Documentation: From a chore to valuable communication

It is no secret that documentation and registrations take up a lot of resources of the care home. Documenting every encounter with the residents usually just adds to an already busy day of work for the carers. Despite the original purpose of creating a better and more transparent level of care through documentation, it is a fact that the carers have never had lesser time to spend with the residents. The actual demands of what has to be documented are as per legislation so this article is not a discussion of what should be documented but more about how you document. In our opinion there are two main purposes of documenting care:

  1. To prove the resident has received the correct care

The first purpose is in regards to evidencing for compliance inspections as well as the Local Authorities that residents, especially those that are infirm, have received the correct professional treatment and care. Here, documentation contributes to an improvement in quality; in order to safeguard the residents and to make sure the level of care is consistent. Documentation systems are made to reflect the reality of the residents and cater to their needs. Hence, the actual purpose is to ensure that the level of care the resident receives is of great quality. In the best case scenario, this is reflected in the actual documentation.

  1. To be smarter tomorrow than we are today

The second purpose is to create next practice and in that regards, how you document and report is important. It is necessary that carers are able to extract the required information easily and without complications, so you can provide care that is standing on the foundation of former experiences from co-workers. Documentation contributes to creating an overview of each individual resident so it is easy to share and pass on the latest information about the resident and thereby provide the best care possible.

Why good documentation is communication

When you are actively using documentation in everyday work and it supports the main purposes of documenting, it will feel less like a chore to do it. If you are able to communicate effectively with your co-workers through documentation, it is possible to transform the demands for documentation from a time-consuming constraint to a valuable communications tool.

By having information in a digitised format and by hand, the information becomes operational. When the carers have access to the latest information about the residents they can transfer this information to the people who need it – this includes bank/agency staff working in the home or anyone from the multi-disciplinary team. Documentation can change character; from being a chore to becoming communication between co-workers. When we reach this point, it is possible to utilise the demands of documentation proactively and create better care instead of experiencing an added pressure from increased workloads thereby shifting the focus back on to what is most important: The residents.

What if something is missed when working digitally?

The transition from paper-based or journal-based documentation to digital communication can be a daunting change. In many care homes, one of the most common fears when digitising is the fear of missing something - or what if we cannot find the information we need? However, the fact is that if you implement an appropriate number of digital workflow processes, you can create a new and improved overview for the entire organisation. Because the continual documentation provides insights into both co-workers and relatives we will no longer need to fear missing important information. And that is how documentation becomes communication. It is not hidden away in some folder in the office, among a pile of papers, or on a post-it note. It is readily available and easy to access right when the carers need it.

The purpose it to bring the focus back on the residents and ease the documentation through an intuitive workflow (and interface) that supports the carers job the best way possible. That is exactly what the Orton Manor Nursing home in Birmingham have done.

Best practice care home in Birmingham

A number of factors weighed in when the director of Orton Manor nursing home in Birmingham Shahzada Ahmed was choosing between digital care planning suppliers. Chief among the factors were how user-friendly the technology is. The reason being that you can only start to leverage the technology when everyone is able to use it and understands the benefit of it.

Director Shahzada Ahmed explains: “I wanted something more, something that would integrate the different platforms into something that would be much more user-friendly so that my carers were using the technology to be able to deliver a much higher standard of care, to give more care time, to free their time up”

The results of the care home’s digitisation are evident. The result is better care for the residents and fewer mistakes made:

“I have seen a measurable return on investment for me, I have held resident meetings, family meetings and I have seen significant changes in families and residents noticing much greater time that is allowed in direct contact from carers and service-users without the need for duplicating paperwork” Director Shahzada Ahmed concludes.

Read more about Orton Manor nursing home
Orton Manor Nursing Home in Water Orton just outside Birmingham, took a step forward onto the digital path saying goodbye to their paper records.
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