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1. A ward-based writing coach program to improve the quality of
nursing documentation
Diana Jefferies a,
⁎, Maree Johnson b
, Daniel Nicholls c
, Shushila Lad d
a
School of Nursing and Midwifery, University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW, 1797, Australia
b
School of Nursing & Midwifery, Centre for Applied Nursing Research (Joint facility of SSWAHS & the University of Western Sydney), College of Health & Science, University of Western
Sydney, Penrith South, DC. NSW, 2751, Australia
c
Clinical Chair in Mental Health Nursing, ACT Health Directorate & Faculty of Health, University of Canberra ACT 2601, Australia
d
Women's Health and Neonatology, Liverpool Hospital, Locked Bag 7103, Liverpool BC 1871, NSW, Australia
s u m m a r y
a r t i c l e i n f o
Article history:
Accepted 30 August 2011
Available online xxxx
Keywords:
Nursing
Documentation
Writing coach
Quality improvement
Ward-based education
A 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 con-
dition, 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.
© 2011 Elsevier Ltd. All rights reserved.
Introduction
Nursing documentation is important because it maintains a perma-
nent record of the patient's condition, care and response to care. This
record can be accessed by nurses, other health professionals, patients
and their carers (Gebru et al., 2007). However, many nurses regard
documentation as an aspect of care that is challenging (Martin et al.,
1999) and burdensome (Staunton and Chiarella, 2008). Nurses need to
address this issue because communication breakdown has been
identified by the Joint Commission on the Accreditation of Healthcare
Organizations in the US as the cause of 65% of sentinel events (Haig et
al., 2006). In Australia, the Australian Commission on Safety and Quality
in Healthcare reports that communication problems contributed to 11%
of adverse outcomes during hospital admission (Australian Commission
on Safety and Quality in Health Care, 2008). Research by Tran and Johnson
(2010) identified that 13% of clinical management errors in nursing were
related to documentation errors (Tran and Johnson, 2010).
Nursing documentation records all patient information pertaining to
nursing and is the major reference regarding the nurse's care of the
patient from a legal perspective (Allen, 1998; De Marinis et al., 2010;
Frank-Stromborg et al., 2001b; Jacobsen and Juste, 2010). This paper de-
scribes and innovative approach to improving nursing documentation
using a writing coach strategy.
What Is Ward-based Writing Coaching?
Coaching has been described in the literature as a process that builds
on prior knowledge and skills (Waddell and Dunn, 2005). This is
achieved by establishing a rapport, forming a trusting relationship,
sharing a mutual desire to learn and incorporate new knowledge and
skills into practice. The success of the process can be gauged by feedback
(Waddell and Dunn, 2005). It is a technique that mentors, rather than
manages, staff (Baldwin and Chandler, 2002). It is a technique that
actively encourages the learner to acquire a new skill through a combi-
nation of experience and reflection (Fowler, 2008). It is often used in
academic settings to improve the writing skills of new academics and
postgraduate students. One study found that there was an increase in
publications, an improvement in collegial relationships and team build-
ing after a period of intense coaching at a writing retreat for students
and academics (Jackson, 2009). Writing coaching is also used in clinical
settings to develop clinicians' skills when writing presentations, articles
and professional portfolios (Lannon, 2007).The success of these other
projects makes it likely that a ward-based writing coach would be
successful in producing improvement in nursing documentation.
Quality Nursing Documentation
The focus of this education program was to improve the nursing
notes within the patient healthcare record. A systematic review of
studies relating to nursing documentation had previously been
undertaken by the researchers resulting in the development of
Nurse Education Today xxx (2011) xxx–xxx
⁎ Corresponding author. Tel.: +61 2 96859304; fax-+61 2 96859023.
E-mail address: d.jefferies@uws.edu.au (D. Jefferies).
YNEDT-02088; No of Pages 5
0260-6917/$ – see front matter © 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2011.08.017
Contents lists available at SciVerse ScienceDirect
Nurse Education Today
journal homepage: www.elsevier.com/nedt
Please cite this article as: Jefferies, D., et al., A ward-based writing coach program to improve the quality of
nursing documentation, Nurse Educ. Today (2011), doi:10.1016/j.nedt.2011.08.017

2. seven principles of quality nursing documentation (Jefferies et al.,
2010) which ultimately became the local health service policy.
These principles as presented in Table 1. These principles formed
part of the content of the education program.
