Complete reporting and documentation

ContentsComply with the organisation’s reporting requirements including reporting observations to supervisor 2

Verbal reports 2Written reports 4Telephone reports 4

Complete documentation according to organisation policy and protocols 6

Expected standards 6

Maintain documentation in a manner consistent with reporting requirements 8

Written reports 8

File documentation according to organisation policy and protocols 12

Release of information 12Storing and maintaining information electronically 13

Resources 16Internet 16Texts 18

Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading 1© NSW DET 2009

Comply with the organisation’s reporting requirements including reporting observations to supervisor

In the community services industry you will be required not only to provide ‘hands on support’ to clients, but to give written and verbal reports on their support and care.

Verbal reportsVerbal reports are used to ensure the person taking over responsibilities for the client (this could be other workers or the person’s carer) has full information concerning the most current care needs of the person. Verbal reports are normally given at the start of each shift (usually called the handover or changeover report), when care needs change throughout a shift and when changes occur in a resident’s condition or needs.

Workers finishing their shift should also give a verbal report of any tasks or care not completed for residents to the person taking over their responsibilities.

All verbal reporting should be:

• clear

• accurate

• concise (to the point)

• factual

• objective (what you actually see and hear not what you feel or think).

Staff receiving a verbal report should clarify points if they are not clear or they do not understand.

This would be a good time to attempt Activity 1 before moving on with the remainder of this reading.

2 Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading © NSW DET 2009

Appropriate verbal reporting mechanisms

There are many different types of verbal reporting mechanisms including:

reports made to supervisor regarding changes in resident’s condition and/or needs

the relaying of messages

meal-break handovers

end of shift, handover/changeover report

inquiries about the person

telephone inquiries, reports

case/team conferences.

As a worker you will have access to confidential and personal information. Generally, it is not part of your role to give inquirers information of a confidential nature. (Always check your role statement and the organisation’s policies to ensure you are aware of correct procedures.) Examples of confidential information are:

client details and condition

worker’s home address and/or telephone numbers

person’s financial details.

Basic skills in observation in order to report changes

Observing clients is a vital part of the care worker’s role. To be able to report changes in a client’s condition or needs, the carer must be a good observer. To observe people in your care, you must use ALL your senses. Observing is much more than just looking at the person.

Anything unusual or out of the ordinary should be noted and reported to the supervisor. For example, you may smell a strange odour, hear a moan or groan or feel an unusual swelling or lump on the skin. It is good professional practice to establish a methodical way of observing.

As already stated, it is necessary to be knowledgeable about the client you are working with in order to be effective in the care you give. ‘Care’ includes being vigilant to change and reporting that change appropriately. The age, sex and known condition and diagnosis of the client must be kept in mind when making observations. Workers must first know what is ‘normal’ before they can recognise what is not normal.

Assisting clients with personal hygiene is a good opportunity to observe skin integrity, communication skills, orientation and any changes in behaviour. Transferring clients from one location to another can provide an opportunity to observe mobility. If you are not alert during all interactions with clients then changes will be missed.

Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading 3© NSW DET 2009

Written reportsThere are many types of reports a disability support worker may utilise to document relevant information when working with a person with a disability or an older person.

This would be a good time to attempt Activity 2 before moving on with the remainder of this reading.

The expected standard of recording and reporting must meet the following requirements.

They must be legible; if your handwriting is unclear then it is advisable to print your reports.

They must be written in English.

The year, date and time must appear on each entry.

The record must clearly identify on each page the client’s:

o family nameo first nameo date of birtho medical record number (if applicable).

At the end of each written report, it must be signed and the name of the signee printed.

Alterations and errors

Errors must be appropriately corrected. The original (incorrect) entry must remain readable by ruling a single line through the incorrect entry which is then initialled by the health care worker making the correction. The correct information is then written legibly next to the error. There are to be no spaces between each individual worker’s reports.

