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A record of something a care actor has seen, heard, or noticed in reference to the health or social wellbeing of a personthe Subject of care. These can include objective and subjective observations and can be recorded by healthcare professionals and/or other care actors.Image Removed

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Observations are recorded by a Care Actor and refer to the Subject of Carecare.

AnObservationispreformed in performedin a Locationandmultiple Care Actors Actors could be involved. Observations Observations influence Assessments, Care Planplans and Instructions and can trigger Reviews.Some Observations are healthcare specific e.g. Allergies, Investigation Results and the Problem list and and these have been included in the Social Care Record, whilst others are associated predominantly with Social Care Provision, as well as being a trigger forReviews.

Observations recorded as part of social care provision including:

• Needs

• Risks

• Safeguarding concerns

• Strengths

• Wishes

• Preferences

• Daily Living

• Alert

• Incident

• Circumstance (including Environment)

• Outcome

Some Observations would typically be recorded as part of healthcare provision such as:

• Allergies

• Investigation Results

• Problem list

and should be shared with adult social care providers and included in an Adult Social Care record.