Observation, reporting, and documentation of client status and the service, including changes in functional ability and mental status demonstrated by the client presented in this section.
Documenting Client Care
Maintaining accurate client care notes assists families, medical doctors, care managers and other caregivers to stay current with the client’s status and enables higher quality care.
Senior caregivers working as companion caregivers, certified nursing aides, certified home health aides and personal care assistants are responsible for reporting and documenting information about the client receiving care.
Client Care Documentation Components:
Care Plan Outlining Care Routine
Care Plan Daily Note via Phone Application or Note Sheet for Recording Daily Activities
Confidentiality of Information
Caregiver Duties and Performance Review
Names for Care Reporting & Documentation Include:
Care Plant Notes
Clinical Record
Patient Chart
Medical Record
Legal Issues for Documentation:
Quality care plan notes for each client care shift assist with the following protections:
Protects the caregiver by confirming the duties took place.
Protects the senior care company by confirming the care duties were performed.
Confirms specific care items were performed at specific times, such as: turning the client to prevent bed sores every 2 hours or monitoring medication, fluids or bathroom visits. By confirming the care services took place as instructed, the caregiver is protected should anything out of the ordinary occur.
Subjective Notes Vs. Objective Notes
Remember that everyone involved in the senior’s care will be reviewing the Care Plan Notes.
Care Plan Notes MUST BE OBJECTIVE
Objective Notes are Facts
Subjective Notes are Opinions
Do:
Use EXACT Quotes from the Client when they are communicating pain or discomfort
Only use Abbreviations which are Standard
Use correct spelling
Record accurate information regarding the client’s care plan
Record important telephone calls
Note activities throughout the day as they occur
Note meals eaten
Confirms medications taken
Write neatly and legibly
Proofread your written documentation notes
Do Not:
Share your opinions
Wait until later to make notes about care events
Share notes about your own personal incidents
Wait until the end of your shift to record all activities
IMPORTANT ITEMS WHICH ARE OFTEN MONITORED IN CARE PLANS ARE:
Meals
Hydration (fluids drank)
Bathroom visits
Sleep
Activities
Changes in mental awareness
Changes in physical condition and abilities
Most Senior Care Companies will have a Daily Care Notes form which you can fill out each day will include these types of items:
SAMPLE DAILY CARE NOTES
Health & Hygiene
Transform from bed to chair
Bathroom visit
Catheter care / diaper change
Shower / bed bath
Dressing assistance
Hair care
Skin care / lotion
Dental care
Medication reminder
Exercise routine
Nutrition
Grocery shopping / meal plan
Meal preparation
Set-up meal
Assisting with feeding
Feeding tube care
Breakfast
Lunch
Dinner
Snack
Fluid monitoring
Activities
Physical therapy
Exercise
Reading
Mental exercise game
Other activities: ____
Client Routine
Wake-up time:_____
Nap A.M._____
Nap P.M._____
Bed Time:_____
Bathroom Visits:____
Indicate Client Status : Good, Fair, Poor
Household Cleaning
Changed bed linens
Laundry
Sorted mail
Cleaned kitchen
Cleaned bathroom
Swept floors
Dusted rooms
Vacuumed rooms
Errands
Pet care
Other
Watch Video for Ideas for Activities with Seniors with Alzheimer’s Disease and Memory Loss:
Legal Issues
Poor Care Plan documentation could make it look like a caregiver is giving poor care or indicate neglect. Caregivers must be sure to provide sufficient care notes each day.
Long-term Care Insurance Companies: Care Plan Notes may be required in order for the insurance to pay the claim. This is why it is extra important to maintain professional notes daily and correctly document daily care activities.
Medication Reminder Charts: Medication monitoring is not the same as medication administration. Caregivers only “monitor” the medications to be sure the person receiving care took the medications as authorized in their medication chart.
Incident Reports: If a work injury occurs, such as a fall or damage of (client’s personal) property, this is separate from the Plan Of Care. Call your supervisor and follow your company system for incident reports.
Care Plan Safety: Protect yourself as the caregiver and the client by IMMEDIATELY REPORTING any significant changes in health conditions, safety concerns or new developments. If elder abuse seems to be apparent by a family member or friend when you arrive for a shift, act immediately by calling your company manager and document what you observe.
Observe: We have 2 ears and 1 mouth so we can listen twice as much as we talk. Observe with all of your senses - listen, smell, and touch to observe changes in condition.
Quality of Care Plan Information: Remember that a long-term care insurance company, family members, doctors, nurses, and in some cases an attorney acting as a legal guardian may be reading the care plan notes. Keep them professional and be sure to proof them at the end of your shift.
💡 Tip Sheet
Make Objective Observations, Document Care Services Daily, Understand Objective Notes vs. Subjective, Medication Monitoring is Just That - a Reminder to Take A Medicine As Scheduled, Protect Yourself and Your Care Company and Document Care Provided