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Recording care with objectivity, legibility and speed!

Friday 1 May 2015 - Filed under care home management + CQC Inspections + domiciliary care and supported living + nursing home management

It goes without saying that in a CQC audit the Inspector will look for written proof of the care that has been provided. After all that is what an audit is about; select a small number of residents as sample cases and analyse their records. If any anomalies come to light then drill down further and possibly widen the audit to include other resident records.

But that means the care provider has to ensure their care staff are recording their shift notes in the quantity and quality required to provide the depth of record sets that an Inspector requests. Which brings to mind a number of obstacles. Handwritten notes can be subjective and may contain what could be regarded as inappropriate phraseology. Text such as ‘enjoyed a good day’ may be deemed meaningless as a record of the mood or care provision of the resident.  Additionally, recent years have seen an influx of overseas staff into the care sector. A percentage of these will have English as their second language which could present problems with the meaning and accuracy of the words used in care records. Beyond these concerns legibility would always be an issue from the mix of handwriting styles that carers bring with them and also, how contemporaneous the notes are without authoritative electronic means of time stamping.

Our care-Log+ care record management software addresses these areas by a two pronged approach. First, carers are presented with shift note documents that have multiple prompts each with a selectable option menu for them to record what happened across care needs such as continence, drinks taken, quantity of food consumed, etc. Additional text can be entered as well if a greater description is required. Second, care-Log+ presents these shift note documents on tablet PCs. With touch screen ease of use combined with placement in accessible  locations around the home, all recordings are automatically time and date stamped together with the user ID and then wirelessly added to the central database automatically.

The end result is that the required volume of records is achieved with objectivity and speed yet with reliability and accuracy that is fully auditable. In short, the balance between giving care and recording care is firmly restored in favour of what carers are actually employed to do.

If you would like to discuss any functionality or issues raised in this blog please call one of our team on 01892 834406 or e-mail us on info@easylog.co.uk

 

 

2015-05-01  »  administrator

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