Are You Up to Snuff on Your Spelling and Grammar?
I read this article, “Teaching the Literacy of Professionalism: When Clinical Skills Are Not Enough,” which was aimed at research and writing more than clinical nursing, but the conclusion caught my attention:
“Professional literacy is an important skill all nurses should possess.”
I would change that to just plain literacy is a skill all nurses should possess. Granted, I have a degree in literature and spent a decade as a professional full-time editor, so I am probably more of a stickler than your average Joe (or Josephine); however, I still think that egregious errors in written material make people look stupid—or uneducated, or careless (take your pick). Charting is written material, and in it nurses should not look stupid, uneducated, or careless.
This opinion is not out there, shared by no one else, either. I’ve heard of my colleagues being called on the carpet for their grammar, spelling, and usage, and they are without fail angry about it. “What does it matter?” It matters if the situation goes to court, for one thing, because the language can be used so incorrectly that it changes the meaning, but failing that, people read after us when we chart. It is distracting to have to try to figure out what the previous nurse meant, and it can be annoying to have to take that time. At worst we see that our colleagues cannot write a complete sentence and lose a little respect for them.
Floating around my department right now, for example, is the “tendernitis” joke. Our assessments carry through to a large extent in our computerized flowsheets, so if the patient has been there before, his or her history will appear filled in for us to add or change during the current encounter. On one patient’s history, “other” had been checked, and a nurse had typed in tendernitis. The nurse doing the new assessment got irritated about it. “Who does that? Are you kidding me?” Then it became a huge joke. “That must be when it gets all inflamed, that’s the -itis part, and when it does, then it’s tender, obviously.” Hilarious. But this is in an official medical chart (the treating RN did correct the chart, by the way). Stuff like that makes nurses as a whole look bad.
That’s a mildly funny example, but I’ve read some triage notes (simply the most likely reason for me to read another nurse’s charting notes on a regular basis) that were so badly written I literally could not tell what was meant. Not only does this make the initial patient encounter look sloppy, but it delays patient care if I have to track someone down to find out what the patient actually said.
And by the way, I’m letting physicians off the hook here only because of space limitations. They’re really not much better. The point for all of us in healthcare is that we may be all about science and patient care and 3,892 new rules and regulations imposed on us for patient satisfaction and reimbursement, but we really need to focus on our written communication. If you use electronic charting, almost certainly there is a spell-check function. Please use it. Re-read your notes to ensure that they are correct and readable. We have gotten too sloppy, even if we aren’t writing for publication.
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