Journal notes
Journal notes must be clear, factual, and respectful. They are used to follow up on interventions and to improve health and social care.
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Writing Journal Notes
Basic Requirements
Journal notes must:
- Be written as close in time as possible to the completed intervention.
- Be concise yet clear.
- Be dated and signed by the person making the entry.
Content and Purpose
Journal notes should:
- Describe factual events and circumstances relevant to the intervention.
- Record both positive and negative events.
- Be objective, accurate, and never derogatory.
- Be written with respect for the service user’s integrity.
- Provide useful information for follow-up, evaluation, and development of services.
Examples of Use
Journal notes can be used to show:
- How often a service user experiences pain and how it affects daily life.
- Whether an assistive device is working and when contact has been made with an occupational therapist or physiotherapist.
- Changes in the service user’s willingness to participate in activities such as meals, bathing, or mobility.
Examples of Wording
- “Lisa finds change difficult. She became angry and shouted loudly when I took out the wrong lunch box from the fridge.”
- “Kalle did not want to shower today since his daughter helped him with this yesterday.”
- “The apartment smelled bad because he wore dirty clothes. I aired out the apartment and helped him change.”
- “Berit was very happy this morning, she helped set the breakfast table and said she felt energetic.”
Journal Notes under the Health and Medical Services Act (HSL)
Delegated Interventions
As staff, you may be assigned to carry out health care interventions delegated by licensed professionals, such as a nurse, physiotherapist, occupational therapist, or counselor.
Documentation Requirements
If you carry out interventions under the Health and Medical Services Act (HSL), they must be documented in the health care record. This is not the same as the social documentation required under the Social Services Act (SoL) or the Act Concerning Support and Service for Persons with Certain Functional Impairments (LSS).
Why It Matters
Health care documentation is:
- Required by law.
- A way to ensure equal and consistent practice.
- Support for both staff and service users to know what should be done.
- Legally secure for both service users and staff.
- A means of monitoring progress, improvements, or deterioration.
- A way of showing how the service user is involved in their care.
Care Processes and Care Plans
In municipal health care, different terms such as “care process” or “care plan” may be used. These are prepared by licensed health care professionals and describe:
- How interventions are to be carried out in practice.
- Significant events related to the health care intervention.
Distinguishing Between HSL and SoL/LSS
It can sometimes be difficult to know what belongs in which type of documentation. A general guideline is:
- SoL/LSS: Document what has been decided by the case officer.
- HSL: Document what has been prescribed by licensed health care professionals.
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Contact
Citizen Service
E-mail: kommunen@boden.se
Phone: +46 921 620 00