Q: Would you please state your job title, where you currently work, and how long it’s been since you graduated from college?
A: I’m a registered nurse, I’m a dual position, so I work in the local hospital just as what they call a float nurse, so I’ll come in and work wherever they need me for the day, but I also work in the outpatient center that’s connected to the hospital, and there I work in their anticoagulation clinic. So I consult with patients who are primarily on a medication called warfarin, and we do education and we do blood tests, and then we give them a warfarin dose to be taking until they see us the next time. So that’s what I do. And I graduated from college ten years ago.
Q: Great, great. And have you worked in nursing for that entire ten year period?
Q: Wonderful. And can I ask just a clarifying question – what types of medical issues might someone have if they were taking that medication that you work with?
A: Um, there’s a couple, but primarily it’s people who are more likely to have blood clots or have had a blood clot, so that includes people with atrial fibrillation, which is an irregular heart rhythm, which can cause a stroke if you’re not on an anticoagulant, or people who have blood clots, it’s called a DVT, deep vein thrombosis, or PE, pulmonary embolism, who need to have anticoagulation until their body is able to break that blood clot down, or people who have genetic predisposition for blood clotting, or people who have like artificial heart valves that can more easily clot of they’re not on an anticoagulant.
Q: Gotcha, thank you. This will obviously be a little challenging because you mentioned that you’re a floater, so you’re doing different types of nursing tasks day to day when you’re in the hospital, but could you give sort of a brief overview or description of your primary job functions?
A: Sure. I’ll speak to the floating nurse part first. So when I come into that day, I am assigned between three and five, sometimes six patients for the day. I need to assess them, I need to administer medications and treatments, decipher lab values. I’m in constant communication with the other members of the care team, which are other nurses, like my supervising nurse, the physician who is of course in charge of the patient, as well as any consulting physicians, and then auxiliary healthcare team members, like physical therapy, occupational therapy, speech therapy, that sort of thing. So we all work together during the day to bring all those treatments to the patient. And then of course notifying the physician if there’s anything out of the ordinary that’s going, and then all the documentation of everything that all those people have been doing [chuckle] during the day as well. So that’s what I do when I’m floating. And then in the clinic setting, it’s really, it’s different, and it’s really, I like the dichotomy there because I kind of get to do two different things. So in the clinic I see one patient at a time, which is different in and of itself, and then I have to ask them a series of interview questions related to the medication that they’re on, warfarin. First we talk about what other medications that they’re on, then we discuss if they’ve had anything abnormal over the past few weeks since it’s been, or however long it’s been since they were last seen in our clinic, we talk about if they’ve had any issues with bleeding, because it’s an anticoagulant so it make you bleed more easily. And then of course, we talk about if they’ve had any other clotting symptoms as well, because that would mean that the blood levels aren’t correct, either – hopefully they’ve been in the emergency room in either of those scenarios, but sometimes that doesn’t happen. And then we talk about other things that affect the medication, so diet, alcohol intake, smoking, that sort of thing. And then after we go through all that, then I check their blood level, which is called the INR, and it helps us know if that medication, the warfarin medication, is therapeutic. And then if it is therapeutic, then we continue the current weekly warfarin dose that they’re on, and if it’s not, then we address if there’s a reason why it’s high or low, if it is, we correct that through counselling and then give them a new medication dose. If there is no reason, then we have to correct the medication dose anyway to try and get that level more therapeutic. And because I’m a registered nurse, I have to have it cosigned or I have to consult with my supervising nurse practitioner or pharmacist that I’m working with that day. So usually I go through all that, everything, and then I just run out to them quickly and discuss the case with them, we come up with a warfarin dose for them, and then I give that information to the patient and we send them on their way. And then if I haven’t already made the note of that visit while I’m talking to them, I finish up the note after that. And that’s it.
Q: Perfect, thank you. Either in terms of those notes or if there are additional writing tasks, could you estimate in an average week what percentage of your job requires writing?
A: Um, on the floor probably maybe like 25, 30 percent. In the clinic, I would say it’s probably higher than that, maybe 50 percent.
