Documentation, or rather ‘good’ client documentation, is the cornerstone of quality care outcomes.
Well written care plans along with detailed progress or case notes both support and demonstrate quality care.
In our experience working across many services, one of the common reasons that organisations fail aspects of their quality review or audit is not because they don’t provide quality care, but because their documentation is not in order. The service is unable to demonstrate on paper what has been happening in the workplace – and generally, it is the day-to-day progress notes that people get stuck on.
Unfortunately, it’s not wise to underestimate the importance of good documentation. When something goes wrong or you need to provide evidence, that’s when we find out its true value. Auditors, legal representatives and family members may seek information, be that after an incident or during a review. You want to ensure you have well-written evidence to back up any claims, actions or outcomes.
So what are the main reasons for documenting?
Client documentation is an effective method of sharing information amongst staff and other service providers. In the world of Consumer Directed Care there may be more than one service provider supporting an individual, so it’s best for everyone to be on the same page.
Coordinators and case managers can use client progress notes as a primary reference source when conducting a re-assessment. They can utilise the information to measure how well a particular approach is meeting the individual’s stated goals. Notes may also indicate improvement or deterioration of the individual and prompt changes in service delivery or identify needed referrals.
Continuity of Care:
As well as being useful for effective communication, good documentation helps all staff to understand the current care needs of a client. This in turn promotes continuity of support and care. Documentation can be used to prompt or remind staff or family members of specific actions. For example, when regular staff go on holidays and a relief support worker is brought in.
Think about a time when you have either been in hospital or visited a family or friend in hospital. Staff, including doctors, work different shifts and a patient may be seen and supported by a number of different staff members during the period of their stay. Client documentation allows each staff member to understand the medical history of the individual and any interventions that are relevant to their care and support needs. This history can then be used to direct future interventions and actions. Organisations that provide aged care services also rely on this ability to share relevant information between staff to promote quality outcomes.
As we discussed earlier, accurately reported facts are the best defence against litigation. Any and all documents that relate to the care and support of an individual can be called upon as evidence in a court of law. All consumers of care have a legal right to safe, professional care and support – including accurate and truthful documentation.
Continuous Quality Improvement:
This is an important aspect of providing quality care. Although there are identified standards that support the industry, and your organisations might be currently assessed as meeting these, you cannot become complacent. The expectations of individuals and their families’ change. Good documentation can assist in picking up trends in the needs of an individual, your target consumer group and the needs of your workforce going forward.
In residential settings, documentation assists aged care facilities to receive appropriate funding for an individual from government agencies. Progress notes act as a measure of the care needs of residents, allowing resident dependency to be correctly assessed. It is important that changes in the individual consumer are recorded so that correct subsidy levels can be accessed.
In the community setting, an individual’s progress notes can indicate a need to refer the person for a higher level of care package.
‘If it isn’t written down, it never happened.’
Without documentation, you have no concrete evidence of services delivered or interventions implemented. As we noted earlier, some organisations fail their quality audit/review, primarily because they cannot prove they delivered services due to poor client documentation.
- while you can provide the best possible care and support to an individual,
- while you might meet all the requirements of supporting the person with consumer directed care,
- and while you can see that what you are doing is effectively meeting the needs of the consumer,
without the accompanying documentation that captures all that has been done, you may be seen as ineffective and non-compliant.