In addition, accurate and complete documentation protects providers from Here are examples of customer service policies that will help you in ensuring a quality customer service in your business. Client notes are legal documents that provide rationale for treatment and documentation of quality care ! • All client care reports and documents must be kept confidential. 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. The CCBHS-MHP establishes documentation standards in order to help realize the commitment to clinical and service excellence. Client notes record what worked, what didn’t and why ! 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. 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. document that details the care and services the client should receive. DOCUMENTATION serves as a permanent record of client information and care. It is not a finished document; it continues to get reviewed and revised depending on needs, conditions, progress. Complaints help your workplace improve client care and/or fine new ways to meet a client's needs. 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. This lesson provides caregivers with a review of the basic principles of client care documentation, including the ethics and legalities involved in documentation. It contains the diagnosis, goals, interventions. 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 ! 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 DOCUMENTATION AND REPORTING 2. Keep reading to learn more about reporting and documenting your client care! Discusses the DOs and DON’Ts of documenting client care in a variety of healthcare settings. Evaluating The Client Responses to An Error, Event or Occurrence 1. Progress Notes contribute to the review and updating of Care Plans to ensure these care needs are adequate. For treatment of injuries, refer to Chapter 9, Fire, Safety and Emergency Procedures. 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