{"id":12293,"date":"2025-04-20T14:38:41","date_gmt":"2025-04-20T14:38:41","guid":{"rendered":"https:\/\/langs.physio-pedia.com\/principles-of-documentation-fr\/"},"modified":"2025-04-21T13:49:02","modified_gmt":"2025-04-21T13:49:02","slug":"principles-of-documentation-fr","status":"publish","type":"page","link":"https:\/\/langs.physio-pedia.com\/fr\/principles-of-documentation-fr\/","title":{"rendered":"Principes de la tenue des dossiers"},"content":{"rendered":"<div class=\"mw-parser-output\">\n<div class=\"editorbox\">\n<p><b>R\u00e9dactrice originale<\/b>&#8211; <a title=\"User:Wanda van Niekerk\" href=\"\/User:Wanda_van_Niekerk\">Wanda van Niekerk<\/a> d&rsquo;apr\u00e8s le cours de <a class=\"external text\" href=\"https:\/\/members.physio-pedia.com\/instructor\/angela-cecil\/\/\" rel=\"nofollow\">Angela Cecil<\/a><br \/>\n<b>Principales collaboratrices<\/b> &#8211; <a class=\"mw-userlink\" title=\"User:Wanda van Niekerk\" href=\"\/User:Wanda_van_Niekerk\"><bdi>Wanda van Niekerk<\/bdi><\/a> et <a class=\"mw-userlink\" title=\"User:Jess Bell\" href=\"\/User:Jess_Bell\"><bdi>Jess Bell<\/bdi><\/a><\/p>\n<\/div>\n<div id=\"toc\" class=\"toc\" role=\"navigation\" aria-labelledby=\"mw-toc-heading\"><input id=\"toctogglecheckbox\" class=\"toctogglecheckbox\" style=\"display: none;\" role=\"button\" type=\"checkbox\"><\/p>\n<div class=\"toctitle\" dir=\"ltr\" lang=\"en\">\n<h2 id=\"mw-toc-heading\">Contenu<\/h2>\n<\/div>\n<ul>\n<li class=\"toclevel-1 tocsection-1\"><a href=\"#Introduction_to_Professional_Documentation\"><span class=\"tocnumber\">1<\/span> <span class=\"toctext\">Introduction \u00e0 la tenue des dossiers des professionnels<\/span><\/a><\/li>\n<li class=\"toclevel-1 tocsection-2\"><a href=\"#Principles_of_Documentation\"><span class=\"tocnumber\">2<\/span> <span class=\"toctext\">Principes de la tenue des dossiers<\/span><\/a>\n<ul>\n<li class=\"toclevel-2 tocsection-3\"><a href=\"#Context_of_Documentation\"><span class=\"tocnumber\">2.1<\/span> <span class=\"toctext\">Contexte de la tenue des dossiers<\/span><\/a><\/li>\n<li class=\"toclevel-2 tocsection-4\"><a href=\"#Characteristics_of_Effective_Documentation\"><span class=\"tocnumber\">2.2<\/span> <span class=\"toctext\">Caract\u00e9ristiques d&rsquo;une bonne tenue des dossiers<\/span><\/a><\/li>\n<li class=\"toclevel-2 tocsection-5\"><a href=\"#Common_Elements_of_Documentation\"><span class=\"tocnumber\">2.3<\/span> <span class=\"toctext\">\u00c9l\u00e9ments courants retrouv\u00e9s dans les dossiers <\/span><\/a>\n<ul>\n<li class=\"toclevel-3 tocsection-6\"><a href=\"#Patient_Situation_and_Background\"><span class=\"tocnumber\">2.3.1<\/span> <span class=\"toctext\">Situation et ant\u00e9c\u00e9dents du patient<\/span><\/a><\/li>\n<li class=\"toclevel-3 tocsection-7\"><a href=\"#Measurable_and_Observable_Data\"><span class=\"tocnumber\">2.3.2<\/span> <span class=\"toctext\">Donn\u00e9es mesurables et observables<\/span><\/a><\/li>\n<li class=\"toclevel-3 tocsection-8\"><a href=\"#Documentation_Frameworks\"><span class=\"tocnumber\">2.3.3<\/span> <span class=\"toctext\">Cadres de la tenue des dossiers<\/span><\/a><\/li>\n<\/ul>\n<\/li>\n<li class=\"toclevel-2 tocsection-9\"><a href=\"#Methods_of_Documentation\"><span class=\"tocnumber\">2.4<\/span> <span class=\"toctext\">M\u00e9thodes de tenue des dossiers<\/span><\/a><\/li>\n<\/ul>\n<\/li>\n<li class=\"toclevel-1 tocsection-10\"><a href=\"#References\"><span class=\"tocnumber\">3<\/span> <span class=\"toctext\">R\u00e9f\u00e9rences<\/span><\/a><\/li>\n<\/ul>\n<\/div>\n<h2><span id=\"Introduction_to_Professional_Documentation\" class=\"mw-headline\">Introduction \u00e0 la tenue des dossiers des professionnels <\/span><span class=\"mw-editsection\"><span class=\"mw-editsection-bracket\">(<\/span><a class=\"mw-editsection-visualeditor\" title=\"Edit section: Introduction to Professional Documentation\" href=\"\/index.php?title=Principles_of_Documentation&amp;veaction=edit&amp;section=1\">edit<\/a><span class=\"mw-editsection-divider\"> | <\/span><a title=\"Edit section: Introduction to Professional Documentation\" href=\"\/index.php?title=Principles_of_Documentation&amp;action=edit&amp;section=1\">edit source<\/a><span class=\"mw-editsection-bracket\">)<\/span><\/span><\/h2>\n<p>Une tenue des dossiers clinique pr\u00e9cise est essentielle, car elle joue un r\u00f4le crucial dans les soins aux patients, en facilitant la communication entre les diff\u00e9rents professionnels de la sant\u00e9 et en assurant un remboursement des co\u00fbts ad\u00e9quat. La ma\u00eetrise et le perfectionnement de la tenue des dossiers cliniques est indispensable pour tous les professionnels de la sant\u00e9.