What is the main purpose of social documentation?

Documentation is done in different systems, depending on what is to be documented. This is because the operation is governed by two different laws and also two different principals, the municipality to the greatest extent but the doctor's work is governed by requirements from the region. Much of the support for the residents is provided under the Social Services Act but a lot of efforts are carried out under the Health and Medical Services Act. The doctor is obliged to keep patient records. This means that the same events can be described in three different journal systems stored in three different places.

There may be confidentiality between employees regarding certain information. It is therefore not certain that the nursing assistant is aware of things that the nurse, occupational therapist or physiotherapist have been informed about or vice versa. If the cooperation works well then it is not a problem. By obtaining consent from the resident for information transfer or by sitting down and talking together, it is possible to avoid someone ending up in an information shadow. For the resident, it is often obvious that information can be spread, but to do the right thing requires written consent.

What does document mean?

We need in some way in writing to show what care efforts we have made. It can be about writing in text, signing in a signing list or in a digital app or otherwise showing the basis for an assessment or what has been done. It can also be about, for example, photographing a wound in order to compare wound healing over time. It is also important to consider how we document. It should be a support for the care process but must not be subjective or be perceived as offensive by the individual. Journal text should not be used to send messages between healthcare staff.

Storing information about the resident

If the operation writes in paper journals, which is now unusual, it can be difficult to find information for, for example, a nurse who works on call.
Documentation can be done in many different ways. The simplest is to sign that a task has been completed. Other efforts may require more extensive documentation. One principle when it comes to care injuries or mistakes that are revealed is that what is not documented is not done. To strengthen the nursing assistants' documentation, there are operations that appoint some nursing assistants to be documentation supporters for the rest of the group.

Incorrect documentation can mean that the resident cannot assert their rights. In elderly care, it is probably most relevant if a care injury occurs and the resident wants compensation from the patient injury insurance. In these cases, a journal entry can be decisive.
The General Data Protection Regulation (GDPR) is superior to other legislation when it comes to handling personal data, for example in documentation and information transfer.
Personal data must absolutely not end up on data discs or in emails. These are not secure and storing personal data in the wrong way can, in addition to being an intrusion on the individual's privacy, be very costly for the operation that is sloppy.

If nothing else is prescribed by another statute, the rules of the data protection regulation apply. When it comes to health and medical care interventions, there is the Patient Data Act, the Patient Data Ordinance and the National Board of Health and Welfare's regulations which contain supplementary national provisions when it comes to requirements for both the patient record and the social documentation.

One of the basic principles of the data protection regulation concerns the requirement for security. Personal data must be protected both against intrusion from outside and unauthorized access from within the operation. One question concerns consent. Consent cannot be used in relation to the patient or resident in matters that are not prescribed by another statute.

Health plans

Creating good health plans or health plans requires a good working method. If you too much base your work on standard health plans, you risk losing the perspective of the resident. The health plan and the implementation plan should interact. The resident is one of the experts in the team.

In health plans, interventions that are assessed as health and medical care are documented. Such can be medication management, incontinence protection, diabetes, wound care, nutritional intake, palliative care, movement training and other rehabilitative interventions. The plan contains information about allergies, hypersensitivity, infection and the like. The planning is based on the individual's health and resources. The patient's resources are identified with the help of the patient's own story.

The health plan is based on creating good contact with residents and relatives. The resident should experience their existence as meaningful and the interventions and the care environment are made more personal. Increased security provides increased trust and reduced anxiety. The initiative and the feeling of independence are strengthened. It's about dignity, will, trust and reciprocity in the creation of the health plan. It is a partnership where the resident is one of the experts in the room.

It is possible to slow down a negative development for the elderly if we treat each resident as a unique individual with holistic assessments of the individual's conditions and a well-planned team work. The goal should be intensive preventive work to preserve the health of the resident, which is the most important purpose of the health plan.

Healthcare staff should promote health and counteract illness and take advantage of the individual's life force. The elderly should be met with respect for their person and as a partner and equal. All communication should take place in dialogue with the elderly and relatives.

The health plan and the implementation plan should be a support for creating a well-functioning everyday life for the resident. A uniform way of working with the preparation and updating of plans facilitates.

