Making Client Documentation Easier
1. Keep a note pad in the vehicle as staff drive around the community. Have them note down anything that was reported to them by clients or their carers or anything they noticed, including if clients were absent and their supposed whereabouts. Ask your staff to give you a run down of the notes on their return – this information and / or the notes can then be written up by the coordinator in the afternoon after staff have finished for the day.
2. Similar to the first idea, keep a note pad / exercise book in the centre. This can be used for staff to note down any activities, incidents between clients or observations. The coordinator should check this in the afternoon before staff finish for the day to allow for clarifying issues and checking to see if there is any follow up required. The information can then be transferred into individual client progress notes where required.
3. Keep a daily diary in the office. The A4 day to a page diaries are great for referring back to incidents, visitors and quickly noting down things that need follow up. They are also great for reminding the coordinator and staff of essential tasks due on a particular day, such as re-assessment dates. If you and your staff get into the habit of writing in the daily diary it will make it easier to catch up on missed documentation.
4. Use your phone. Many people now have smart phones that have the capacity for note taking, be that written, audio or even visual. Notes, audio recordings and photos have date stamps on them and are useful if you are out and about and have no paper or pen on you. A smart phone can be a great asset in this instance, and even if you don’t have an electronic client management system that this can be uploaded to, you can transcribe from your notes or recording or upload to your computer and print out.
Whatever method you choose to gather the raw information, it is important to ensure you transfer relevant records to the individual client notes. Don’t leave it too long to do so as it will only make your job harder. If you can, get into the habit of reviewing your daily notes and transferring them at the end of each day, it will make your life a lot easier.