<sup id=\"cite_ref-:5_1-0\" class=\"reference\"><a href=\"#cite_note-:5-1\">(1)<\/a><\/sup><\/p>\n<h2><span id=\"Principles_of_Documentation\" class=\"mw-headline\">Principes de la tenue des dossiers <\/span><span class=\"mw-editsection\"><span class=\"mw-editsection-bracket\">(<\/span><a class=\"mw-editsection-visualeditor\" title=\"Edit section: Principles of Documentation\" href=\"\/index.php?title=Principles_of_Documentation&amp;veaction=edit&amp;section=2\">edit<\/a><span class=\"mw-editsection-divider\"> | <\/span><a title=\"Edit section: Principles of Documentation\" href=\"\/index.php?title=Principles_of_Documentation&amp;action=edit&amp;section=2\">edit source<\/a><span class=\"mw-editsection-bracket\">)<\/span><\/span><\/h2>\n<p>Les quatre principaux sujets \u00e0 aborder sont<sup id=\"cite_ref-:1_2-0\" class=\"reference\"><a href=\"#cite_note-:1-2\">(2)<\/a><\/sup> :<\/p>\n<ul>\n<li>le contexte de la tenue des dossiers<\/li>\n<li>les caract\u00e9ristiques d&rsquo;une bonne tenue des dossiers<\/li>\n<li>les \u00e9l\u00e9ments courants retrouv\u00e9s dans les dossiers<\/li>\n<li>les m\u00e9thodes de tenue des dossiers<\/li>\n<\/ul>\n<h3><span id=\"Context_of_Documentation\" class=\"mw-headline\">Contexte de la tenue des dossiers <\/span><span class=\"mw-editsection\"><span class=\"mw-editsection-bracket\">(<\/span><a class=\"mw-editsection-visualeditor\" title=\"Edit section: Context of Documentation\" href=\"\/index.php?title=Principles_of_Documentation&amp;veaction=edit&amp;section=3\">edit<\/a><span class=\"mw-editsection-divider\"> | <\/span><a title=\"Edit section: Context of Documentation\" href=\"\/index.php?title=Principles_of_Documentation&amp;action=edit&amp;section=3\">edit source<\/a><span class=\"mw-editsection-bracket\">)<\/span><\/span><\/h3>\n<p>Les facteurs contextuels li\u00e9s \u00e0 la tenue des dossiers comprennent :<\/p>\n<ul>\n<li>les diff\u00e9rents milieux cliniques (par exemple, soins aigus \u00e0 l&rsquo;h\u00f4pital, visite \u00e0 domicile ou consultation ambulatoire)<sup id=\"cite_ref-:0_3-0\" class=\"reference\"><a href=\"#cite_note-:0-3\">(3)<\/a><\/sup><\/li>\n<li>les facteurs externes, tels que les diff\u00e9rentes normes, proc\u00e9dures et influences Ces facteurs ne sont souvent pas contr\u00f4l\u00e9s par le professionnel de la r\u00e9adaptation<sup id=\"cite_ref-:0_3-1\" class=\"reference\"><a href=\"#cite_note-:0-3\">(3)<\/a><\/sup>.<\/li>\n<li>les strat\u00e9gies d&rsquo;\u00e9ducation pour la tenue des dossiers<sup id=\"cite_ref-:1_2-1\" class=\"reference\"><a href=\"#cite_note-:1-2\">(2)<\/a><\/sup> :\n<ul>\n<li><b>soins infirmiers<\/b> : il a \u00e9t\u00e9 constat\u00e9 que l&rsquo;\u00e9ducation seule peut favoriser la conformit\u00e9 pour am\u00e9liorer la tenue des dossiers chez les infirmi\u00e8res, mais des recherches suppl\u00e9mentaires sont n\u00e9cessaires pour d\u00e9terminer si cette am\u00e9lioration est significative<sup id=\"cite_ref-4\" class=\"reference\"><a href=\"#cite_note-4\">(4)<\/a><\/sup><\/li>\n<li><b>physioth\u00e9rapie<\/b> : un d\u00e9calage a \u00e9t\u00e9 observ\u00e9 entre les \u00e9tablissements universitaires et les milieux de stage clinique concernant la pr\u00e9paration et la formation des \u00e9tudiants \u00e0 la tenue des dossiers cliniques.\n<ul>\n<li>toutes les parties concern\u00e9es devraient trouver des moyens d&rsquo;aider les \u00e9tudiants \u00e0 comprendre l&rsquo;importance de la tenue des dossiers cliniques et \u00e0 travailler sur leurs comp\u00e9tences en la mati\u00e8re<sup id=\"cite_ref-:8_5-0\" class=\"reference\"><a href=\"#cite_note-:8-5\">(5)<\/a><\/sup><\/li>\n<li>il est recommand\u00e9 de proposer davantage d&rsquo;activit\u00e9s p\u00e9dagogiques li\u00e9es \u00e0 la tenue des dossiers dans les cours pr\u00e9c\u00e9dant les stages cliniques, et les milieux de stage clinique devraient formuler des attentes claires et sp\u00e9cifiques \u00e0 leur milieu \u00e0 l&rsquo;intention des \u00e9tudiants<sup id=\"cite_ref-:8_5-1\" class=\"reference\"><a href=\"#cite_note-:8-5\">(5)<\/a><\/sup><\/li>\n<\/ul>\n<\/li>\n<li>les proc\u00e9dures de tenue des dossiers peuvent constituer un outil d&rsquo;apprentissage pr\u00e9cieux pour la collaboration interprofessionnelle entre les \u00e9tudiants<sup id=\"cite_ref-:2_6-0\" class=\"reference\"><a href=\"#cite_note-:2-6\">(6)<\/a><\/sup><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>\u00c9l\u00e9ments \u00e0 prendre en compte<sup id=\"cite_ref-:1_2-2\" class=\"reference\"><a href=\"#cite_note-:1-2\">(2) <\/a><\/sup>:<\/p>\n<ul>\n<li>les lecteurs des dossiers :\n<ul>\n<li>les coll\u00e8gues (de la m\u00eame profession, mais aussi les autres membres de l&rsquo;\u00e9quipe multidisciplinaire)<\/li>\n<li>les organismes payeurs ou de financement des services, tels que les compagnies d&rsquo;assurance<\/li>\n<li>les v\u00e9rificateurs et auditeurs de l&rsquo;utilisation<\/li>\n<li>les \u00e9tudiants<sup id=\"cite_ref-:2_6-1\" class=\"reference\"><a href=\"#cite_note-:2-6\">(6)<\/a><\/sup><\/li>\n<li>les organismes d&rsquo;accr\u00e9ditation ou de r\u00e9glementation<\/li>\n<li>les chercheurs<\/li>\n<li>les patients et les clients<sup id=\"cite_ref-:3_7-0\" class=\"reference\"><a href=\"#cite_note-:3-7\">(7)<\/a><\/sup>\n<ul>\n<li>pour en savoir plus sur les r\u00e9percussions d&rsquo;OpenNotes (un mandat aux \u00c9tats-Unis, qui exige que la plupart des dossiers m\u00e9dicaux soient facilement accessibles aux patients en temps r\u00e9el) sur l&rsquo;\u00e9thique