If you are running a care home, you would already know the importance of record keeping. An accurate record keeping is an integral part of the care management of the residents. There are several reasons record-keeping is important but primary reasons are:
- Easy access to a complete record of the resident’s medical journey.
- It ensures a seamless circulation of information among the different teams involved in the resident’s treatment or care.
- With well-kept records, you can identify the areas of improvement of practices and implement changes accordingly.
While there are no two ways that good record keeping is an essential aspect of caregiving. There are certain fundamental principles that should be followed. Whether your records are hand-written or digitized, here are some of the principles that help you maintain accurate records at your care home:
1.Know the tools of record-keeping: Make sure the care workers handwrite legibly so that when the document is referred to again, it is easily understood without any confusion. Any spelling error or missing word may lead to confusion. If your care home uses a computerized record, make sure all the entries are keyed correctly. Before writing or keying the information, make sure that it is accurate. Ensure that the staff members are up to date on the information systems and tools that are used at the workplace.
2.Maintain the integrity of the record: It is your duty to ensure the confidentiality of the records maintained. Care workers should not share with anyone – any passwords or cards that are given to them to enable access to the systems. They should make it a point not to leave written records in places where unauthorized people might see them. If your care home uses an electronic system, make sure each and every care worker signs out when they are done.
3.Avoid convoluted phrasing: Records are not just for internal communication but they can also be used as evidence in case of a complaint. It is thus crucial that events are recorded accurately and clearly. The care staff should avoid unnecessary abbreviations or convoluted phrases that may not be clear to other team members. They should write in a simple language so that if the resident or his or her family member wishes to see the record at some point, they will understand without difficulty.
4.Avoid overwriting: Care workers should not change or overwrite somebody else’s entry. If they do wish to make amendments, they need to ensure that it is done clearly. Make sure the change has been signed by the concerned staff and the date reflects when the change was made.
5.Record information relevant to the residents’ care: The care team must record events they may think are contributing to the resident’s care. If a resident’s behavior seems off-key then it must be recorded. However, while recording such an episode, they must focus on facts and not assumptions and speculations. The language used to describe the event should be dignified and in no way insulting or derogatory.
Maintain records effectively with electronic MAR sheet
Record keeping should be a routine practice and not something optional. Record keeping makes the continuity of care easier. Many care homes in the UK have switched to eMAR, electronic medication administration record system, to keep streamline operations. The electronic template is the same as paper-based MAR sheets, making it easy for care workers to adapt. eMAR not only helps in reducing medication errors but it also records medication notes prepared by the staff.