CD001: What and When To Document

This week Carrie and Kell look at documentation. This episode is the first of a four part series on documentation.

1. What and when to document
2. How to create defensible notes
3. How to easily capture information to be used in progress notes
4. How to store information correctly

Today we look at what and when to document. If you would like to more detailed information on the topic of exception reporting you can read about it on our blog post ‘Progress Notes – what should you document’. The standard for reporting is ‘Exception Reporting’ – this means you don’t need to report anything that falls within the expected service plan, merely deviations from this. Issues you would report on would cover, observed changes in a person’s

• Behaviour
• Emotional state
• Physical wellbeing or
• Physical appearance

You would also note

• 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

How often should you document? While the general rule is for Exception Reporting, your organisation may have a requirement for regular weekly or monthly notes in each person’s progress notes. It is important that any notes added are relevant and have value. Thanks for listening in, tune in next week for our episode on creating progress notes that meet legal and organisational requirements. To avoid missing an episode subscribe to the Care Directions podcast over on iTunes or Stitcher.