Social Care Training Barbara Gregg Training Services Barbaragregg1@Hotmail.co.uk

Session Three Record Keeping & Documentation

Session Three - Aims The consider the importance of accurate and comprehensive documentation in the service user file. To understand how to record service user activities within a Reabling context.

Why Record? Legal requirement To ensure continuity, consistency and high standards of care To ensure effective communication of information relating to the service user between all members of the team To monitor progress and inform review team Courts of Law and Complaints Tribunals tend to adopt the attitude “If it has not been recorded - it has not been done!” “Shoddy records = Shoddy care”

Effective Documentation Should be: Accurate, factual Is consecutive - Contemporaneous (written asap) & chronological Not jargon or meaningless phrases or text style abbreviation Date and time, chronological order, Legible handwriting black ink Signed Free from speculative / opinion-based statements Free from humour / sarcasm No blank lines

Principles of Good Record Keeping Errors, Alterations, Additions Dated and Time-stamped (24 hour clock) Signed in full (no initials) Crossed out with a single line (errors only), so original entry can be read No correcting fluid No falsifying of information i.e. do not write notes and sign on behalf of others.

How to record to reflect a Reablement ethos?

Reablement recording Assistance: means hands on help Supervision: means no physical hands on help but you don’t think they are at a point of being left to manage the task without someone there. Verbal prompts: Encouraging client to help themselves but not physically assisting Set-Up: Items placed within easy reach Independent: means you would be happy for them to complete the task without you or anyone else in the home

Break down activities to ensure recording is accurate Personal care (break your documentation down into subsections) e.g. setup, washing upper/lower half, dressing upper/lower half. Write in each section the level of assistance, what they are being assisted with and why you are giving it Mobility/transfers/stairs – what equip are they using, any safety concerns, balance issues, if assistance is needed write the amount each time, what you are assisting with and why. Meals – break into subsections e.g. prep of food: can they find all the needed food items in the kitchen, safe with utensils and equipment, sequence the task, serving: are they safe to lift/transport food, document assistance given, what with and why. Medication – what level of assistance did you give the client : can they manipulate the meds and remove the meds from the pack safely, document assistance given, what with and why. Report if client declines to take medication

Practical Session Example of recording in notes may be: 13/01/2019 Personal care and dressing – Client assisted to transfer from lying to sitting. Client walked to bathroom independently using rollator. Toileted independently -washed upper half with supervision and required assistance with lower half sitting on stool. Clothing selected by client completed upper half dressing independently sitting on bed. Client needed minimal assistance in lower half dressing to put on trousers, socks and shoes.

Practical Session Example of recording in notes may be: 23/02/2019: Meal- Encouraged Mr Young to participate in breakfast preparation – Mr Young able to reheat porridge in microwave. Required prompting to make toast. Client filled kettle and made tea - used kitchen trolley to transport to kitchen table. Noticed client had shortness of breath on exertion. Medications – Client required prompting to take medication. Once prompted observed client take appropriate tablets from blister pack.

Practical Session Example of recording in notes may be: 10/03/2019: Personal care – Assisted client to transfer from bed. Required supervision walking to bathroom. Set up provided – client used stool at sink. Miss Kayes independent removing nightdress and able to wash hands and face. Required prompting to completed upper half washing. Client needed assistance for lower half washing. Independent with hair, deodorant and make-up. Client became tired on exertion and required minimal assistance to dress….

Why record in detail? Accurate documentation in the client file is vital in helping the SW or Care manager make informed decisions about how a service user is managing over a period of time. Informs the client and family of what is being provided It records progress or concerns Helps plan care appropriate to need

Barbara Gregg Training Services For further information contact: barbaragregg1@hotmail.co.uk