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This week Carrie and Kell look at documentation. This episode is the first of a four part series on documentation.
The post CD001: What and When To Document appeared first on CDCS (Culturally Directed Care Solutions).- What and when to document
- How to create defensible notes
- How to easily capture information to be used in progress notes
- How to store information correctly
- Behaviour
- Emotional state
- Physical wellbeing or
- Physical appearance
- Incidents that have or may impact on the client
- Relevant information passed on by friends and / or family
- Issues around service delivery (e.g. services that were not able to be provided due to organisational issues)
- Information and / or discussions from the health clinic, doctors surgery or discharge planner
- Changes to the household dynamics that may or have impacted on the person
- Complaints
Latest posts by Carrie and Kell (see all)
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- CD019 Holiday Planning – Is Your Service Ready? - November 22, 2017
- CD018 Holiday Planning – How do Your Staffing Levels Look? - November 13, 2017