Macaspac Stephen Macaspac Steven Holmes English 100 15 September 2013 Oooops Wrong Side: Importance of Effective Writing

Skills in Nursing On July 20, 2007, Rhode Island Hospital performed surgery on the wrong side of the

brain for the third time. Because of their medical offenses, this institution lost millions of dollars, credibility, and most significantly, the lives of their patients. These surgical blunders were resultants of poor rhetorical communication by the presiding nurse (Griffin). Generally, there isnt much emphasis in the importance of writing in the nursing field. Many have the misconception that nurses only clean up feces or give old people baths. In reality, there is immense pressure and responsibility on the part of nurses, especially with activities that incorporate writing skills. They may not have to write extensive reports on the condition of the patient, but there is still an array of tasks that involve some sort of written communication that impact the quality of medical service. In order to provide the most holistic, continual care in the nursing field, it is essential to produce authentic medical documentation, chart accurate health notes, and effectively communicate among fellow health care workers. One of the most critical forms of writing within the nursing field is medical documentation. In an interview with RN, Arlene Macaspac, she stated that, written documentation is often performed by nurses and must be clear, concise, accurate, and coherent. Thereafter, she described the multitude of roles documentation plays within the field. One of these key roles include providing a universal medical record reference for all health care workers. A medical record consists of previous treatments, test results, x-rays, reports,

Macaspac administered drugs, family history, etc (Wood). She noted that having this plethora of information at hand serves as a major asset within health care because it gives all health care workers access to the web of information. In essence, every person involved with a patient has the necessary information to provide optimum care. Another crucial role documentation plays within the nursing field pointed out by Nurse Macaspac, is that it enhances efficiency of care. Nurses and doctors can easily pull from a patients record and use the notes to perform diagnosis and plan possible treatments right then and there, especially in exigent cases. For example, if a patient required immediate blood transfusion, a physician can easily find out a persons blood type from medical notes. A current college freshman named Brian Chung, who aspires to

become a pediatric nurse someday, emphasized the role of documentation in legal cases. One out of three nurses face some sort of lawsuit within the span of his or her career, hence, detailed and coherent notes are imperative (Wood). Medical documents are analyzed before any court hearing and are often a reflection of the defendants professionalism. The prosecution strives to vitiate the credibility of the nurse (Wood). Poorly written notes give off a questionable connotation, which is why authentic notes are critical. If nurses produce proper documentation, critical information can be efficiently accessed in any time of need. Along with proper documentation, Mrs. Macaspac indicated that medical charting is another important form of writing within the nursing profession. She explained how charting follows the SOAP formula, which is an acronym for the four components of medical notes taken by the nurse: Subjective, Objective, Assessment, and Plan. Under the Subjective section, it is the role of the nurse to translate the patients chief complaint into a written narrative, without losing the integrity of the patients self-proclaimed symptoms. She characterized this section to be the patients own diagnosis of their current condition and that it is the job of the nurse to

Macaspac extrapolate pertinent information from the patients words. After subjective notes are taken,

objective information is then recorded. This includes patients vitals, lab results, and any other form of measurements (SOAP Notes). According to nurse Macaspac, it is important to take precise notes because a minor miscalculation can skew the following section, which is the Assessment. In this section the nurse hypothesizes several diagnoses based on their subjective and objective notes. From there, they move on to the Plan section to come up with a solution to the patients current state. Whether its prescription of medication or a referral to therapy, notes should be coherent for anyone to read and understand. Misinterpretation of poorly written notes can be catastrophic; a pharmacist could mistakenly give out Inderal (beta-blocker for high blood pressure) instead of Adderall (ADHD stimulant), which is one of the most common pharmaceutical mistakes that may lead to death (Griffin). Macaspac conceded that spelling is a serious aspect of the nursing field. Without consummate writing skills, each segment of medical charting could be polluted with incomprehensible and potentially lethal notes. This is why it is important that proficient writing skills are utilized in medical charting. While nurses exploit concise forms of writing in medical documentation and charting, they also compose pervasive reports as well to communicate or educate other health care workers. Nurse Macaspac explained how they often collaborate in their perspective workers union or even in world health organizations to make proposals on funding or protocol. Written propositions will not even be considered if the writing is disjointed and confusing. She noted that Professionalism makes this persuasive form of writing more convincing. An anonymous student in the direct entry program for nursing at UH Manoa pointed out that it is also very common for seasoned nurses to publish their medical research and insight. As early as the 19th century, books like Notes on Nursing by Florence Nightingale, have paved the way to the development of the

Macaspac profession today (Hamilton). Because of written contributions through books, medical reports, and online articles, information can spread to a vast number of people. These publicized works require consummate writing because ineptitude of grammar, style, language, and structure can tarnish any credibility even though ones written arguments may be valid. In order for ones

writing to be taken seriously in the field of nursing, a nurse must have professionalism in written communication. After looking at all this evidence, it is self-evident that writing plays an essential role within the nursing field. Without this rhetorical skill, everyday tasks such as medical documentation, charting, and effective communication would be impractical. Though most forms of writing within the nursing field are brief and concise, the necessary rhetorical skills are needed in order to provide optimum care within a health care environment. With negligent writing skills, one cannot hope to flourish in the nursing field. Though often taken lightly, writing is a quintessential skill in the nursing profession. For the sake of ones job, fellow colleagues, and most importantly the care of the patients, nurses should develop proficient writing skills and endorse them into their daily activities on the job.

Macaspac Works Cited 1. Griffin, Simon. "10 Horrible Cases Of Medical Malpractice." Listverse. Listverse, 29 May 2013. Web. 15 Sept. 2013. <http://listverse.com/2013/05/29/10-horriblecases-of-medical-malpractice/>.

2. Hamilton, Stephen J. "Clinical Development: A Framework for Effective Communication Skills." Nursing Practice and Peer-reviewed Clinical Research for All Nurses. Nursingtimes, 23 Nov. 2007. Web. 15 Sept. 2013. <http://www.nursingtimes.net/nursing-practice/leadership/clinical-development-aframework-for-effective-communication-skills/296359.article>. 3. Macaspac, Arlene V. "Interview With Arlene Macaspac." Personal interview. 8 Sept. 2013. 4. "SOAP Notes." EHR EMR Consulting Services. EMRSOAP, n.d. Web. 15 Sept. 2013. <http://www.emrsoap.com/definitions/soap/>. 5. Wood, Christopher. "The Importance of Good Record-keeping for Nurses." Nursing Practice and Peer-reviewed Clinical Research for All Nurses. Nursingtimes, 14 Jan. 2003. Web. 15 Sept. 2013. <http://www.nursingtimes.net/nursingpractice/clinical-zones/practice-nursing/the-importance-of-good-record-keepingfor-nurses/205784.article>.

Macaspac Commentary

This essay was a research paper on the importance of writing within the field of nursing. I attained my research from a multitude of sources. My main source was an interview with RN Arlene Macaspac, but I also got input from students in my English 100 class and from outside sources online. After the research process, I created an outline in order to organize my main ideas and information for my essay. I then did a short free-write and so to say, vomited my ideas in an initial draft. Then I started to write more structured in my final draft, which was then peer reviewed in class by two fellow classmates. If there was any major problem in completing this assignment, it would have to be integrating the information into a organized and well thought out paper. Because this was my first college essay, I had to spend a decent amount of time composing my paper. Next time, I hope to be more efficient in by doing more pre-writing and not being afraid to make mistakes on my first draft. Overall, this essay will be a sentimental piece of work as I continue to push forth in attaining my degree in nursing.