It is absolutely imperative that charting is done consistently and continuously throughout every shift. This is completed by using either the Point Click Care system, pen to paper, or whichever other method is used by the facility you are working in at that time. Every interaction and task performed for a resident must be documented. If you are unsure whether or not something should be documented, ask your superior or when in doubt always document it.
As a general rule, all residents will have a reassessment every quarter and/or annually. These assessments will include a fall risk, continence management, behavioral etc. All assessments are to be documented including any changes in the resident’s condition. It is also important that any changes observed in the resident between these quarterly/annual assessments are documented thoroughly in the president’s plan of care and reported to a supervisor if required.
The person who documents shall note their professional designation and the date and time of the documentation if handwritten. If the documenting is done on Point Click Care it is vital that staff completing the documentation for a resident has logged in under their own name. The login will be provided to you by the facility, not by GAIA Care.