5.1 Appropriate communication in the appropriate place
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.
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’.
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.
- I was tidying Mr Brown’s bedroom when he suddenly kicked off and pushed me out the door.
- Joan really enjoyed her lunch and loved her trip to the garden centre.
- Eddie got out of bed on the wrong side today. He’s been in a really bad mood since breakfast.
- I think Mum is feeling depressed. She seems in a really low mood.
- Did Mr Brown want you in his bedroom? Perhaps you should have asked his permission first. How would you record that? This statement says more about the way the carer has behaved, which is not respectful of Mr Brown’s privacy. Perhaps you could say ‘I knocked on Mr Brown’s door and he didn’t answer, so I went in to see if he was all right. He didn’t speak to me so I started to put some of his clothes away. He said in a loud voice “Get out and leave me alone”. Then he took hold of my arm and pushed me towards the door’.
- Did Joan tell you she enjoyed her lunch? Can you honestly say that you know that? Perhaps it would be more accurate to write: ‘Joan finished her lunch and didn’t refuse any of it. In the afternoon we all visited the local garden centre’.
- Why has Eddie been ‘in a bad mood’ since breakfast? Has he told anyone? Maybe he is in pain? Maybe he wanted something different for breakfast and nobody asked him? You could write ‘Eddie appears to be agitated this morning. He refused his breakfast and was pacing up and down the kitchen for 20 minutes and wringing his hands’ and then try to find out what the problem is.
- What has Mum said to make you think she is depressed? What exactly is a ‘low mood’? Would anyone who read it know what it meant? You could say something like ‘Mum has been much less talkative than usual and has not wanted to go out when I have suggested outings recently. Her appetite seems to have reduced as she is only picking at her food. She spends a lot of time just sitting in her chair. I asked if anything was wrong, and she said she “just can’t be bothered with anything”’.
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.