3.1b Reporting and Recording Systems

Explain the difference between subjective and objective recording

Objective recording only contains the facts, whereas subjective recording also contains the individual’s own personal thoughts, feelings and views.

From your experience, identify three consequences of inaccurate or incomplete records
  1. An appointment is missed
  2. Time is spent doing something that has already been completed by someone else
  3. Medication overdose (given twice as first administration was not recorded)
Consider why and how you might share records with people who access care and support, carers and relatives

Personal information about a client should only be shared with their consent unless not doing so would result in harm or injury to themselves or others or result in the law being broken.

Information should then only be shared in a private setting and on a need-to-know basis and should also be in the client’s best interests.

What difference might this make to the format and storage of any records?

Records should be kept and archived until no longer needed.

Provide specific examples of how you might use accurate records to support positive outcomes for people who access care and support

Showing records of a clients meals and snacks to their dietitian so that they can offer the best health advice for the individual.

Informing a pharmacist of the conditions and current medications of a client  before supporting them to buy over-the-counter medication.