Q: Great, great. So could you tell me a little bit about the forms or types of writing, or the documents that you most often complete? Sort of what are they, what form do they take, but also who are the audiences and what are you trying to accomplish with them?
A: Sure. In the hospital, everything is documented on our online charting, electronic medical record. So it’s a series of, like when I’m doing an assessment, it’s a series of clicks basically. We do something that’s called charting by exception, so we can assess the patient and then just say, “This system,” for example neurological, “is within normal,” so there’s nothing unusual there. But let’s say for example the patient has a history of an old stroke, then I would not say everything’s normal, because maybe they have a residual drooping of one side of their face. So then I would check that, and then I would also want to check that this is an old thing, and it’s not something new. Because if it’s something new, then we’re going down a whole other line of assessment and notifications and checking the patient to see if the patient has had a new stroke, et cetera. So basically that documentation is click click click click click all the way through. If there’s a note that I want to add in there, like that discussion of it being an old stroke, it’s just another quick right click to add a little comment basically. So it’s clicks and comments. And then I will also write a short note usually, at least once a shift, just to talk about my care of the patient, if there’s anything abnormal, usually if it’s a pretty good healthy day for the patient, it’s a real quick note saying, “I assumed care of this patient at this time, this xyz happened,” excuse me one second, [interviewee talking to her child]. Sorry [chuckle]. Can you remind me what I was saying [chuckle]?
Q: Yes, you were talking about the click system. Oh no, you were talking about writing a note once a shift to talk about it.
A: Okay, yeah. So it might just be a little blurb about my care of the patient that day. But, if something abnormal happens, which often something abnormal’s happening because the patient’s sick and in the hospital, then I would speak to that maybe more in detail than just the standard assessment boxes that I can check about the patient’s abnormality. Like so if the patient had that facial droop, I would of course be writing a note about what time I noticed that, who I notified, and our hospital is a stroke hospital, so we would call this alert, and the patient would go off to a series of tests to see if the stroke is a true stroke and if it needs any further treatment. So it just goes down this long sort of path of all the other things I have to say about what happened. But because I just feel like it’s better to have that note in there too, just to cover everything that I have done. A lot of times it is double documenting, but I am of the thought that it’s better to say more than to not say enough about whatever has happened to the patient during the day.
A: So, go ahead.
Q: Oh no, I was just going to say, yeah. So this might feel like a silly question, but because I don’t know that world very well, so why is it better to say more than less? What are you trying to accomplish with those notes?
A: Well, so you asked me who my audiences were, the people that might be reading this later, number one, would be the nurse that’s following me, so she or he’s going to want to know went on. I will of course give that to them in report, but if they want to reference that to see what has happened, a lot of times it’s easier to pull up a nurse’s note than it is to like filter through all those sections of clicking that I did before. It’s just, I can make it more succinct I guess in a note, and just kind of give the highlights of whatever the issue was that was addressed. And then the other people that might be the audience for that – physicians, I don’t really know actually how much physicians read nurses notes [chuckle] it’s just so much information and they’ve got enough going on. I know that physical therapists and social workers, everyone else on the team might reference that. And then of course, we always think in the back of our minds about the possibility that if something ever came up that went to court, we want the people that are prosecuting to know that we have done everything we can, and just to say like, “Hey, I did it. I followed all the steps and all the protocols of what needs to happen when something abnormal like this goes on in the hospital setting.” So they say, the acronym CYA, so just cover your ass when you’re in healthcare because you want everyone to be safe number one, but also to know that you’ve done everything you can and again, that saying, “if you didn’t document it, it didn’t happen.” So it has to be shown in your documentation what you did for the patient.
Q: Great, great. Thank you so much. Other than those notes and the click through system, where you’re leaving comments, is there any other kind of writing or documents that you work on?
