Documentation or charting, the wheel of communication, allows caregivers to communicate honestly and objectively about the care they have provided. It promotes good continuity of care, and describes, in detail, what was provided to the client, and how the client responded. Through charting, we communicate to other caregivers and the family our observations, decisions, actions, and outcomes. Documenting should be clear, concise, accurate, objective, factual, organized, unbiased, and should always include time. It secures that our client will receive consistent, proper continual informed care and services. Documentation is not optional. It is a MUST in all senior care situations.
When should we chart? Record your tasks, actions, and client responses along with the time they occurred. Never chart before care has been given.
What to chart? Chart your observations, care, symptoms, clients’ own words, response to care and activities, illness, unusual situations or change of condition, family info if necessary, psychosocial aspects, abrasions, cuts, pressure sores, treatments, adverse reactions to medications, initial signs, and any action you take in response to a client’s problem. When you chart an action performed by another person, make sure you note who administered the care.
How to chart? Date, time of entry, print legibly, make sure your notations are descriptive, and sign all entries.
At Home Care Assistance, we are fortunate to have an online solution that can help us with our charting needs. We also have “The Family Room,” where we invite family members access to a short verbal summary by the caregiver describing how their family member is doing. Keeping everyone in the loop is critical to providing the highest quality of care.
Always remember - “Chart as if you’re painting a picture.”
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