Self Directed Learning Package - University of Queensland

148 • The Palliative Approach ToolkitWriteDocument your actionsMany residential aged care facilities expect careworkersto document information on assessment charts and in theclinical record. If this is part of your role, try and avoid generalstatements. Be as specific as possible.Avoid general statementsPOOR COMMUNICATIONGOOD COMMUNICATIONEvaluation of interventions ‘with effect’ or ‘Resident commenced on treatment for‘effective’.mouth ulcers. Sore spot on inside ofmouth resolved’.ReviewEvaluate and reassess as necessaryThinking PointYou identified that Alfred cannot swallow anymoreand you reported this to the nurse. When you enterhis room, you always swab his mouth and apply lipbalm. Great job! Can you tick this off your list? Notquite yet.There is an important question to answer: Did yourstrategies work?You can check the effectiveness of your management strategiesby checking Alfred’s mouth (as detailed in the SEE section prior).Key PointOnce you review and reassess a resident it is veryimportant that you pass this information on to anurse (and document your assessment if this is partof your role as a careworker).