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Documentation is an essential component of effective communication. Given the complexity of health care and the fluidity of clinical teams, healthcare records are one of the most important information sources available to clinicians. Undocumented or poorly documented information relies on memory and is less likely to be communicated and retained. This can lead to a loss of information, which can result in misdiagnosis and harm.1,2 The intent of this criterion is to ensure that relevant, accurate, complete and up-to-date information about a patient’s care is documented, and clinicians have access to the right information to make safe clinical decisions and to deliver safe, high-quality care. Documentation can be paper-based, electronic or a mix of both. It can also take a number of forms, including the care plan, handover notes, checklists, pathology results, operation reports and discharge summaries. For this criterion, organisations are required to have in place systems to ensure that essential information about a person’s care is documented in the healthcare record. For documentation to support the delivery of safe, high-quality care, it should:3 Be clear, legible, concise, contemporaneous, progressive and accurate Include information about assessments, action taken, outcomes, reassessment processes (if necessary), risks, complications and changes Meet all necessary medico-legal requirements for documentation. Regardless of who records information in the healthcare record, organisations need to ensure that their systems and processes for documentation meet the requirements of this standard. This involves supporting the workforce to document information correctly, and could include policies or training that clearly describe: The workforce’s roles, responsibilities and expectations regarding documentation When documentation is required How to gain access to the healthcare record and templates, checklists or other tools and resources that support best-practice documentation. Clinical information systems and technologies play an increasingly important role in documentation in the healthcare system. It is essential to consider the safety and quality issues that may arise when designing, implementing or integrating digital health solutions. Any digital health record system that is implemented should meet the elements of best-practice documentation and support effective clinical communication. This criterion is supported by actions in the Clinical Governance Standard that require organisations to make the healthcare record available to clinicians at the point of care, support the workforce to maintain accurate and complete healthcare records, and integrate multiple information systems if they are used (Action 1.16). Item
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The importance of assessment in residential care settings cannot be underestimated. It underpins the philosophical approach to person-centred care, an ideology that provides clients with greater control and responsibility regarding their own health and lifestyle. Related: Person-Centred Care Defined Why Do We Need to Assess Clients?Every client entering residential care should be given a comprehensive assessment to identify individual needs, preferences, and strengths. The assessment is undertaken by an interdisciplinary team and covers various aspects of their’ lives such as: physical, spiritual, cognitive, social, mental, and emotional. Client assessments lead to informed decisions that impact on care planning, resources allocation and other services. The assessment process determines the most appropriate and effective way to support clients. Assessment usually starts soon after admission, however it depends of the organization and availability of staff. Benefits of Conducting a Client Assessment
Who is involved in a Client Assessment?A partnership between the interdisciplinary team and client is necessary to conduct a successful assessment. Clients should be actively involved in their assessment as well as their family/ caregivers and close friends. In many organizations a case manager is assigned to support clients during the assessment process. Leisure and Health staff are responsible for the Social/Spiritual Care Plan that includes recreation, relaxation, community trips, club affiliation, and other aspects of daily life. Channels for Identifying Client Needs
Identification of Needs DefinedStaff should address the needs of clients and their families in a holistic way. This means that the assessment focuses on the whole person and their entire well-being, including physical, emotional, spiritual, mental, social and environmental. The Social & Spiritual Profile collects a client’s personal as well as confidential information that the facility may or may not share in the future and therefore should have secure storage.
Gathering information may require more than one meeting with clients.
Tips for conducting a Client InterviewBe supportive and non-judgemental to encourage cooperation.
Tips for Conducting Family/Friend InterviewsTalking to family and friends may provide useful information about clients. Use discretion and be courteous.
Related: Communication Strategies that Improve Client Engagement Tips for Gathering Information through Client Observation
Some Useful Questions to Ask
Next Step: Developing a Care PlanBefore developing a care plan, it is important that staff communicate with other health practitioners to gather information outside the scope of their own roles e.g. behaviour management, psychological issues, and special dietary requirements amongst others. Related: How to Write a Care Plan |