Where an individual has a diagnosed health condition it is important that their condition is observed, monitored and recorded for a number of reasons:
- to monitor the individual’s overall well-being (physical and mental)
- monitoring and observation enables early identification of changes in an individual’s daily routines, communication, behaviour, mood
- to check on any changes in health e.g. shortness of breath, rashes
- to monitor any changes in personal care by the individual (e.g. a previously neat and tidy individual appearing unkempt)
- to monitor the effectiveness of medication being administered
- to identify if there are any side effects from medication
- to indicate if any changes in medication are needed
- to ensure a duty of care towards individuals is met
- to identify concerns about an individual’s health
- to ensure conditions (e.g. diabetes/blood pressure) are being controlled by medication
- to monitor whether an individual is developing any mental health issues as a result of a physical condition (e.g. anxiety or depression)
- to identify the needs of an individual and create and amend care plans
- to share information with the individual to promote joint decision making.
It is important that clear records are kept with full details e.g. date/time for a number of reasons:
- to support consistent, safe and high-quality care
- to identify any trends, patterns or concerns
- to evaluate and to amend care plans
- to seek advice from professionals such as doctors
- to be able to make decisions about medication
- to clarify any complaint issues
- to enable effective handovers to other staff and provide consistent round the clock care.
Any concerns or changes in the health and well-being of individuals should be reported for a number of reasons:
- to access specialist support, enable hospitalisation
- to be able to contact family members
- to adjust medication
- to avoid the spread of any infection/infectious illness
- to be able to increase observation and monitoring
- to investigate any possible neglect of duty of care or abuse
- to amend care plans
- to facilitate changes to routines for the individual
- to plan and implement activities and routines to support mental well-being
- to be able to access any specialist equipment required
- to identify and record any near misses or mistakes.
Os oes gan unigolyn gyflwr iechyd, mae'n bwysig arsylwi ar ei gyflwr, ei fonitro a'i gofnodi am nifer o resymau:
- er mwyn monitro llesiant cyffredinol yr unigolyn (corfforol a meddyliol)
- mae monitro ac arsylwi yn fodd i nodi newidiadau yn arferion dyddiol unigolyn, y ffordd mae'n cyfathrebu, ei ymddygiad a'i hwyliau
- er mwyn cadw golwg ar unrhyw newidiadau o ran iechyd, e.e. diffyg anadl, brechau
- er mwyn monitro unrhyw newidiadau yng ngofal personol yr unigolyn (e.e. unigolyn a oedd yn drefnus ac yn daclus o'r blaen yn ymddangos yn flêr)
- er mwyn monitro effeithiolrwydd meddyginiaeth sy'n cael ei rhoi
- er mwyn nodi unrhyw sgil effeithiau meddyginiaeth
- er mwyn gweld a oes angen unrhyw newidiadau i feddyginiaeth
- er mwyn sicrhau bod dyletswydd gofal tuag at unigolion yn cael ei chyflawni
- er mwyn nodi pryderon ynglŷn ag iechyd unigolyn
- er mwyn sicrhau bod cyflyrau (e.e. diabetes/pwysedd gwaed) yn cael eu rheoli gan feddyginiaeth
- er mwyn monitro a yw unigolyn yn datblygu unrhyw broblemau iechyd meddwl o ganlyniad i gyflwr corfforol (e.e. gorbryder neu iselder)
- er mwyn nodi anghenion unigolyn a chreu a diwygio cynlluniau gofal
- er mwyn rhannu gwybodaeth gyda’r unigolyn er mwyn hyrwyddo gwneud penderfyniadau ar y cyd.
Mae'n bwysig cadw cofnodion clir sy'n cynnwys manylion llawn, e.e. dyddiad/amser, am nifer o resymau:
- er mwyn cefnogi gofal cyson a diogel o ansawdd da
- er mwyn nodi unrhyw dueddiadau, patrymau neu bryderon
- er mwyn gwerthuso a diwygio cynlluniau gofal
- er mwyn ceisio cyngor gan weithwyr proffesiynol fel meddygon
- er mwyn gallu gwneud penderfyniadau ynglŷn â meddyginiaeth
- er mwyn egluro unrhyw faterion yn ymwneud â chwynion
- er mwyn gallu trosglwyddo'n effeithiol i aelodau eraill o staff a darparu gofal cyson bob awr o'r dydd a'r nos.
Dylid rhoi gwybod am unrhyw bryderon neu newidiadau i iechyd a llesiant unigolion am nifer o resymau:
- er mwyn gallu cael cymorth arbenigol ac anfon yr unigolyn i'r ysbyty
- er mwyn gallu cysylltu ag aelodau o'r teulu
- er mwyn addasu meddyginiaeth
- er mwyn osgoi'r perygl y bydd unrhyw heintiau/salwch heintus yn lledaenu
- er mwyn gallu gwneud mwy o arsylwi a monitro
- er mwyn ymchwilio i unrhyw achos posibl o esgeuluso dyletswydd gofal neu gam-drin
- er mwyn diwygio cynlluniau gofal
- er mwyn hwyluso newidiadau i arferion yr unigolyn
- er mwyn cynllunio a chynnal gweithgareddau ac arferion i gefnogi llesiant meddyliol
- er mwyn gall cael unrhyw offer arbenigol sydd eu hangen
- er mwyn nodi a chofnodi unrhyw gamgymeriadau neu ddamweiniau a fu bron â digwydd.