PAB/PSW Documentation Basics in Quebec
The short answer
In Quebec, the préposé aux bénéficiaires (PAB) records the care given, what they observed and who they reported it to, in factual and specific words. The basics are the same as anywhere in Canada. What is specific to Quebec is the working language and your employer: in most settings the chart is kept in French, but confirm your establishment's policy, and use its forms and procedures.
PABs are generally not members of a professional order the way nurses are, so the rules you follow for charting come mainly from your employer, the care plan and instructions from the nurse (infirmière) or practical nurse (infirmière auxiliaire) you work with. Check with your employer if you are unsure.
What to record
- The care you provided and the time (bath, toileting, mobility, meals, repositioning).
- What the person ate and drank, as a portion or an amount.
- Skin, mobility, mood and behaviour: what you saw or heard, not a diagnosis.
- Any refusal, with the person's own words.
- Who you informed and when.
Report first, then write
If you notice something that worries you, such as a fall, a new skin mark, a change in breathing or alertness, or choking, tell the nurse or supervisor immediately. Then record what you saw and who you told. A note does not replace a verbal report for something urgent.
An example (fictional resident)
"10:30 Mme R. : bain complet avec aide, peau intacte, aucune rougeur remarquée. Elle a mangé environ la moitié de son déjeuner. Elle a dit : « Je suis fatiguée. » Marche avec la marchette, stable. Infirmière S. avisée à 10:45 de la baisse de l'appétit."
English meaning: Full assisted bath, skin intact, no redness noted. Ate about half of her breakfast. Said she was tired. Walks with walker, steady. Nurse S. told at 10:45 about the reduced appetite.
A short glossary
| English | French (as commonly used) |
|---|---|
| Assisted bath | bain avec aide |
| Skin intact | peau intacte |
| Redness | rougeur |
| Fall | chute |
| Refusal of care | refus de soins |
| Fluid intake | apport liquidien |
| Nurse informed | infirmière avisée |
| Walker | marchette |
Use the terms your establishment uses, since vocabulary can vary between settings.
Confidentiality
A person's health information is confidential. Look at records only for the people you are caring for, and do not discuss them outside work. Your employer's privacy policy describes what is allowed.
Common mistakes
- Writing opinions ("difficult", "lazy") instead of observations.
- Recording a task as done before it was done.
- Leaving out the time or who you informed.
- Using abbreviations your establishment does not approve.
Where Fiabita fits
Fiabita can help turn a fragmented note into clearer structured language in English or French, and you review it before it goes anywhere. It does not replace your employer's policy, your nurse or your own judgment.
FAQ
Q: Which language should I chart in?
Follow your establishment's policy. In many Quebec settings records are in French, so confirm what your employer expects.
Q: Do I assess the person?
You observe and report. Assessment and clinical judgment belong to the nurse or other regulated professional.
Q: Is this legal advice?
No. It is educational. Check your employer's policies and official Quebec sources for your role.
Sources and further reading
- Ordre des infirmières et infirmiers du Québec (OIIQ) — regulator for nurses; confirm requirements there
- CNO: Working with Unregulated Care Providers