Client Records and Service Delivery Notes

In short

• Write a service delivery note for every visit before you leave the home. Never write a note ahead of time.
• Record each task as done, not done or refused, and say why and whom you told when a task was not done.
• Write down any change in the client, any fall or injury, and anything that worries you, with the name of the nurse you told.
• Sign and date every entry. Never sign for someone else or let anyone use your login.
• To fix a mistake on paper, draw one line through it, write "error", your initials and the date. Never use correction fluid.
• Clients may see their own record. Pass any request to the office the same day.