Observing, Documenting, and Reporting

A Home Care Aide is an important member of the client’s care team. Since you are the client’s day-to-day caregiver, you are in the best position to observe changes in their condition. Part of your job responsibility is to document and report these changes to the appropriate care team member. Some changes in a client’s condition, symptoms, or abilities require an adjustment to the service plan. By observing, documenting, and reporting, you make sure the client always receives the support they need.

Observing Changes from Baseline

A client’s physical, mental, and emotional condition may improve or decline over time. You need to know the client’s baseline and monitor carefully to recognize any changes.

A Client’s Baseline

A client’s baseline means their usual condition and level of ability. A baseline is also called a client’s customary range of functioning. You can learn about the client’s baseline from the client, their service plan, and other care team members.

What Would You Do?
A client you work with complains that they often get dry, patchy areas on the legs. How can you find out if these areas are unusual for them?

Observing Changes

Make regular observations a part of your routine and get to know the client. Each time you meet them, compare what you observe to what you know about their baseline. Stay alert and pay attention to any changes.

Sometimes the client will tell you about changes they are experiencing. Encourage the client to tell you how they are feeling and any pain they are having. Listen carefully and give them time to answer completely. Use all your senses when observing a client. You may see, hear, smell, or feel signs of change or problems.

Reference Pages 87-88 for examples of changes to look for in your client.

Documenting Observations

When you observe changes in the client’s condition, you need to write them down. Documenting observations means keeping a written record of any changes or concerns about a client, including:

changes in a client’s condition or baseline;
signs of problems or symptoms of illness; and
concerns about a client’s behavior or a specific incident or event.

Creating a written record of your observations helps you and other members of the care team to:

remember important details;

see patterns of changes over time; and
communicate accurate information about supporting the client.

Objective Documentation

The goal of documentation is to record the facts as you observed them. Objective documentation does not include your personal opinion or interpretation. Subjective information like this is less useful to other care team members. If you are documenting something that the client told you, write down their exact words. If you are asked to give your opinion regarding a change or observation about a client, always start with the objective facts that led to your conclusion.

Objective vs Subjective
Read the examples below. What makes the first example subjective? Why might the subjective example be misleading to other care team members?
Subjective: Carol did not like her breakfast this morning, so she didn’t eat it. I asked her if she wanted something else, but she did not. I guess she will be extra hungry tonight, so we should give her two helpings of dinner.
Objective: Carol did not eat her breakfast this morning. She said, “I do not want to eat this.” I asked her if she wanted something else, but she said “No, I will eat later.”

Care Settings and Documentation

The specific kind of documentation that you need to do depends on your care setting. Your employer will have rules and procedures on how, when, and what you need to document. Make sure you understand your responsibilities regarding documentation. In any setting, it is always a good idea to keep notes or a log of your observations. In most care settings, you will write daily or weekly notes on residents’ progress and status. These may be called “narratives,” “progress notes,” or something else. These notes are in addition to specific changes or incidents that might occur.

Documentation Guidelines

You must learn the documentation policies in your own care setting. In general, when documenting your observations:

make sure you have the correct client’s record before you begin writing;
use a blue or black pen (do not use a pencil), your narrative is part of the permanent record;
write clearly and legibly;
do not use abbreviations that are not widely used;
include the correct date and time;
make sure your documentation is complete:
o Description: what happened, when, and who was there?
o Action: What did you, as the caregiver, do about the problem/issue/incident?
o Response: How did the client respond to the problem, incident, or issue and your actions? What was the outcome?
sign your notes, and
never change or erase a record.

If you are told to change a record for any reason, clearly initial and date the entry with the date the alteration occurred.

Poor Documentation vs Good Documentation
Poor Documentation:
Monday afternoon. Yelling in the bathroom. Trapped herself in and is really angry.
Good Documentation:
10/11/20, 4:30 P.M. Heard Mrs. Hirono in the bathroom yelling “Let me out.” Found Mrs. Hirono’s bathroom door locked. Used key to unlock the door. Mrs. Hirono said she was scared about being locked in the bathroom, so I assured her she was safe, showed her how to unlock the door on her own, and visited with her until she appeared to be no longer scared.

Signed Mx. Careful Caregiver

The good documentation gives a complete, factual picture of what happened. The caregiver wrote what they observed and heard, what the client said about their situation, and what they did to respond. The documentation is also dated and signed.

Reporting

Your employer will have rules and procedures on how, when, what, and to whom you should report. Make sure you understand these procedures and ask your supervisor if you have any questions. When you make your report, include the objective observations you have documented. After you make your report, you should document the fact that you have reported and to whom.

When you observe changes from baseline, report them immediately to the appropriate person in your care setting.

Reporting Guidelines

Remember to always follow the specific rules and procedures around documenting and reporting in your care setting. In general, make a report when:

you hear of or suspect abuse or neglect;
you have concerns or questions about changes in a client’s condition;
the client develops a new problem;
the client has personal care needs that are not being met;
the client is getting better and no longer needs help with some of the tasks you are doing;
you know of additional resources that would add to a client’s quality of care or independence;
you are unable or uncomfortable doing the tasks outlined in the care plan; or
you are asked to perform tasks not outlined in the care plan and cannot resolve this with the client.

Reporting Exercise
While helping Mr. Ito dress in the morning, you notice that he becomes frustrated and irritated. He suddenly tells you to stop helping and leave him alone. You ask what is wrong, but he refuses to answer you. You give him some time and come back a few minutes later. Mr. Ito lets you finish helping him dress but still seems unhappy. What steps would you take to document this incident? Would you report it to your supervisor? If so, when?