Practice task 8

Read the case study, then answer the questions that follow.

Case study

Leroy is a community services worker and is required to complete electronic progress notes regarding the care he provides to people.

Leroy’s supervisor Shannon has noticed that Leroy’s documentation sometimes includes incorrect terminology that could lead to confusion when read by other workers.

Yesterday Shannon met with Leroy and asked him to explain what he meant when he documented ‘Mr Todd independently managed his medications from the pack’. Leroy explained that Mr Todd had a container that divided the medications into individual sections for the morning and afternoon of each day of the week.

Shannon explained to Leroy that what he was describing was a medication or pill organiser and that it was a memory support aid to help people manage their medications. Shannon also explained that incorrectly documenting the medication organiser as a ‘pack’ may lead to other workers believing that Mr Todd could independently manage his medications straight from the medication boxes. As Mr Todd’s form of medication organiser requires staff to manually dispense his tablets into each section this misinformation may have negatively impacted on Mr Todd’s care.

Shannon encouraged Leroy to clarify industry terminology in future before logging an entry in the progress notes.

There are three questions.