This will weed out articles that include

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“bone,” “marrow,” and “transplant” but not together. For instance, he might otherwise find an article about someone named Josh Marrow who was in a car accident and broke bones in his skull, rendering him brain dead, so his kidneys were transplanted to patients in renal failure.

Use the “advanced search” button on most search engines to add qualifiers to your search. The nurse might only want articles from the last 5 years, so he could rule out results older than that. The nurse may also choose the preferred language or format of results.

Google Scholar, CINAHL, Proquest Nursing, STAT!Ref, Medline, and BIOSIS are good databases to search for nursing articles.

When searching for websites and not journal articles, use the qualifier “site: .edu” or “site: .gov” to come up with more reliable documents from university and government sources.

Ask one of your school’s reference librarians for further assistance (Pulley, 2011). You have probably been told to never use Wikipedia. However, this site may be helpful in giving

you an overview of your subject, so that you know what related topics to search for in more credible databases. Do not cite information from it in your paper, though.

You must critically analyze all your sources before you reference them in a paper. It is your responsibility as a nurse writing a literature review to synthesize these sources into an accurate summary and analysis of the topic. Literature reviews can also take the form of meta-analyses, which are statistical summaries (American Psychological Association, 2010).

Clinical TrialsClinical trials are experiments used to prove cause and effect. Correlation is not good enough in nursing, because it is a science. You must design an experiment that holds controls over all variables except the one you are intending to test. You will be testing to see if an independent variable, such as a particular drug, affects a dependent variable, such as heart rate. In the case of testing a drug to reduce heart rate in people with tachycardia, you will need to find a large group of people with tachycardia. You will then need to randomly assign these patients into a test group in a control group, so that factors, such as age, ethnicity, diet, and other differences among the individuals become less important. You must give the test group the drug and the control group a placebo. Neither the person observing results nor the people taking the pill should know who has the placebo and who has the medicine. This is called a double-blind study. An assistant will give the pills and record who had what, so that the researcher can be sure that the medicine is effective. You will probably have to propose your experimental design to a professor, the hospital, or someone you want funding from to conduct the research. This proposal will have to be detailed and persuasive. You will need to be detailed and accurate when you write up the results of your study, and your analysis will also have to be well-written. As a nurse, you will need to use the results of clinical trials to guide your evidence based practice.

ContentsResearch articles are often set up in a specific format. As a nurse writing research articles, you will need to include the major sections, which are the abstract, introduction, methods, results, discussion, and references.

AbstractThe abstract is basically a preview of the article. It is usually 150-250 words long (American Psychological Association, 2010). It helps readers decide if your article is worth reading. It will provide a basic overview of your experiment and a brief summary of the results. When searching for articles, users can often read the abstract before purchasing the full text. In a printed version, the abstract will be on your cover page.

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Introduction The introduction provides background information and at least somewhat of a literature review. Your introduction will present the problem and why it is important, as well as what your hypothesis is about the outcome (American Psychological Association, 2010). This section will include information from other sources. When researching a disease, you should include the epidemiology, prevalence, and incidence in your introduction (Siwek, Gourlay, Slawson, & Shaughnessy, 2002).

MethodsYour section on methods will explain your experimental design in the greatest detail possible. You will include the number of participants, the independent and dependent variables, the controls, the process used to measure results, and how you recorded information. It is important for you to write this section well, because your peers will be quick to criticize any flaw in your design.

ResultsYour results section will provide the raw data from your experiment. Do not analyze your data until the discussion section. This section will need to be very technical. You will not want to include your voice in this section either. It should be purely scientific.

DiscussionYou will analyze your results and what they mean in the discussion section (American Psychological Association, 2010). Like the introduction, you will need to cite other sources in this section. This is the part of the paper that is most likely to include your voice and opinions. Critically evaluate the strengths and weaknesses of your experiment, and based off your findings, propose further studies that should be done. When focusing on a particular disease, this section can include “etiology, pathophysiology, clinical presentation, diagnostic evaluation, differential diagnosis, treatment, prognosis, prevention, and future directions” (Siwek, Gourlay, Slawson, & Shaughnessy, 2002). Include as much relevant information as possible. This discussion also serves as your conclusion, so make sure your writing ties up any loose ends.