Following the policy development process, the authors examined
examples of nursing documentation. This examination demonstrated
that problems existed which related to sentence structure, grammar,
and logical presentation of material within the nursing notes. Nurses
were writing in a style of language that could be described as frag-
mented and were using abbreviations extensively throughout their
documentation, (Brous, 2009; Campos, 2009; Griffith, 2004; Jefferies
et al., in press). Although some abbreviations were found on official
abbreviations lists that were developed by each hospital, many
other abbreviations were not and could be open to multiple interpre-
tations making the nurse's documentation ambiguous (Kuhn, 2007).
The use of fragmentary language and unofficial abbreviations made
reading nursing documentation difficult for both nurses and others
outside the profession. One example reported in the literature was
that nurses from Non English Speaking Backgrounds (NESB) found
the use of abbreviations and other examples of fragmented language
made nursing documentation difficult to understand (Deegan and
Simkin, 2010). If other nurses could not understand nursing docu-
mentation, it was unlikely that readers outside the profession would
understand what patient information the nurse was attempting to
communicate. Furthermore, nursing documentation could be judged
as not worth reading (Lawler, 2007). Aspects such as the use of frag-
mentary language and inappropriate use of abbreviations also formed
the content of the education program.
How nurses learn documentation practices could influence the style
of their writing. Anthony Paré makes the point when commenting on
writing education for social workers that values and beliefs about docu-
mentation are passed from generation to generation without a critical
examination of reporting practices (Pare, 2005). It follows that nurses
also learn documentation practices by tradition and these practices are
not given the critical scrutiny that is required for a process of continuous
improvement. As Pare explains, this process of learning documentation
by tradition means that practices that make nursing documentation
difficult for many to understand are simply seen as the ‘way things are
done’ because they have taken on an air of normalcy by the nurse com-
pleting the documentation (Pare, 2005).
With the work of Pare in mind, the authors developed Ward-based
Writing Coach Program. Its aim was to encourage the development of
a sense of critical scrutiny by nurses so that they considered how their
nursing documentation could be improved. This would be achieved by
asking nurses to consider how their audience would react to what
was written in nursing documentation. Campos defines the audience
as being: the nurse documenting their patient's condition and care;
other nurses; other healthcare professionals; the patient, their family
or carers; lawyers and experts when a lawsuit occurs; a judge or magis-
trate; and non-medical and non-legal members of the jury (Campos,
2009). Nurses were asked to critically reflect on current documentation
practices so that they could develop strategies to improve the readabil-
ity of their documentation and make it relevant to all members of the
healthcare team and other potential readers of nursing documentation.
Approach
The program was developed by the authors and was conducted in
two parts: two didactic information sessions followed by one-to-one
coaching of nursing staff over a two-week period. First, nurses on two
busy medical surgical wards in a major metropolitan hospital in Sydney
Australia were asked to attend two one-hour writing workshops; and
second, nurses, who attended the workshops, received one-to-one
writing coaching as they wrote their nursing documentation during
their shift on the ward (See Table 2). The objective of the didactic infor-
mation sessions was to promote an understanding of the purpose of
nursing documentation and how current documentation practices
could impede understanding of readers outside the profession. Once
this is completed, the education program focused on developing strate-
gies to improve the quality of nursing documentation. The coaching
provided an opportunity for nurses to incorporate what was learned
in the didactic sessions into their documentation under the guidance
of the writing coach.
The Attributes of the Writing Coach
The following qualities would enhance the role of the writing coach
in the ward setting. The writing coach should be an experienced regis-
tered nurse who has an interest in nursing documentation. As this is a
program that is designed to fit into the ward routine, the writing
coach should be flexible enough to conduct the didactic sessions as a
part of the ward education program and to organise writing coaching
around the times when nurses are generally completing their docu-
mentation. The writing coach should be willing to work collaboratively
with nurses to improve documentation. Although the writing coaching
helps the nurse improve their documentation, it is the nurse who
knows their patients and who understands the clinical setting. Clinical
nurse educators may be most suitable for this role.
The Workshops
Two didactic workshops were developed by researchers to be pre-
sented to nurses in any clinical setting during their work time. The
duration of each workshop was one hour so that it would easily fit
into the usual education programs conducted at ward level.
The first workshop has three focal points to encourage nurses to
develop skills to scrutinise their nursing documentation. First, the
workshop emphasises how documentation can present a picture of
the patient from admission to discharge that is sensitive enough to
allow all members of the healthcare team to detect changes in the
patient's condition and to be able to plan care accordingly (Johnson
et al., 2010). Asking nurses to consider nursing documentation from
the perspective of being a communication tool that kept all members
of the healthcare team informed about relevant information for the
patient could, potentially, reframe the nurses' concept of nursing doc-
umentation as an important aspect of nursing care.
