Grammar, Documentation, and Writing Skills in Nursing Practice

Introduction: Writing Skills and Nursing Practice

After reviewing the topics covered in this course, clear connections between my nursing practice and the course material became apparent. The course topic that I felt related most to my current practice is grammar and punctuation, for the following reasons. Nurses must be precise and effective when documenting, which makes grammar and punctuation essential skills to understand and perfect. The purpose of documentation in nursing practice is to promote effective communication, ensure quality patient care, and meet professional legal standards. Documentation is a vital component of the healthcare delivery system and is essential for communication among professionals. It is the means by which healthcare providers can ensure continuity and quality of care for patients.

Proper documentation accommodates patient needs and protects the nurse by providing an audit trail in a court of law. Inadequate documentation can give rise to claims of negligence or malpractice (Curtin, 2014). Clear and precise documentation can therefore serve as vital evidence for nurses facing a dispute over quality of care. In frequently hectic workplaces, registered nurses face constraints to accurate documentation that must be overcome in order to capture the requisite clinical data (de Ruiter & Demma, 2011).

The Importance of Accurate Clinical Documentation

Regardless of the working environment, nurses must accurately record all relevant facts concerning their patients' conditions (Green, 2014). In addition, nursing documentation should include all primary clinical concepts relating to current and future patient care (Green, 2014). Finally, nursing documentation must provide the associated ICD-10 codes for the recorded patient conditions (Green, 2014). This last point is especially important because, as of October 1, 2014, the ICD-10 code set replaced the former ICD-9 code set, with a corresponding increase in the number of codes that nursing staff are required to learn and use routinely (Green, 2014).

Many documentation errors are caused by misunderstandings or miscommunications, but in some cases the sources of documentation problems are less readily discernible. Research shows that in some improper documentation incidents, nurses have left blank spaces on patients' charts that were subsequently filled in by other nursing staff, causing delays in treatment and medication. In other cases, nurses have wrongly recorded telemetry data, resulting in delayed or omitted physician-ordered interventions (Curtin, 2014). Regardless of the cause, inaccurate documentation can result in disciplinary action, dismissal, and malpractice lawsuits against nursing staff and their healthcare organizations (Curtin, 2014).

Consequences of Improper Documentation

Beyond the impact on nursing staff, improper documentation can also be detrimental to a facility and to cooperation between clinicians and allied health professionals. Facilities can lose accreditation and reimbursement opportunities from third-party payers (Green, 2014). In addition, medication errors and other medical misadventures can be caused by imprecise documentation practices (Fox & Andrus, 2011). For instance, according to Merkle and Boronow (2008), at one hospital in Maryland, "Reams of illegible handwritten paperwork resulted in functionally unusable charts which, in turn, led to increased potential for medical errors" (p. 33). In fact, more than one-quarter — 26% — of all medication errors are caused by documentation errors (Wachter, 2008).

Moreover, improving documentation practices is consistent with growing calls for nurses to assume greater leadership roles in their organizations and to serve as advocates for improved patient care (Murphy, 2012). As St. John and Keleher (2006) point out, "Good communication supports community nurses in their roles as a team member, client care manager and client advocate, as well as in their community capacity building activities, collaborative initiatives, submissions, and in some cases legal issues" (p. 319).