WWYD? – The Record Doesn’t Match the Reality

WWYD? – The Record Doesn’t Match the Reality
A resident becomes distressed during personal care and repeatedly declining support requesting staff to stop - The task is eventually complete with no physical harm occurring
Later, you read the care notes. They simply state:
“Personal care completed. Resident reassured throughout.”
There is no mention of the resident’s distress, refusal of care, or the approach staff took to resolve the situation.
When you question it, a colleague replies,
“Why write everything down? It’ll only raise questions, and the outcome was fine.”
Another says,
“The notes aren’t inaccurate—they’re just brief.” WWYD.