Is this phrase, written almost as a reflex, okay or not?

It's almost 4:00 p.m. Your shift is ending.

In front of the screen, you hesitate: am I sufficiently protected if I don’t add anything else?

This is often where we write “No complaints filed”, “We are monitoring the situation”, “Under control”. A short phrase, or reassuring expression, that we almost use reflexively.

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.

THE PROBLEM

The problem is that this sentence does not demonstrate anything about our assessment. For a stable and unspecific user, we do not know what is being discussed. For an unstable user, or at risk of complications, it does not say what we have actually checked.

WOE OF WHAT

Do we want to talk about symptoms, discomforts, pain, mental state, etc.?.

One Simple reformulation that changes everything :

• «No new symptoms» — same wording, but this formulation demonstrates that an evaluation did indeed take place, and that its results were recorded.
• ”Pain well controlled with current interventions” – for a patient suffering in a situation where the last hours are to be summarized.

It’s not a question of writing more.

It is a matter of naming what we have really evaluated.

Unfortunately, I will not be able to overcome the lack of time or the complexity of the situations we face on the ground; that is part of our reality.

But if this little example can help you ease even a little bit this task of writing notes, I would have achieved my goal.

A situation that makes you hesitate in your own notes? Write to me at mireille.guillemette@mireformations.com — your questions often inspire my upcoming content.

Mireille Guillemette, RN, B.Ed.

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