You open a patient’s file.

You are looking for key information — an evaluation, a change of status, a justification for care.
And here it begins: you scroll through lines and lines of text.
Details that do not contribute anything to clinical understanding.

And the information you’re really looking for? It’s somewhere in there, buried among the rest.

If this scene speaks to you, you are not alone. It is a reality experienced by the vast majority of nurses and nursing assistants, regardless of the healthcare setting.

Why did we end up here?
Between paper files and digital files, it often seems that «documenting well» means «writing more.» But a note that’s too long becomes difficult to read, and it dilutes the essential rather than highlighting it — which wastes valuable time for the colleague next to you, or for yourself later on.

What the standard really expects

The OIIQ documentation standard does not require a lot of writing: it requires documenting what is relevant, precise, and representative of our clinical judgment. A note can be short, telegraphic in style, and perfectly consistent, as long as it reflects our evaluation, the interventions made, and the person’s response.

Three traps to watch out for

• Redundancy: repeating what is already recorded elsewhere in the file
• The narrative details that dilute the clinical evaluation itself
• Vague formulations that do not inform anyone about what was actually observed

Prevention and interventions are primarily non-pharmacological.

Intervention: prioritizing non-pharmacological approaches

Unfortunately, I will not solve the lack of time or the complexity of the situations we face on the ground — that is part of our reality. But if this small reminder can alleviate, even a little, this heavy task of writing our notes, I will have achieved my goal.

A situation that makes you hesitate in your own notes? Write me at mireille.guillemette@mireformations.com — your questions often inspire my future content.
Mireille Guillemette, B.Éd.
 

Click here: discover an example illustrated in a video (80 seconds).