This week sees the third in our Care Planning 101 Series, which aims to help you get to grips with the basic fundamentals of care plans and care recording. This edition covers how you can work to improve your care recording processes. We all know that record keeping is an integral part of providing care. Keeping good records are not optional and that the quality of your record keeping can reflect the standard of your professional practice. Robust record keeping is a mark of skilled and safe carers, whereas careless and incomplete record keeping often highlights other issues. Good record keeping helps to protect the welfare of people in care and support services.
How do you know if your care records are fit for purpose?
CQC has set out a whole host of different guidelines and recommendations when it comes to care planning. For a full in depth set of resources, we’d always recommend you visit the CQC website to ensure you are up to date. However as a clear starter we’d advise that, care records must present information that is:
- Sufficiently detailed to enable proper care
- Clear and concise
- Relevant to providing a person’s care
- Accurate and factual
- Non-discriminatory and non-judgemental*
*Remember this reflects a commitment to person-centred care, equality & diversity principles
How can you improve your care recording?
- Be self-aware
Always think and ask yourself, would I be happy to read this report if it were written about me or my mother?
- Don’t guess or add
Only write down only what you directly experience and know to be true, not your assumptions or guesses.
- Be specific
Saying “I found Mary crying today” is better than “Mary seemed upset” as it accurately describes your experiences.
- Accurately describe your actions
Recording “I helped Vera to dress by fastening her buttons” is better than “carried out care tasks”.
- Keep polite at all times
Avoid using offensive terms and phrases no matter the circumstances.
- Do not ‘label’ a person
Avoid using words that label a person such as “Max is an aggressive person”.
- Ensure you’re always relevant
Choose carefully what to record and consider both care needs and outcome related requirements.
- Consider who you are writing about
Always ask yourself: “Is what I am writing acceptable to the person I am writing about?”
- Write accurately and factually about behaviour
Describe the behaviour first, for example “Val was banging on the table” and then note the person’s feelings; “This was because she was bored and not supported with meaningful occupation” instead of just writing “Val was aggressive”.
How can you improve your care recording processes?
Recording care notes via pen & paper, has been the accepted norm within the care industry, however with growing affordability of electronic management systems, CQC and other regulatory bodies are becoming more aware of the necessity of updating guidelines to enforce their use, in line with their 2021 vision. Systems like Nourish empower carers during care recording by,
- Speeding up the process of care note taking for carers means that even more care records are taken (Carers using nourish have just recorded over a million care notes in under 4 months)
- This increase in efficiency allows carers to add more detail whilst care recording, and results in better care provision as carers are more informed
- Management are able to have a complete overview into the care recording processes of the teams they manage, therefore measures can be taken to help improve staff performance and define training requirements
How can you find out more?
If you’d like to find out more about how Nourish can help you improve your care planning and recording processes, then give us a call on 02380 002 288 alternatively you can drop us an email at Caring@Nourishcare.co.uk and one of our experts will happily respond.