Guide de rédaction - Notes d'é

The Writing Guide - Progress Notes, published by the Quebec Order of Nurses, is intended for licensed practical nurses who write progress notes every day on the medical file. The nursing assistant has an important role in the care team, and her contribution to the assessment of the person's health makes the note that she writes even more important. The notes reflect the quality of care provided. A progress note must be well written so that the medical file is as consistent as possible with the best practices. A well-written note is also a guarantee of efficiency and reduces the time spent on the episode of care.

 

This guide presents the general obligations and elements that govern the writing of the note. First and foremost, it is written in such a way as to facilitate the quick identification, thanks to a color code, of the key elements to be found in a progress note on the file. For detailed documentation, refer to the books listed at the end of this guide, in particular The OIIAQ Glossary, a tool and an aide-memoire essential in the use of the appropriate terminology of the writing of notes.