What must be documented in an individual's record following an assessment?

The documentation of the results of the assessment and how they were explained is essential because it provides a comprehensive understanding of the individual's needs, strengths, and areas that may require support. This information serves multiple purposes: it informs care planning, ensures that everyone involved in the individual's care is on the same page, and allows for transparency in the assessment process. By explaining the results to the individual, it also supports their understanding of their own situation, fostering better engagement in their care plan.

This practice aligns closely with the principles of person-centered care, which emphasize the importance of involving the individual in decisions about their support and ensuring that they comprehend the information related to their assessment. Properly documenting this process can also help with accountability and continuity of care, as future team members will have access to the assessment findings and the context in which they were shared.

In contrast, documenting the assessment average of all individuals would not be relevant to the specific needs or insights about the individual being assessed, while recording contact information may be useful, it is not a primary focus of the assessment documentation. Noting the name of the assessor, while important for accountability, does not encapsulate the findings or the implications of the assessment on the individual’s care and support needs.