CHARTING WITH CLARITY, A Documentation Guide For Nurses and Health Professionals

Working in the healthcare sector is under constant pressure. The nursing profession, already burdened by the complexity of care, comorbidities, and an aging population, has undergone numerous transformations in recent years. Recruitment challenges have added to the workload. There are more patients, shorter hospital stays, and consequently, more notes to write—notes that must be thoroughly documented and often written more quickly to keep up with demands.
In addition to these new realities, there have been significant changes in the roles and scope of practice of healthcare professionals. Recent legislation on the administrative reorganization of care and the advent of new technologies have had a major impact on many tasks, including the writing of medical notes. Over time, through meetings, visits to healthcare settings in Canada, Switzerland, and Australia, and research, I quickly realized that the need for a documentation guide was shared by nurses everywhere. We all face similar challenges.

The laws and regulations are similar.

This second edition is therefore tailored to the members of the OIIQ (Québec Nurses Association) but could also be adapted for international use.
The quality of the daily work of health professionals is not always reflected in the reading of progress[…] »

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