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The importance of good documentation in care work

Maintaining accurate records plays a crucial role in providing effective care. Not only can maintaining clear and up-to-date records improve the health and well-being of clients, but it can also help care providers to better comply with CQC regulations.

Here we provide insight into the numerous benefits of good documentation and how you can use accurate record-keeping to improve the quality of life of the people you support.

WHY IS ACCURATE RECORD-KEEPING SO IMPORTANT?

Good clinical notes detail the medical history of a client. By keeping accurate records, you are recording important information for future reference.

Keeping a detailed medical history through accurate records is not only important for continuity of care, but it can also provide valuable insight in case of a contested medical or care decision. In the social care and health sector it is often said, if you don’t write it down then it did not happen.

Accurate record-keeping provides many benefits for the people receiving care as well. Maintaining clear and up-to-date records can have a profound impact on a person’s lifelong health. For instance, client records can be used to measure how well a particular approach is meeting health goals.

In the alternative, poorly maintained records may misinform care workers and healthcare professionals about the overall health of a person and can even lead to serious consequences such as inaccurate diagnoses.

Common Guidelines for Record Keeping

Guidelines by the General Medical Council UK state that clinical records must be clear, accurate, legible and written in a scientific manner. 

In order to comply with these guidelines, here are some procedures that we apply at Prestige Nursing & Care to ensure the efficiency and accuracy of our client records: 

  • All entries should be clear and legible. 
  • Ensure that all the information included is correct and that each entry and personal information is updated when it is needed.
  • Complete all records at the time or as soon as possible after an event, recording if the notes are written sometime after the event.
  • Complete all entries as objectively as possible without including any assumptions. 
  • If a record needs to be edited, the original entry should still remain visible.
  • Involve patients in establishing their records and how they feel about different treatments, so they feel understood and heard.
  • Client records should always be stored securely and disposed of following the NHS guidelines for the destruction of patient records

The Benefits of Good Documentation in Care Work 

Maintaining CQC Compliance

The Care Quality Commission (CQC) is the independent regulator of health and adult social care in England. Regulation 17 of the Health and Social Care Act 2008 requires that health and care providers must securely maintain accurate, complete and detailed records for each service user. The CQC is responsible for regulating this. 

In order to become CQC compliant, care providers must meet the key lines of enquiry set by the CQC. The care provided must be safe, effective, caring, responsive and well-led. 

Although many factors are influential in meeting these requirements, keeping clear and up-to-date records can have a positive impact on fulfilling them. Keeping accurate documentation demonstrates that a care provider is organised, responsible and well-led. 

Client documentation should include the time and date of every visit to the home, the service provided and anything significant that occurred. With the consent of the client, this documentation should be kept in the homes of the people who use the service.

Supporting the Health of Our Clients 

Accurate records are vital to our client’s safety and well-being. They foster better communication between our care teams, families and other healthcare professionals and they keep everyone informed about important information regarding the care being provided. 

For instance, to adhere to the CQC’s guidelines, a MAR chart must be used to record when medication has been administered to a client along with keeping track of all information regarding a person’s medication regime. This allows everyone involved with that person’s care to know what medicines have been taken and when. With this information, everyone involved has the information necessary to assist with medicines being taken safely. 

Continuity of Care 

As well as being an effective tool for communication, client records allow all staff members to obtain a clear and accurate picture of the care needs of a client. This in turn allows for a continuity of support and care. Keeping up-to-date and accurate records about each client is the best way to not only ensure that the quality of care is being maintained but also consistently improved. 

Documentation can be used to inform staff or family members about important client information such as when medication should be taken or if a client was feeling unwell. This can be particularly helpful when regular support staff take a holiday and a respite care service is used. 

Collaboration Between Team Members

Client documentation is one of the best methods for sharing important information amongst care teams, families and other professionals involved in a client’s care. Improving communication is a key aspect of improving client safety and well-being. Client records can be used to share vital information between multidisciplinary teams including changes in a client’s condition, concerns or evaluations regarding their care and other pertinent information. 

Exceptional Care at Home 

If you or a loved one could benefit from one-to-one dedicated care at home, our competent and compassionate carers can help. For over 75 years, Prestige Nursing & Care has been trusted by our clients and their families to provide skilled and compassionate care that is focused on improving health and overall well-being. 

Through accurate record keeping and individualised care plans, our highly-trained carers deliver exceptional nurse-led care and hourly home care. You will receive a personalised care and support plan that outlines not just your specific care needs but also covers your choices, preferences and how you wish to live your life. 

The care plan identifies specific care and support tasks involved in your care detailing when, where and how they should be carried out and by whom. This ensures you get the right care at the right time – all from the comfort of your own home.  

Our care plans are flexible and continually monitored to ensure they’re always generating positive outcomes and meeting expectations, even if your care needs change over time. 

Contact our friendly care experts to discuss your care needs and how Prestige Nursing & Care can help. 

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We are here to take your call and will provide impartial support and guidance – contact our friendly care experts today to discuss your care needs.


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