HOME & COMMUNITYPolicy No.: PM-10-30

SUPPORT SERVICESRevised

-♥-OF GREY-BRUCE-♥-Effective Date: May 2016

Page: 1 of 2

SECTION: PROGRAM MANUAL

TOPIC: OVERNIGHT RELIEF

POLICY TITLE: OVERNIGHT RELIEF DOCUMENTS

POLICY STATEMENT

The Overnight Relief Program will maintain an organized system of ongoing data collection and documentation in order to plan and provide optimal care for our clients. Included will be information received upon referral, during the admission process, during attendance at the program and information received from outside sources, for example caregivers, family physicians, CCAC Case Managers.

PROCEDURE

  1. When a client has been referred to the Overnight Relief Program, or expresses an interest in the Overnight Relief Program, the client caregiver will be contacted by telephone. Information about the Program will be provided, and an information package (Form ON – 1 –Overnight Client Preparation Package) will be mailed in advance of the proposed first Overnight Stay. When received, this information will be used to plan for the client’s needs and routines. In addition, any relevant client information from another Day Program will be requested to include in the client chart. A signed copy of Form PM-10 Over The Counter Medication Permission must also be requested from the caregiver.
  1. Clients will be identified by name and date of birth on all agency records and charts. . All recording shall be done in ink. Data entry on all forms must be accompanied by the initials of the staff member who is performing the documentation or, where indicated on the form, by the full signature of the staff member. All staff members involved in charting must give a sample of their complete signature followed by a sample of initials on the Record of Initials (Form DA-19) located at the end of each chart. Those staff members who have a professional designation, eg. Reg.N., RPN, are advised by the College of Nurses to sign with this designation regardless of whether employed in this capacity. All staff members are asked to sign the Initials Sheet using their designated job title.
  1. An Overnight Client Chart will be created for each client, containing

●Overnight Client Preparation Package

●Attendance Record

●Client and Communication Notes

●CIMS Notes

●Medications and MAR

●Record of Initials

●CCAC Referral Documents

●Consent Forms

●Form PM-10 Over the Counter Medication Permission

and the Kardex (Form DA-7) will be completed (or requested from another Day Program by the Family and Client Care Coordinator.) The Team Leader must ensure that a photo is taken and printed and included in the Kardex ..

  1. After the client's first day of attendance the Day AwayAttendance Record (Form DA-16) will be completed and a note will be made on the progress notes. Thereafter, there will be a notation on a weekly basis on the Attendance Record.
  1. The UFirst Client Profile (Form DA-29 ) will be completed as necessary to provide more detailed information about client focused care and approach.
  1. Any information that is removed from the client's records will be done so using the strikeout method.
  1. Information as to client's health status, any unusual incidents at the program, information from caregivers or community agencies, will be recorded in the Client Notes (Form PM-11). In the event of any significant occurrence, documentation should be done as soon as possible. If the incident is one where significant injury occurs or emergency services are accessed then an Incident Report must be completed. (See policy ADM-6-50 Incident Report)

PM-3-140 Documentation of Client Information - Ongoing