Electronic Record Check Lydian Care Electronic Records Daily Check Electronic Record Check FormTo be completed weekly by a Lydian representative. You can choose to check a carer's record in Carer notes or you can chose a client and their records within client notes.Date Completed:* DD dash MM dash YYYY Lydian Representative Completing:Dean FosterJoanne MorganDanielle MageeNadine CheeversKirsty BurnsAoibhinn McComiskeyCaitlin O'TooleCallum EdwardsNola O'TooleMelanie CarrollCarol SavageRachel DeeryFiona KanePlease select your Name from the drop down list.Area Check Completed For:*BallygowanBallymenaBallynahinchBelfastCastlewellanComberCrossgarDownpatrickDrumanessKillyleaghNewcastleSaintfieldSeafordeDundonaldPlease select your Name from the drop down list.Note Check Completed for:*Care Worker RecordsClient RecordsDate Period From:* DD slash MM slash YYYY Date Period To:* DD slash MM slash YYYY What shift does your check include?*AMLUNCHTEABEDNIGHT SITVARIOUSPlease upload a screenshot of the information you are reviewing. You can do this by selecting the print screen icon on your keyboard - once screenshot(s) have been completed paste into either paint or microsoft word and the save the attachment -then upload here by selecting "select files" and attaching. Drop files here or Select files Max. file size: 496 MB. Care Worker RecordsYou are checking the carer notes for this form.Care Worker Name:*How many client calls are you checking within the carer record?*1. Were all client notes recorded as scheduled for that carer?* Yes No This includes if the carer reported call cancelled/client in hospital/respite etc..2. Has the carer read the care plan and previous care notes before starting the call.* Yes No Notes reflect understanding of client’s current needs, changes, or instructions.3. Do the Notes contain tasks that are listed in the care plan or on the task list?* Yes No Compare notes with care plan/task list.4. Are the notes of good quality, reflect care given, and do not contain abbreviations or slang. They are written clearly, concisely, and professionally?* Yes No 5. Notes are factual, objective, and free from opinions or assumptions?* Yes No Review of language used.6. Any declined or uncompleted tasks are recorded with clear reasons?* Yes No e.g., ‘Client declined lunch, preferred tea and toast.’7. Are ALL call times logged in and out for all calls within that period?* Yes No detail any missing call logs:*8. Are there any follow up actions required?* Yes No Carer notes auditor summary:*Completeness of Records, Accuracy and Factual Detail, Professional Presentation, Compliance with NISCC standards and Lydian Care’s recording and reporting policy. Follow up with the carer and actions taken:*Detail discussion with the carer about areas identified, date discussed and carers responses. A follow up review of the notes if required and the timeframe for improvement.Client RecordsYou are checking the client notes record for this form.Client Name:*How many calls within check period:*How many carers attended during check period:*1. Are the times of the visits consistent? Yes No 2. Does the record suggest continuity of care? Yes No 3. Are the tasks completed clearly documented as per care plan? Yes No If no to anything above please detail:*4. Are there any unexplained gaps in the record? Yes No If yes detail:*5. Are there any follow up actions required?* Yes No If any follow up actions detail here and also comment on the overall quality or accuracy of the notes reviewed:*
