Documentation and Reporting (~35 Minutes)

You are providing care to people whose health and well-being need to be monitored closely. You have a responsibility to observe clients and communicate any changes or concerns efficiently and quickly to all necessary care team members.  This is especially important when people work on different shifts or in different departments.

Observe

As an LTC worker, you may be the first person to notice a change in a client’s physical, mental, or emotional condition.  It is your responsibility to watch for these changes.

• Use your senses of touch, sight, smell, and hearing to observe as you care for a client. 
• Watch for changes in mood.
• Listen when a client tells you about feelings or pain. 
• Change in grooming ­ dirty clothing, dirty hair, body odor.
• Change in mood unusually quiet or teary, anxious, fearful, showing extreme grief, or paranoia (saying that someone is out to get them or is taking their money), or talking of suicide.
• Confusion, forgetfulness, lack of cooperation, giving answers to questions that don’t make sense.
• Any change in the ability to walk, stand, or do daily self-care.
• Physical changes may mean illness, such as swelling, skin rashes, cough, and difficulty breathing.
• Change in eating or cooking habits, loss of weight, loss of interest in food and eating, any sign of not having enough to eat.
• Talk of financial problems or asking for help with a problem.

  Look for signs of change as you give care.

Cover all the facts when documenting and reporting!

WHEN…date and time you observed the change, behavior, or incident.

WHAT… happened – write down the objective facts.

WHERE…you observed this happening.

HOW…long and often it happened.

WHO… was present, involved, or notified about what was happening.

WHAT… action you took and the outcome.

---

Documenting

Remember! Client records contain very personal and confidential information.  State and federal laws outline strict guidelines for how a client’s records, especially medical records, must be handled.

Understand and follow the documentation policies and procedures where you work.

General documentation tips.

• Always protect a client’s right to privacy. Never leave notes or forms in places where others can see them.
• Print clearly so others aren’t struggling to read your writing.  Use black ink when documenting.
• Describe what you observe clearly so that someone who was not there will easily understand.
• Describe only what you see. These are called “observable facts”.  Leave out your personal opinions and interpretations of what you think happened.
• Never make an entry into a client’s record for someone else or sign an entry for something that you did not do or see done.
• Remember that what you write becomes a legal document.

---

Tips for keeping a client’s records confidential

  Look for signs of change as you give care.

Reporting

The home or facility where you work will have clear rules about when to report your concerns to other care team members. These are often situations where more immediate action is needed or the client must be more closely monitored. 

It is your responsibility to make sure you follow these rules and have a thorough understanding of when you are required to report and to whom. 

If a client refuses care

Any client always has the right to refuse care. Sometimes a client may not want you to do one or all of your assigned tasks.  Take the time to figure out why and if there is anything you can do to help. It may be that the client does not feel up to it that day but will the next time you are there. 

Do you need to document or report the client’s refusal to get care? It often depends on the task(s) that didn’t get done and if there are safety concerns for the client.  If you are not sure, ask your supervisor. 

Know what does and does not need to be documented or reported and when.