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Staci Sinex is an intensive care nurse at MUSC in Charleston, SC. When interviewed about writing and communication in a hospital environment she replied that clear communication is extremely vital. Throughout the interview I noticed that writing is a key tool for effective communication in a hospital. For example, when a doctor calls in an order, the nurse writes down the instructions and then repeats them back to the doctor to prevent miscommunication. However, frequently the nurses fail to repeat the order because they are in a hurry, distracted, or confident they understood which can led to medical errors. The American Hospital Association cites a common factor that contributes to medical errors: “miscommunication of drug orders.” The miscommunication can involve poor handwriting, confusion between drugs with similar names, misuse of zeroes and decimal points, confusion of metric and other dosing units and inappropriate abbreviations.” Staci informed me that nurses are required to take a medical terminology class to learn and understand medical abbreviations. In addition, nurses are only allowed to use approved abbreviations. Some prohibited abbreviations at MUSC are Q.D. which means everyday and Q.I.D. means four times a day. If there is a miscommunication due to bad handwriting a patient could possibly receive four times their prescribed dose which can lead to deadly mistakes. Doctors are notorious for horrible handwriting; therefore, nurses must make sure that the physician writes a clear, legible order.
Also, nurses must objectively write everything in the patient’s chart. There is a saying in the medical community that “if it wasn’t charted it wasn’t done.” If the patient complains of pain, nurses must follow a certain procedure and record every step. They must identify the pain, explain how they intervened, and report on the follow up. Each write-up in the chart must be concise and thorough. If a high blood pressure is written down, the nurse must sight what actions she took-even if it was just to inform the doctor. Every conversation between the nurse and the patient’s family must be noted. When a nurse teaches a family member how perform a task, they must fill out a form. The nurse must state if the family member understood what they were taught or if they need more supervision. Writing everything in the patient’s chart can also protect you in court. On 20/20, a nurse witnessed a mother abusing her child by trying to make him sick, a syndrome called munchausen-by-proxy. However, the nurse did not write what she observed in the chart and the mother got away with her crime.