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Nurse making patient notes

On Nursing Documentation

By: Fidelindo Lim, DNP, CCRN, FAAN

A healthcare document records the following: A 70 y/o male, BIBA with a CC of SOB 3 days PTA asso. with Lt sided CP and AMS. No LBM, n/v or LOC. Pt. has Hx of COPD, TVAR, HTN, T2DM, and OA. Denies IVDA, or use of OTC drugs, but takes ASA, HCTZ, Alb. MDI, and NPH SQ BID.

This stretch of information has been drastically shortened by the use of abbr. (abbreviations), acronyms, and hospitalese; morphing into a language of its own. If you have ever written something similar in a patient’s healthcare record, then you are a basic short note (BSN) writer.

In today’s precarious healthcare environment, not only is the patient’s LOS shortened, but healthcare language is also speeding up. Can you identify all the acronyms and abbreviations listed above? No? Google them, STAT. The late William Safire, The New York Times’ On Language columnist, called this language-shortening pattern “linguaclip.” There is no better place to see the practice of linguaclipping—the deliberate shortening of words and phrases, not the stitching up of the tongue—than in the healthcare setting. Providers, at all levels, perform what I call “lingaugectomy” ad lib and PRN, requiring no PA (prior authorization).

Where did it come from?

When I was a new ICU nurse, I used to recite all the words and phrases in full during handoff, like so: “The patient is in normal sinus rhythm with premature ventricular contractions, every other beat.” I also recall being intimidated by more senior nurses who just blurted out “sinus with bigeminy!” The use of linguaclips, according to Safire, is done not to save time, but to exhibit insiderhood, a verbal badge to flash one’s membership in a select or selective group. In other words, it also can be used to stratify hierarchy, novice vs. expert nurses, and potentially taint efforts for inclusivity. When the time came that I could roll ERCP, ROSC, and AF with RVR off my tongue without hesitancy or feeling like an impostor, I knew I was “in.”

Am I confusing you?

In practice, speaking in acronyms and medical slang is seen as proxy for clinical confidence and as an indicator that we are speaking the same language. But are we really talking about the same things? Consider the initials BS. Depending on your specialty (or level of irritation) this could mean blood sugar, bowel sounds, breaths sounds, or bed sheets. How about DNR? It is either “do not resuscitate” or “do not restrain.” Before we tie down the linguaclippers, let’s not forget to give them credit for those catchy, if not lifesaving phrases, such as “banana bag” and “call a code.” Code has the commanding power that “cardiopulmonary resuscitation” doesn’t. In an emergency, speed and brevity can make a big difference.

The trend to condense words and phrases is accelerating, but nurse titles are stretching and ever more elastic. RN is no longer adequate to describe who we are, what we are capable of doing, and why the public revere us for our ethical practice. Test yourself. How many of these credentials can you recognize? CNOR, CPHQ, ACNP, AOCN, CWON, and MSOL? Having difficulty? You may be suffering from “initialitis.” An early warning sign is an uneasy feeling when addressing a colleague who holds initials other than an RN. A late sign is when your own string of credentials outnumbers the total number of letters in your full name. Overall, however, it is best to be cared for by certified nurses because certification is associated with better patient outcomes, but only when care is provided by baccalaureate-prepared nurses.

I think one of the reasons for the language shortening endemicity is electronic technology. Long before CTs and MRIs, clinicians wrote in great detail what they saw, heard, and felt during their physical examination of the patient. Diagnoses and patient encounters were elaborated, not abbreviated. We are a generation of watchers, tweeters, texters, and clickers; we’re not writers. These days, clinicians have become dependent on images (moving or still) and it is increasing their cognitive load—an ongoing threat to patient safety and a cause of burnout.

Take note of this

A 2022 study that analyzed 40,113 H&P notes from 18,459 patients for sentences containing a negative descriptor (“resistant” or “noncompliant”) of the patient or the patient’s behavior found that Black patients had 2.5 times the odds of having at least one negative descriptor compared with White patients. These findings highlight the importance of addressing implicit bias to avoid the use of stigmatizing language in the EHR as one of many strategies to address racial and ethnic healthcare disparities. I wonder if the gender and age of the patient have an effect on how we write about them in our care notes? It is clear that we should be mindful and assiduous in our documentation, given that we bring who we are to what we write about our patients. Come to think of it, a note is more than just a record, it is a life narrative.

The original hope was that electronic technology would ease the burden of documentation. The irony is that there is more electronic “paperwork” now than ever before, not to mention the unrelenting stream of electronic alerts. We can assume that the declining quality of care notes is partly due to the combined burden of higher demands for documentation, tech stress, and infodemic. During a 4-hour observational study, researchers found that nurses spend about 1 hour on documentation. Ironically, electronic documentation is one of the skills that is practiced the least in undergraduate nursing programs. So, what are we going to do about this? I don’t quite know. But let me leave you with a question to ponder: Does your nurse’s note reflect the actual care you provided? I can’t really tell you how or why, but I am certain the way we document care mirrors the way we treat our patients. But, then again, maybe not.


Fidelindo Lim is a Clinical Associate Professor at New York University Meyers College of Nursing

 

 

References

Kendall-Gallagher D, Aiken LH, Sloane DM, Cimiotti JP. Nurse specialty certification, inpatient mortality, and failure to rescue. J Nurs Scholarsh. 2011;43(2)188-94. doi:10.1111/j.1547-5069.2011.01391.x

Sun M, Oliwa T, Peek ME, Tung EL. Negative patient descriptors: Documenting racial bias in the electronic health record. Health Aff. 2022;41(2):203-11. doi:10.1377/hlthaff.2021.01423

Let Us Know What You Think

3 Comments. Leave new

  • Fidelindo Lim
    January 12, 2023 2:10 pm

    Hello Cindy,

    Thank you for sharing your insights. I agree that care notes will never be able to fully capture the worth of what bedside nurses do. I also suspect that currently there is more “charting” (more like “entering”) than there is “reading”. I struggle finding notes in the innumerable drop down menus in EHR compared with the chart binder of the old days.

    Best wishes,

    Fidel

    Reply
  • Cindy L Garrison
    January 11, 2023 5:01 pm

    When I started in nursing Late 70’s, we did do narrative charting, however we had many abbreviations, acronyms, symbols we used, in which it helped shorten the amount of time spent on charting. As time passed many facilities started making their own lists of approved abbreviations until the majority were no longer approved, then new abbreviations and acronyms started showing up in documentation that were not approved by the facility, and we are here. I do not think that computer documentation reflects what the nurse does at the bedside any longer. It is a quick menu of choices that may or may not fit the situation. Yes, there are areas for notes, however I have not seen them used as effectively as the “old” narrative charting. This is just my experience when auditing charts and teaching novice nurses.

    Reply

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