Discusses the DOs and DON’Ts of documenting client care in a variety of healthcare settings. • All client care reports and documents must be kept confidential. Reporting & Documenting Your Client Care The Purposes of Documentation 2 Making Observations 3 History of Clinical Documentation 4 Characteristics of Good Documentation 5-7 Documenting in Here are examples of customer service policies that will help you in ensuring a quality customer service in your business. Everyone thinks that money is the lifeblood of every business but the truth is the customers are the ones who contributes a lot to the growth of any business. This lesson provides caregivers with a review of the basic principles of client care documentation, including the ethics and legalities involved in documentation. The CCBHS-MHP establishes documentation standards in order to help realize the commitment to clinical and service excellence. In addition to reporting all medical errors, the nurse must assess the client's condition, render the care that the client needs as the result of the injury or accident, and also document the client's responses to these interventions. In addition, accurate and complete documentation protects providers from Keep reading to learn more about reporting and documenting your client care! It is not a finished document; it continues to get reviewed and revised depending on needs, conditions, progress. For example, be sure to document if a client refuses care or if the heat in the client's room doesn't work. Client notes record what worked, what didn’t and why ! 1. document that details the care and services the client should receive. (again, use the client's exact words.) Aged Care - Progress Notes Overview Each client, who is receiving aged care assistance, must have a Care Plan in place to ensure on-going care needs are met. There is some degree of legal protection from liability for counsellors and organisations by demonstrating planning and rationale ! It contains the diagnosis, goals, interventions. Progress Notes contribute to the review and updating of Care Plans to ensure these care needs are adequate. Unusual Events Report anything out of the ordinary that happens while you are with a client. For treatment of injuries, refer to Chapter 9, Fire, Safety and Emergency Procedures. DOCUMENTATION serves as a permanent record of client information and care. Complaints help your workplace improve client care and/or fine new ways to meet a client's needs. Reporting and documenting client care examples Reporting and documenting client care examples Documentation as Communication Reporting and recording are the major communication techniques used by health care providers. Family, Katie A, Forensics, Transitional Services, and Adult & Older Adult systems of care. Chapter 6 – Observing, Reporting and Documenting Principles of Caregiving: Fundamentals 6-5 Revised January 2011 • Numbness or tingling: This may be a sign of nerve compression. Emphasizes the importance of accuracy, attention to detail, and timeliness. Reporting & Documenting Client Care Categories Car , Care , Death , Health , Human , Mental Health , Suicide Download paper 32 The customer may ask for a status report in the middle of a reporting period, or anytime in between, so the service provider should be prepared and ready anytime. 3. DOCUMENTATION AND REPORTING 2. Client notes are legal documents that provide rationale for treatment and documentation of quality care ! Evaluating The Client Responses to An Error, Event or Occurrence Care or if the heat in the client 's exact words. are with a client reporting and documenting client care examples care or the... Examples document that details the care and services the client 's exact words. of quality care variety of settings! 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reporting and documenting client care examples

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