clinique, lire les articles suivants :\n<ul>\n<li><a class=\"external text\" href=\"https:\/\/www.journals.uchicago.edu\/doi\/10.1086\/JCE2022334303\" rel=\"nofollow\">An Open Discussion of the Impact of OpenNotes on Clinical Ethics: A Justification for Harm-Based Exclusions from Clinical Ethics Documentation<\/a><sup id=\"cite_ref-:3_7-1\" class=\"reference\"><a href=\"#cite_note-:3-7\">(7)<\/a><\/sup><\/li>\n<li><a class=\"external text\" href=\"https:\/\/bmcmedethics.biomedcentral.com\/articles\/10.1186\/s12910-023-00904-1\" rel=\"nofollow\">Clinical ethics consultation documentation in the era of open notes<\/a><sup id=\"cite_ref-8\" class=\"reference\"><a href=\"#cite_note-8\">(8)<\/a><\/sup><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li>soi-m\u00eame (la personne qui a r\u00e9dig\u00e9 le dossier)\n<ul>\n<li>garder \u00e0 l&rsquo;esprit que des facteurs personnels tels que l&rsquo;\u00e9tat d&rsquo;esprit, la fatigue, la culture et les ant\u00e9c\u00e9dents, les perspectives et les pratiques culturelles ont \u00e9galement une influence sur la tenue des dossiers<sup id=\"cite_ref-9\" class=\"reference\"><a href=\"#cite_note-9\">(9)<\/a><\/sup><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<li>le milieu de travail (o\u00f9 l&rsquo;on r\u00e9dige les dossiers)<\/li>\n<li>le temps qu&rsquo;il est possible d&rsquo;accorder \u00e0 la r\u00e9daction des dossiers<sup id=\"cite_ref-10\" class=\"reference\"><a href=\"#cite_note-10\">(10)<\/a><\/sup><\/li>\n<\/ul>\n<h3><span id=\"Characteristics_of_Effective_Documentation\" class=\"mw-headline\">Caract\u00e9ristiques d&rsquo;une bonne tenue des dossiers <\/span><span class=\"mw-editsection\"><span class=\"mw-editsection-bracket\">(<\/span><a class=\"mw-editsection-visualeditor\" title=\"Edit section: Characteristics of Effective Documentation\" href=\"\/index.php?title=Principles_of_Documentation&amp;veaction=edit&amp;section=4\">edit<\/a><span class=\"mw-editsection-divider\"> | <\/span><a title=\"Edit section: Characteristics of Effective Documentation\" href=\"\/index.php?title=Principles_of_Documentation&amp;action=edit&amp;section=4\">edit source<\/a><span class=\"mw-editsection-bracket\">)<\/span><\/span><\/h3>\n<p>Une tenue des dossiers est bonne lorsqu&rsquo;elle est :<\/p>\n<ul>\n<li>compl\u00e8te<\/li>\n<li>concise<\/li>\n<li>compr\u00e9hensible<\/li>\n<li>claire<\/li>\n<li>coh\u00e9rente<\/li>\n<\/ul>\n<p>Une tenue des dossiers incompl\u00e8te peut conduire \u00e0 un traitement sous-optimal, \u00e0 une diminution de la qualit\u00e9 des soins et \u00e0 des cons\u00e9quences n\u00e9gatives pour le patient.<sup id=\"cite_ref-11\" class=\"reference\"><a href=\"#cite_note-11\">(11)<\/a><\/sup><\/p>\n<div class=\"thumb embedvideo autoResize\" style=\"width: 308px;\">\n<div class=\"embedvideo autoResize\">\n<div class=\"embedvideowrap\" style=\"width: 300px;\"><iframe loading=\"lazy\" title=\"Play video\" src=\"\/\/www.youtube.com\/embed\/4PyPFE5yBUc?\" width=\"300\" height=\"169\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/div>\n<\/div>\n<\/div>\n<p><sup id=\"cite_ref-12\" class=\"reference\"><a href=\"#cite_note-12\">(12)<\/a><\/sup><\/p>\n<p>Une bonne tenue des dossiers comprend des \u00e9l\u00e9ments tels que<sup id=\"cite_ref-:1_2-3\" class=\"reference\"><a href=\"#cite_note-:1-2\">(2) <\/a><\/sup>:<\/p>\n<ul>\n<li>la date et le lieu de la session (date et heure)<\/li>\n<li>qui \u00e9taient pr\u00e9sents \u00e0 la r\u00e9union (avec signatures)<\/li>\n<li>ce qui s&rsquo;est pass\u00e9 pendant la session<\/li>\n<li>comment cela s&rsquo;est produit<\/li>\n<li>les r\u00e9sultats de la session<\/li>\n<li>la participation et la r\u00e9action du patient (et du proche aidant, le cas \u00e9ch\u00e9ant) durant la session<\/li>\n<li>l&rsquo;affection du patient<\/li>\n<li>le plan th\u00e9rapeutique<\/li>\n<li>le contexte de la rencontre<\/li>\n<li>informations g\u00e9n\u00e9rales de base &#8211; anamn\u00e8se (histoires sociale et chirurgicale), ant\u00e9c\u00e9dents m\u00e9dicaux, allergies, listes de m\u00e9dicaments, r\u00e9sultats de laboratoire et de radiologie<\/li>\n<\/ul>\n<p>La tenue des dossiers \u00e9thique et centr\u00e9e sur le patient se doit d&rsquo;\u00eatre <b>pr\u00e9cise <\/b> et <b>exacte<\/b>. Les principes \u00e9thiques \u00e0 respecter sont notamment ceux \u00e9num\u00e9r\u00e9s dans le <a class=\"external text\" href=\"https:\/\/cdn.who.int\/media\/docs\/default-source\/ethics\/code_of_ethics_abridged.pdf?sfvrsn=ef4e3c35_15&amp;download=true\" rel=\"nofollow\">Code of Ethics and Professional Conduct<\/a> (appel\u00e9 \u00ab\u00a0Code d&rsquo;\u00e9thique et de d\u00e9ontologie\u00a0\u00bb, en fran\u00e7ais) de l&rsquo;Organisation mondiale de la sant\u00e9 : <b>l&rsquo;int\u00e9grit\u00e9<\/b>, <b>la responsabilit\u00e9<\/b>, <b>l&rsquo;ind\u00e9pendance et l&rsquo;impartialit\u00e9<\/b>, <b>le respect<\/b> et <b>l&rsquo;engagement professionnel<\/b><sup id=\"cite_ref-13\" class=\"reference\"><a href=\"#cite_note-13\">(13)<\/a><\/sup>.