1.1 Care plans and daily records and contributing to them are part of my daily job. I should be observant and thoughtful to the needs of my clients so that what I say and write in their records is accurate and true. The main source of information is the client themselves, providing they are able to do so appropriately. They should be able to provide the most information about their past and present illnesses, life-style, and health care needs. They are in the best position to describe their feelings about health and illness and can identify specific problems or goals they might have. Another source of information is the client’s family. This source becomes vital in situations where the client is unable to participate, such as when the client does not have the mental capacity. The family are also important in clarifying or validating the client’s information they may have told me. Medical records, previous assessments etc. are all sources of gaining information about the client, communicating with other members of staff and the health care team can also be a good source of information. Nurses, social workers, occupational therapists, GP’s, and others can all add to the information about the client. Specific care plan activities for which I’m responsible, I will have to refer to the clients care plan. The clients care plan will have been assessed and will include details of how to meet the clients: physical, Emotional, Social, Cultural needs and I will follow the instructions to the best of my ability.
Information that is recorded by carers on a daily basis will be used to make appropriate changes to the care plan when it is reviewed. Reviews are essential as client’s circumstances and needs are frequently changing. At agreed dates everyone involved in the clients care will meet to discuss and reflect on the care package to ensure it is still meeting the client’s requirements and needs some of the people