Active’s Record Keeping Procedure
Information that needs to be recorded on a ‘Record of Visit’
Active has devised a standard written record for the purposes of recording key events and activities this is called a ‘Record of Visit’. Staff need to complete a record of visit every time they work with a client and if two people are working then both staff need to sign and date the record to show that they agree with the information written in it. The “Record of Visit” contains information on:
- Name of the Client;
- Time and date of every visit, with a description of the services provided;
- Assistance with medication and other requests for assistance with medication and action taken;
- Financial transactions undertaken on behalf of the Client;
- Details of any changes in the Client’s (or carer’s) circumstances, health, physical condition and care needs;
- Any accident however minor to the Client and/or care or support worker;
- Any other untoward incidents;
- Any other information which would assist the next health or social care worker to ensure consistency in the provision of care.
The ‘Record of Visit’ provides the client’s family/carer with details of what they have done during the day. It allows them to feel confident that the correct support is being provided. Staff need to show how they have supported their clients to meet their outcomes.
(A ROV must be completed with your client throughout the day. This is a CQC requirement. Centres – Completed ROV’s and any art work produced should be handed to the Group Leader to be checked and photocopied prior to the client’s departure).
Use to answer question 14.1a of the Care Certificate