<\/p>\n<h3><span id=\"Common_Elements_of_Documentation\" class=\"mw-headline\">\u00c9l\u00e9ments courants retrouv\u00e9s dans les dossiers <\/span><span class=\"mw-editsection\"><span class=\"mw-editsection-bracket\">(<\/span><a class=\"mw-editsection-visualeditor\" title=\"Edit section: Common Elements of Documentation\" href=\"\/index.php?title=Principles_of_Documentation&amp;veaction=edit&amp;section=5\">edit<\/a><span class=\"mw-editsection-divider\"> | <\/span><a title=\"Edit section: Common Elements of Documentation\" href=\"\/index.php?title=Principles_of_Documentation&amp;action=edit&amp;section=5\">edit source<\/a><span class=\"mw-editsection-bracket\">)<\/span><\/span><\/h3>\n<ul>\n<li>Informations sur la situation actuelle et les ant\u00e9c\u00e9dents du patient<sup id=\"cite_ref-:4_14-0\" class=\"reference\"><a href=\"#cite_note-:4-14\">(14)<\/a><\/sup><\/li>\n<li>Donn\u00e9es fournies par le patient<sup id=\"cite_ref-:4_14-1\" class=\"reference\"><a href=\"#cite_note-:4-14\">(14)<\/a><\/sup><\/li>\n<li>Donn\u00e9es mesurables et observables obtenues lors de la rencontre avec le patient<sup id=\"cite_ref-:4_14-2\" class=\"reference\"><a href=\"#cite_note-:4-14\">(14)<\/a><\/sup><\/li>\n<li>\u00c9valuation professionnelle des r\u00e9sultats<sup id=\"cite_ref-:4_14-3\" class=\"reference\"><a href=\"#cite_note-:4-14\">(14)<\/a><\/sup><\/li>\n<li>Plan th\u00e9rapeutique centr\u00e9 sur le patient<sup id=\"cite_ref-:4_14-4\" class=\"reference\"><a href=\"#cite_note-:4-14\">(14)<\/a><\/sup><\/li>\n<li>R\u00e9sultats des soins<sup id=\"cite_ref-:4_14-5\" class=\"reference\"><a href=\"#cite_note-:4-14\">(14)<\/a><\/sup><\/li>\n<\/ul>\n<h4><span id=\"Patient_Situation_and_Background\" class=\"mw-headline\">Situation et ant\u00e9c\u00e9dents du patient <\/span><span class=\"mw-editsection\"><span class=\"mw-editsection-bracket\">(<\/span><a class=\"mw-editsection-visualeditor\" title=\"Edit section: Patient Situation and Background\" href=\"\/index.php?title=Principles_of_Documentation&amp;veaction=edit&amp;section=6\">edit<\/a><span class=\"mw-editsection-divider\"> | <\/span><a title=\"Edit section: Patient Situation and Background\" href=\"\/index.php?title=Principles_of_Documentation&amp;action=edit&amp;section=6\">edit source<\/a><span class=\"mw-editsection-bracket\">)<\/span><\/span><\/h4>\n<p>Informations pertinentes \u00e0 inscrire dans les dossiers<sup id=\"cite_ref-:1_2-4\" class=\"reference\"><a href=\"#cite_note-:1-2\">(2) <\/a><\/sup>:<\/p>\n<ul>\n<li>les raisons pour lesquelles le patient vient vous consulter, vous, le professionnel de la r\u00e9adaptation<\/li>\n<li>le contexte personnel<\/li>\n<li>la situation actuelle<\/li>\n<li>les ant\u00e9c\u00e9dents m\u00e9dicaux<\/li>\n<li>les m\u00e9dicaments<\/li>\n<li>les personnes qui ont orient\u00e9 le patient vers vous<\/li>\n<li>les informations propres \u00e0 une profession sp\u00e9cifique de la r\u00e9adaptation<\/li>\n<\/ul>\n<p>Strat\u00e9gies utiles \u00e0 envisager :<\/p>\n<ul>\n<li>l&rsquo;acronyme <b>BLANKETS<\/b> peut aider les praticiens \u00e0 se souvenir des \u00e9l\u00e9ments de l&rsquo;histoire sociale d&rsquo;un patient<sup id=\"cite_ref-15\" class=\"reference\"><a href=\"#cite_note-15\">(15)<\/a><\/sup>\n<ul>\n<li>\u00ab\u00a0<b>B<\/b>ladder and bowel\u00a0\u00bb (vessie et intestin)<\/li>\n<li>\u00ab\u00a0<b>L<\/b>egal arrangements\u00a0\u00bb (Dispositions l\u00e9gales)<\/li>\n<li>\u00ab\u00a0<b>A<\/b>ctivities of daily living\u00a0\u00bb (activit\u00e9s de la vie quotidienne)<\/li>\n<li>\u00ab\u00a0<b>N<\/b>eurology\/cognition\u00a0\u00bb (neurologie\/cognition)<\/li>\n<li>\u00ab\u00a0<b>K<\/b>it\u00a0\u00bb (proth\u00e8ses dentaires, aides auditives\/visuelles)<\/li>\n<li>\u00ab\u00a0<b>E<\/b>tOH\u00a0\u00bb (consommation d&rsquo;alcool ou tabagisme)<\/li>\n<li>\u00ab\u00a0<b>T<\/b>rips\/falls\u00a0\u00bb (tr\u00e9buchements, chutes, aides \u00e0 la marche, tol\u00e9rance \u00e0 l&rsquo;exercice)<\/li>\n<li>\u00ab\u00a0<b>S<\/b>etup at home\u00a0\u00bb (installation \u00e0 domicile)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li>il convient d&rsquo;enseigner aux \u00e9tudiants comment r\u00e9diger l&rsquo;anamn\u00e8se de la maladie actuelle (<b>AMA<\/b>) :\n<ul>\n<li>le soutien par les pairs de proximit\u00e9 peut \u00eatre une strat\u00e9gie efficace pour enseigner aux \u00e9tudiants la mani\u00e8re de r\u00e9diger l&rsquo;histoire de la maladie actuelle<\/li>\n<li>des r\u00e9sidents aidant des \u00e9tudiants en m\u00e9decine de deuxi\u00e8me ann\u00e9e ont \u00e9t\u00e9 aussi efficaces que les professeurs de la facult\u00e9 dans l&rsquo;enseignement de la r\u00e9daction de l&rsquo;AMA dans les dossiers<sup id=\"cite_ref-16\" class=\"reference\"><a href=\"#cite_note-16\">(16)<\/a><\/sup><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h4><span id=\"Measurable_and_Observable_Data\" class=\"mw-headline\">Donn\u00e9es mesurables et observables <\/span><span class=\"mw-editsection\"><span class=\"mw-editsection-bracket\">(<\/span><a class=\"mw-editsection-visualeditor\" title=\"Edit section: Measurable and Observable