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Home Care - 5.7 Record keeping
5.7 Record keeping
From a perspective of providing care, it has become convenient to refer to five stages related to HIV infection:
If continuity of care for PLHA is to be maintained throughout these stages then it is important that a simple but effective system of patient records should be established and maintained. During the pilot phase, a system of record keeping using specially designed “yellow cards” was developed. Each patient was assigned a card which was used to collect data on the location of the patient, history of the disease, present condition, family situation, and current medication. The cards were held by the nearest HCT and were used for referrals when taking a patient for testing or to hospital. The cards also provided a record of the evolving condition of the patient and could be used for monitoring progress and planning appropriate home care visits.
During observations of home care visits, it was noted that, while some teams continued to use these cards, there was no pattern of consistent use in other teams. Given the breakdown in the referral system with hospitals, there is perhaps some justification for discontinuing using the cards. However, it was also noted that the standard of record-keeping was generally uneven and sometimes inadequate. Maintaining good patient records is important for client monitoring, prioritising needs, planning visit schedules and structuring the visits themselves.
It is recommended that the Home Care Network Group reviews and strengthens the system of record keeping, planning and prioritising visits to patients.
From a perspective of providing care, it has become convenient to refer to five stages related to HIV infection:
- people uninfected, but at risk
- asymptomatic HIV+
- early HIV disease
- severe disease equivalent to AIDS
- terminal illness
If continuity of care for PLHA is to be maintained throughout these stages then it is important that a simple but effective system of patient records should be established and maintained. During the pilot phase, a system of record keeping using specially designed “yellow cards” was developed. Each patient was assigned a card which was used to collect data on the location of the patient, history of the disease, present condition, family situation, and current medication. The cards were held by the nearest HCT and were used for referrals when taking a patient for testing or to hospital. The cards also provided a record of the evolving condition of the patient and could be used for monitoring progress and planning appropriate home care visits.
During observations of home care visits, it was noted that, while some teams continued to use these cards, there was no pattern of consistent use in other teams. Given the breakdown in the referral system with hospitals, there is perhaps some justification for discontinuing using the cards. However, it was also noted that the standard of record-keeping was generally uneven and sometimes inadequate. Maintaining good patient records is important for client monitoring, prioritising needs, planning visit schedules and structuring the visits themselves.
It is recommended that the Home Care Network Group reviews and strengthens the system of record keeping, planning and prioritising visits to patients.