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If it’s not written in the care records, then it didn’t happen!

How many times have I heard this phrase said to families?

I recently updated a care needs report for a client’s relative in preparation for a CHC review. The care records showed their needs had remained unchanged since the previous review. At the time I felt confident that funding would continue for another year. To my surprise, instead of accepting the assessor’s recommendation, the Clinical Commissioning Group asked for more information to support it. Once the assessor provided more evidence, I am pleased to say funding was granted for another 12 months.

The question of whether there is sufficient evidence to support a primary health need, and therefore NHS funding, can be contentious, because ‘how much evidence is necessary?’ The National Framework says ‘that evidence does need to be proportionate to the situation’ page 115 21.2

Yet in practice, there can be a disproportionately ‘forensic’ attitude in requests for evidence.  Of course, I acknowledge the need to provide evidence to show how an individual’s needs are being met, for example when the focus of the need is behaviour - in this scenario behaviour charts will normally suffice.

In my experience the phrase ‘it’s not written in the records’ is often voiced at Continuing Healthcare Assessments. The implication of this is that undocumented needs cannot be considered. This, in turn leads to frustration and distress for families who feel let down by those caring for their loved ones, as well as the NHS, because of its impact on assessment of the level of needs within each domain, and more importantly whether funding is awarded.

Care staff often report that time pressures result in little opportunity to complete detailed care notes. I do not condone why inadequate recording takes place, but this is frequently the reality due to the current system in place, which is far from perfect.

The interpretation of proportionality is too varied in practice and so when reviewing client’s health needs, I am acutely aware of the fact that the notes may not fully reflect a client’s needs. If a client’s needs are not being captured adequately, I address this with those caring for them to ensure that when it comes to a review or full CHC assessment that the client’s needs are fully documented. I would advise family members to do the same, acknowledging the acute pressures that care staff can be under.

Record keeping is fundamental to nursing practice and its importance is embedded in our Code of Practice - Read my full article here:  Care Records & NHS Continuing Healthcare 

If you have somebody who requires assistance in the preparation of a Continuing Healthcare Review or Assessment, or you are concerned about inadequate record-keeping  – please do not hesitate to get in touch.

Blog by: Judy Timson | Clinical Advisor 

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