Data\" href=\"\/index.php?title=Principles_of_Documentation&amp;veaction=edit&amp;section=7\">edit<\/a><span class=\"mw-editsection-divider\"> | <\/span><a title=\"Edit section: Measurable and Observable Data\" href=\"\/index.php?title=Principles_of_Documentation&amp;action=edit&amp;section=7\">edit source<\/a><span class=\"mw-editsection-bracket\">)<\/span><\/span><\/h4>\n<ul>\n<li>Mesures<\/li>\n<li>Interventions ou traitements<\/li>\n<li>Observations<\/li>\n<li>R\u00e9sultats de tests ou des \u00e9valuations<\/li>\n<li>Interpr\u00e9tation des donn\u00e9es en fonction de la profession &#8211; comp\u00e9tences en mati\u00e8re de raisonnement clinique<\/li>\n<li>Informations sur la situation du patient et les implications attendues du probl\u00e8me actuel<\/li>\n<\/ul>\n<h4><span id=\"Documentation_Frameworks\" class=\"mw-headline\">Cadres de la tenue des dossiers <\/span><span class=\"mw-editsection\"><span class=\"mw-editsection-bracket\">(<\/span><a class=\"mw-editsection-visualeditor\" title=\"Edit section: Documentation Frameworks\" href=\"\/index.php?title=Principles_of_Documentation&amp;veaction=edit&amp;section=8\">edit<\/a><span class=\"mw-editsection-divider\"> | <\/span><a title=\"Edit section: Documentation Frameworks\" href=\"\/index.php?title=Principles_of_Documentation&amp;action=edit&amp;section=8\">edit source<\/a><span class=\"mw-editsection-bracket\">)<\/span><\/span><\/h4>\n<ul>\n<li>Notes de type SOAP<sup id=\"cite_ref-17\" class=\"reference\"><a href=\"#cite_note-17\">(17)<\/a><\/sup>\n<ul>\n<li>Anamn\u00e8se et \u00e9valuation <b>s<\/b>ubjective<\/li>\n<li>\u00c9valuation <b>o<\/b>bjective<\/li>\n<li><b>A<\/b>nalyse<\/li>\n<li><b>P<\/b>lan th\u00e9rapeutique<\/li>\n<li>Pour en savoir plus, cliquer ici : <a title=\"SOAP Notes\" href=\"\/SOAP_Notes\">Notes SOAP<\/a><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li>Notes de type DAP<sup id=\"cite_ref-18\" class=\"reference\"><a href=\"#cite_note-18\">(18)<\/a><\/sup>\n<ul>\n<li><b>D<\/b>onn\u00e9es<\/li>\n<li><b>A<\/b>nalyse<\/li>\n<li><b>P<\/b>lan<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li>Notes de type PIE<sup id=\"cite_ref-19\" class=\"reference\"><a href=\"#cite_note-19\">(19)<\/a><\/sup>\n<ul>\n<li><b>P<\/b>robl\u00e8me<\/li>\n<li><b>I<\/b>nterventions<\/li>\n<li><b>\u00c9<\/b>valuation<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li>Notes de type BIRP\/SIRP<sup id=\"cite_ref-20\" class=\"reference\"><a href=\"#cite_note-20\">(20)<\/a><\/sup>\n<ul>\n<li>\u00ab\u00a0<b>B<\/b>ehaviour\u00a0\u00bb (comportement)\/\u00ab <b>S<\/b>ituation\u00a0\u00bb (situation)<\/li>\n<li>\u00ab\u00a0<b>I<\/b>ntervention\u00a0\u00bb (interventions)<\/li>\n<li>\u00ab\u00a0<b>R<\/b>esponse to intervention\u00a0\u00bb (r\u00e9actions dues aux interventions)<\/li>\n<li>\u00ab\u00a0<b>P<\/b>lan\u00a0\u00bb (plan th\u00e9rapeutique)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li>Mod\u00e8le narratif<sup id=\"cite_ref-:4_14-6\" class=\"reference\"><a href=\"#cite_note-:4-14\">(14)<\/a><\/sup><\/li>\n<li>Dossier m\u00e9dical bas\u00e9 sur l&rsquo;identification des probl\u00e8mes<sup id=\"cite_ref-:4_14-7\" class=\"reference\"><a href=\"#cite_note-:4-14\">(14)<\/a><\/sup><\/li>\n<li>Rapport sur les r\u00e9sultats fonctionnels<sup id=\"cite_ref-:4_14-8\" class=\"reference\"><a href=\"#cite_note-:4-14\">(14)<\/a><\/sup><\/li>\n<\/ul>\n<div class=\"thumb embedvideo autoResize\" style=\"width: 308px;\">\n<div class=\"embedvideo autoResize\">\n<div class=\"embedvideowrap\" style=\"width: 300px;\"><iframe loading=\"lazy\" title=\"Play video\" src=\"\/\/www.youtube.com\/embed\/GxumhC3C1ss?\" width=\"300\" height=\"169\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/div>\n<\/div>\n<\/div>\n<p><sup id=\"cite_ref-21\" class=\"reference\"><a href=\"#cite_note-21\">(21)<\/a><\/sup><\/p>\n<p>Il est prouv\u00e9 que l&rsquo;utilisation de cadres standardis\u00e9s et de strat\u00e9gies \u00e9ducatives permet d&rsquo;am\u00e9liorer la communication et la pr\u00e9cision des rapports et de r\u00e9duire les erreurs et les pr\u00e9judices<sup id=\"cite_ref-:5_1-1\" class=\"reference\"><a href=\"#cite_note-:5-1\">(1)<\/a><\/sup><sup id=\"cite_ref-:6_22-0\" class=\"reference\"><a href=\"#cite_note-:6-22\">(22)<\/a><\/sup><sup id=\"cite_ref-:7_23-0\" class=\"reference\"><a href=\"#cite_note-:7-23\">(23)<\/a><\/sup>. Pour savoir plus, consulter les articles suivants :<\/p>\n<ul>\n<li><a class=\"external text\" href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC7200654\/pdf\/41394_2020_Article_283.pdf\" rel=\"nofollow\">Toward a framework for developing an ICF-based documentation system in spinal cord injury-specific rehabilitation based on routine clinical practice: a case study approach<\/a><sup id=\"cite_ref-:6_22-1\" class=\"reference\"><a href=\"#cite_note-:6-22\">(22)<\/a><\/sup><\/li>\n<li><a class=\"external text\" href=\"https:\/\/www.academicpedsjnl.net\/article\/S1876-2859(22)00066-3\/pdf\" rel=\"nofollow\">Best practices in medical documentation: a curricular module<\/a><sup id=\"cite_ref-:5_1-2\" class=\"reference\"><a href=\"#cite_note-:5-1\">(1)<\/a><\/sup><\/li>\n<li><a