Doctor: Nurse, how is that little girl doing who swallowed ten quarters last night?
Nurse: No change yet!
Knowing how to write in various formats whether it be for the patient or coworkers is one of the most crucial factors that determines a patient’s outcome. Writings such as assessments, care plans, charting, and research articles in nursing, can help advance a patient’s recovery, provides care options, and reduces the chances of complications. These concepts are critical to not only maintaining patient privacy but positive outcome for the patient. In order to provide a patient with these factors, a nurse must first know how to gather and maintain the knowledge.
Researching is a formal type of writing in the nursing field that can provide diverse ways of solving a patient’s health problem. Implementing a research article can help nurses elevate their education, keep up with the newest medical breakthroughs, and therefore provide the best care for their patients. Learning how to write for your specific field is important and can be used in multiple different ways such as hospitals, nursing homes, or informing medical professionals. A problem that may occur during the researching process is becoming biased based on the information found. The main goal of researching in this profession is to attain and improve the present standards of how patients should be taken care of and to not be biased in research. Writing research is a lengthy process that allows the audience, nurses, to learn how to advance in patient care and reduce risks. For nursing research, the writing style called American Psychological Association, or better known as APA, is used to write a research article because it produces understandable guidelines. A research article for this profession contains several different parts such as an abstract, information found, methods being used, results, discussion and lastly, a conclusion. It is extremely important for research writings to follow this format to avoid any misunderstanding. If an article is done incorrectly, professionals could interpret the method in alternative ways. Improper interpretation because of an inaccurate research article could lead to performing a procedure incorrectly and could cause a vast amount of complications such as, loss of a life. A research article’s main purpose is to develop alternative care options that will help avoid complications and create new forms of care for patients.
Finally, knowing how to research is a necessity because almost all medical breakthroughs are created through experimentation. Research also allows nurses to review ideas or further their knowledge on certain outcomes. Without this process, nurses wouldn’t be able to see the positive and negative outcomes of a particular type of treatment. The majority of advancements in a patient’s health and avoidance of complications comes from multiple researchers developing research together, instead of from one isolated source. Research articles are key to helping medical professionals learn how assess a patient’s health, like in an assessment.
The phase where nurses keep track and plan for patients’ health over a period of time is also known as assessments. Nurses perform these assessments to identify the needs, condition, and abilities of the patient. This is required for provision of the patient and family centered care. There are three major types of tests done during evaluation. To begin the evaluation, nurses start with an admission assessment: checking the patient’s history, appearance, and vital signs. A physical exam is also conducted during this time. The nurse then follows up with the shift and focused assessments. The shift assessments focus on any changes the patient may experience, followed by a routine check-up. The focused assessments are more information based. These revolve around specific body systems and the nurses have to use their judgment to determine which elements of the test are more beneficial to the patient. If assessments are not done correctly, a patient’s care could be compromised. An example would be a misdiagnosis taking place. If this were to happen, the patient’s health plan would become disarrayed and complications would occur.
Overall, assessments give insight on a patient’s needs upon arriving in a care facility. From that point, a personalized plan is created and based around what can be done to improve the patient’s health for a timely recovery. Assessments include developing a Care Plan; a plan that documents the patient’s future health objectives. A Care Plan is a verbal and written agreement between the nurse and the patient that states the patient’s health goals. It is vital for a nurse to have proficiency when creating a Care Plan for each patient because it allows the nurse to understand what care options are appropriate for each patient to ensure a quick recovery. The purpose of knowing how to Care Plan goes beyond treating a patient to health. A Care Plan allows a patient to be actively involved in their process, therefore, it is created through a time of consultation. Only the individual knows how their body works, so creating a care plan is described as “the meeting of two experts.”
During this time of consultation, patients get to discuss goals with the nurse such as, when to return to work and making changes in diet. It is important for patients to take part in Care Planning so that self-care can be experienced. This allows the patient to ponder on goals that can be accomplished independently once being discharged from a facility. This type of writing goes beyond detailing dieting rituals and medication types. The main purpose of Care Planning can be seen within the elderly generation during times of exacerbation. For example, if a man has a severe case of Pulmonary issues and wishes for no artificial treatment, that would be discussed with the nurse and be put into the Care Plan. This type of writing allows patients to manage their own health. Studies have shown that those who have control over their health, have more confidence and live a better quality of life.
Similarly to Care Planning, Charting in the medical field has to include precise documentation in order to see the patient’s current standing. This insures that future care options are adequate for each patient. Charting records patient measurements, medications taken by the patient, diagnosis results, and even go as far as collecting family medical history. A patient’s chart, gives information of their health from birth until the present, recording dates, and reasons for going to the doctors throughout their life. Proper charting is essential to understanding the type of care each patient needs. Charting is the communication between nurses, and other healthcare providers. The patient’s chart must be read to promote understanding of the patient’s health status. This means nurses can’t go based off verbal communication, but must look at the patient’s chart. Dr. Mathai stated that inpatient documentation is more collaborative and more frequent, which means that certain nurses will have to communicate verbally, but what is said through verbal communication needs to be documented as well. Comprehensive records are essential in healthcare and nurses need to dedicate time to documentation.
Charting enacts in the medical profession because if done wrong, there is a huge risk of a malpractice lawsuit against the healthcare organization. Law courts adopt the attitude that if something is not recorded, it didn’t happen. Therefore, nurses have a professional and legal duty to keep records. Current nursing student, Danielle Bright, stated that proper knowledge of writing in nursing is essential because it is considered a legal document. In other words, having accurate and precise charting relieves the stress of the patient’s legal rights being broken. This displays the importance of sufficient documentation, which can help support and promote the quality of patient care by preventing complications in the patient’s condition, as well as enabling a smooth recovery.
Writings in the nursing field provide new techniques and resources, nurture a patient back to health, and help nurses avoid patient complications. With these tools, a nurse in any environment will be able to keep their knowledge up to date for them to provide the most satisfactory work towards their patients and coworkers. Throughout these types of writing in the nursing profession, there will always be one goal in mind, and that is to promote adequate patient care. Along with this knowledge, nurses will not only open the doors to success in their career, but also open the doors to a successful recovery for any patient they must provide for.
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