Care Notes
"Client had a BM 💩👍"
"I think..."
What is improper about these notes?
Emojis and personal opinion
When do you read your clients ADL's?
- When the schedule is released
- The day of the shift.
If I am having trouble clocking in or out, submitting care notes or completing ADL's, I should call the office right away for assistance.
True or false
True
Meredith had a last-minute family emergency and wasn't going to make it to her shift. She quickly texted the scheduler to let her know before packing her suitcase to head to the airport.
- Initiating communication with the office through text
- Not calling the office
If you are running late to your shift, _________ should be done before the shift start time
Call the office
Why is "Client refused shower" incomplete?
Lacks reason, redirection attempts and client response.
Your client refused their medication today; check off Med reminders ADL as complete.
True or false?
False
I complete my ADL's after I have already clocked out.
True or false?
False - all ADL's must be completed before you clock out
A client offers you cash as a 'thank you'. What should you do?
Politely decline & report to the office per Synergy policy.
Your client almost falls but you are able to successfully able to stabilize them. What should you do next?
1) Notify the office
2) Document incident in care notes & complete incident form.
3) Safely monitor client
What is the risk of documenting care notes after your shift instead of in real time?
Inaccurate details, compliance issues and legal risk.
You notice your clients laundry hamper is full, you ask your client if they would like help getting laundry done, this task is not listed in their ADL's, but they agree and tell you that it would be really nice to start having help with their laundry. What should you do to make sure the client has regular assistance with laundry?
Call the office to the let them know so the ADL's can be updated
I should read through the ADL's at the end of every shift.
True or false?
False
Taylor arrives for her shift and her client appears to be sick and running a fever. The client asks Taylor to take her temperature and so Taylor does and it is 102 degrees. Taylor tells the client this and then notes it in the care notes.
Name policy violation.
1) Taking a client's temperature
2) not calling the office to notify of a change of condition
3) Documenting vitals
You notice a bruise on your client with dementia, she cannot explain where it came from. What should you do?
Document the bruise and notify the office and complete change of condition
Care note says: "Helped my client to the bathroom."
What is missing?
Level of assistance needed, any mobility aids used, toileting outcome, safety concerns (if any)
If I observe a change in my clients condition or their routine is now different from the ADL's, what should I do?
Call the office, document in care notes, and complete change of condition form (if needed)
I should discuss my availability and schedule directly with my clients
False
Linda forgot to get gas in her car so she had to stop on the way to Windcrest for her shift which didn't give her time to find a parking spot right away. She decided she would clock in once she parked her car because she was "on the property and near the client's building".
Name the Policy Violation
Clocking in before she is standing in front of the client
Not calling the office to inform them of the tardy
Harry's client told him today that she does not need to take her critical medication at 9am.
What steps should Harry take next?
1) continue to encourage her
2) call the office
3) Document in care note and ADLs
What four things should care notes include?
Hourly time stamps, tasks performed, level of assistance and clients response.
Your client refuses a shower today, but it is a required ADL. You do not check off "Showers" in ADL's since it was not complete. What else must be done?
Documentation in care notes
Call the office
If my client cannot open their pill box and remove their medications, I can take it out for them and hand them each pill.
True or False
False
Your client that you regularly see asks you to come in on a day that you are not usually scheduled; you agree because you feel guilty and don't like to tell your clients no, but you have plans you already committed to you don't want to miss.
What is the policy violation?
Discussing schedules with your clients - call the office.
During shift change for my 24/7 client, the relieving caregiver asks me if I can swap shifts with her tomorrow. What should I do to ensure I am following Synergy's procedure and policies accurately?
Do not agree, advise the caregiver to call the office to inform them of the situation. The Synergy office will handle all scheduling matters.