ReferencesThe last page of your document should be your references. In nursing and other sciences, sources are credited in American Psychological Association (APA) format. APA format is discussed below. Your references page must have sources listed in alphabetical order, double spaced, with a hanging indent.

APA CitationYou will need to credit your sources with in-text parenthetical citations as well as a list of sources on the references page of your document. The APA publishes books with details about how to properly credit various kinds of sources, ranging from blogs to personal interviews to textbooks to journal articles. As a nurse, you will primarily be using journal articles and books in your research. Journal articles are cited with the author first, then date, then article title, then the journal name in italics, the volume number, issue number, page, and then the digital object identifier (DOI) or website. In APA format, you only capitalize the first letter of the first word of the title. See the outline and fictional examples below:

Author. (Date). Title of article. Title of journal. (Volume)Issue. Page-page. DOI.

Wilson, K. (2008). The effects of drinking caffeine on the kidneys. American Journal of Nephrology. (20)6. 97-103. DOI: 1499920-00299.

Vickers, L., Jacobson, P.C., & Alton, K. (2004). Removing tonsils to prevent strep throat: Is it worth it? Pediatrics Today. (48)7. 4-15. Retrieved from

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http://www.research/tonsils=sid-29300948/surg-peds=query:removal-40285948 on March 11, 2010.

Though these are not, remember that everything in APA format should be double-spaced. The variations for multiple authors and other differing specifications can be found in an APA publishing manual. As a nursing student, you should purchase the latest version when you enter school. Becoming familiar with APA style will help you get full credit on your school papers, as well as a published researcher later in your career. Following is the general outline for books and fictional sample:

Author. (Date). Title of book. Publishing City, Publishing State. Publishing Company.

Frank, Y.L. & Hunter, L.C. (2007). Anatomy of the human body. Chicago, IL. Golden Publishing, Inc.

Within your text, you will cite almost all sources the same. At the end of a sentence or a couple of sentences written with information from another source, you must add parentheses with the author or authors’ last names, then a comma, then the year. If you say the author’s name in the sentence, you only need to include the date. See these examples:

The human body has 206 bones. The three smallest bones are the incus, malleus, and stapes, which can be found in the inner ear (Frank & Hunter, 2007).

Dr. Kenneth Wilson, a nephrologist, suggests that people limit their caffeine intake to one drink a day to improve kidney functioning (2008).

Again, you will need to learn many more styling rules before writing as a nurse, but these examples should give you a general idea of what APA format is like. It is crucial to cite your sources accurately so that you are not plagiarizing or infringing on copyright laws, even accidentally.

VI. Legal, Political, and Ethical ConsiderationsLiabilityYou are responsible for what you write as a nurse. If you sign another healthcare provider’s document, you better be sure that you are willing to be liable for what is written in it. Do not put your signature on anything that you have not thoroughly verified. Make sure your records are detailed and accurate. No matter how good of a nurse you are, a patient may later sue you. “As far as the law is concerned, if you didn’t write it, you didn’t do it,” says Barbara Harper, RN. When in doubt, write more than you think is necessary.

PrivacyAs a nurse, you will have access to very personal information. You are responsible for protecting the privacy of patients, ethically and legally. Jolynn Knizner, RN, says “As a nurse, you can’t tell anybody anything you learned while at work, even if you don’t think it seems like private information” (2011). This means you have to be careful about what you write down and how your written documents are stored and transferred.

HIPAAWith the advent of the Health Insurance Portability and Accountability Act (HIPAA) in 1996, confidentiality became a legal standard. The text of the law itself can be very confusing, but basically, you cannot share any information you learn in the confidence of your patients. Violating HIPAA could cause you to lose your job and/or your nursing license. It is a very serious offense to share privileged information. You need to make sure everything you write about a patient is secure.