Timeliness of documentation

Documentation should occur at the time of, or as soon as possible after, the provision of care, observation, assessment, diagnosis, management, treatment, professional advice, or any other matter worthy of note.

4 Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading © NSW DET 2009

Telephone reports

.Taking a telephone report may be necessary to relay information to a client, their relatives/significant others, other workers or carers.

Things to do:

Always answer the phone politely and pleasantly.

Slowly and clearly state who you are.

Write down a rough outline of the message.

Repeat the message back to the caller to confirm the details.

Be helpful by making suggestions if you cannot do what is being asked. For example, if a relative wants to speak to the supervisor who has gone to lunch, suggest you take the caller’s telephone number and have the supervisor ring them back after lunch.

Always end the conversation politely (eg ‘Thank you for your call, good afternoon’).

Ensure you pass on messages.

Ensure messages are written in the communication book if they are relevant to all staff.

Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading 5© NSW DET 2009

Complete documentation according to organisation policy and protocols

Reports are important as a means of providing an indication of a client’s status so that effective evaluation of care options can be planned and implemented. Reports may be in a written form (hardcopy or electronic health care records) or a verbal form (in person during staff handover or as a telephone report to another care worker). Reports that are inadequate due to sparse information, or that include irrelevant information, can have serious outcomes for funding and for the client’s care.

We live in an increasingly litigious environment in which a client or their relatives may claim negligence has occurred during or as a result of their care many years after the event, in civil and criminal proceedings. Poor documentation may therefore lead to a care worker’s competence and credibility being questioned if there are glaring inaccuracies or omissions. It is imperative for care workers to acknowledge their role in providing quality information for reporting.

Expected standardsDocumentation is an integral component of reporting and in the past ten years has become a complex task for care workers. Documentation has a central role in the process of securing government funding and quality monitoring so all records that are part of this process are open to scrutiny.

The challenge care workers face is to provide high quality direct care to clients while also providing high quality documentation that provides adequate information for the planning, implementation and evaluation of a client’s care.

There are many factors needed to be considered when filling out forms and documents. It is imperative that they are filled out in accordance with the organisation’s protocols and procedures so it is very important that you become familiar with your organisation’s requirements.

This would be a good time to attempt Activity 3 before moving on with the remainder of this reading.

6 Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading © NSW DET 2009

As care workers, we are accountable for the service we provide to our clients and the service for which we work. We are also accountable for keeping all forms and documentation up to date. One way of being accountable and ensuring care plans are the most accurate and appropriate is through record keeping.

There are a number of issues to be aware of in record keeping:

Confidentiality: Information in these records of a person’s life will be very personal in nature. So they should be kept in a secure location where only those people who need to view the records can.

Language: Language used in these files should be non-judgmental and positive. Remember that the person who the records are about should be able to read them without feeling insulted. It is a good idea to keep records jargon free as well, so everyone who reads them will be able to understand them. Don’t forget your writing needs to be clear and legible as well. The organisation you work for may have standards that are required of you with regard to this.

Identification: As previously mentioned, you are accountable, so records you are completing should clearly state your name and signature and the date. They should be arranged in an ordered way so access to different forms is easy.

Accuracy: Your records should only contain facts. If you include information about what you feel or believe, then you must state this. Don’t use language such as ‘Joey doesn’t like working with Hamish’ because you observed Joey getting irritable with Hamish when working with him in the youth program. Instead, you could state, ‘Today I observed Hamish looking confused when Joey got annoyed with him’: this is fact. You could add, ‘I am concerned that possibly Joey doesn’t like working with Hamish, I will need to investigate further’.

Including the person’s views and goals, and those of the significant others in their life: Make it easy for the person to have an opportunity to have their own entries in the records, and allow them to challenge and change entries you may have made.

It is most important that the person consents to information about them being shared. Having the person or a responsible person sign a consent form acknowledges that permission has been granted to do so.

Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading 7© NSW DET 2009

Maintain documentation in a manner consistent with reporting requirements

Health and community services records are permanent, legally accountable documents that must accurately record client needs, the actions of the worker/s concerned and general service delivery practices.

As already mentioned, these records may be produced in court to substantiate or refute client claims, to support funding submissions, and/or to measure service outcomes and quality care provisions.

Organisations and agencies usually have guidelines and procedures about correct documentation methods. Workers need to comply strictly with these organisational requirements.

To find out about an organisation’s policies: ask your supervisor or work-based learning coordinator look at the organisation’s policy and procedures manual ask other staff members inspect current case files, letters, etc if you have permission.

You have a responsibility to find out what the organisation expects and then abide by the rules. If you don’t agree with the organisation’s guidelines and procedures, you need to discuss your concerns with your supervisor.

In general however, follow the basic rules outlined below.

Written reportsReports, regardless of their particular written form (eg charts, progress notes) must be:

legible—print if your handwriting is unclear

written in plain ENGLISH

include the date and in some instances the time of each entry

identify the person’s family name, first name, date of birth, medical record or client number

stored for seven years after the person ceases to receive services.

8 Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading © NSW DET 2009

Legal implications

CSI and health documentation can be subject to close and careful scrutiny during civil (allegations of negligence) and criminal legal proceedings and therefore must reflect a professional approach. It must be:

accurate

objective

legible

brief and complete.

Written records are ‘legally accountable’ and therefore the person who gives the care must record their actions or observations factually. Do not use yellow sticky notes, these get lost, do not write in pencil, do not erase entries, and do not leave spaces between entries to write things in later.

Record all the important issues but do not ‘pad out’ the record with non-essential information.

Workers often need to gather and record information about a person to assist in the development, monitoring and evaluation of service plans. Be observant, this will help in the early identification of potential problems. Document needs and problems but most importantly document any changes in the client and/or variations in normal service delivery.

Alterations and errors

Errors must be appropriately corrected. The original (incorrect) entry must still be legible after the correction. The care worker making the correction rules a single line through the incorrect entry, and initials it. The correct information is then written legibly next to the error.

There are to be no spaces between individual care worker reports. This ensures that information cannot be added at a later stage.

Do not use correction fluid to correct errors.

Do not use water soluble ink, red or blue pens or pencils.

Accuracy

It is very important that records are accurate at all times and completed in identified timeframes.

Things to do: Ensure the client’s name is on all pages. Check the client’s name on the record before making an entry. Write date and time on all entries.

Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading 9© NSW DET 2009

Make sure entries are in chronological order. That is, date and time of reports must follow on, with no gaps between reports.

Document what you observe and do for the client. Be brief and complete about issues relevant to the clients’ support. Document events and observations as they occur to minimise

confusion of the events.

Things not to do: Do not write reports on behalf of other workers. Do not use abbreviations which are not widely acceptable by the

organisation. Do not use words you do not know the meaning of. Do not document events witnessed by others as factual if you did not

witness the event yourself.

Ensure your reporting is accurate. For example, do not write, ‘Mr Miller was assaulted by another client’ if the correct entry should read, ‘Mr Miller stated he was assaulted by another client’.

Legibility

Things to do: Write the documents clearly to avoid mistakes. Printing may be an alternative when handwriting styles are not easy

to read. Write reports in English. Draw lines through errors using a ruler and initial the change. The

original incorrect record must remain readable. Document using a black ballpoint pen only to avoid smudging. Use correct spelling, punctuation and grammar at all times when

documenting.

Things not to do:

Do not use correction fluid to correct errors.

Do not use water soluble ink, red or blue pens or pencils.

10 Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading © NSW DET 2009

Comprehensiveness

Things to do:

Consider the readers of your documents.

Check previous entries for continuity of support and follow-up action.

Consider the purpose of your records (eg are you reporting what you have observed or found, are you presenting ideas or recommending actions be taken).

Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading 11© NSW DET 2009

File documentation according to organisation policy and protocols

All client information should be stored and maintained in accordance with organisational protocol and procedures that are based on legislation, in particular the Information Privacy Act 2002.

Care records are working documents that must be accessible to all authorised care workers when required for the care and management of the client, however, a system needs to be in place for their secure filing, storage and retrieval. The policies and procedures which guide workers cover issues such as documentation, the maintenance of confidentiality, methods of filing and retrieval.

Release of information and removal of records from the organisation should only be allowed in response to a search warrant, subpoena or written authority from the Coroner. Policies and procedures provide security safeguards in organisations to protect the information of individuals. It is your responsibility to become accustomed to the policies and procedures of the organisation you work for.

This would be a good time to attempt Activity 4 before moving on with the remainder of this reading.

Release of informationInformation may only be released in accordance with statutory and legal requirements, and record handling should respect the privacy of clients at all times. Ensure you follow your organisation's policies and procedures in relation to release of information by telephone, faxing of clinical information or the use of e-mail.

When faxing sensitive information, use a cover sheet that includes a confidentiality note. Thermal paper faxes should always be photocopied before filing in any records because the print on thermal paper fades over time. Confidential records should only be faxed from one organisation to another in exceptional circumstances, and then only if the receiving institution can guarantee the confidentiality of the information provided.

12 Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading © NSW DET 2009

Personal information is often collected and used to plan appropriate treatment and care for the individual. Personal information may also be discussed where legally required, for instance submission of data to the NSW Department of Health. Reasonable steps must be made to make sure that the personal information collected, used or disclosed is accurate, complete and up to date. Remember, privacy and confidentiality of personal information must be respected at all times.

Remember, only authorised persons may:

access client information

use client information

disclose client information.

This would be a good time to attempt Activity 5 and 6 before moving on with the remainder of this reading.

Storing and maintaining information electronicallyIncreasingly, community service organisations are storing information electronically. This saves paper and storage costs, and can be accessed securely and easily by a number of staff. But, like a manual system, there is a need to have an organised way to store and access the information. Some organisations now have quite a sophisticated system of storing information including shared files and intranet. But whether you are working in a small or a large organisation it is vital that there is a system for storing information that is accessible and that all staff understand. This system is usually written about in the policies and procedures manual.

You will need to know or be able to learn how to set up electronic files, save them and put them in folders. Most organisations now use individual passwords for staff to access their individual computer or the organisation’s computer network. This ensures security of information.

You need to consider the rights of clients in being able to access their information. Does the person require computer literacy to access their information or are they reliant on a worker for their password? This is where hard copies are useful as a backup.

Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading 13© NSW DET 2009

Creating and accessing files

At a basic level, workers are often expected to create a file, save it and then access it again to make changes to it. Once you can do this, it makes writing so much easier.

This would be a good time to attempt Activity 7 before moving on with the remainder of this reading.

Password

When you deal with confidential information that you are storing on computer, it is important that you have a password. This means that someone else cannot access information you have written. Try and think of a password that someone else would not guess easily. Do not leave the password written on a piece of paper stuck to your computer or on a noticeboard near your computer. This is an invitation for unauthorised people to access your work or documents. In case you forget what your password is, it’s a good idea to write down your password in a private place that only you know about.

Backing up information

Your organisation will have a policy on backing up information. You may be required to back up your own information. Alternatively, there may be someone in the organisation whose role it is to regularly back up information on all computers. Most organisations would be backing up at least once a week and often it will be more regular, depending on the nature of work undertaken in the agency.

Intranet

When there are a number of people in an office or in a number of offices/locations, an internal system to access and manage files is often adopted. This is called an intranet. An intranet is an internal website that stores organisational information. It’s usually only accessed by staff of the organisation that have a password to the system. An organisation’s intranet may contain guidelines, policies and procedures, forms, minutes of meetings and newsletters.

14 Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading © NSW DET 2009

Databases

A great way to store information that once was put in bulky directories is to use a database such as Microsoft Excel or Access. Databases are flexible and can update easily. There is often one person in the organisation responsible for updating the database.

