Nursing documentation : how meaning is obscured by fragmentary language

This article looks at the effect of using fragmentary language in nursing documentation. Fragmentary language is defined as phrases and abbreviations found in records of nursing care that are understood at the local ward level but would make it difficult for anyone reading the documentation beyond this local level to construct meaning. Sixty-seven entries of nursing documentation were investigated using textual analysis. Each entry was examined to determine how grammatical and linguistic features of the text could impede meaning. Three entries are discussed in detail to demonstrate possible difficulty for readers in understanding the patient’s condition and care. Education programs that encourage nurses to view their documentation as a crucial aspect of care are recommended. Writing nursing documentation in a manner that allows readers from both within and outside the profession to understand the patient’s condition and care required is supported. If readers cannot understand what is written in nursing documentation, there is a danger that misinterpretations could lead to clinical errors and adverse events.