There are a few exceptions to HIPAA, though. If you suspect that a child is being abused, you are obligated to report it to the Department of Social Services immediately. You will also be exempt

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from HIPAA when reporting other cases of suspected abuse, even if the victims are not children. If you receive a subpoena, you must turn over the patient’s records. If public health is a concern, such as if a patient has virulent tuberculosis, you may need to report it to the Department of Health and Environmental Control. Other exceptions to HIPAA include, but are not limited to, exchanging information with the coroner or funeral director, information used for cadaveric organ and tissue donations, and for research purposes (Hicks, 2011). Barbara Harper, RN, suggests, “Always consult your supervisor before relaying privileged information for any reason” (2011). You must also document any data transfers you perform.

HITECHIf you violate HIPAA, your employer, could be held responsible under the Health Information Technology for Economic and Clinical Health (HITECH) Act. When HIPAA first came out, punishment was not as severe; however, today, companies could be fined several million dollars for your indiscretion (Dean, Oscislawski, & Sina, 2011). Be extremely careful about what you write down and who can see what you write!

EHRThough one of the goals of EHRs is to improve information security by making sure only approved providers can access them, hackers and other technology flaws have allowed the virtual information to fall into the wrong hands. Never write down your password into the EHR, because you could allow unauthorized personnel into the system and be held liable for their actions. Be careful what you print; it is just as important as what you write down.

As a nurse, you will be required to write down confidential information. There is no getting around this. You need to be vigilant about where you leave your writing and shred everything that you no longer need.

Scope of PracticeIn healthcare, you must stay within your scope of practice. Scope of practice is a set of things you are licensed to do. For instance, a medical doctor (MD) has a wider scope of practice than a CRNA, which has a wider scope of practice than an RN, which has a wider scope of practice than an LPN, which has a wider scope of practice than a certified nurse’s assistant (CNA). The scope of practice for RNs is determined at a national level, whereas advanced practice nurses (APNs), like NPs and CRNAs, have their scope of practice defined by individual states.

Medical DiagnosesRNs cannot write medical diagnoses. Only doctors or APNs can write medical diagnoses. As discussed earlier, a medical diagnosis usually refers to a disease or disorder, like Acquired Immunodeficiency Syndrome (AIDS) or Stage 3 ovarian cancer. As a nurse, you will write nursing diagnoses that focus on the problems associated with the medical diagnosis a doctor has already given. Do not write medical diagnoses!

PrescriptionsRNs cannot write prescriptions. Doctors or APNs write the prescriptions, and the nurse may give the medicine and/or instruct the patient on how to take the medicine, based on the doctor’s orders. If you go beyond nursing school to become an APN, you may be able to write prescriptions, depending on your state’s laws.

Do not write anything that is out of your scope of practice or risk facing serious consequences. When in doubt, ask a supervisor if what you are writing is appropriate for your position.

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Legal DocumentsAt some point in your career as a nurse, you will probably have to write a legal document. Following are some legal documents you may need to write or be involved in writing.

Incident ReportsAn incident report is a detailed description of an event that was out of the ordinary. The event may or may not have resulted in injury. For instance, if a patient falls while you are out of the room, you may have to write an incident report, even if the patient was fine and it was not your fault. Incident reports are reviewed to help prevent similar problems from happening in the future. They are also important for refreshing your memory if it turns into a legal issue (Harper, 2011). Incident reports do not go in patient’s records, but instead become records of the institution (Knizner, 2011). When you write incident reports, you will likely be provided with a form to fill out. Make sure you answer all necessary questions and add any other pertinent information, even if the form does not ask for it.

DSS Referrals Unfortunately, as a nurse, you may see patients that are abused. This includes, but is not limited to, children, mentally challenged individuals, physically handicapped people, and the elderly. You are obligated legally to report suspected child abuse to the Department of Social Services (DSS), and you are obligated ethically to report any other suspected abuse. DSS referrals you write while nursing are not put in the patient’s record and they should not be traceable back to you (Knizner, 2011). You will not be held liable for wrongful accusations if done in good faith that the patient is being abused. When in doubt, write a DSS referral and let them follow up.

Birth CertificatesYou may input information about a new baby into a form used for making his or her birth certificate. You must be perfectly accurate recording the time of the birth, the spelling of the parents’ names and addresses, and how the parents wish to spell the baby’s name. Check this form over and over again, and verify it with the parents more than once. You will also be responsible for foot printing the new baby. Though it is not writing, it is still an important form of nursing documentation.

