Following several complaints from families and visitors about a perceived lack of care secondary to patients not remembering what had happened during the day we adapted the Care Diary Initiatives that were used widely in ITU setting.
Visitors were repeatedly saying that their loved one had had therapy that day, not seen a doctor or had "just sat in the chair all day". As a community rehab inpatient ward we knew that this was not true and that each patient had been reviewed and undertaken various activities throughout the day.
Visitors were getting angry at having to ask each time they visited what had been done as the professional notes were locked away in the medical notes for confidentiality. We sought a solution and as a small group of shared governance decided to trial the diary approach. This would not duplicate the documentation but be a quick reference to what had gone on and not replace the thorough documentation in the medical notes. The diaries would be the property of the patient and would go home with them so that they could remember what had happened while they were in hospital. These were mainly used for patients with delirium or dementia diagnosis.
We had to ensure that IG compliance was maintained and that they were not available for anyone to see - so they were kept on the patients locker alongside their belongings.
Complaints about lack of communication and information decreased.
You can find out more about the project HERE