I Need Help To Improve Writing Skill On Nursing Notes

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As a non-English speaker, I definitely have a hard time writing progress notes and reports. I usually give my instructor a confusing to read them because of inappropriate words using. I found some sample sentences and words to write nursing notes and reports. However, it is not enough. I'm wondering if somewhere I can learn the sentences and words describing normal and abnormal statements of patients, such as respiratory system, mobility or psychosocial. 

To indicate how worse my writing skill is, I posted two examples of writing I just made.

patient 1: Dx - dementia; time - morning

Data: Received patient in bed. Asleep. Woke up when name called. Oriented by name only. Raised HOB 30 degrees to take VS. VS stable with BP 170/70. Denied pain when asked. Morning care done by HCA. No BM. Fed 30% breakfast and tolerating well. Action: Strictly monitor and record I/O fluid as per doctor's order. --------------yx5001

patient 2: Dx - hip fracture; time - morning

Data: Received patient in bed. Asleep. Easy to aroused. Oriented by three. Observed a severe non-productive cough. Denied pain when asked. Assisted HCA to do morning care and transfer the patient to wheelchair.  -------------------------------------yx5001

Action: Assessed for lungs and found fine crackle sounds at right low base. Had a teaching of deep breathing and coughing technique by graphic because of language barrier. ----------------------------------------------------------------------------yx5001

Respons: No more coughing after being transferred to wheelchair.

Thank you for any feedback and suggestion

 

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Specializes in Med-Surg/Tele/ER/Urgent Care.

No need to say raised hob to take vs. BP 170/70 IS NOT STABLE

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10 minutes ago, PollywogNP said:

No need to say raised hob to take vs. BP 170/70 IS NOT STABLE

Thank you. In this case, the patient's baseline is hypertension. How should I mention the VS stable and highlight the BP appropriately in DAR chart?

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Specializes in Med-Surg/Tele/ER/Urgent Care.

 I have never seen this DAR this data action what is the R stand for. As for action since BP is elevated what actions/what did you do about it? Recheck in other arm, recheck in 15 minutes, call doctor, alert charge RN?? Again you cannot say Stable vs since BP is high. What’s the pulse rate?

 

hip fracture pt - has pt had surgery? You helped get pt in wheelchair, can they bear weight? How much assist to get out of bed. Again no need to say assessed lungs.  Fine crackles auscultated right lower base. Instructed to cough & deep breath. ? Did lungs clear with C&DB? What is a graphic? And what language does pt speak?

 

English is my second language. You should read what other nurses document. Are there other students that speak your native language that can help you? Sadly many mono-lingual English speaking faculty are clueless as to how bilingual brains work. I taught in a BSN program for 10 years & encountered faculty that assume bilingual or trilingual students had poor command of English but actually my experience was that they actually used more accurate terms than monolingual English students.

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Specializes in Med-Surg/Tele/ER/Urgent Care.

What is your first language? How old were you when you learned English?

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2 minutes ago, PollywogNP said:

What is your first language? How old were you when you learned English?

Thank you for your reply. 

Mandrian. IDK when I learned english

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From the samples you have posted I don't think there is a significant problem with the words you are using. The main area for improvement will be charting what is relevant and leaving out what isn't--which is true for pretty much all students and some nurses, too, not just those for whom English is a second language.

I think you've done a good job as far as the English-related/readability aspect. ?

Re: "Stable" vitals and "VSS" -- there are more useful things to chart. Stable means "to remain unchanged" so by definition someone's abnormal vital signs may be stable, even though as the phrase VSS has been used it is generally referring to a situation where a patient's condition is understood to be stable as evidenced by normal vital signs. Because of this latter understanding of what VSS means, it's best to not use it when either the patient is not stable or the vital signs fall out of normal ranges. Overall it is more useful to directly acknowledge and address abnormal vital signs if they are present.

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T

14 hours ago, JKL33 said:

From the samples you have posted I don't think there is a significant problem with the words you are using. The main area for improvement will be charting what is relevant and leaving out what isn't--which is true for pretty much all students and some nurses, too, not just those for whom English is a second language.

I think you've done a good job as far as the English-related/readability aspect. ?

Re: "Stable" vitals and "VSS" -- there are more useful things to chart. Stable means "to remain unchanged" so by definition someone's abnormal vital signs may be stable, even though as the phrase VSS has been used it is generally referring to a situation where a patient's condition is understood to be stable as evidenced by normal vital signs. Because of this latter understanding of what VSS means, it's best to not use it when either the patient is not stable or the vital signs fall out of normal ranges. Overall it is more useful to directly acknowledge and address abnormal vital signs if they are present.

Thank you for your comments. It helps so much ? I believe that learning the writing skill from other nurses' notes is a better way for improvement.

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Specializes in nurseline,med surg, PD.

Saying "received patient in bed" means you were in the bed. Just delete that sentence as it is irrelevant. If you must you can say "patient lying supine in bed". 

By "fed patient" do you mean that you fed him, or do you mean that he fed himself.? If he fed himself, you say that "he ate". 

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Specializes in Former NP now Internal medicine PGY-3.

I wouldn't sweat it too much, the above reads much better than half the notes from foreign docs and a lot of American ones also probably.

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Specializes in Med/Surg, LTACH, LTC, Home Health.
On 10/24/2021 at 9:56 PM, PollywogNP said:

 I have never seen this DAR this data action what is the R stand for. 

It’s another version of charting similar to SBAR. Some places utilize an ‘F’ before the DAR.

(F): Focus - Hypertension, BP  follow-up, etc..

(D): Description - brief statement of problem.

(A): Assessment - data collection pertaining to, and  duration of the problem.

(R): Response - nurse’s intervention and patient response to it. 

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