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How to Record Care Reviews in Cloud

This guide explains how to complete a full Care Review within the Care Planning app for a service user (resident). The Care Review feature allows you to formally assess and document a resident’s current needs, dependency level, and overall wellbeing. During the review, you can record changes in condition, update levels of need, calculate care minutes based on site settings, and document the actions and expected outcomes that will support the resident moving forward.

The Care Review also enables you to reference relevant notes and documents to evidence your assessment, ensuring the review is thorough and person-centred. Once completed, the review must be finalised with consent, including recording mental capacity, capturing signatures where required, and documenting a witness. When submitted, the completed Care Review becomes the active review for the service user, providing a clear and auditable record of their current care requirements.

Interactive Guide

Text based guide

Enter the Care Planning App

Click Visit under Resident Care Plans

Open the Essentials drop-down

Choose Care Reviews

To start a new Care Review, click the Start New Care Review button

Enter details into the Overview box for the introduction

Select if you have asked the resident to take part in the review

Select if you have asked an advocate or family member to be part of the review

Enter how you have included the resident, family, or advocate in this review

Enter the weight of the resident — the previous weight will be displayed next to the question

Click Next when finished in this area to move to the next one

The area you are currently in will be highlighted on the left

Choose the Level of Need

You can view the guidance for the levels by clicking this button

Click the Dependency Level to see how long the service user requires

The total Care Minutes per Day is calculated by the Level of Need and is based on the site’s settings

Enter the present situation with this domain

Choose the actions that you are going to take to help

Choose the expected outcomes with the actions

You can add Note References using the Add New button

You can filter using the options above and then click Fetch Results to find the note

Select the note(s) you want to add to this area

Click Add Selected Notes to confirm your selection

You can also add Document References using the Add New button

Documents will be listed on the left-hand side

When selected, click Add Selected Documents to input them into the review section

Finish the rest of the areas of the care review by clicking Next

Once you have completed the review, input concluding comments within this box

Submit the conclusion and finalise the care review

Consent will be required to finish the review

Open the consent type drop-down

Choose Last Care Review

Enter the Frequency if not pre-set

Choose if the service user has mental capacity to consent

Choose if the resident is able to sign

Add the signature using this button

Draw the signature in this box

Click Save Signature when done

Choose who witnessed the consent

Enter their name within this box

Click Save Consent when done

Now you have completed the review, click the x to close the box

The review just recorded will now be set as active

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