Social documentation in home care: Journal under SoL

The Swedish National Board of Health and Welfare's documentation regulations (SOSFS 2014:5) apply to services under the Social Services Act. The provider documents how the decided service is to be carried out and how it actually is.

• The care plan: what, when and how the service is given.
• Significant events: changes in the person's situation and how the service works.
• Departures from the plan, and what was done instead.
• Follow-up: whether the goals are met and whether the plan needs to change.

Example (invented): "At the morning visit, support with breakfast was offered according to the care plan. The person wished to eat later. New support is offered at the next planned visit."

• Write factually what happened, not interpretations or judgements.
• Distinguish what the person says from what staff observe.
• State when it happened and who is writing.
• Write only what matters for the service. Not every checked-off visit belongs in the journal.
• Never correct by overwriting. Add a correction with a reason.

Journal works with Caire's planning or on its own. A caregiver with a published visit to the client may read and write around the visit, and a manager can grant time-limited access with a stated reason. Two-factor verification is required for every read and write.

• Drafts are saved and can be reopened before signing.
• Signed entries and published care plans never change. A correction is added as a new signed entry.
• Every opening of a journal is logged before the content is shown, and the manager can review the access log.
• A person with the export permission can export the whole journal.
• Journal text is never sent to AI models, partners or the optimisation.