Field Reference Guide
Field Reference Guide
Writing Progress Notes
Subjective: Capture client's expressions, feelings, and thoughts.
Objective: Record observable facts, behaviors, and actions.
Assessment: Provide a professional analysis based on observations.
Plan: Outline future care, interventions, or goals.
Consistency: Use uniform terminology to ensure clarity.
Confidentiality: Share information only within the professional context, respecting privacy.
Incident Reports
Immediate Action: Ensure safety first, then assess the situation.
Details: Include precise information about who, what, when, where, and how.
Witnesses: Include statements and contact information if available.
Follow-Up: Notify supervisors promptly, document actions, and adhere to organizational protocols.
Confidentiality
Protect Information: Share only with authorized individuals, maintaining client trust.
Legal Obligations: Adhere to local privacy laws, including any specific to Tasmania.
Organizational Policy: Follow company guidelines, consult with supervisors if unsure.
Professional Boundaries
Relationships: Maintain professionalism, avoid personal relationships with clients.
Gifts: Follow organizational policy, consult with supervisors if needed.
Personal Information: Maintain professional distance, avoid sharing personal details.
Quick Contacts in Tasmania
Emergency: 000
If you have a hearing or speech impairment and your life or property is in danger, you can contact police, fire or ambulance on 106 directly through a TTY (also known as a teletypewriter or textphone).
Tas Home Nursing: 0422 961 296
Poisons Information Hotline: 131 126
Health Direct: 1800 333 000
If a Client is Suicidal
Immediate Response: Stay calm, stay with the client, ensure safety.
Ask Directly: Ask if suicidal, use compassionate language.
Seek Help: Call 000 if immediate danger, or Lifeline 131 114.
Notify Supervisor: Inform your supervisor promptly.
Document: Record incident, follow organizational protocols.
If a Client is Seriously Injured
Safety First: Assess, provide first aid, ensure immediate safety.
Call Emergency Services: Dial 000 if needed.
Notify Supervisor: Contact supervisor, follow organizational guidelines.
Incident Report: Document details, include witnesses if available.
If a Client Poses a Danger in the Community
Assess the Situation: Determine risk, consider immediate and long-term safety.
Maintain Safety: Prioritize everyone's safety, including your own.
Notify Authorities: Call 000 if immediate danger, follow legal obligations.
Contact Supervisor: Seek guidance, follow organizational protocols.
Documentation: Record incident, include all relevant details.
If a Client Displays Antisocial Behavior
Assessment: Identify behavior, consider underlying factors.
Intervention: Use de-escalation techniques, consult with specialists if needed.
Notify Supervisor: Consult for guidance, follow organizational protocols.
Documentation: Record behavior, include details for future reference.
Community Resources: Utilize local assistance, connect with community support.
Decision-Making Tips
Know Policies: Familiarize with guidelines/laws specific to Tasmania.
Use Judgment: Assess and rely on training, consult with supervisors if needed.
Consult Resources: Utilize this guide, organizational resources.
Document Decisions: Maintain a record, ensure transparency.
Reflect: Review and learn from decisions, seek continuous improvement.
Safety Protocols
First Aid: Know basic first aid, keep a kit accessible.
Vehicle Safety: Follow guidelines for personal vehicles, ensure regular maintenance.
Infection Control: Adhere to hygiene standards, use PPE if required.
Technology
Using Shift Care App: Clock in/out; add notes securely, follow organizational guidelines for technology use.
This guide is designed to be a comprehensive field reference. Always align with Tas Home Nursing's specific policies and local regulations in Launceston, Tasmania. Consult with supervisors in complex situations, and prioritize safety and professionalism at all times.