The CCBHS-MHP establishes documentation standards in order to help realize the commitment to clinical and service excellence. This lesson provides caregivers with a review of the basic principles of client care documentation, including the ethics and legalities involved in documentation. There is some degree of legal protection from liability for counsellors and organisations by demonstrating planning and rationale ! (again, use the client's exact words.) Chapter 6 – Observing, Reporting and Documenting Principles of Caregiving: Fundamentals 6-5 Revised January 2011 • Numbness or tingling: This may be a sign of nerve compression. Evaluating The Client Responses to An Error, Event or Occurrence Keep reading to learn more about reporting and documenting your client care! Reporting & Documenting Client Care Categories Car , Care , Death , Health , Human , Mental Health , Suicide Download paper 32 Everyone thinks that money is the lifeblood of every business but the truth is the customers are the ones who contributes a lot to the growth of any business. In addition, accurate and complete documentation protects providers from The customer may ask for a status report in the middle of a reporting period, or anytime in between, so the service provider should be prepared and ready anytime. 3. For example, be sure to document if a client refuses care or if the heat in the client's room doesn't work. Here are examples of customer service policies that will help you in ensuring a quality customer service in your business. For treatment of injuries, refer to Chapter 9, Fire, Safety and Emergency Procedures. Complaints help your workplace improve client care and/or fine new ways to meet a client's needs. Documentation as Communication Reporting and recording are the major communication techniques used by health care providers. Client notes are legal documents that provide rationale for treatment and documentation of quality care ! 1. Reporting and documenting client care examples Reporting and documenting client care examples DOCUMENTATION AND REPORTING 2. Progress Notes contribute to the review and updating of Care Plans to ensure these care needs are adequate. Unusual Events Report anything out of the ordinary that happens while you are with a client. Discusses the DOs and DON’Ts of documenting client care in a variety of healthcare settings. Family, Katie A, Forensics, Transitional Services, and Adult & Older Adult systems of care. document that details the care and services the client should receive. It is not a finished document; it continues to get reviewed and revised depending on needs, conditions, progress. • All client care reports and documents must be kept confidential. Aged Care - Progress Notes Overview Each client, who is receiving aged care assistance, must have a Care Plan in place to ensure on-going care needs are met. Reporting & Documenting Your Client Care The Purposes of Documentation 2 Making Observations 3 History of Clinical Documentation 4 Characteristics of Good Documentation 5-7 Documenting in It contains the diagnosis, goals, interventions. DOCUMENTATION serves as a permanent record of client information and care. Emphasizes the importance of accuracy, attention to detail, and timeliness. In addition to reporting all medical errors, the nurse must assess the client's condition, render the care that the client needs as the result of the injury or accident, and also document the client's responses to these interventions. Client notes record what worked, what didn’t and why ! Not a finished document ; it continues to get reviewed and revised on! 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