If you or your team record case notes, write reports, take decisions that impact on others or inspected by #CQC then you need to make sure your notes, records, reports and decisions are accurate, robust and fully defensible.
That is to say that in the event of challenge by clients or services users, at any point up to and including court action, your documentation will support your decisions and withstand the toughest of interrogation.
Poorly written notes and reports leave your decisions open to challenge and #litigation; with potentially serious consequences for you and your organisation.In the event that any organisation faces claims for damages, the managers and staff involved will rightly have their own performance questioned.
High quality documentation provides robust evidence to show that staff are fulfilling their duties properly. They also give staff peace of mind that every aspect of care has been completed correctly.
Further they help improve care for clients and service users. Robust tracking, recording and planning improves the consistency of care and allows for faster and more reliable identification of changes in the client or service user’s condition.
It is imperative that all managers ensure that the notes, records and reports their staff produce are high quality, accurate and fully defensible.That, if necessary, they can be produced in court and they will support the decisions that have been taken and present a favourable image of the organisation those involved.
Given the potential consequences of poor quality documentation managers and organisations need to ensure all case notes, records and reports are to a high standard. A 5 point strategy is proposed
1.Clear standards for the quality of notes, records and reports need to be developed
2.Staff and managers need to understand these standards, policies and procedures
3.Staff and Managers need be trained in these standards, shown examples of good and bad documents and understand the consequences of poor documentation
4.Documentation needs to be audited/moderated on a regular basis
5.Development plans and retraining needs to evolve from the audit and moderation action
To assist with implementation Concrew Training has developed a lively, fun and participative one-day training course for managers and staff.