The red tape surrounding legal documents can be cumbersome, but these laws are enacted to protect patients and their integrity. Make sure you learn the laws that pertain to writing as a nurse and that you adhere to them.

Political InvolvementYour duty as a nurse is to promote the health of all people. Though you will not treat everyone as a patient, you can help society by becoming politically involved. You should support laws, like those that outlaw public smoking or mandate seatbelt usage, to advocate for all people as if they were your patient. You can do this by writing to your congressmen and other public officials or by writing editorials. Writing a shorter letter means it is more likely to be read by a politician, but you still must include all the pertinent information. Try not to sound too emotionally charged, as this will hurt your argument, but still be assertive and persuasive.

VII. ConclusionIt is wonderful that you are considering becoming a nurse! Our country is facing a nursing shortage, and people will always get sick and hurt. Nursing, though difficult, can be an extremely rewarding and helpful profession. Please pursue your nursing education rigorously! Though this guide focuses on

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writing as a nurse, writing will only be a small part of your job. Your number one duty as a nurse is to care. If you care enough, everything else will fall into place.

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VIII. References

American Psychological Association. (2010). Publication manual of the American Psychological

Association, 6th ed. Washington, DC. American Psychological Association.

Bell, B. & Thorton, K. (2011). From promise to reality: Achieving the value of an EHR. Healthcare

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5d2c-47b7-b409-5660addb5f3f%40sessionmgr13&vid=4&hid=11 on June 1, 2011.

Dean, N., Oscislawski, H., & Sina, D. (2011). Million dollar-plus fines signify tougher enforcement of

HIPAA. HIPAA Regulatory Alert. Retrieved from

http://web.ebscohost.com.proxy.lib.clemson.edu/ehost/pdfviewer/pdfviewer?sid=ad509f26-

3591-4450-a97b-cde5c1e4b4ce%40sessionmgr4&vid=1&hid=24 on June 2, 2011.

Grose, S. (2010). Bites: Head lice. Glendale, CA. CINAHL Information Systems. Retrieved from

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35ce-4fd3-9e31-912d806cf3d1%40sessionmgr13&vid=6&hid=10 on June 4, 2011.

Gylys, B.A. & Wedding, M.E. (2009). Medical terminology systems, 6th ed. Philadelphia, PA. F.A. Davis

Company.

Hicks, K. (2011). Hip, hip, HIPAA, hooray. ASBN Update. Retrieved from

http://web.ebscohost.com.proxy.lib.clemson.edu/ehost/pdfviewer/pdfviewer?sid=5485c455-

5e77-47a3-a7f2-2dcc212d4773%40sessionmgr15&vid=2&hid=24 on June 1, 2011.

Harper, B. (2011). Personal interview on May 20th.

Knizner, J. (2011). Personal interview on June 2nd.

LaRochelle, J.M., King, A.R., Tanas, M., Day, K., Marshall, H.M., Tyler, A.M. (2011). Writing a review

article. American Journal of Health Systems Pharmacology. 68. Retrieved from

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http://web.ebscohost.com.proxy.lib.clemson.edu/ehost/pdfviewer/pdfviewer?sid=faf2da74-

0ce6-41bf-bb2f-b65825643928%40sessionmgr11&vid=2&hid=21 on June 1, 2011.

Mast, M. (2000). Evidence based practice: What it is, what it isn’t. Oncology Nursing Society News.

15(6). 1, 4-5. Retrieved from

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3592-444f-a8e6-86e51f292caa%40sessionmgr10&vid=2&hid=11 on June 4, 2011.

North American Nursing Diagnosis Association. (2011). Diagnosis submission. Retrieved from

http://www.nanda.org/DiagnosisDevelopment/DiagnosisSubmission/SubmissionsPending.aspx

on June 4, 2011.

Pulley, W. M. (2011). Top 10 research tips from a professional investigator.

Siwek, J., Gourlay, M., Slawson, D.C., & Shaugnessy, A.F. (2002). How to write an evidence-based clinical

review article. American Family Physician. (65)2, 256. Retrieved from

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Nursing diagnoses grouped by diseases/disorders. (2009). Taber’s cyclopedic medical dictionary, 21st ed.

Philadelphia, PA. F.A. Davis Company.