You are looking for key information \u2014 an assessment, a change of status, a justification for care. And the information you are really looking for? It is somewhere in there, drowned out in the rest.<\/p>\n <\/p>\n How did we end up like this What the standard actually expects<\/p>\n 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.<\/p>\n <\/p>\n <\/p>\n Intervention: Prioritize non-pharmacological approaches<\/strong><\/p>\n Unfortunately, I won't fix the lack of time or the complexity of the situations we experience in the field\u2014that'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.<\/p>\n
\n<\/strong> And then it starts: you scroll through lines and lines of text.
\n<\/strong> Details that do not contribute to clinical understanding.<\/strong><\/p>\nIf this scene resonates with you, you are not alone. It\u2019s a reality experienced by the vast majority of nurses and licensed practical nurses, regardless of the care setting.<\/h3>\n
\nBetween paper files and digital folders, we often get the impression that \u00abgood documentation\u00bb means \u00abwriting more.\u00bb But a memo that is too long becomes difficult to reread, and it dilutes the main points rather than highlighting them\u2014which wastes precious time for the colleague on the next shift, or for yourself later on.<\/p>\n\n<\/ul>\n
Three traps to watch out for<\/h3>\n
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Prevention and interventions are primarily non-pharmacological<\/h3>\n