A: Yes, thank you for reminding me [chuckle]. In the clinic setting it’s a lot different, I really enjoy it actually, because when there’s a new patient that’s come to the clinic, you do an intake, so you have to get to know the patient and sort of what their medical history is, as well as what brought them to be on this new medication of warfarin. So that interview, it’s a longer visit because it’s the first visit with us and we do a lot of education there as well. And after I get their whole story of what brought them to me, then I have to sort of write that out as succinctly and sort of pointed toward our specific medication as possible, as that first admitting note. And then subsequent visits we sort of have a template that we use and we change it for variations from the normal. So they’re all again, in the computer, we use a specific computer program made for this type of clinic, but we do our own writing of those notes. The first note is different because it’s sort of like a narrative, versus the other notes, which I guess are also narratives but they’re a template that we just sort of fill in what we need to for the patient.
Q: Okay. Gotcha, that makes perfect sense. Could you walk me through the process for a recent project or sort of one of the typical things that you write that you mentioned? Just sort of start to finish, even if it’s something, maybe the actual click through and comments makes sense because it’s something that you do so frequently. What is the process like from start to finish, how long does it take, and sort of what steps do you take?
A: Sure. Maybe I actually will speak to that admitting note, because it’s probably the most writing.
Q: Oh great, yeah.
A: So like I said, the patient comes in, I sort of just ask them like, “What brought you here?” And then most people really like to tell you everything that’s gone on, so you just listen, sometimes that takes a really long time [laughter], but listen to them, and then try to draw out specific pertinent medical history, because that’s what ends up going in the note. I take notes while they’re talking, and then I have a sort of a loose paper that guides my questions as well if I’m forgetting something. So after I take the notes, we do the visit, I do the education, we do the blood test, all that stuff, send them on their way, then what I often do if the patient has been in our hospital – which often they have because our hospital is the only one in the county so most of the people that are coming to the clinic have been in our hospital and were referred to use from there – I’ll actually look up their most recent hospital admissions as well, just to see if there’s anything else that was mentioned in their physician notes that maybe the patient forgot, or a lot of times patients have a really good understanding of what’s happened, but maybe they don’t have the right verbiage, so I like to go into the physicians to see what was the actual diagnosis, or what was the actual procedure that happened, because they might give me layman’s terms but I don’t want to assume that what the patient has told me went on is actually what was you know, the medical term for that. So a lot of times I’ll just like go in and double check any pertinent history in their electronic medical record, and then I sort of come up with this narrative. We use something a SOAP note, so situation, objective, assessment, and plan. So situation, “This is a 70 year old patient who comes to our clinic,” and the narrative is the same for each of these new patients but then you say, “because they had a blood clot in their lower left extremity. They came to the hospital on this day, they were started on warfarin on this day, here’s their past medical and surgical history, allergies, the medications they’re currently on,” and then we talk sort of specifically toward warfarin. So we’ll say you know, “They didn’t miss any warfarin doses since they started on the medication. This is what they’ve taken so far. They haven’t had any issues with bleeding,” or maybe they have, “they still have swelling in their lower extremity,” that would be normal. We’ll talk about other symptoms of clotting to make sure that we’ve said that they don’t have any other symptoms of clotting. We’ll talk about their diet because diet can affect the levels of warfarin in your blood, and we’ll talk about alcohol and smoking, and if they have been sick lately. So that’s all in the situation part of that note. Objective stuff, we will say they have — that usually we leave blank except sometimes we will put in weight and height and that sort of thing. Assessment we will say after we’ve done the blood test, whether it’s therapeutic, not therapeutic, and whether they have or do not have signs of bleeding and clotting. And then in the plan part of the note, we will say, “This is what we told the patient to take with their warfarin for this so many days until they return to see us.” And then in that initial note I will always also document, “We covered all this education,” and I like list all the different things I did with them, “and it took me this long to have this visit with the patient,” because that’s something the billing people have to know. And then that’s it.
Q: Okay, that’s excellent. And so is it just a sort of, you write it and it’s done? Do you ever return to those to revise them?
