SHARP practice: joining up care giving and record keeping.
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Biomedical subjects
Publications and source records attributed to Cathy Butterworth.
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Obtaining informed consent is a fundamental part of the care-giving process. Current policy documents emphasise the importance of including patients in planning their care. This article explores the concept of consent and the challenges to this concept for older people in long-term care, where consent is not a one-off event requiring a 'consent form', but just one stage in the continuum of involvement for service users. At one end of the spectrum, service users may be unaware that they have a service user plan (care plan), while at the other end they may be enabled to complete an advance statement of their wishes, thus demonstrating significant involvement in planning their care.
Following an audit of nursing homes inspection reports which revealed inadequate record-keeping, a project was set up to devise a care planning and documentation system for use in nursing homes. A pilot study in seven homes in Somerset showed that the system was user-friendly, resulted in fuller records being kept and that care assistants felt more involved in the care of their patients.