General
Good customer documentation is the foundation of Gillie's artificial intelligence. The higher the quality of the documentation, the better the alerts and recommendations.
Characteristics of Good Documentation
- Concrete — describe observations, not interpretations.
- Measurable — use numerical values when possible (e.g., "walked 50 m").
- Timely — document soon after the visit.
- Customer-oriented — use the customer's own language whenever possible.
What to Document
- Condition (general, pain, mood, nutrition, sleep).
- Functional ability (mobility, independence).
- Medication and its effects.
- Measurements (blood pressure, pulse, weight, etc.).
- Procedures performed.
What to Avoid
- General expressions such as "condition good" without justification.
- Abbreviations that others do not understand.
- Retrospective memory-based entries without notation.
Important. The documentation is also communication for the next shift, the customer's legal protection, and learning material for Gillie's artificial intelligence.