A: Um, the only time I would return to revise them is if I just forgot to put something in there which happens frequently, so just add an addendum on the end of that. I do return to those notes, I wouldn’t say frequently, but sometimes if I’m looking to see maybe did they have this medical history, like let’s say it’s been a couple years since they’ve been in our clinic, and all of a sudden it pops up that they have this history of diabetes, and I never knew that before and I wanted to look back and see, did we know that when they first came to the clinic? So we I might look back and see, we have several places where we document their medical history, but sometimes if I can’t find it anywhere I’ll look back at that initial note to see, did we know it then, or is this actually a new diagnosis that they’re telling me about for years after the fact? So I do reference those occasionally, or maybe I wanted to know more of the story, like we have a chart that says why they’re on the medication, but sometimes you want to know a little bit more specifics of why they’re on, so I might look back at that note to see, what was the story? Like what actually, how did that all come down in the beginning that they started on the medication?
Q: And as you are thinking about writing those notes, like the more narrative pieces of it, is there anything that you avoid saying?
A: Well I can talk of course about being a nurse versus someone with a higher, like a prescribing power. Like I can’t say any kind of diagnosis, this goes for anywhere that I’m working, like I couldn’t say that, “I believe that they are diagnosed with atrial fibrillation,” or a blood clot or whatever. I always have to say, you know, “They were found to be in xyz diagnosis when they were admitted to the hospital,” or by their primary care, whatever. That’s never something that I say, even if I know, like that these symptoms might be present. I can’t say that they are diagnosed with, under my license. So if I’m going to say something about diagnoses, I will always tack on where they got that diagnosis from. Past medical history is a little bit less like that, but for a new diagnosis, you would definitely want to say you know where they got the diagnosis from. I’m never currently in that moment diagnosing anybody, nor would I say that in a note.
Q: Okay, I see, that’s useful, yeah.
A: I’m trying to think what else. You certainly don’t, like if the patient’s warfarin has been mismanaged by another physician, like let’s say they used to go to a different clinic and that clinic told them to do ridiculous things, and it made them issues, I’m not necessarily going to– we try to be very diplomatic. So I’m not going to say, “it’s this clinic’s fault that xyz happened,” but I would say, “the patient was told by this clinic to do this with their warfarin, and here is their INR today.” I will give the beginning and the end, but I wouldn’t say, “and it’s their fault.” Because again, we’re not going to throw other healthcare providers under the bus, but we do need to document what has happened and what the effect of that may be.
Q: That makes perfect sense. Is that more of a sort of community standard? Or is it a legal concern that you want to be cautious of?
A: I would say, I mean I was never taught about a specific legal concern that says, “don’t throw your other healthcare providers under the bus,” but I think it’s just kind of standard in medicine. Like if something really terrible happened of course there would be follow up about that, and we have certainly, if a patient comes to use in a dangerous situation, we absolutely follow up with wherever they came from, and like, “Hey, what the heck happened?” But we again, would write that in a diplomatic way. We wouldn’t necessarily write you know like,”We called this other doctor and yelled at them because they messed this patient up,” [chuckle] kind of thing. But at the same time, while you’re being diplomatic, you are highlighting and what should always highlighted in healthcare is the patient’s safety, so that is like a running theme of all documentation that we do, is showing what we did to keep the patient safe, or to get the patient safe.
Q: Excellent, excellent, thank you. So this next question feels a little bit broad, but how did you know how to perform the types of writing that you currently perform?
A: In the clinic setting, it’s certainly been a learning process. I think mostly just from reading other people’s intake notes, and when I first started there, I had to sit in with those initial visits and follow up, and my supervisor would read those notes afterward and you know, tell me if I needed to change anything. In a broader sense, we learn all of that in nursing school from very early on, I would say maybe the first or second semester of nursing school we’re learning about how to write a patient note. I learned on paper, this is before the computers were really up and running, so we would like write out our notes and sign them on a piece of lined paper, and then our instructors would check those. And I believe we had some sort of maybe a couple of days of reading examples of notes and how you might write them. I certainly remember practicing and submitting many notes throughout nursing school to be looked at by our instructors.
Q: Gotcha, okay. Has there ever been a time in your career that you felt unprepared as a writer at work?
