Recording and Evidencing Person-Centred Practice in ABI Services
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In acquired brain injury services, good person-centred practice must be visible in records as well as in delivery. Commissioners and inspectors regularly report that practice may appear strong verbally but is poorly evidenced in documentation. ABI providers must ensure records clearly demonstrate how person-centred planning shapes daily support.
This article explores how ABI services can record and evidence person-centred practice effectively. It should be read alongside Recording & Evidencing Person-Centred Care and Person-Centred Planning & Strengths-Based Support.
Why recording matters in ABI services
Records are the primary source of assurance for inspectors and commissioners, particularly where cognition or communication is impaired.
Commissioner and inspector expectations
Expectation 1: Clear links between plans and practice. Inspectors expect daily records to reflect person-centred goals.
Expectation 2: Evidence of involvement. Commissioners expect records to show how views were sought and revisited.
Operational example 1: Outcome-linked daily notes
An ABI provider restructured daily notes to reference person-centred outcomes, improving clarity.
Recording involvement and decision-making
Records should capture how involvement was supported and how decisions were reached.
Operational example 2: Decision-making summaries
A service introduced short summaries explaining how choices were explored and balanced.
Using records to support review and improvement
Good recording supports learning, supervision and service improvement.
Operational example 3: Audit-led recording improvement
A provider used audit feedback to improve consistency and inspection confidence.
Evidencing person-centred practice
Providers should evidence:
- Links between plans, outcomes and daily support
- Supported involvement
- Regular review and adaptation
Recording as part of quality assurance
In ABI services, strong recording is essential to demonstrating person-centred, strengths-based practice at inspection.
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