A record of something a care actor has seen, heard, or noticed in reference to the health or social wellbeing of a person. These can include objective and subjective observations and can be recorded by healthcare professionals and/or other care actors.
Observations are recorded by a Care Actor and refer to the Subject of care.
An Observation is performed in a Location and multiple Care Actors could be involved. Observations influence Assessments, Care plans and Instructions, as well as being a trigger for Reviews.
Observations recorded as part of social care provision including:
Needs
Risks
Wishes
Daily Living
Circumstance (including Environment)
Some Observations would typically be recorded as part of healthcare provision such as:
and should be shared with Social care providers and included in an Adult Social Care record.