Daily Reporting - Are your service user`s Daily Reports following Best Practice?
The daily report is a form on which day to day occurrences should be recorded. A court of law would assume that if care is not documented then it has not been provided to the service user. So day to day reports are vital to ensure all the appropriate care is being given.
(firmenpresse) - Northampton, January 2016 - The daily report is a form on which day to day occurrences should be recorded. A court of law would assume that if care is not documented then it has not been provided to the service user. So day to day reports are vital to ensure all the appropriate care is being given.
Service user daily records should be factual, consistent, and accurate and a true account of what has happened. Reports should be relevant and relate to the information in the care plans.
In the daily record should be written an account of the service user’s progress and any nursing or medical interventions that took place with appropriate rationale for these. It should be similar to that which we would write in a diary although these accounts should not be written in a subjective, chatty, or judgemental style. The report should focus on what the nurse/carer observed what was done, and how the service user responded.
Any unexpected events that occur in the service user’s day should be recorded or any visits that the service user may have from other members of the community team (e.g. GP, dietician, chiropodist) or family members and how the service user responded to that (maybe they particularly enjoyed a visit or were very unhappy to see a particular person).
This daily report may be used in a court of law to clarify what happened and in what order the events occurred. This is why it is important to date and time against each written entry as well as to initial and sign and print your own name next to the entry. Daily records should be completed as soon as possible after an occurrence or change in service user’s condition. If an incident occurs involving a service user it is advisable to make a record both in the daily report and follow local policy (i.e. record the incident additionally on an incident form or book). Also if you are concerned in any way about the condition, welfare, safety or environment of care for a particular service user it is advisable to record it in the daily report (this includes relevant conversation, letters and telephone calls). Poor handwriting, spelling and events which occur in the wrong order and inappropriate words or phrases are usually why reports are difficult to read and follow. The courts may consider that because professional communication is poor, that the documentation is a reflection of the quality of care in the home.
The daily report record is a legal document - in a court of law if it hasn`t been written down it hasn`t been done.
Hints for excellent daily reporting:
• Do not include abbreviations and jargon. Professional language should be simple and direct. Check the language you use will be clearly understood by those who are reading it (i.e. other carers, staff from other countries, members of the caring team, inspectors)
• Do not use meaningless phrases like ‘slept well’ or ‘good day’. Better to say ‘Mr/Mrs ….…… slept for 8 hours, getting out of bed only once to use toilet’ or ‘Mr/Mrs ………. spent a quiet day not wishing to interact with other service users, but enjoyed a visit from the priest who called this afternoon’. This is being factual, saying why you believe someone slept well or what he or she did during the day to make you believe it was enjoyable for them.
• Do not predict outcomes or make a diagnosis when recording – this may be inaccurate or misleading to other members of the team.
• Do not make offensive, subjective statements – such as ‘sweet, old lady, pleasantly confused’.
• Rather than label someone confused, it is better to describe the actions the person is doing which leads you to believe they are confused.
• Do not use Tippex or ‘white-out’. If a mistake is made put one line through it and countersign it.
In conclusion your reports should contain relevant information about the service user at any given time and the measure you have taken to respond to their needs. Evidence should be given that you have understood and honoured your duty of care, that you have taken all reasonable steps to support the service user and that any actions or omissions on your part have not compromised their safety in any way. It is a vital document in ensuring continuity of care as a result of effective communication.
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About Standex Systems:
Standex Systems Ltd is a dynamic and expanding company within the field of health and social services. We offer standardised and individualised products for our customers, suited to their needs and up to date with market development. We customise and influence the handling of patient record systems. Our customers are mainly hospitals, nursing & residential homes, domiciliary care and general practitioner surgeries/ clinics. We are also a supplier of clinical furniture and other related products in the healthcare sector. We have our own production, design and development facilities with skilled nursing staff. Standex Systems Ltd has a strong focus on product development and documentation systems and offers consulting services and training. We also provide in-house seminars. Standex Systems successfully supports around 13,000 customers in UK, Germany and Austria as well as neighbouring European countries with professional products and services.
Standex Systems Ltd
39 Charter Gate
Moulton Park Ind Est
Northampton, NN3 6QB
Phone: 01604 646 633
Fax: 01604 644 646
info(at) standexsystems.co.uk
https://www.standexsystems.co.uk/
Standex Systems Ltd
Doreen Kupke
Großmoorring 7
21079 Hamburg
eMail: dku(at)standardsysteme.de
Datum: 04.01.2016 - 14:57 Uhr
Sprache: Deutsch
News-ID 442142
Anzahl Zeichen: 4647
contact information:
Contact person: Doreen Kupke
Town:
Northampton, NN3 6QB
Phone: +44 (0)1604 646 633
Kategorie:
Healthcare
Typ of Press Release: Produktankündigung
type of sending: Veröffentlichung
Date of sending: 04.01.2016
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