A ward-based writing coach program to improve the quality of nursing documentation

SummaryA ward-based writing coach program was piloted at a metropolitan hospital in Australia to produce a quality improvement in nursing documentation. This paper describes the education program, which consisted of two writing workshops, each of one-hour duration followed by one-to-one coaching of nurses. This program could be carried out in any clinical area as a part of the regular education program. Nurses are encouraged to view their documentation practices in a critical light to ensure that the documentation is meaningful to readers within or outside the profession. The importance of nursing documentation as a communication tool for all health care professionals is emphasised. Barriers to meaning, such as fragmentary language or the use of unofficial abbreviations, are discussed. Nurses are also encouraged to document the patient's condition, care and response to care using defined principles for nursing documentation. This program would be transferrable to any clinical setting looking for a ward-based education program for nursing documentation.