You open a patient's file.

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

And the information you are really looking for? It is somewhere in there, drowned out in the rest.

If this scene resonates with you, you are not alone. It’s a reality experienced by the vast majority of nurses and licensed practical nurses, regardless of the care setting.

How did we end up like this
Between paper files and digital folders, we often get the impression that «good documentation» means «writing more.» But a memo that is too long becomes difficult to reread, and it dilutes the main points rather than highlighting them—which wastes precious time for the colleague on the next shift, or for yourself later on.

What the standard actually expects

The OIIQ documentation standard does not require writing a lot: it requires documenting what is relevant, precise, and representative of our clinical judgment. A note can be short, in a telegraphic style, and perfectly compliant, as long as it reflects our assessment, the interventions performed, 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 tell no one what was actually observed

Prevention and interventions are primarily non-pharmacological

Intervention: Prioritize non-pharmacological approaches

Unfortunately, I won't fix the lack of time or the complexity of the situations we experience in the field—that's just part of our reality. But if this kind of little reminder can lighten, even a little, the heavy task that is writing our notes, I will 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.
 

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