A: Um, probably that first year of nursing, I was just, it’s just overwhelming. All the preparation does not you prepare you to just start working in the hospital. You just have to go in a start doing it. So I definately, I had some excellent preceptors when I was new to nursing, and we would stay two hours after my shift was over sometimes [chuckle], like going through all my documentation and double checking everything, I had one lady that was, she was insane, and she was always like dotting my i’s, crossing my t’s, everything. But it’s good I think to start that way, and then, you know, some of those things like dotting your i’s and crossing your t’s may not be the most important thing, but it’s good to be completely thorough I think at first just to get your grips on it. As far as now, I mean there’s certainly been some times where, I will run by a note with the nurse practitioner that I work with, if I want to make sure that I’m wording it correctly if it’s kind of a touchy situation. Like we have a lot of times in our clinic, you know, you as a patient, you’re entitled to your own decisions and opinions and it’s your body, but a lot of times we’ll recommend something, like, “You need to go to the emergency room,” and the patient outright refuses. And so in that narrative, I want to make sure that I’m saying that we educated the patient on the risks of not going to the emergency room, and that the patient refused or declined our suggestion, and I want to say that in a way that shows that we are trying to keep the patient safe, and so that if there’s ever a situation where that patient, God forbid something happened to them, and then they said, “Well, they didn’t tell me that,” then I can look back at that note and say, “Well actually I did tell you that, we told you should go to the emergency room,” kind of thing.
Q: Right, right. Gotcha, okay.
A: But that’s the kind of thing I would run by my supervisor just to make sure that I have that wording in a way that makes the most sense and speaks concisely to the issue that is at hand.
Q: Perfect, okay. Does anyone oversee your writing?
A: In the clinic, my supervisor does. She doesn’t read all my notes, she would only read it if brought something to her attention. They are signed off on either by her our medical director. And then in the hospital setting, there’s again, there’s just so much in the hospital setting, there’s so much information, that I don’t know that anyone specifically looks at my charting. I think that they do random audits, where there’s like a whole department in the hospital for auditing and looking at nursing documentation, so they will now and again audit certain parts of your charting to make sure that you are completing it as you’re supposed to. As far as, in my ten years of nursing, I have never had a note brought back to me about you know, whatever, edits or whatever like that. But there certainly have been times where an auditor will call me and say, “Hey, you forgot to chart your pain reassessment, can you please do that?” And so then I will go back in and do that for them.
Q: Great, okay, okay. How long do you typically have to complete a writing project? Like you know for the average sort of notes on a patient, for instance if you’re on the floor.
A: On the floor, just a couple minutes probably. I don’t spend that much time unless it’s a significant issue that needs to be typed out in which case, maybe five or ten minutes. They’re not long, I mean I don’t know that I write paragraphs about any of my patients, even if it is a big issue, because again, you can accomplish a lot of the information intake by clicking through the checkmarks. But yeah, not very long.
A: [Interviewee speaking to her child]. Alright, go ahead.
Q: Sorry. So you talked a little bit about this, but other than practicing those notes, are there any kinds of writing that you remember being asked to do as a student?
A: Hold on just a second [interviewee speaking to her child]. Go ahead [chuckle].
Q: If you need to cut this short, we understand completely.
A: Oh it’s fine, we’re good.
Q: Okay, so I was asking about, were there writing tasks that you completed as a student other than notes that you remember doing? Other than those practice notes that you mentioned?
A: We do, in nursing school they’re big on care plans, which involve something called a nursing diagnosis, where we would talk about the symptoms a patient has, and how we would go about managing those symptoms and then what we would look for as a favorable response to that, and sort of a goal that they would accomplish through that response. Again, it’s all very vague, not vague, but you’re skirting around the actual diagnosis because you can’t say the actual diagnosis. So we would do a lot in nursing school. You wanted just specifically nursing school or like undergrad in general?
Q: No, in general sort of your undergrad education.
A: I mean, we were all required to do a, I don’t know if it was creative writing class, or some kind of writing class, no it wasn’t creative writing, I think it was just like English 101. Just basic papers, I remember my English 101 lady was really into animals, so we did a lot of animal papers [laughter]. And you know, I was just remembering, in nursing school then we did do a research writing course, where we had to research a specific study and sort of write about that study or about several studies just to sort of gain familiarity with how to read through a clinical study. So we did do that, not very much of it, I don’t think we did – I think maybe we did one or two big papers over the course of that semester, but that was something we had to do as well.
