Forum Discussion

Hi Tony,
That is a very good question and most organisations will have something in place to assist you when documenting. "Nil changes" is frowned upon and not seen as an evaluation.
If the resident/client has some identified interventions in place then you will need to evaluate if those interventions are currently working, if you have trialed something new or modified the interactions/social enngagement with the person then document that new activity. if the plan or goals of care are to support the person to maintain any type of activity that you have identified then have you listed out the set resources. For example we have a resident that reads his bible 3 x a day. By discussing his plan with him we found it was a particular bible that he must use, and he has a calandar as a book mark with the set readings 3x a day for the whole year! So the evaluation of his assessment in this case, included the update of identified resources that he requires and where they are to be placed in readiness for his access. Also organisations and accreditation teams really like to see that you have spent time 1:1 with the resident/client and their significant other/s in the evaluation process. So you can add that- f"amily/resident/client was involved with this evaluation" and write their comments to your evaluation. Most goals of care and interventions don't detail the idiosyncracies that are unique to that resident/client, often your volunteers will be able to value add to your interventions and evaluations for you if you make time to illicit the responses from them! Good luck it is never easy evaluating and documenting your evaluations!