In this presentation you will learn about:

Types of documentation Handover Basic writing – Progress notes Care planning Aged Care Funding Instrument (ACFI)

To ensure that continuity of resident care

is provided by all health care professionals through professional, accurate and contemporary documentation in keeping with legislative and ethical requirements

Care ReportsACFI, progress notes, incident reports, care

plans etc Other reportsDaily, Hazard and maintenance etc Requisition forms Transfer letters Phone calls

We can communicate what is happening

Funding can be dependent on what is

contained in reported information

Continuity of client care – so that we all are

‘on the same page’ - If a particular worker records

everything accurately in notes and care plans, the next

workers can easily take on the support of the clients, without

missing any details of what has already occurred, what is in

process and what needs to be done

Relevant

Documented

Timely This is a legal requirement Can also become part of an audit process It is generally considered that if something is not documented it is not done!

Extremely important that reports be presented within the appropriate time frame

Plan ahead Negotiate a new deadline if need be Examples: -message re care of resident

-frayed toaster cord -providing a new sharps container

Which is the most urgent?

They are all equally important to be reported to the right person in the right format

Familiarise yourself with all of the types of forms used in your organisation - assessment, admission, care plans, case notes, incident reports, ACFI, Pressure care

Records are always confidential - keep them secure – shut down computer screens, return paperwork to correct storage area, don’t leave identifiable items in public areas

Brief information exchange at the change of a shift

Essential information you need to pass on:◦ details of client preferences◦ details of anything which happened that was out

of the ordinary◦ new treatments, symptoms◦ any information required to provide continuity of

care – Drs appointments, day leave etc

Be factual, concise and accurate- be objective and nonjudgmental

Make sure your writing is neat, clear and legible

Writing should be in blue or black ink

Use exact words when quoting - use quotation marks to show it is a direct quote

Never use whiteout - draw a single line through the error, initial and date the change

Record the date and time - especially when relating incidents that have occurred

Present information in logical sequence

Use abbreviations approved in your organisation

Use correct spelling, punctuation and grammar - use a dictionary !

Edit your report before presenting it - get rid of errors and mistakes

Always sign and date each entry, with your surname printed and designation at the end

Eg: (OTOOLE, PCW)

Make sure you check your organisation’s requirements regarding documentation

Read through this common abbreviation list and undertake the matching activity

Insert hyperlink activity here

Remember that each organisation should have its own accepted abbreviation practice guideline or policy that you will need to abide by

Not necessary to write any entry every day – known as by exception

E.g change in behaviour, visit by GP and commencing new antibiotic

If it is already on the long term care plan there is no need to write another entry as nothing new has happened

If is a new problem then write in the progress notes and be specific- read your entry back to make sure it makes sense to someone who has not cared for the client before

Date Time Designation Written in the correct time sequence Be concise and factual Signature and Name clearly identifiable

What happened – subjective and objective information

What you saw / heard or did What action you took What the result was Subjective

Resident’s description of problem/evente.g. ”Mrs Brown stated she had abdominal pain”

ObjectiveObjective data that can be measured or observed by youe.g. “Mrs Brown pale, holding abdominal area, lying in bed”

AssessmentAssessment of the subjective and objective data availablee.g. “Vital signs recorded – NAD, no vomiting or diarrhoea”

PlanWhat you are going to do/have done about ite.g “ Pain relief given by RN for pain in abdomen, warm gel pack offered. Mrs Brown to remain in bed and review in 2/24”

A full assessment of the health status and care needs of each resident is to be carried out and documented as part of the admission process and an ongoing re assessment of care needs is carried on a continuous basis

This ensures a holistic and individualised approach is undertaken in providing care to each resident, that is meaningful to them

The crucial information that explains what you need to do for a client

Can be in an electronic format

2 TYPESShort term

problems of short duration e.g skin tear

Long termContinuous ongoing problems

e.g. mobility

1. Assessment phase – on each aspect of care

2. Planning phase – write up the care plan3. Implementation – share information with

others, discuss plan of care, implement the care you’ve planned

4. Review – at least monthly if not before, living document; can change as necessary to meet the clients needs

Read these care plan guidelines and look at the examples provided

Identify the issue Statement of the issue/s or problem One per care plan Basis of what you are writing the care plan

about If it is clearly stated it is easy to work out

the interventions

Overall aim of what you want to achieve

What do you want to achieve for the resident?

What does the resident want to achieve? Ideally the resident would be an active

participant in setting the goal/s of their care What does the family want to achieve?

What you are going to do about it

Review the assessment documentation Eg personal hygiene assessment – how

much help does the client need when showering, don’t assume they can’t do anything themselves

Use information recorded in the assessment documentation to work out the content of the care plan

Consideration is to be given to the residents abilities, needs, expectations, choices and preferences, wants and needs in relation to each of the following:

·        Residents rights·        Personal affairs·        Social·        Cultural·        Spiritual·        Physical·        Emotional (psychological)

Puts the plan into action – guides your care

Implementation includes the documenting of care in progress notes, treatment sheets, medication charts

Documenting is part of the carer’s direct responsibility, rather than a clerical function, it is a vital part of the professional care practice, providing a permanent record of what you want to achieve, how, when and why you do it

Determines the extent to which goals or outcomes have been met or achieved

Final phase in the process which is an integral part of professional practice, it is ongoing

Based on resident need, facility policy, legal requirements

Could be date or funding driven

Interim Care plan Short Term Care plans Mini Care plans Electronic care plans Community Care plans Mental health plan

Long Term Care PlanFor ongoing total care

Interim Care PlanSnapshot picture on admission

Short Term Care PlanFor problems of short duration

Mini Care PlansSnapshot picture – often found in a client’s wardrobe

Electronic Care Plans“I Care” one example of a computer

generated care plan used on palm pilots

Community Care Plans

Other FacilitiesVary greatly but every facility will have the same basic components, ensure you find out at your orientation how to document care plans properly – particularly if your funding relies on it!

Care Planning is a partnership with residents, it is resident focused not driven by or for staff convenience

ALWAYS engage the client to be an active participant in what is

happening to them