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.
There is a complete lack of duty of care in this instance. If anything were to be brought up in a court of law, the documentation would need to support whatever has occurred during the time spent with the resident. This certainly would not be sufficient information to explain what has actually taken place.
Everything you do for the client no matter how insignificant you think it may be, has to be documented accurately and no abbreviations.
If the client declined care, medication or recommended advice or anything else. This also has to be documented accurately.
Any discussion you have with the client needs to be documented word for word.
This is part of giving wholistic care, informed choices and the right to say no
If this is not happening, safeguarding can be raised.
It is better to document everything however small than to miss something important for the client and carers safety.