In the healthcare sector, communication between professionals is essential for effective patient care. A term often used by nurses in Switzerland, France and Quebec is "clinical impression ofA clinical impression is an evaluation based on observations, clinical experience and professional judgment. But does this clinical impression constitute a medical diagnosis?
When a nurse assesses a patient, she relies on a combination of signs, symptoms and her expertise to formulate a clinical impression. For example, if a patient presents with a fever, cough and breathing difficulties, the nurse can make a note in his or her therapeutic nursing plan (TNP) or in its development notes :
This notation means that the nurse suspects pneumonia on the basis of her assessment, but does not make a medical diagnosis in the strict sense of the term. Medical diagnosis remains the responsibility of the physician, who will confirm or refute this hypothesis with the help of clinical examinations and medical imaging.
The use of this term allows nurses to :
✔️ Effectively communicate their observations to other members of the medical team.
✔️ Contribute to a informed decision-making.
✔️ Offering quality care guiding the actions of the care team.
In nursing practice, a nursing assistant might simply write :
This difference underlines the importance of level of expertise and the role of each professional in interpreting clinical signs.
As the Guide to writing medical record notesthe formulation of nursing observations must be rigorous, objective and consistent with current standards. A well-written note facilitates continuity of care and understanding of the patient's condition by the entire care team.
Nurses therefore play a key role in assessing patients and passing on information to doctors, while respecting their own scope of practice. L'clinical impression is a powerful tool for guiding medical decisions while respecting the legal framework of the healthcare professions.
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