When thinking about record-keeping and reporting, one of the important things to remember is that there is a right way to record and there is also a right place to record.
Allow about 5 minutes
Read these two different messages left for the next shift in a supported living unit.
A message in the communication book: ‘John I cleaned the kitchen for you AGAIN.’
A note written on a scrap of paper and left on the table: ‘Brenda needs to be taken to the doctor as soon as possible.’
Was there anything inappropriate about these messages? If so, what would you do instead?
The message about cleaning the kitchen does not belong in a communication book. It is a conversation about roles and responsibilities that should take place between the people involved or with a line manager if appropriate.
The message about the doctor is very important and should be in a communication book or on a message board. It should also be communicated verbally to the next person on shift. Notes written on bits of paper can easily be lost, especially if left in a place that is constantly in use.
If you work as a paid carer all records you keep are legal documents and may be used as evidence in court. This means that anything you write should be dated and signed by you, leaving no space for additional information to be inserted.
It is important that all records are factual. You should report only what you actually know or have seen, not your opinion of why it happened or how the person was feeling, unless they are actually able to tell you this information.
For example, you should not record a statement like ‘Dad had a good night’ unless he tells you himself that he had a good night. Instead, you could write something like ‘Dad appeared to be asleep every time I checked.’
Allow about 10 minutes
Look at these statements and rewrite them in a way that is factual and accurate, not using any language that can be interpreted differently by different readers.
You are probably thinking now that it all seems very complicated, but it gets easier. When you record information about the people you support, try to get in the habit of reading it back and asking yourself ‘Is it fact or opinion?’ and ‘Does it paint a clear and factual picture of events?’
It all comes with practice, and if you can share the task with another person you will be able to work together on improving your record-keeping and reporting skills.
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