The types of records and reports you are required to complete within your work role and how to complete them
The types of records and reports that I am required to complete within my work role include:
- Care plans – up to date, factual, accurate information developing on a daily basis
- Daily handover sheets – comprehensive, factual sharing of information relating to each individual
- Risk assessments – accurate data application
- Accident reports – factual, who, when, where, how Injuries, witnesses etc
- Outside agency reports – GP, DN, Dentist, optician etc. Why they visited the individual (symptoms etc) any treatment given and the outcome
- MAR sheets – medication administration records – medication given/refused, no longer required, including homely remedies
- Nutritional records – records of meals/drinks/snacks etc to enable staff and others to monitor dietary needs of individual. Completed after meals etc
- Fluid/bowel etc records – to monitor fluid intake and out put and bowel habits usually only completed when individual is unwell, constipated etc
- Staff training records – kept up to date to enable training up dates to be arranged and further training needs to be identified
All of these records and reports need to be completed to a high standard, clear and without errors and used and stored in line with the Data Protection Act 2000. The data in these reports and records can be either written, numerical or statistical depending on which task is being undertaken i.e. some risk assessments might require a numerical answer, on a scale of 1-5 for example, 1 being the least likely and 5 being highly likely etc.
