Documentation disability
- 2. Nerrilyn Agius 2 Does your documentation protect you? Your documentation is a reflection of you. Excellent Very good Average Below average Poor OUTCOME: You will look after yourself Choose to document well and choose to be prepared when bad things happen
- 3. Nerrilyn Agius 3 Documentation Protects you Provides evidence of: Competent staff Teamwork Procedure informed practice Write in everyday language
- 4. Nerrilyn Agius 4 All aged care/disability services must have efficient and effective reporting and documentation protocols. Accurate information is essential to ensure clients needs are met and effective and quality services are delivered. Accurate recording and reporting is essential to ensure that accountability for services and funding requirements are maintained at all times. …… “if it isn’t written down, then it didn’t happen”
- 5. Nerrilyn Agius Rules for reporting/documentation Documentation is the official record of services that are proposed/provided to a client All workplaces will have their own methods of reporting and recording 5
- 6. First rule of reporting: All reports and documents must use OBJECTIVE language. this means……… describe → ONLY what you saw or heard (were told) ← “THE FACTS” Objective language is important for accuracy, accountability and legal purposes. Nerrilyn Agius 6
- 7. Nerrilyn Agius Extract from the report Re-written objectively Sofina was up all night screaming and creating havoc Peter cannot be trusted to stay in the car with out a staff member, as he provokes the other clients Richard refuses to discuss moving into an aged care facility and becomes aggressive when the matter is raised. He is unrealistic about his understanding of his abilities to take care of himself Mary appears distressed when the support worker arrives in her home and will not comply with any request the support worker makes 7
- 8. Nerrilyn Agius 8 Reporting and documenting • Verbal (spoken): - telephone - face-to-face • Non-verbal (written): - progress notes - case notes - hazard and incident forms - care plans
- 9. DOCUMENTATION AND THE CARE CYCLE
- 10. Nerrilyn Agius Maintain documentation and client records Every client’s documentation and daily occurrences, daily tick/observation charts, reports etc must be completed daily as required. Records of daily/weekly visits to HACC clients must be completed at each visit. Any changes in client situations or circumstances must be documented and reported immediately. Information on existing clients must be readily available when required. New information should be placed to the front of previous information. 10
- 11. Nerrilyn Agius Updates of client information should be added to their files immediately it is received e.g. results of pathology tests Information must be kept current e.g. change of address. NOK Out of date information may lead to the wrong course of action being taken e.g. resistance to some antibiotics, development of lactose intolerance , food allergies, incorrect treatment may be given Client files can become very full. When this occurs, some of the older information can be removed and filed separately but must remain within easy access for future reference – for the duration of the period that the organisation is caring for them. 11
- 12. Nerrilyn Agius When completing client notes and written reports the general rules of reporting/documentation are: • Writing must be neat and easy to read. • Use the correct spelling and grammar. • Describe everything using OBJECTIVE language • Do not leave blank lines between entries. Rule a line through gaps – prevents tampering/unauthorised additions • Check that you have the correct client file! • Use BLACK ink. NEVER use pencil • Write the date and time at the beginning of every entry • Use 24 hour clock time 12
- 13. Nerrilyn Agius • Sign all entries with signature (must be legible) and title (if applicable). A. Carer PCA • Document ASAP. • Follow the flow of information. • Late entries – if you forget to include some information, or further information needs to be added – date and time and state “Additional” at commencement • No criticism • 13
- 14. Nerrilyn Agius • If you make a mistake draw a single line through the error and initial the correction. Mark the mistake as “ME” (mistaken entry) or “Entered in error” NEVER USE WHITE-OUT OR CORRECTION TAPE • Record your own actions only. • If information/instructions are received by phone then state this in the notes • Do not alter someone else’s entries • Only use abbreviations and terminology that is used by your organisation – avoids any misunderstandings/mistakes • Legible 14
- 15. Nerrilyn Agius 15 Relevant documentation Duty of Care Care support plans Goals – completion, barriers, outcomes Choice, control, independence, re-enablement, strengths Your role Procedures / guidelines-will guide you Risks What risks are you responsible for managing?