Second, the likely audience of nursing documentation is discussed
so that nurses could understand the importance of writing in a man-
ner that is meaningful to anyone reading their documentation. Nurses
are asked to consider whether current practices using fragmentary
language or abbreviations that may or may not be found on official
abbreviation lists hampers the ability of readers to understand the pa-
tient information being reported by the nurse. Examples of actual
nursing documentation containing abbreviations and fragments of
language are presented for discussion. One example used is the
following:
Table 1
Principles of quality nursing documentation.
Principle 1 Nursing documentation should be patient centred
Principle 2 Nursing documentation must contain the actual work of nurses
including education and psychosocial support
Principle 3 Nursing documentation is written to reflect the objective clinical
judgment of the nurse
Principle 4 Nursing documentation must be presented in a logical and
sequential manner
Principle 5 Nursing documentation should be written contemporaneously, or as
events occur
Principle 6 Nursing documentation should record variances in care within and
beyond the health care record
Principle 7 Nursing documentation should fulfil legal requirements
2 D. Jefferies et al. / Nurse Education Today xxx (2011) xxx–xxx
Please cite this article as: Jefferies, D., et al., A ward-based writing coach program to improve the quality of
nursing documentation, Nurse Educ. Today (2011), doi:10.1016/j.nedt.2011.08.017

3. 14/06/2009 0615 Nursing: Pt. slept well o/night. Afebrile. Sa 02
95% on RA. BSL 4.1 mmol/l this am. Pt given OJ as felt dizzy. Better
after OJ. Returned to sleep. (Name/designation/signature)
An analysis of the language used in this example highlights two
important aspects about current practices in nursing documentation:
first nurses are not using correct sentence structure, and second the
use of abbreviations can lead to ambiguity, especially if the abbrevia-
tions are not found on official abbreviation lists.
The first point leads to a discussion about correct sentence struc-
ture and nurses are reminded that to ensure meaning most sentences
should have a subject, verb and object. The second point is elaborated
by discussing how the abbreviation ‘RA’ in the example can have sev-
eral meanings including room air, right arm and rheumatoid arthritis.
The example is rewritten using correct sentence structure and abbre-
viations from the official abbreviation list:
14/06/2009 0615 Nursing: The patient slept well overnight. He is
afebrile, Sa O2 at 95% on room air and his BSL is 4.4 mmol/l this
am. The patient complained of feeling dizzy and was given orange
juice. He said he felt much better and returned to sleep. (Name/
designation/signature)
The nurses are asked to consider which example is easier to read.
Third, a strategy presenting a more comprehensive picture of the
patient's condition, care and response to care is discussed. Nurses are
encouraged to document in a more systematic manner by assessing
the patient's condition and, if required, recording any intervention
undertaken by the nurse, and the outcome of that intervention. An
example is given to demonstrate how a nurse might use this system
of documentation:
The patient (or Mr …) complained of pain in the left side of his chest
radiating into his jaw and down his left arm. Glyceral trinitrate was
administered sublingually as per the order on the medication chart.
Mr Jones said that he was no longer experiencing chest pain.
This example presents the assessment (the patient has pain), the
intervention (the administration of medication), and the outcome
(the patient is pain free). Although this example only cites one inci-
dent in a patient's admission, nurses were asked to consider how
writing nursing documentation in this particular manner would cre-
ate a more complete picture of the patient's condition, care and re-
sponse to care.
The second workshop places its emphasis on the seven principles
of nursing documentation that we developed in the metasynthesis of
nursing documentation literature (Jefferies et al., 2010).
Each principle is presented to the nurses with an explanation of
how it can be incorporated into current documentation practices.
The first three principles focus on developing a documentation style
that creates a more complete picture of the patient by including the
patient's viewpoint and ensuring that the nursing contribution to pat-
ent care is included in an objective manner. The first principle asks
nurses to make the patient the central focus of their documentation
and suggests that one strategy to achieve this could be to include
any comment made by the patient about their condition, care or
Table 2
Content and participants of ward-based writing coach program.
