Publications from ODSW Social Insights: Letters by DSW (Vol 1) | Page 137

Good Questions and Show of Evidence

explain the process of how an assessment is made and the follow up actions.
What should the documentation show? It should show that there is proper
assessment, a plan that is followed and reviewed, and the evaluation of
interventions and outcomes. Assessment and evaluation must be made by
persons with the appropriate knowledge, skill and judgment.
Each requirement or cluster of requirements will aim to confirm one key
domain in the standard of care or a key concern such as safeguarding the
dignity of the person. It is important to explain the understanding behind a
particular practice and how the practice complies with the standard of care.
Evidence should also show the inter relationships that support the clients.
Documentation should demonstrate (i) communication and respect for the
clients; (ii) accountability of staff and the program and (iii) attention to the
care, safety and welfare of the clients.
Documentation is used to communicate among those involved in the care of
the client. It establishes the facts and circumstances related to the care given
and assist in the recall of details in a specific situation. As such, documentation
should be clear, concise, factual, objective, timely and legible.
Integral to due diligence is decision making by the appropriate level of
authority or professional practice. By this we mean that an appropriate person
is assigned a specific level of decisions and based on a set of professional
principles that are documented.
Good practice begins with taking time to ask good questions. It continues
with documenting the planning, implementation and decision making
process. Safe practice is about being professionally and ethically accountable
and delivering services to clients right to the last mile.
14th August 2015

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