WRITE LESS TO COMMUNICATE MORE INFORMATION

The world of healthcare is constantly changing. Tasks have changed, demand for care is on the rise, and staffing shortages are the order of the day. To write less and say more, while respecting current professional standards, is the importance of a new medical record writing guide that takes into account the evolution of the profession and the importance of health assessment in medical record writing. This new guide will provide all healthcare professionals, and more specifically graduate nurses and nurses in training, with quick shortcuts for adapting their note-writing to current standards.

The nurse's job has evolved considerably in recent years, and her responsibility for assessing the patient's state of health is now an activity that is reserved for her. The justification for all clinical decisions must be found in the notes.

These major changes in the role and scope of practice of caregivers, combined with the various laws recently passed on the administrative reorganization of care, have had a major impact on most tasks, including that of writing the note to the file. The advent of new technologies and interdisciplinarity have made it necessary to write notes that are more concise, relevant and understood by all members of the care team.

The note in the file is written proof of the nurse's professional activities. It must reflect this appropriation of the full exercise of her field of practice.265 PAGES

10 CHAPTERS

1. A note in the file: an obligation
2. What needs to be recorded
3. Elements of a quality score
4. General editorial guidelines
5. Initial and ongoing assessment
6. Note a special condition
7. Rate a treatment
8. Stages of the care episode
9. Follow-up by healthcare sector
10. Writing methods

11 APPENDICES: abbreviations, vocabulary, anatomical landmarks, head to toe, lexicon for assessing mental condition

Over 60 practical EXERCISES. At the end of each chapter, a variety of exercises and scenarios.