How is resident care documented in long-term care facilities?

The documentation of resident care in long-term care facilities is primarily accomplished through care plans and electronic health records. Care plans are individualized documents developed for each resident that outline their specific needs, preferences, and the interventions required to support their health and well-being. These plans are essential for ensuring that all staff members understand the resident's care requirements and can provide consistent and appropriate care.

Electronic health records (EHRs) further enhance this process by allowing for timely and accurate recording of residents' health information, medications, treatment plans, and progress notes. EHRs facilitate easy access to information for staff, support communication among multidisciplinary teams, and help maintain compliance with regulatory standards.

Handwritten notes, while still used in some facilities, can be prone to errors and are less efficient compared to digital documentation. Monthly summaries sent to families may provide updates but do not serve as comprehensive documentation of ongoing care. Verbal reports to management, although important for operational communication, do not constitute formalized records of resident care. Thus, the combination of care plans and electronic health records represents best practices in documenting care in a long-term care setting.