Provide support for mobility
Handout 5: Observation and record keeping
Learning outcome 4 Assessment criteria: 4.1, 4.2, 4.3
Observation
As you provide support, you will be observing the individual and their mobility. You will notice any changes to their condition, the progress they are making and any problems they are having.
They may tell you, or you can see by their responses to the activities. Your observations may also relate to any of the following:
· the choice of mobility activity
· the equipment or appliances used
· the amount and nature of support you provide.
Your observations will help to inform the care team about the individual’s needs and should be recorded according to the agreed ways of working in your workplace. Records used for this purpose include:
· care plan
· mobility risk assessment
· moving and handling risk assessment.
Keeping records
· Keeping a record of harmful effects or changes in the individual’s condition will enable the care team to develop support which is safe and will be beneficial to the individual.
· Individual choice, preferences about their mobility or any harmful effects should be recorded for future reference.
· Records on progress can be discussed with the individual and can act as a powerful motivator (especially in a visual format) for future improvement.
· Information is essential to the delivery of high quality, evidence-based care on a daily basis.
· Records are a valuable resource because of the information they contain.
· This information can support decision making and improve individualised care through clear communication for a consistent approach to team working.
· Information should be recorded clearly, accurately, legibly, completely, objectively using the organisation’s documentation, and in line with its policies and procedures, and your own job role.
· Recording should be in black ink, only using accepted abbreviations and technical terminology as appropriate.
· Any mistakes should be scored through once only. Liquid eraser must not be used.
· The person recording the information should date and time the entry and sign their name in full.