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.

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