Databases might include information about:

local community organisations

members of the community organisation

clients.

Confidentiality is very important with regards to databases.

Folder heading system

You need to have a system of naming files within folders so you can find your files. Like a filing cabinet, you need to have drawers, and folders within the drawers, that are clearly labelled so you can find information. When there are multiple users of computers and files it is essential that the file names are clear and ordered. Some organisations use a letter and numbering system to store their electronic files and documents while others have a series of clearly identified words.

Most organisations will have a Service User File which holds important information about the person, such as their profile and medical history. The following documents should be placed in the appropriate section of this file:

individual plan

any consent forms

reviews

medical reviews.

These documents should be kept accurate and up to date as changes occur.

Even within these folders there may be other sub-folders; that is, a folder within a folder.

If the agency has a network you may find that some files are stored on the network while others may be stored on individual computers. Next time you are at your workplace or visiting another agency ask them how they organise their information on computers.

Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading 15© NSW DET 2009

Resources

InternetAged Care Organisations - http://www.drstqm.com.au/downloads/confVan05.pdf

Aged Care Standards & Accreditation Agency LTD – Accreditation standards - http://www.accreditation.org.au/accreditation/accreditationstandards/

Australian Bureau of Statistics 2005, Australian social trends – health – older people with disabilities – http://www.abs.gov.au

Australian Bureau of Statistics 2008). 4704.0 The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander people - http://www.abs.gov.au

Carers Australia NSW http://www.carersnsw.asn.au/storage/pdfs/policyNew/LTCSCNSWsubAug05.pdf

Carers Australia – Surviving the Maze – How to find your new carer role in residential care - http://www.survivingthemaze.org.au/BCFC/PDFS/GEN-04-07.pdf

Carers Resources on-line http://www.community.wa.gov.au/DFC/Communities/Carers/Carers_Statistics.htm

Commonwealth of Australia 2007 Charter of Residents Rights and Responsibilities http://www.health.gov.au/internet/main/publishing.nsf/content/ageing-publicat-resicharter.htm

Commonwealth Disability Act (1986) http://www.hreoc.gov.au/disability_rights/Standards/standards.html

Department of Ageing, Disability and Home Care (DADHC). NSW Disability Services Act (1993).http://www.dadhc.nsw.gov.au/NR/rdonlyres/898B1EC7-FFED-4F87-83F0-E7C25D504C61/668/Standardsinaction_93582882.pdf

16 Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading © NSW DET 2009

Department of Health and Ageing – Your role as a carerhttp://www.agedcareaustralia.gov.au/internet/agedcare/publishing.nsf/Content/Your+role+as+a+carer-2

Government of South Australia – Information sheet - Equipment to Assist with Vehicle Transfershttp://www.dircsa.org.au/wp-content/uploads/2008/04/ilc-equipment-to-assist-with-vehicle-transfers-2007.pdf

Interactions – a guide to assisting people with disabilities - http://www.studentservices.utas.edu.au/adcet/nswcoop/interact/p3hfpa.htm

JobAccess – Australian Government – Mobility aidshttp://www.jobaccess.gov.au/JOAC/Advice/SupplierOrAssessorTwo/Mobility_Aids_Australia_P.htm

JobAccess – Australian Government – Transfer aidshttp://www.jobaccess.gov.au/JOAC/Advice/ProductOrSolutionTwoB/TransferAidsSpecificTypes.htm

London Health Sciences Centre http://www.lhsc.on.ca/critcare/icu/focis/words/dvt.html

Mosby’s Nursing Consult http://www.nursingconsult.com/das/patient/view/1304477292/10072/23197.html/top?sid=826885590&SEQNO=3

Nucleus Medical Art – Anatomy of the eye http://catalog.nucleusinc.com/display_interactive.php?movie=interactive/IM_EYE.swf&name=EyeAnatomy&title=Interactive Anatomy of the Eye&width=720&height=480&bgcolor=ffffff

