One of the things that was pointed out to us in our 2016 inspection was that we weren’t evidencing input from the multidisciplinary team enough in resident’s notes. In order to give us the best chance of improvement we decided to create a series of resources to help record visits from dietitians, the SALT team, Occupational Therapists and anyone else who helps provide care and support to our residents.
This document is a really quick, easy and useful way of ensuring you get all the evidence you need as well as helping to ensure that you understand any recommendations from the visiting practitioner. Simply hand the sheet over at the end of the session and ask for it to be filled in. There’s space for recommendations, notes, date & signature. It also gives different members of the team the opportunity to see each other’s recommendations which can be really useful when designing a holistic plan of care for a resident.