Keeping a record of each visit against what was agreed

Some days after a visit, a question comes in about it. The person receiving care wants to go back over what was done, or a colleague taking on their support needs to know. What follows covers a record of each visit kept against what was agreed with the person, the person's own decisions, including saying no, and openness with care workers about what that record holds. This is information, not legal advice.

Keep each visit's record against the person's plan

In Ireland, the Health Service Executive's home support specifications describe a record of each visit being kept against the person's care plan and schedule of services, with a copy of that record accessible in the person's home. The Social Care Institute for Excellence (SCIE) in England says recording supports good care and support, promotes continuity of care, and is key to accountability, both to the people who use services and to managers.

Read together, those two points give a visit record a plain job: a question about a visit that comes back later can be answered from what was written against what was agreed.

Write it up while the visit is fresh

SCIE, writing for England, says a good record is easier to achieve when it is made promptly, and that where a record is not made at the time, it is good practice to note that it was written later. NICE's home care guideline for England says home care workers should record any changes.

Respect the person's right to decide, and to say no

NICE's guideline on people's experience of adult social care in England recommends respecting each person's right to decide for themselves. The HSE's specifications for Ireland say the views, will and preferences of the people receiving support are actively sought and respected, and that people are helped to reach their own decisions.

In Ontario, Canada, the right to give or refuse consent to any home and community care service is one that Ontario Health atHome sets out for those it serves. Those HSE specifications for Ireland also describe the care worker letting their own service know straight away when a person refuses a visit, or stops one before it is finished.

Tell care workers what their visit information is for

In Canada, the Office of the Privacy Commissioner says employees have a right to know how their information is being collected and used. Ireland's Data Protection Commission says it should be clear to people that their information is being gathered and put to use, and that the purposes should be settled when it is gathered. Planning visit routes across an area applies the same openness to route planning.

For visit records, the same openness means a service being plain with its care workers about how information about their visits is collected and used, and what it is for.

Take visit-record questions to the rules where you operate

Canada (nationally and in Ontario), Ireland and England supply every source here. Beyond what is described here, a visit record is for each service to work out under its own policies and the law where it operates; your regulator and professional advice there can help.