Nucleus Medical Art – Measuring your blood pressure http://catalog.nucleusinc.com/display_interactive.php?movie=interactive/high_blood_pressure.swf&name=HighBloodPressure&title=Measuring%20Blood%20Pressure&width=1024&height=768&bgcolor=A5AA79

Royal Children’s Hospital Melbourne http://www.rch.org.au/rchcpg/contact.cfm?doc_id=5865

SEE http://www.changechampions.com.au/resource/Anne_C_Duncan.pdf Victorian Respiratory Support Service

Shaun McKay Queensland Department of Health http://www.health.qld.gov.au/qals/docs/prosthetist_ah.pdf

Solange Kindermann 2007 Golden Carers resources for leisure and recreational professionals = http://www.goldencarers.com.au/how-to-write-a-care-plan.php

Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading 17© NSW DET 2009

Standards In ActionAgeing and disability department http://www.dadhc.nsw.gov.au/NR/rdonlyres/898B1EC7-FFED-4F87-83F0 E7C25D504C61/668/Standardsinaction_93582882.pdf

Thirdage http://www.thirdage.com/health-wellness/percutaneous-endoscopic-gastrostomy-peg

University of Virginia What is a Percutaneous Endoscopic Gastrostomy (PEG)? http://www.healthsystem.virginia.edu/internet/digestive-health/nutrition/WhatisaPEG.pdf

Victorian Respiratory Support Service http://www.changechampions.com.au/resource/Anne_C_Duncan.pdf

Wikipedia – Mobility aids http://en.wikipedia.org/wiki/Mobility_aids

Workcover. http://www.workcover.nsw.gov.au/Documents/safebusiness/pdf/CommunityServicesSafetyPack_4421.pdf

TextsAccess Economics (2005). The Economic Value of Informal Care August 2005, commissioned by Carers Australia. Definitions taken from Australian Bureau of Statistics (2004). Disability, Ageing and Carers, Australia: User Guide, 2003.

De Maria, A. 2005 Personal Care in a Home and Community Care Environment, Enable Learning Guides

Printwest TAFE NSW 2004 Assist in Provision of an Appropriate Environment

Printwest TAFE NSW 2004 Comply with Aged Care Information

Printwest TAFE NSW 2004 Orientation to Aged Care Work

Printwest TAFE NSW 2004 Plan and Monitor Service Delivery Plans

Printwest TAFE NSW 2004 Provide personal care

Printwest TAFE NSW 2004 Provide Support to an Older Person

Printwest TAFE NSW 2004 Support the Older Person—Emotional and Psychosocial Needs

Ranasinghe - Where to Begin Risk Management in Long Term Care in Australia

18 Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading © NSW DET 2009

Sorrentino, SA, & B Gorek 1999, Textbook for Long-Term Care Assistants, Mosby Inc. Missouri.

State of New South Wales, Department of Education and Training 2007 - CHCAC1C Provide support to an older person

State of New South Wales, Department of Education and Training 2007 - CHCAC2C Provide personal care

State of New South Wales, Department of Education and Training 2007 - CHCAC6C Support the older person meet their emotional and psychosocial needs

State of New South Wales, Department of Education and Training 2007 - CHCDIS10B Provide care and support

State of New South Wales, Department of Education and Training 2007 - CHCDIS12A Provide care and support for students with severe physical disabilities

State of New South Wales, Department of Education and Training 2007 - CHCDIS13A Support older people with disabilities

State of New South Wales, Department of Education and Training 2007 - CHCDIS17A Provide care and support for students with disabilities

State of New South Wales, Department of Education and Training 2007 - CHCINF8A Comply with information requirements of the aged care and community care industry

TAFE NSW 2008 Aged Care in Australia: a guide for aged care workers

Certificate IV in Disabilities: CHCICS401A: LO 8575 Reading 19© NSW DET 2009