Documenting in the Client Journal


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​Client Journal
The Client Journal is an informational tool used by the Home Instead Senior Care network to provide CAREGivers with background information about the client as well as their preferences and routine. Equally important, it provides a place to record the day's activities, track client progress, and inform other CAREGivers of the client's needs. The Client Journal serves as a valuable resource for the client's family members as they will often refer to the Client Journal to learn how their loved one spent their day.
Your role as a CAREGiver is to understand your client's conditions, recognize how these conditions affect his or her life and observe changes that may occur. We welcome your insight on how the client is progressing or declining; you are the eyes and ears of our Home Instead Senior Care franchise office. Please share important information with us, and record it in the Client Journal.

Documenting in the Client Journal
You are required to completely and accurately document all client activity in the Log Notes/Documentations for all shifts worked. Clients, family members, and franchise office staff review a client's activity log for various reasons, including health concerns, emotional stability, and to ensure that our CAREGivers are meeting the needs of the client. Someone from the office will periodically gather the pages from the Client Journal for review. Keep comments brief by providing just the facts, stay positive in your reporting, and always print legibly. Keep in mind that the Client Journal is not only subject to review by the client and their family members but also Home Instead, Inc., neighbors, attorneys, physicians, case managers, insurance companies, doctors, nurses, and aides. It's important that all documentation be client driven. Remember you are there to meet the client's needs, not your own. Report only factual information, recorded objectively without adding your personal opinion or feelings.
Properly using the Client Journal impacts your client by keeping communication open between the family, other CAREGivers, and the office staff and providing documentation on the care needed so the client doesn't have to educate new CAREGivers.
Properly using the Client Journal impacts you because it is the most important document you will use when caring for a client.   It provides the information you need, a written history of changes that may occur over time, and offers documentation of the tasks you perform for the client.
Properly using the Client Journal impacts the Home Instead Senior Care brand by helping to ensure that we are meeting the needs of the client and his or her family.  Insurance providers and   other  outside  agencies,   such   as  our   Licensing   Board,   often   require  this  type  of documentation for clients who receive our care.

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