There is no doubt that stories we hear and read about in the media regarding poor and inadequate care will necessitate a scrutiny of nursing records as part of any investigation. The reality is that care staff frequently report time pressures, resulting in little opportunity to complete detailed care notes. These are often written at the end of a shift as opposed to as and when care is actually completed.
The implementation of digital record keeping i.e. hand held devices, has assisted in enabling ‘real time’ documentation of care. In the acute sector, mobile devices are revolutionising the real time communication of treatment, plans and results between professionals.
However, in the context of preparation for a NHS Continuing Health Assessment, the issue of insufficient detail regarding an individual’s needs remains one of the biggest frustrations for the relatives of an individual going through the process.
With the recent pandemic preventing relatives visiting their loved ones in care homes, I am receiving many calls from relatives due to attend an assessment who are anxious about their disconnect in terms of ‘what is the actual clinical care their relative is needing or receiving’. In turn, they feel at a disadvantage in terms of how they can adequately prepare and advocate for them from an informed basis.
Judy Timson | Clinical Advisor