Activity Duration of activity Number of participants Content of activity
Workshop
1
1 hour and designed to fit into ward education program 16 nurses currently on duty
on the intervention wards
A didactic session covering the following topics:
1. What is the purpose of nursing documentation? To present a
picture of the patient from admission to discharge that is sensitive
enough so that all members of the healthcare team can plan care;
2. To discuss the potential audience that could read nursing
documentation (this includes other nurses, other healthcare
professionals, patients and their carers and members of the legal
profession);
3. How using correct sentence structure and only official
abbreviations make nursing documentation much easier to read by
ensuring that all sentences have a subject, verb and an object;
4. The presentation of a problem solving approach to nursing
documentation that presents a more complete picture of the
patient's condition, care, and response to care-assessment, nursing
intervention and outcome.
Workshop
2
1 hour and designed to fit into ward education program 16 nurses currently on duty
on the intervention wards
A didactic session explaining how the 7 guiding principles of
nursing documentation developed by the authors can be
incorporated into documentation practices. Each principle is
presented with an example of how it is used in nursing
documentation. These could include actual examples of nursing
documentation that demonstrate how the principle is used or not
used in the health care record.
Coaching A Ward-based Writing Coach is available to nurses who have
attended the workshops for a 2 week period as these nurses
complete their nursing documentation.
8 nurses received coaching
on a 1:1 basis during the
2 week trial period.
When a nurse has agreed to participate in a writing coaching
session, the following steps are undertaken:
1. The writing coach asks the nurse to select the records of 2 patients
currently under their care;
2. The coach asks the nurse to discuss each patient's diagnosis, their
current care plan, and current issues;
Each coaching session is approximately 20 minutes in
duration.
3. There is a further discussion about what is happening with the
patient at the current time (current observations, comments the
patient has made about their condition, nursing interventions that
have occurred during the shift and the outcome of that
intervention);
4. The nurse and the writing coach document the patient's
condition, care and response to care ensuring that abbreviations
from the official list and full sentences are used;
5. The writing coach asks the nurse for feedback about the
documentation and the coaching session.
3
D. Jefferies et al. / Nurse Education Today xxx (2011) xxx–xxx
Please cite this article as: Jefferies, D., et al., A ward-based writing coach program to improve the quality of
nursing documentation, Nurse Educ. Today (2011), doi:10.1016/j.nedt.2011.08.017

4. response to care. In essence the nurse is asked to write their docu-
mentation from the patient's, rather than the nurses, viewpoint.
The second principle asks nurses to record the actual work of the
nurses. This principle asks nurses to record their own significant con-
tribution to patient care, which the literature tells us is often missing
in the healthcare record. It also provides a point of reference for other
healthcare professionals when they are consulted. The third principle
asks nurses to write objectively and avoid using language that makes
the reader question whether the nurse is making an objective state-
ment. A simple way to explain this notion to nurses is to ask them
not to use words such as ‘appears’ and ‘seems’ when describing
their patient's condition. Again nurses can be reminded that this can
also be avoided if they record what the patient says about any prob-
lem they experience.
The next three principles focus on the content of nursing documen-
tation. Reiterating that nurses will produce a more comprehensive
picture of the patient if they write in a logical and sequential manner,
the fourth principle asks nurses to record the patient's condition, care
and response to care in a systematic manner. We suggest that one
system is documentation via a problem solving approach, such as
discussed above: assessment, intervention and outcome. To ensure
that information is as accurate as possible, the fifth principle asks nurses
to document any incidents, unusual events, as soon as possible after the
event has occurred. If the nurse does not document these events until
the end of the shift, the report of the incident may not be accurate as
recall of these events is not as sharp. The sixth principle asks that nurses
do not fill up nursing documentation with observations or other indica-
tors of a patient's condition that fall in the normal range and are
recorded in other areas of the healthcare record. If nursing documenta-
tion is to be sensitive enough to allow all healthcare professionals to
detect changes in the patient's condition, care and response to care,
only observations or indicators of the patient's condition that present
a change should be recorded in the nursing documentation (Frank-
Stromborg et al., 2001a). The final principle asks nurses to document
according to legal requirements. Of course, legal requirements differ
from country to country and any discussion in a writing coach program
must conform to local needs.
Each principle is illustrated with examples of nursing documenta-
tion and the nurses attending are given opportunities to clarify a
point by asking questions. The workshop closes with an explanation
of the role of the writing coach.
The Process of Writing Coaching in the Clinical Setting
Once the workshops have been completed, the writing coach can
begin the ward-based coaching sessions with nurses who have
attended the workshops. The coaching occurs on a one-to-one basis
on the ward as the nurse completes the nursing documentation. In
order to ensure that the coaching does not disrupt the ward routine,
the coach conducts sessions at times when nurses write major parts
their documentation. Nurses are reminded that events occurring out-
side the period of coaching must be recorded in the nursing docu-
mentation as well.