- 16. Nerrilyn Agius 16 Documenting Risks & Incidents Legal and complaints protection The Facts – ‘what and when’ did you – see, hear, do (actions) and communicate What prevention strategies were in place (Facts – see or hear) What have you put in place (Actions)
- 17. Nerrilyn Agius 17 Key points 1. Remember your audience 2. Document Facts. Not what you think or feel 3. Structure you documentation to reflect the clients care / support 4. Document when a client chooses to not follow advice, waives risk, refuses care. Consequences and choices 5. Document the management of risk – prevention strategies 6. Allocate time for documentation – I didn’t have time is not a defence
- 18. Nerrilyn Agius 18 Storage of records All client records must be stored securely and safely. Privacy and confidentiality must be maintained at all times. Workplace policy for storage of records must be followed at all times. Client records must be kept by the organisation for several years after they cease to be clients e.g. following their death
- 19. VERBAL REPORTING • Be factual • Be clear • Be concise • Follow legal requirements, Duty of Care • Meet organizational requirements, formally go through each client in a set pattern of reporting or only exception reporting. • Report these vague statements and write how you could change these into something objective • Everything is terrible • TAFE is great • I feel sad • I feel happy
- 20. Nerrilyn Agius 20 Acknowledgement; • Microsoft Office – clip art • 2010 Pearson Australia (a division of Pearson Australia Group Pty. Ltd).
Editor's Notes
- #13: When completing client notes and written reports the general rules of reporting/documentation are: Writing must be neat and easy to read. This avoids confusion, difficulty working out what it says, misunderstandings and time wasting Use the correct spelling and grammar. Ask if you are unsure, or use a dictionary Describe everything using OBJECTIVE language Do not leave blank lines between entries. Rule a line through gaps – prevents tampering/unauthorised additions Check that you have the correct client file! Use BLACK ink. NEVER use pencil as this is not considered a permanent record for legal purposes Write the date and time at the beginning of every entry Use 24 hour clock time - avoids confusion between am and pm
- #14: Sign all entries with signature (must be legible) and title (if applicable). A. Carer PCA Document ASAP. This ensures accuracy and avoids forgetting important facts. Follow the flow of information. Refer to previous entries and comment if required. Cover one topic at a time, in order of sequence. Late entries – if you forget to include some information, or further information needs to be added – date and time and state “Additional” at commencement If you make a mistake draw a single line through the error and initial the correction. Mark the mistake as “ME” (mistaken entry) or “Entered in error” NEVER USE WHITE-OUT OR CORRECTION TAPE Record your own actions only. If another care worker has something to report ask them to write this themselves. If it is necessary to record the actions of another person, make sure you include their name. If information/instructions are received by phone then state this in the notes Do not alter someone else’s entries Only use abbreviations and terminology that is used by your organisation – avoids any misunderstandings/mistakes
- #15: Sign all entries with signature (must be legible) and title (if applicable). A. Carer PCA Document ASAP. This ensures accuracy and avoids forgetting important facts. Follow the flow of information. Refer to previous entries and comment if required. Cover one topic at a time, in order of sequence. Late entries – if you forget to include some information, or further information needs to be added – date and time and state “Additional” at commencement If you make a mistake draw a single line through the error and initial the correction. Mark the mistake as “ME” (mistaken entry) or “Entered in error” NEVER USE WHITE-OUT OR CORRECTION TAPE Record your own actions only. If another care worker has something to report ask them to write this themselves. If it is necessary to record the actions of another person, make sure you include their name. If information/instructions are received by phone then state this in the notes Do not alter someone else’s entries Only use abbreviations and terminology that is used by your organisation – avoids any misunderstandings/mistakes