Social documentation

Social documentation creates the conditions to be able to follow up interventions and to be able to improve the support for the resident. It happens quite often that nursing assistants receive criticism or even become lex Sarah-reported for neglecting the documentation. The starting point when there is an investigation is that what is not documented is not done.

There are often signature lists for recurring efforts. Most commonly it is in connection with medication management, but it can occur in connection with showering, oral care, activities, outdoor stays and other interventions.

Upon moving in, conversations are held with the resident and relatives. Information about life story, habits and wishes the resident has in everyday life is documented. Some operations have a contact book with relatives. The time before the implementation plan is drawn up, detailed notes are made in the social journal in order to thereby create a basis. An implementation plan is written relatively soon after the person has moved in. At the same time, there is a dialogue between the nursing assistant and licensed staff over necessary health and medical care interventions which is documented in the health plan.

Continuously, significant events, deviations from what is implemented or complaints that have been put forward are written. Offers that are given that the individual declines should be documented. Other things that have emerged of importance in contacts with the individual or others who have provided information in connection with the implementation should be documented. Likewise, important events in the individual's life, both positive and negative, should be written down.

The implementation plan
The implementation plan is based on the planning that starts at the move-in and builds further on the life story. It is the resident's implementation plan but it is written and updated by employees, usually the contact man. It's about seeing what support the resident wants and then agreeing on how the help should be conveyed.

There should be goals with the interventions. It should be clear what is to be done, who should do what, when and how. When a person moves in, it depends on the person having needs that cannot be met in ordinary housing. The operation is obliged to document how these needs are met so that the resident can complain if the interventions are insufficient for the resident to have a decent life. Follow-up and evaluation as well as adjustments as a result of these are documented in the implementation plan.

The implementation plan becomes a basis for what should be documented in the journal, as much of the documentation should be about evaluating the interventions that the resident receives. The resident's goals become the staff's map, a valuable aid in supporting the resident in continuing to live life according to their wishes. It is always the resident's perspective that should be the starting point in the implementation plan. It's about ability, interests, wishes and needs.

Staff can, based on experiences, have a pre-understanding and have in principle decided what should be in the implementation plan before the actual planning begins. If so, the resident's influence over the implementation plan decreases and it tends to become more of a job description than an implementation plan in its proper meaning. It happens that residents consider it pointless to participate.

For the plan to be good, the resident can have a person that he trusts and that there is a culture where the resident dares to bring up sensitive issues, even criticism. A good way to work when updating the implementation plan is to also revise the health plan at the meeting. Fall prevention work is often included in the planning. The resident may have wishes that can contribute to improving health. Write the plan so that all colleagues understand what is meant.

The implementation plan is revised regularly. Often at least every three months, to evaluate what has been achieved in relation to the set goals for the intervention. Likewise, if the conditions have changed so that the plan does not meet the needs. With a good implementation plan, the conditions for the care to be good increase. An implementation plan that does not stem from the resident's wishes and interests is not an implementation plan.

If the resident says no to the implementation plan, there will be none. Document that the resident does not want to participate for the moment. For the contact man, it is about creating trust and understanding why the resident does not want to participate and to still get to know the resident and his interests. Often it is possible to build trust and get started with the implementation plan after a while when the resident sees more the benefits of the employees knowing how the resident wants it.

Reflection - documentation
Care staff:
• What do you do to ensure that information transfer is done in a safe way?
• Do you feel that you have good support from the health plans that are set up?
• Do your implementation plans work as good support for substitutes, for example?

Manager, nurse, occupational therapist and physiotherapist:
• Does the information transfer between the different professional groups and around the clock work?
• Is there a good dialogue in the planning of care between SoL and HSL staff?
• Are the implementation plans updated and of good quality?
• Is there a red thread between the implementation plan and health plans?

Resident and relative:
• Do you feel that the information transfer is working well?
• Does it happen that you have to tell the same thing several times for the information to get through?
• Have you been able to participate in and discuss the content of the health plan and the implementation plan?

Erland Olsson
Specialist nurse
Sofrosyne - Better care every day