When the nurse agrees to be coached, the writing coach asks the
nurse to select the healthcare record of two current patients they
are caring for. One is a patient whose condition is stable and whose
care is unchanged, the other is a patient whose condition has changed
and requires changes to their documented care plan. The coach asks
the nurse to discuss each patient focusing on the following topics, di-
agnosis, their care plan, and current issues. Another discussion nar-
rows the focus to what is happening to the patient at the time of
writing. This includes current observations of the patient's condition,
including any relevant comments made by the patient, any nursing
interventions carried out on the current shift; and the outcome of
nursing interventions. Once this discussion is completed the coach
and the nurse document the patient's condition, care and response
to care together ensuring that it is written in full sentences and that
only abbreviations found on the official abbreviation lists are used.
The coach then asks the nurse if the documentation written during
the coaching session is different from the documentation normally
written by the nurse. When the nurse has completed the documenta-
tion on both patients, the writing coach asks the nurse if they have
any comments or questions arising from the session. Another coach-
ing session can be arranged as necessary.
Evaluation of the Writing Coach Program
The effectiveness of the writing coach program can be assessed by
a pre and post program documentation audit. We recommend that
the Nursing and Midwifery Documentation Content Audit Tool
(NMCAT) be used (Johnson et al., 2010). The NMCAT is a designed
audit tool that has 16 criteria relating to the seven principles of qual-
ity documentation and nine criteria relating to the legal requirements
of nursing documentation. Using a time sampling approach, 24-hour
segments of the admission can be audited as necessary. Each audit
takes approximately ten minutes. We suggest that for quality control
purposes, a 24-hour segment of every tenth record is transcribed ver-
batim and all references that could identify any person removed.
These transcripts can be used to evaluate factors such as the use of
fragmentary language or abbreviations and the focus of content.
They can also be used to demonstrate areas for improvement. The
NMCAT does not prescribe a specific system of nursing documenta-
tion but measures whether or not the documentation includes infor-
mation about the assessment of the patient's condition, any
interventions undertaken by the nurse, and the patient's response
to the intervention. This is a tool that can be used to evaluate nursing
documentation in any clinical setting.
This paper has reported an innovative education program
designed to produce a quality improvement in nursing documenta-
tion at the ward level. This is a program that can be conducted on
the ward during the working day with minimal disruption to the
ward routine. The didactic component can easily be slotted into the
regular ward education program. The goal of the program is to give
nurses skills to critically examine their own documentation styles
and strategies to improve their clinical reporting. These skills include
documenting the patient's condition, care, and response to care in a
systematic manner using the three steps of assessment, intervention,
and response. Nurses also ensure that documentation can be read by
all readers though the use of correct sentence structures and employ-
ing abbreviations only found on official abbreviation lists. Emphasis is
placed on nursing documentation containing a complete picture of
the patient's admission that is sensitive enough to enable all health-
care professionals to detect changes in the patient's condition and
care requirements.
Good communication systems are an essential component of patient
safety because they keep all members of the healthcare team informed
about the patient. However to ensure that nursing documentation can
fulfil this function, it must be written so that it is meaningful to a
wide-ranging audience. This innovative education program based on
giving nurses the skills to view their documentation in a critical light
is intended to provide nurses with the skills required to improve their
documentation. The approach may be a new role for the ward-based
clinical nurse educator.
Conflict of Interest
All authors declare that there is no conflict of interest.
Contributors
Study conception and design: MJ, DN, DJ.
Manuscript preparation: DJ, MJ, DN, SL.
4 D. Jefferies et al. / Nurse Education Today xxx (2011) xxx–xxx
Please cite this article as: Jefferies, D., et al., A ward-based writing coach program to improve the quality of
nursing documentation, Nurse Educ. Today (2011), doi:10.1016/j.nedt.2011.08.017

5. Critical revisions for important intellectual content: MJ, DN, DJ, SL.
Supervision: MJ, DN.
Funding Statement
This project was made possible by a grant from the Nursing and
Midwifery Office, NSW Department of Health, Sydney, Australia.
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Please cite this article as: Jefferies, D., et al., A ward-based writing coach program to improve the quality of
nursing documentation, Nurse Educ. Today (2011), doi:10.1016/j.nedt.2011.08.017