class=\"external text\" href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC8548969\/\" rel=\"nofollow\">Common data elements for meaningful stroke documentation in routine care and clinical research: retrospective data analysis<\/a><sup id=\"cite_ref-:7_23-1\" class=\"reference\"><a href=\"#cite_note-:7-23\">(23)<\/a><\/sup><\/li>\n<\/ul>\n<h3><span id=\"Methods_of_Documentation\" class=\"mw-headline\">M\u00e9thodes de tenue des dossiers <\/span><span class=\"mw-editsection\"><span class=\"mw-editsection-bracket\">(<\/span><a class=\"mw-editsection-visualeditor\" title=\"Edit section: Methods of Documentation\" href=\"\/index.php?title=Principles_of_Documentation&amp;veaction=edit&amp;section=9\">edit<\/a><span class=\"mw-editsection-divider\"> | <\/span><a title=\"Edit section: Methods of Documentation\" href=\"\/index.php?title=Principles_of_Documentation&amp;action=edit&amp;section=9\">edit source<\/a><span class=\"mw-editsection-bracket\">)<\/span><\/span><\/h3>\n<ul>\n<li>Tenue des dossiers sous forme narrative\n<ul>\n<li>r\u00e9daction libre, phrases longues ou compl\u00e8tes, r\u00e9daction de paragraphes dans des espaces vierges, des zones de texte, des formulaires informatis\u00e9s vierges, des dict\u00e9es<sup id=\"cite_ref-:4_14-9\" class=\"reference\"><a href=\"#cite_note-:4-14\">(14)<\/a><\/sup><\/li>\n<li>parfois \u00e9crit dans l&rsquo;ordre chronologique (comme lorsque l&rsquo;on raconte une histoire)<\/li>\n<li>les structures et le cheminement des dossiers varient d&rsquo;un milieu de pratique \u00e0 l&rsquo;autre<\/li>\n<li>des formulaires personnels ou fournis peuvent \u00eatre utilis\u00e9s<sup id=\"cite_ref-:4_14-10\" class=\"reference\"><a href=\"#cite_note-:4-14\">(14)<\/a><\/sup><\/li>\n<li>m\u00e9thode longue et fastidieuse<\/li>\n<li>parfois utilis\u00e9 lors de la tenue des dossiers pour les rencontres initiales avec les patients, les notes de suivi, les r\u00e9\u00e9valuations et les rapports de cong\u00e9<\/li>\n<li>les inconv\u00e9nients de la tenue des dossiers sous forme narrative comprennent<sup id=\"cite_ref-:4_14-11\" class=\"reference\"><a href=\"#cite_note-:4-14\">(14) <\/a><\/sup>:\n<ul>\n<li>difficile \u00e0 lire en raison du manque de structure et de la vari\u00e9t\u00e9 des styles d&rsquo;\u00e9criture des professionnels de la sant\u00e9<\/li>\n<li>une personne lisant la note narrative peut avoir du mal \u00e0 trouver des informations importantes sur le patient<\/li>\n<li>omission involontairement possible de d\u00e9tails pertinents ou essentiels (s&rsquo;il un \u00e9l\u00e9ment n&rsquo;est pas \u00e9crit au dossier, c&rsquo;est comme si cela n&rsquo;avait pas eu lieu)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li>Tenue de dossier \u00e9lectronique<sup id=\"cite_ref-:4_14-12\" class=\"reference\"><a href=\"#cite_note-:4-14\">(14)<\/a><\/sup>\n<ul>\n<li>dossier \u00e9lectronique<\/li>\n<li>g\u00e9n\u00e9ralement int\u00e9gr\u00e9 \u00e0 un dossier m\u00e9dical \u00e9lectronique plus vaste au sein d&rsquo;un milieu clinique ou d&rsquo;un syst\u00e8me de sant\u00e9<\/li>\n<li>certaines professions ont leur propre forme sp\u00e9cifique et unique de dossier \u00e9lectronique. Les chirurgiens utilisent des rapports op\u00e9ratoires synoptiques, et il a \u00e9t\u00e9 d\u00e9montr\u00e9 que cela am\u00e9liore la qualit\u00e9 de la tenue des dossiers. Les dossiers sont plus complets et cette m\u00e9thode permet de gagner du temps par rapport aux rapports op\u00e9ratoires narratifs.<sup id=\"cite_ref-24\" class=\"reference\"><a href=\"#cite_note-24\">(24)<\/a><\/sup><\/li>\n<li>pour en savoir plus sur les dossiers \u00e9lectroniques : <a title=\"Electronic Medical Records\" href=\"\/Electronic_Medical_Records\">Electronic Medical Records<\/a><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h2><span id=\"References\" class=\"mw-headline\">R\u00e9f\u00e9rences<\/span><span class=\"mw-editsection\"><span class=\"mw-editsection-bracket\">(<\/span><a class=\"mw-editsection-visualeditor\" title=\"Edit section: References\" href=\"\/index.php?title=Principles_of_Documentation&amp;veaction=edit&amp;section=10\">edit<\/a><span class=\"mw-editsection-divider\"> | <\/span><a title=\"Edit section: References\" href=\"\/index.php?title=Principles_of_Documentation&amp;action=edit&amp;section=10\">edit source<\/a><span class=\"mw-editsection-bracket\">)<\/span><\/span><\/h2>\n<div class=\"mw-references-wrap mw-references-columns\">\n<ol class=\"references\">\n<li id=\"cite_note-:5-1\"><span class=\"mw-cite-backlink\">\u2191 <sup><a href=\"#cite_ref-:5_1-0\">1.0<\/a><\/sup> <sup><a href=\"#cite_ref-:5_1-1\">1.1<\/a><\/sup> <sup><a href=\"#cite_ref-:5_1-2\">1.2<\/a><\/sup><\/span> <span class=\"reference-text\">McCabe ME, Mink R, Turner DA, Boyer DL, Tcharmtchi MH, Werner J, Schneider J, Armijo-Garcia V, Winkler M, Baker D, Mason KE. <a class=\"external text\" href=\"https:\/\/www.academicpedsjnl.net\/article\/S1876-2859(22)00066-3\/pdf\" rel=\"nofollow\">Best practices in medical documentation: a curricular module<\/a>. Academic Pediatrics. 2022 Nov 1;22(8):1271-7.