Care Notes
What four things should care notes include?
Sally's client told her today that she does not need to take her critical medication at 9am. Sally encouraged her again but she got upset so Sally let her be.
Not calling the office
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
Your client refused their medication today; check off Med reminders as complete.
True or false?
False
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. Name the policy violation.
- Initiating communication with the office through text
- not calling the office
Why is "Client refused shower" incomplete?
Lacks reason, redirection attempts and client response.
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
A client offers you cash as a 'thank you'. What should you do?
Politely decline & report to the office per Synergy policy.
"Client had a BM 💩👍"
"I think..."
What is improper about these notes?
Angelica arrives for her shift and her client appears to be sick and running a fever. The client asks Angelica to take her temperature and so Angelica does and it is 102 degrees. Angelica tells the client this and then notes it in the log notes. Name the policy violation.
1) Taking a client's temperature
2) not calling the office to notify of a change of condition
3) Documenting vitals
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)
What is the risk of documenting care notes after your shift instead of in real time?
Inaccurate details, compliance issues and legal risk.