The medical record is not just a daily report of professional activities.  Above all, it is a legal obligation and must comply with strict standards.  Writing medical record notes is a demanding daily challenge in a context of ever-increasing pressure on healthcare environments.  The importance of acquiring simple writing methods and rules is essential to facilitate and speed up medical record entries.  Once seen as a simple report of daily activities,  Today, medical record keeping is an activity report that reflects the scope of practice reserved for the various healthcare professionals involved in an episode of care. 

Interdisciplinarity requires writing that not only conforms to fields of practice, but is also consistent across the care team.   Hence,  the importance of these rules of writing and all the memory aids developed over the years.   Writing is not as easy a task as it might seem, so we need to develop a precise vocabulary and rigor to enable us to write less and say more about patients' health.  You don't just have to write well, you also have to be  relevant, concise, clear and in compliance with all legal requirements for an unadulterated file with the author's signature and professional title.

The nurse's assessment of the patient's state of health and the contribution now recognized to the nursing assistant must also be reflected in the medical record.  It's a major change in nursing practice that can't always be read in the chart notes.   The note is the trace of this important role played by the health professional, who guides all the interventions of the care team.

Good training!

Mireille Guillemette