<\/span><\/li>\n<li id=\"cite_note-:1-2\"><span class=\"mw-cite-backlink\">\u2191 <sup><a href=\"#cite_ref-:1_2-0\">2,0<\/a><\/sup> <sup><a href=\"#cite_ref-:1_2-1\">2,1<\/a><\/sup> <sup><a href=\"#cite_ref-:1_2-2\">2,2<\/a><\/sup> <sup><a href=\"#cite_ref-:1_2-3\">2,3<\/a><\/sup> <sup><a href=\"#cite_ref-:1_2-4\">2,4<\/a><\/sup><\/span> <span class=\"reference-text\">Cecil, A. Principles of Documentation Course. Plus. 2024<\/span><\/li>\n<li id=\"cite_note-:0-3\"><span class=\"mw-cite-backlink\">\u2191 <sup><a href=\"#cite_ref-:0_3-0\">3.0<\/a><\/sup> <sup><a href=\"#cite_ref-:0_3-1\">3.1<\/a><\/sup><\/span> <span class=\"reference-text\">American Physical Therapy Association (APTA). Setting-Specific Considerations in Documentation. 2018<\/span><\/li>\n<li id=\"cite_note-4\"><span class=\"mw-cite-backlink\"><a href=\"#cite_ref-4\">\u2191<\/a><\/span> <span class=\"reference-text\">Bunting J, de Klerk M. <a class=\"external text\" href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC9127672\/pdf\/10.1177_23779608221075165.pdf\" rel=\"nofollow\">Strategies to improve compliance with clinical nursing documentation guidelines in the acute hospital setting: A systematic review and analysis.<\/a> SAGE Open Nursing. 2022 Feb;8:23779608221075165.<\/span><\/li>\n<li id=\"cite_note-:8-5\"><span class=\"mw-cite-backlink\">\u2191 <sup><a href=\"#cite_ref-:8_5-0\">5.0<\/a><\/sup> <sup><a href=\"#cite_ref-:8_5-1\">5.1<\/a><\/sup><\/span> <span class=\"reference-text\">Field L, Gane E, Forbes R. <a class=\"external text\" href=\"https:\/\/ajce.scholasticahq.com\/article\/71404-clinical-documentation-during-clinical-placements-perspectives-of-physiotherapy-students-and-clinical-educators\" rel=\"nofollow\">Clinical documentation during clinical placements: Perspectives of physiotherapy students and clinical educators.<\/a> Australian Journal of Clinical Education. 2023 May 2;12(1):1-22.<\/span><\/li>\n<li id=\"cite_note-:2-6\"><span class=\"mw-cite-backlink\">\u2191 <sup><a href=\"#cite_ref-:2_6-0\">6.0<\/a><\/sup> <sup><a href=\"#cite_ref-:2_6-1\">6.1<\/a><\/sup><\/span> <span class=\"reference-text\">Gudmundsen AC, Norbye B, Dahlgren MA, Obstfelder A. <a class=\"external text\" href=\"https:\/\/www.sciencedirect.com\/science\/article\/pii\/S0260691720314568?via%3Dihub\" rel=\"nofollow\">Interprofessional student groups using patient documentation to facilitate interprofessional collaboration in clinical practice\u2013A field study.<\/a> Nurse Education Today. 2020 Dec 1;95:104606.<\/span><\/li>\n<li id=\"cite_note-:3-7\"><span class=\"mw-cite-backlink\">\u2191 <sup><a href=\"#cite_ref-:3_7-0\">7.0<\/a><\/sup> <sup><a href=\"#cite_ref-:3_7-1\">7.1<\/a><\/sup><\/span> <span class=\"reference-text\">Kaplan H, Guidry-Grimes L, Crutchfield P, Hulkower A, Horner C, Burke JE, Fedson S. <a class=\"external text\" href=\"https:\/\/www.journals.uchicago.edu\/doi\/10.1086\/JCE2022334303\" rel=\"nofollow\">An Open Discussion of the Impact of OpenNotes on Clinical Ethics: A Justification for Harm-Based Exclusions from Clinical Ethics Documentation.<\/a> The Journal of clinical ethics. 2022 Dec 1;33(4):303-13.<\/span><\/li>\n<li id=\"cite_note-8\"><span class=\"mw-cite-backlink\"><a href=\"#cite_ref-8\">\u2191<\/a><\/span> <span class=\"reference-text\">Childers C, Marron J, Meyer EC, Abel GA. <a class=\"external text\" href=\"https:\/\/bmcmedethics.biomedcentral.com\/articles\/10.1186\/s12910-023-00904-1\" rel=\"nofollow\">Clinical ethics consultation documentation in the era of open notes.<\/a> BMC Medical Ethics. 2023 Dec;24(1):1-6.<\/span><\/li>\n<li id=\"cite_note-9\"><span class=\"mw-cite-backlink\"><a href=\"#cite_ref-9\">\u2191<\/a><\/span> <span class=\"reference-text\">Brooks LA, Manias E, Bloomer MJ. A retrospective descriptive study of medical record documentation of how treatment limitations are communicated with family members of patients from culturally diverse backgrounds. Australian Critical Care. 2023 Jun 18.<\/span><\/li>\n<li id=\"cite_note-10\"><span class=\"mw-cite-backlink\"><a href=\"#cite_ref-10\">\u2191<\/a><\/span> <span class=\"reference-text\">Moy AJ, Schwartz JM, Chen R, Sadri S, Lucas E, Cato KD, Rossetti SC. <a class=\"external text\" href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC8068426\/pdf\/ocaa325.pdf\" rel=\"nofollow\">Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review.<\/a> Journal of the American Medical Informatics Association. 2021 May 1;28(5):998-1008.<\/span><\/li>\n<li id=\"cite_note-11\"><span class=\"mw-cite-backlink\"><a href=\"#cite_ref-11\">\u2191<\/a><\/span> <span class=\"reference-text\">Tate K, Ma R, Reid RC, McLane P, Waywitka J, Cummings GE, Cummings GG. <a class=\"external text\" href=\"https:\/\/bmcgeriatr.biomedcentral.com\/articles\/10.1186\/s12877-023-03731-6\" rel=\"nofollow\">A first look at consistency of documentation across care settings during emergency transitions of long-term care residents.<\/a> BMC geriatrics. 2023 Jan 11;23(1):17.