Q: Gotcha. And in what ways do you think that the writing you did in college prepared you for the work that you do now?
A: You know, those care plans were kind of annoying, but they did help you learn that language of how nursing speaks to the condition of the patient. And sort of all the auxiliary things that happen around the what the physician might be addressing. So I think that was good in that respect, it’s definitely an approach you have to learn. The research writing was good because it, like I said, it helped me gain familiarity with how to read through a trial or something like that. I don’t think that the English 101 was particularly helpful for nursing in particular. I really enjoyed it, because I also enjoy creative writing, but I don’t think it was very helpful. It’s asking you to write a lot of things, to be as verbose as possible, and that is not how it is in medicine [chuckle].
Q: Yeah, that makes sense. So just a few more questions. Is there anything that would have been useful for you to do or learn as a student that you didn’t do?
A: I think if perhaps there were more scenarios kind of offered, like, “How would you write about this? Like you are telling the patient to go to the emergency room, and they don’t want to go.” Like having that kind of practice would be good, because I think that sort of thing happens a lot in healthcare where you have to say, “I recommended this, and the patient didn’t want to do it,” kind of thing, sort of to cover yourself. So I think that kind of practice would be good, because I think it’s sort of broad and you have to say that in multiple different scenarios. I’m trying to think if there’s anything else. Yeah, just different scenarios like that I think would be good, or just to read that sort of scenario. Maybe we did read them and I just don’t remember [chuckle].
Q: Could you talk a little bit about what is at stake in your writing?
A: Well ultimately, the patient’s safety, but that’s more in your practice than it is in your writing. I feel like my writing comes second to the actual care of my patient, and sometimes that makes me stay extra after my shift is over, because I want to give the care to the patient first, and then write about it later. But in an ideal world, you can do both of those things at the same time because the patient isn’t having any issues at all [chuckle]. So what is at stake? Of course, your license is at stake because if you don’t again, document something you did, that something bad happens to the patient, that will come back to you in a court scenario if you haven’t documented appropriately, even if you did do it, and you didn’t write it down, it will come back to you. So that’s probably the biggest thing that’s at stake in my writing. Also just sort of my reputation kind of in a way, because like I said, the nurse that follows me is going to want to read what I’ve been doing. So if I come in after I know what’s been a train wreck of a shift for the nurse before me, and there’s nothing written down, of course maybe they’re still working on it, sitting next to me while I’ve taken over, but I would want to know what has happened. Or like let’s say it’s been a couple days since this incident happened for the patient, like I want to be able to go back and look and see what actually happened, because nursing report is excellent I would never want to give that up, but as a story gets passed along when you’re in shift report, things might get lost or missed, and like I want to go back and look and see, okay what exactly did happen? You know, where are we at in this process of getting the patient past this event that happened?
Q: Gotcha, gotcha. What would you say is the most challenging thing about writing in your job?
A: I would say being succinct but also accurate. So I want to gather all my data and be able to present that accurately so that it is helping everyone involved in the situation.
Q: Great. How do you believe you’ve evolved or improved as a writer over the course of your career?
A: I think I’ve definitely become more succinct, I mean I enjoy writing a good story about a patient but I also have to sort of rein it in a little bit sometimes. So I think I’ve gotten a little bit better at that, and knowing what’s important to say and what’s not important to say in a note.
Q: Okay. And just two more questions – first, to what extent do you think writing is valued in your organization or in your field?
A: I think that it’s valued secondary to actually keeping the patient healthy and safe. I think it is certainly valued but I’m trying to think how to say otherwise, yeah. Yeah, I’ll just leave it at that.
Q: Yeah, that makes sense. And would you say that you’re a successful workplace writer?
A: Um, I think so. I think people read my notes and can follow what’s going on which is important.
Q: Excellent. And is there anything else that you would want people to know about the writing that you do at work?
A: I think I’ve said what I wanted to say.
Q: Okay, thank you so much.