8 reasons why client and service documentation is so important.

8 reasons why client and service documentation is so important.

Record keeping should be held incredibly high on the priority list. It is so important for the safety of yourself, your business and your clients. 

 

1. Communication:

Client documentation is an effective way for staff and other service providers to share information. Because there may be more than one service provider assisting an individual, it's important for everyone to be on the same page.

 

2. Legal Requirements: 

 In a court of law, all documents relating to an individual's care and support can be used as evidence. All care recipients have a legal right to receive safe, professional care and support, as well as accurate and true documentation. Additionally, ensuring that regular note taking is obtained can protect business practices in cases where participants or managers question delivery of supports. Case notes provide a multitude of important benefits on a legal level.

 

3. Assessment:

Client progress notes can be used as a major reference source by coordinators and case managers when conducting a re-assessment. They can use the data to assess how effectively a specific strategy is accomplishing the individual's stated objectives. Notes may also show if the client is improving or deteriorating, prompting care changes or identifying needed referrals.

 

4. Continuity of Care:

In addition to facilitating effective communication, comprehensive documentation allows all personnel to understand a client's current care needs. As a result, there is more consistency in terms of assistance and care. Staff or family members might be reminded of certain actions via documentation. When regular staff are not available  and a relief support worker is brought in, for example.

 

5. Shared Knowledge:

Consider a period when you were in the hospital or visited a family member or friend who was in the hospital. Staff members, including doctors, work different shifts, so a patient may be seen and helped by a variety of people during their stay. Each staff member can learn the individual's medical history and any interventions that are relevant to their care and support needs thanks to client documentation. The information gleaned from this history can then be utilised to guide future interventions and activities. Organisations that provide care services rely on their employees' capacity to convey pertinent information to achieve high-quality results.

 

6. Continuous Quality Improvement:  

Even though the industry has some established standards, and your organisations may have policies and procedures in place, you cannot get complacent. Individuals' and their families' expectations shift. Good documentation can help you spot trends in an individual's demands, your target customer group's wants, and your workforce's needs in the future.

 

7. Funding:

Documentation aids participants in receiving appropriate and proper financing from NDIS.  Progress notes serve as a gauge for participants care needs, providing for an accurate assessment of their dependency. It's critical to keep track of changes in individuals so that the proper subsidy amounts may be accessible. Additionally, In the community, an individual's progress notes may suggest that the person needs to be referred for a higher level of care.

 

8. Physical Evidence:

‘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. (in the early days, i was bitten by this rule)

 

So, 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.

 

That Business Co Has a range of documentation templates available.

A more detailed template can be found here:

https://thatbusinessco.com/products/daily-care-giving-checklist?_pos=1&_sid=9c14b365c&_ss=r

Our Weekly tracker can be found here:

https://thatbusinessco.com/products/weekly-care-giving-tracker?_pos=1&_sid=0a5b76b19&