A record of something a care actor has seen, heard, or noticed in reference to the health or social wellbeing of the Subject of care. 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
Circumstance (including Environment)
Some Observations would typically be recorded as part of healthcare provision such as:
and should be shared with adult social care providers and included in an Adult Social Care record.