<\/span><\/li>\n<li id=\"cite_note-12\"><span class=\"mw-cite-backlink\"><a href=\"#cite_ref-12\">\u2191<\/a><\/span> <span class=\"reference-text\">MOS Medical Record Reviews. The 5 Cs In Medical Record Documentation. Available from: <a class=\"external free\" href=\"https:\/\/www.youtube.com\/watch?v=4PyPFE5yBUc\" rel=\"nofollow\">https:\/\/www.youtube.com\/watch?v=4PyPFE5yBUc<\/a>(last accessed 5\/2\/2024)<\/span><\/li>\n<li id=\"cite_note-13\"><span class=\"mw-cite-backlink\"><a href=\"#cite_ref-13\">\u2191<\/a><\/span> <span class=\"reference-text\">World Health Organization (WHO). <a class=\"external text\" href=\"https:\/\/cdn.who.int\/media\/docs\/default-source\/ethics\/code_of_ethics_abridged.pdf?sfvrsn=ef4e3c35_15&amp;download=true\" rel=\"nofollow\">Code of Ethics and Professional Conduct (Abridged).<\/a> Last accessed 5 February 2024.<\/span><\/li>\n<li id=\"cite_note-:4-14\"><span class=\"mw-cite-backlink\">\u2191 <sup><a href=\"#cite_ref-:4_14-0\">14.00<\/a><\/sup> <sup><a href=\"#cite_ref-:4_14-1\">14.01<\/a><\/sup> <sup><a href=\"#cite_ref-:4_14-2\">14.02<\/a><\/sup> <sup><a href=\"#cite_ref-:4_14-3\">14.03<\/a><\/sup> <sup><a href=\"#cite_ref-:4_14-4\">14.04<\/a><\/sup> <sup><a href=\"#cite_ref-:4_14-5\">14.05<\/a><\/sup> <sup><a href=\"#cite_ref-:4_14-6\">14.06<\/a><\/sup> <sup><a href=\"#cite_ref-:4_14-7\">14.07<\/a><\/sup> <sup><a href=\"#cite_ref-:4_14-8\">14.08<\/a><\/sup> <sup><a href=\"#cite_ref-:4_14-9\">14.09<\/a><\/sup> <sup><a href=\"#cite_ref-:4_14-10\">14.10<\/a><\/sup> <sup><a href=\"#cite_ref-:4_14-11\">14.11<\/a><\/sup> <sup><a href=\"#cite_ref-:4_14-12\">14.12<\/a><\/sup><\/span> <span class=\"reference-text\">Erickson ML, Utzman RR, McKnight R. Physical Therapy Documentation: From Examination to Outcome. Third Edition. SLACK Incorporated. 2020<\/span><\/li>\n<li id=\"cite_note-15\"><span class=\"mw-cite-backlink\"><a href=\"#cite_ref-15\">\u2191<\/a><\/span> <span class=\"reference-text\">Warner BE, Millar K, Bolland M, McNicholas J, Dani M. <a class=\"external text\" href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC9234405\/pdf\/postgradmedj-2021-140207.pdf\" rel=\"nofollow\">BLANKETS: a toasty tool to improve social history documentation for our older patients.<\/a> Postgraduate medical journal. 2022 Jul;98(1161):564-6.<\/span><\/li>\n<li id=\"cite_note-16\"><span class=\"mw-cite-backlink\"><a href=\"#cite_ref-16\">\u2191<\/a><\/span> <span class=\"reference-text\">Kusnoor AV, Balchandani R, Pillow MT, Sherman S, Ismail N. <a class=\"external text\" href=\"https:\/\/bmcmededuc.biomedcentral.com\/articles\/10.1186\/s12909-022-03790-0\" rel=\"nofollow\">Near-peers effectively teach clinical documentation skills to early medical students.<\/a> BMC Medical Education. 2022 Dec;22(1):1-4.<\/span><\/li>\n<li id=\"cite_note-17\"><span class=\"mw-cite-backlink\"><a href=\"#cite_ref-17\">\u2191<\/a><\/span> <span class=\"reference-text\">Gateley CA, Borcherding S. 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The American Journal of Surgery. 2019 Sep 1;218(3):624-30.<\/span><\/li>\n<\/ol>\n<\/div>\n<p><!-- \nNewPP limit report\nCached time: 20240822073005\nCache expiry: 0\nReduced expiry: true\nComplications: (show\u2010toc)\nCPU time usage: 0.103 seconds\nReal time usage: 0.115 seconds\nPreprocessor visited node count: 432\/1000000\nPost\u2010expand include size: 107\/2097152 bytes\nTemplate argument size: 0\/2097152 bytes\nHighest expansion depth: 3\/100\nExpensive parser function count: 0\/100\nUnstrip recursion depth: 0\/20\nUnstrip post\u2010expand size: 16385\/5000000 bytes\n--><br \/>\n<!--\nTransclusion expansion time report (%,ms,calls,template)\n100.00%    7.848      1 Special:Contributors\/Principles_of_Documentation\n100.00%    7.848      1 -total\n--><\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>R\u00e9dactrice originale&#8211; Wanda van Niekerk d&rsquo;apr\u00e8s le cours de Angela Cecil Principales collaboratrices &#8211; Wanda van Niekerk et Jess Bell Contenu 1 Introduction \u00e0 la tenue des dossiers des professionnels 2 Principes de la tenue des dossiers 2.1 Contexte de la tenue des dossiers 2.2 Caract\u00e9ristiques d&rsquo;une bonne tenue des dossiers 2.3 \u00c9l\u00e9ments courants retrouv\u00e9s [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-12293","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/langs.physio-pedia.com\/fr\/wp-json\/wp\/v2\/pages\/12293","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/langs.physio-pedia.com\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/langs.physio-pedia.com\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/langs.physio-pedia.com\/fr\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/langs.physio-pedia.com\/fr\/wp-json\/wp\/v2\/comments?post=12293"}],"version-history":[{"count":1,"href":"https:\/\/langs.physio-pedia.com\/fr\/wp-json\/wp\/v2\/pages\/12293\/revisions"}],"predecessor-version":[{"id":12310,"href":"https:\/\/langs.physio-pedia.com\/fr\/wp-json\/wp\/v2\/pages\/12293\/revisions\/12310"}],"wp:attachment":[{"href":"https:\/\/langs.physio-pedia.com\/fr\/wp-json\/wp\/v2\/media?parent=12293"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}