It is a legal requirement that all care given is documented.
As we monitor ongoing care, each client is provided with a folder containing the initial assessment, progress notes, diet charts, and observational charts as well as other documentation as required.
Documentation will include:
- All treatment given.
- All drugs administered, including times & dosage.
- Charts of input and output.
- Record of clinical observations.
- Record of any other treatments ordered.
Other health professionals involved with the care of our client are also encouraged to use these notes as a form of communication with the carer, the client and their family.