[Analysis of observations entered on medical charts by health care personnel. Activity by the psychiatric team of Mons].
In a service of unselected patients according to diagnosis, prognosis or behaviour, with a large high quality personnel, a daily chart was started where everybody could write notes on patients. There was no imposed or controlled schema. Observations were dropping with time, the critical point being on week 4th. Furthermore, the content of the observations showed that simple descriptions of behaviour were five times more frequent than interpretations. Behavioural descriptions were often precise and understandable for an outsider: three times more descriptive behaviours with precision than vague behaviours. Interpretations, however, looked vague. Difficulties in understanding words and vocabulary were important. To be understood and avoid losing time in self-interpretation, to distinguish truth from false, it was essential to stick to simple expressions, common, but precise.
D001530:Belgium; D006801:Humans; D008499:Medical Records; D010348:Patient Care Team; D011567:Psychiatric Department, Hospital; D012919:Social Behavior; D014956:Writing
Analyse des observations apportées au dossier par le personnel soignant. Travail de l'équipe psychiatrique de Mons.