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Unlike large organizations, small businesses don't typically have employment law experts on staff or a sophisticated human resources department used to dealing with employee complaints and allegations. However, if your employee does file a claim against the company, the standards of proof are no less stringent for a small company than for a corporate giant.
In the eyes of the law, if it's not documented, it didn't happen. Busy small-business managers must learn which verbal conversations are critical to document, and the best way to do so. Outline the importance of keeping a record of oral communication to the managers in your organization.
The importance of documentation in the workplace is to avoid an employee's allegations becoming a "he said, she said" scenario, no matter how fabricated the story may be. Documentation is critical to refute claims of unfair, discriminatory and retaliatory practices, and meticulous records of each and every counseling session with a poor performer can rebut any claims that he was a stellar employee.
Documentation justifies that your actions and communications were legitimate and taken out of business necessity. It also helps your staff to improve. An employee, angry at your statements or focused on defending his position, may not listen to the message you are trying to convey. But providing written documentation of your conversation to the employee reinforces your statements by allowing him to revisit the information when he is calmer.
Certain types of verbal communications in the workplace should always be documented. For example, a small-business manager must record in writing all counseling sessions and verbal warnings given to an employee. Assess other types of communication – such as voicemails, face-to-face meetings and conference calls – to determine if they are important enough to document. Don't document every verbal communication – or you would never have time for actual work – but decisions, action items and other critical conversations should be recorded.
In some situations, whether you should document the conversation depends on the employee. For example, you might not transcribe a voicemail informing you that an employee is stuck in traffic, if it is an isolated occurrence. But this type of documentation would be important if you were planning to discipline the employee for ongoing tardiness.
Create a written document, memorandum or email for every important conversation, verbal warning or counseling session. Include who was present for the conversation, a summary of the key issues that were discussed and the responses given by the employee. Do not editorialize the conversation, says All Business. This highlights the importance of effective communication in the workplace. The document should also set forth any mutually agreed solutions, future review dates and consequences for failure to improve.
Notations to yourself are better than nothing, and emails to another manager confirming your conversation with the employee is even better, but the most effective documentation is something you formally share with the employee. Maintain a copy of the documentation in your supervisor file for future reference.
Include the date on each piece of documentation you create. Ideally, use a system where the date cannot be disputed – such as a time-stamped email – to verify that the documentation was created at the time of the incident. Without a date, your documentation may be worthless as evidence.
Require an employee to sign your written documentation to acknowledge his receipt of the document, says Northwest University. Failing to require a signature or obtain other evidence of delivery – such as an email receipt notification or signed proof of service – allows the employee to claim he was never aware of the issues.
Documentation is an essential component of effective healthcare communication. Given the complexity of healthcare and the fluidity of clinical teams, healthcare records are one of the most important information sources available to clinicians. Good documentation contributes to better patient outcomes by enabling information exchange and continuity of care by all members of the healthcare team.
Well written care plans along with detailed progress or case notes both support and demonstrate quality care.  In our experience working across many services, one of the common reasons that organisations fail aspects of their quality review or audit is not because they don’t provide quality care, but because their documentation is not in order. The service is unable to demonstrate on paper what has been happening in the workplace – and generally, it is the day-to-day progress notes that people get stuck on. Unfortunately, it’s not wise to underestimate the importance of good documentation. When something goes wrong or you need to provide evidence, that’s when we find out its true value. Auditors, legal representatives and family members may seek information, be that after an incident or during a review. You want to ensure you have well-written evidence to back up any claims, actions or outcomes. So what are the main reasons for documenting?Communication:Client documentation is an effective method of sharing information amongst staff and other service providers. In the world of Consumer Directed Care there may be more than one service provider supporting an individual, so it’s best for everyone to be on the same page. Assessment:Coordinators and case managers can use client progress notes as a primary reference source when conducting a re-assessment. They can utilise the information to measure how well a particular approach is meeting the individual’s stated goals. Notes may also indicate improvement or deterioration of the individual and prompt changes in service delivery or identify needed referrals. Continuity of Care:As well as being useful for effective communication, good documentation helps all staff to understand the current care needs of a client. This in turn promotes continuity of support and care. Documentation can be used to prompt or remind staff or family members of specific actions. For example, when regular staff go on holidays and a relief support worker is brought in. Shared Knowledge:Think about a time when you have either been in hospital or visited a family or friend in hospital. Staff, including doctors, work different shifts and a patient may be seen and supported by a number of different staff members during the period of their stay. Client documentation allows each staff member to understand the medical history of the individual and any interventions that are relevant to their care and support needs. This history can then be used to direct future interventions and actions. Organisations that provide aged care services also rely on this ability to share relevant information between staff to promote quality outcomes. Legal Requirements:As we discussed earlier, accurately reported facts are the best defence against litigation. Any and all documents that relate to the care and support of an individual can be called upon as evidence in a court of law. All consumers of care have a legal right to safe, professional care and support – including accurate and truthful documentation. Continuous Quality Improvement:This is an important aspect of providing quality care. Although there are identified standards that support the industry, and your organisations might be currently assessed as meeting these, you cannot become complacent. The expectations of individuals and their families’ change. Good documentation can assist in picking up trends in the needs of an individual, your target consumer group and the needs of your workforce going forward. Funding:In residential settings, documentation assists aged care facilities to receive appropriate funding for an individual from government agencies. Progress notes act as a measure of the care needs of residents, allowing resident dependency to be correctly assessed. It is important that changes in the individual consumer are recorded so that correct subsidy levels can be accessed. In the community setting, an individual’s progress notes can indicate a need to refer the person for a higher level of care package. Physical Evidence:‘If it isn’t written down, it never happened.’ Without documentation, you have no concrete evidence of services delivered or interventions implemented. As we noted earlier, some organisations fail their quality audit/review, primarily because they cannot prove they delivered services due to poor client documentation. So,
without the accompanying documentation that captures all that has been done, you may be seen as ineffective and non-compliant. |
Why should all communication with the client be documented in the record?
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