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While it is a lawful requirement to provide documentation for the care you provide in your care service or nursing home, this documentation can be used as more than just evidence of the actions you have taken. Naturally, the importance of documentation in healthcare or in aged care facilities will always be important, so the potential for using the documentation more proactively comes from the way your entire organisation is set up to deal with the documentation.
Is it done strictly as a way of covering your back only due to lawful requirements?
This guide aims to encourage you to think of documentation as more than a tedious and time-consuming chore by showcasing some of the possibilities and benefits that can arise from having in-depth documentation. At the end of the guide, we will provide our suggestions for you to get started on improving your documentation practice.
Cases are showing that documentation can be done even though time is a very scarce resource for staff. Usually, carers receive no formal training in how to document and there is no widely accepted guide for it. Only what is legally required? Does this mean that everything else should not be documented? Not necessarily! Since there is a lot of potential in gathering data. This data can be used both to optimise operations and improve care for the residents.
In theory, this all seems quite straightforward, but if it requires a lot of time and attention for the staff to record the information, then a lot of the benefits will evaporate. In order to leverage the potential of documentation, and turn it into valuable communication and planning assets, it is of the utmost importance with an efficient way of gathering data and analysing it.
Nobody wants to make mistakes, and everyone aims to reduce the number of accidents in the nursing setting to a minimum. But some incidents or errors are difficult to prevent even if you are prepared for every scenario. However, by having a complete and thorough observation log it might be possible to identify potential indicators and predictors. These observations can be used as a preventative measure in order to ensure that that particular kind of accident is reduced to a minimum. And the CQC will love you for it!
These observations are typically stored intrinsically in the organisation as tacit knowledge bound to a few employees with a lot of experience and seniority. By having better and richer observations it will help make the knowledge more explicit and easier transferable to the rest of the organisation, agency staff and new hires.
It might seem like blind luck that some care and nursing homes have very few incidents, but as Louis Pasteur said: “Chance favours the prepared mind”
Documentation is the greatest ally when it comes to quality assurance and consistency of care. If the care is thoroughly described, multiple staff members are able to provide a uniform way of care. This is particularly important when dealing with residents suffering from dementia, autism or other service users who are heavily reliant on fixed structures and routines.
When relying on documented practice to provide consistency and quality, it is even more important to avoid documentation errors. To avoid such egregious mistakes, it is important to have a fixed structure for how and what to document. Not surprisingly we recommend creating this structure through a care planning system where all relevant factors for documentation are highlighted and in pre-defined templates. It can be done in a paper version too. However, losing some searchability and accessibility.
With an offset in this previous article one of the most demotivating parts of documentation is the fact that it doesn’t get put to use. Afterwards. People feeling, they are documenting to a faceless machine will quickly provide all sorts of errors. Conversely, meaningful documentation being used among colleagues, sharing information and working collectively on improving lives. Yes, you already get the picture.
By having information in a digitised format and at hand, makes it become operational. When the care workers have access to the latest information about those people that they care for, they can transfer this to valuable service outcomes. Including agency staff!
When we reach this point, the demands of documentation are being proactively used to create better care instead of ongoingly adding pressure to shifts. Putting the focus back on to what is important: The people.
A final point regarding the strengthening of an organisation’s documentation practice is to look at the past, present, and future of the organisation. There is no “one-size-fits-all” approach to improve documentation. Every service is different in terms of history and organisation, and it is important to have this in mind when trying to improve the way we document. On top, monitoring a more needs-based perspective should allow you to further assess whether the right mix of competencies and staff is in place. Looking at the trends to set the team and solve the puzzle.
An essential benefit of documenting should be learning more about the service users. In essence, enabling you to avoid treating symptoms and rather focus on treating the people. Up-to-date and rich care logs will help provide more bespoke care.
Another benefit here is the shift from providing preventive care to a more predictive care operation. How? By using the person-led learnings recorded throughout days, months, or even years, to identify the moment someone in your service starts changing their behaviour to the negative. And proactive measures can be put in place to avoid the downward spiral. This is currently handled in the various Risk Assessments that just need more power and cohesion to fully flourish. In structured data.
Documentation based care like this will empower the staff since they will know that the care they provide makes a tangible difference. In concordance with resident wishes, interests and needs.
Care homes in the UK have their CQC inspection reports turned into a public spectacle. By digitising your documentation, you are also creating an overview of all the activities performed in your care service. This allows for many new things. One of these being a rather compelling dragon-slaying story and documentation for all the complications your staff handle every single day.
This way documentation becomes multi-faceted not only serving as proof of care but painting a much more nuanced picture than that of an inspection report.
Is it actually possible to create more observations in less time? The answer is yes if you ask Quinton House near Stratford-upon-Avon. They used to print out 30,000 sheets of paper each month, like many other nursing homes doing what they can to document sufficiently. Neither cost nor time-efficient. As a solution, they decided to digitalise resulting in way less time spent in the back office, at handovers and finishing documentation when the shift was actually over.
Usually, documentation exists to prove the actions taken by the care service. To justify its worth. When the focus is on convincing others it will quickly turn into a chore. That is why it is important to look at documentation. You are already good enough. Documentation is, therefore, another opportunity to improve as a service by learning from previous experiences.
Sometimes staff over-document, because they are uncertain of what exactly needs to be documented. In these cases, staff will typically spend a long time writing down everything, so nothing is missed. Having predefined templates for documentation combats the differences people have with the written word where some write a lot, and some not so much. All using the same terminology.
Look at how the care plan is set up for each resident? And how the actions taken are contributing towards the plan? This cohesion should dictate the documentation process itself, making it more coordinated towards the residents’ needs as well as the care workers. Do not underestimate how important it is to build cathedrals, and not just lay bricks.
Make it a higher priority to deliver care based on individual needs. It can never be a question of proper care versus documenting properly. Then we are really losing the battle. On the other hand, unreliable or incomplete documentation does not have much value. So, it is important to provide the care workers with everything from a well-thought-of framework to a simple input at the point-of-care, so that documentation can become outstanding. And the care truly person-led, compassionate and professional.
By creating several smaller best practices, it will help structure and standardise the service. However, to avoid potential mistakes and shortcomings, it requires continuous evaluation. It is necessary that important information can be accessed quickly, in order to provide a level of care that is built upon all of the care staffs’ experiences.
Here, documentation plays an important part in enabling care workers and nurses to get an overview of each individual, to easily share important information about the resident and securing their care.
Documentation will never cease to be an important part of the work conducted in nursing and care homes. Consequently, you should leverage the documentation to create benefits for both residents and staff.
Learning from the past is the best way to improve. By having the right documentation and processes in place your organisation can achieve great outcomes.
In conclusion, documentation should never become the primary focus of a care service but rather an important complementary tool to help provide the best care possible. Efficiency improvements to the process should not focus on reducing costs solely but rather improving the conditions in which the staff are able to provide care for the residents. As the Managing Director of Quinton House Nursing Home puts it:
“It’s not all about the cost-saving. It’s about freeing up the staff, freeing up the nurses’ working day. Freeing up the carers to spend more time with the residents and their families.” (Bill Mehta)