Better Care Notes and Documentation

 

better care notes requires a positive focusLately, professional documentation of care notes has been a concern for both care providers and clients. Better care notes serve as a guide for parents and their case managers to know what our care provider and their child have done during their time together. Care notes are used as data to mark the progress of the child and/or concerns that the care provider may have for this child. As a parent, please do not hesitate to ask the care provider to go into greater detail in the care notes, or request that the care notes be rewritten.

Care providers, here are some words of advice to address some of the common concerns about care notes:

How to Write Better Care Notes

1.Make sure all your documentation is professional

2.Use proper grammar in your documentation. There should be no slang.
Write “out of,” not “outta”
Write “had snot and drool,” not “was snotty” (could be misunderstood)

3.Write your name and care notes legibly and neatly. Especially on the medication sheet.

4.Remember to write the facts about what happened, not subjective opinions.
For example, stating a client was being “testy.”  This is opinionated/labeling. Please note clear facts.

5,On shift duties and medication records, be sure to sign your initials or write “n/a” on each line if the duty did not apply to you on your shift. At the end of your shift, make sure there are no blank lines.

6.Try to “paint a picture” of what happened in your documentation so that anyone who reads it has a clear idea of what happened on your shift.
For example, “his pants are wet…as of right now they are in the washer,” should be clear and state that the care provider assisted the client by changing his pants when they were wet.
7.Document when clients get their showers: if the client assisted and with what (i.e. washing their own hair and body).
8.Document the specific activities you did with each client on your shift, where you went, what they did by themselves and what you assisted with. For example, you can state, “I drove Amy to the park and pushed her on the swings. She appeared happy because she was smiling and clapping her hands.

Remember to always include what goals are being addressed!