If it isn’t documented, it isn’t done

Documentation has played a huge role in peoples’ lives for thousands of years. From early writings on papyrus to the Magna Carta, from clay tablets to electronic tablets, even the humble shopping list – documentation is everywhere. Documentation has allowed us to learn and communicate information about people, places, things and events – literally everything we know today has been documented somewhere and on something.

In the health and social care setting, documentation is essential and it serves a number of purposes.  Importantly, every document we use in the care setting is considered a legal document, intended to capture factual information about an individual receiving services to identify the care and support they require. But documentation is actually at the heart of everything we do – assessments, progress notes, handover sheets, care plans, menu plans, risk management, funding, incident management – just to name a few. Above all, effective documentation is the driver of quality care, ensuring that the individual receives quality, consistent, safe and person-centred care at all times.

Health and social care workers understand the importance of the term, “If it isn’t documented, it isn’t done.” Altura Learning understands the importance of effective documentation and we have a number of courses available to our members.

‘Documentation: Care Planning (Residential)’ is a new release course that explores the care planning process and the role of documentation in supporting staff to deliver holistic, person-centred care.

In ‘Documenting in a Care Environment’, we look at the principles of effective documentation and how to apply them in the residential setting.

For our home and community care members, ‘Documenting in a Home Care Setting’ looks at the principles of documentation essential to the delivery of quality support for people living in their own home and how to apply them.