Lesson 5- Documenting Observations and Reporting
Documenting is keeping a written record of any changes or concerns about a client, including a:
Having a written record helps you:
Care settings and documentation
The kind of documentation that you do depends on where you work.
For in-home workers, no documentation is officially required unless you are doing nurse delegated tasks. However, it is highly recommended that you keep a log in a notebook of your observations.
If you work in a boarding home or an adult family home, there are specific procedures on how, when, and what you are to document. Make sure you understand your responsibilities regarding documentation.
Objective versus subjective documenting
What you document should be objective. To document objectively means you write down the facts exactly as you observed or noticed them with your senses. The goal is to describe the specific behavior or changes you observed about the client and/or his/her mood. Your documentation should also include the facts as the client described them to you. When documenting something the client has told you, write down the client’s exact words.
Subjective documenting means you write down your opinion or interpretation of what you observed. Opinions are less useful in documentation because biases and emotions can influence how you interpret what you see. You may not have all of the facts, the medical knowledge, or an understanding of what the client is experiencing. For these reasons, subjective documentation should be avoided.
There may be times when you are asked to give your opinion regarding a change or observation. If you are asked for your subjective opinion about a client, always start with the objective facts that led to your conclusion.
Documentation guidelines
WHEN... date and time you observed the change, behavior, or incident.
WHAT... happened - writing 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.
Poor documentation example
Monday afternoon. Yelling in bathroom. Trapped herself in and is really angry.
Good documentation example
10/11/04, 4:30 P.M. Heard Mrs. Smith in the bathroom yelling “Let me out”.
Found Mrs. Smith’s bathroom door locked. Used key to unlock the door. Mrs. Smith said she was scared about being locked in the bathroom.
Signed Ms. Careful Caregiver
The documentation in the last example gives a complete, factual picture of what happened. The caregiver wrote what she observed and heard, what Mrs. Smith said about her situation, and what she did to respond. The documentation is also dated and signed.
There comes a point where a change in a client’s baseline, or other concerns you may have, need to be reported to the appropriate person in your care setting.
For in-home clients, report changes to the case manager. If you work in a boarding home or an adult family home, there will be communication procedures on how, when, what, and to whom you are to report. If these procedures are unclear to you, ask your supervisor to explain them.
Reporting
There comes a point where a change in a client’s baseline, or other concerns you may have, need to be reported to the appropriate person in your care setting.
For in-home clients, report changes to the case manager. If you work in a boarding home or an adult family home, there will be communication procedures on how, when, what, and to whom you are to report. If these procedures are unclear to you, ask your supervisor to explain them.
The following are some guidelines for when to report to the client’s case manager or your supervisor. Use any documentation notes you have to report what you observed.
Document afterwards what you have reported and to whom.
- Change in a client’s condition or baseline;
- Sign or symptom of possible importance;
- Concern about a client’s behavior or a specific incident or event.
Having a written record helps you:
- See patterns of changes;
- Remember details that could be important to another care team member;
- Give more accurate information;
- Not rely solely on your memory.
Care settings and documentation
The kind of documentation that you do depends on where you work.
For in-home workers, no documentation is officially required unless you are doing nurse delegated tasks. However, it is highly recommended that you keep a log in a notebook of your observations.
If you work in a boarding home or an adult family home, there are specific procedures on how, when, and what you are to document. Make sure you understand your responsibilities regarding documentation.
Objective versus subjective documenting
What you document should be objective. To document objectively means you write down the facts exactly as you observed or noticed them with your senses. The goal is to describe the specific behavior or changes you observed about the client and/or his/her mood. Your documentation should also include the facts as the client described them to you. When documenting something the client has told you, write down the client’s exact words.
Subjective documenting means you write down your opinion or interpretation of what you observed. Opinions are less useful in documentation because biases and emotions can influence how you interpret what you see. You may not have all of the facts, the medical knowledge, or an understanding of what the client is experiencing. For these reasons, subjective documentation should be avoided.
There may be times when you are asked to give your opinion regarding a change or observation. If you are asked for your subjective opinion about a client, always start with the objective facts that led to your conclusion.
Documentation guidelines
- Set aside a specific time for writing notes. A regular routine helps ensure that your observations are documented promptly and the information is accurate.
- Make sure your handwriting is readable and use a blue or black pen.
- Make sure your documentation is complete. Include the date and time of when you are documenting your observations and sign your notes.
- Address the following information:
WHEN... date and time you observed the change, behavior, or incident.
WHAT... happened - writing 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.
Poor documentation example
Monday afternoon. Yelling in bathroom. Trapped herself in and is really angry.
Good documentation example
10/11/04, 4:30 P.M. Heard Mrs. Smith in the bathroom yelling “Let me out”.
Found Mrs. Smith’s bathroom door locked. Used key to unlock the door. Mrs. Smith said she was scared about being locked in the bathroom.
Signed Ms. Careful Caregiver
The documentation in the last example gives a complete, factual picture of what happened. The caregiver wrote what she observed and heard, what Mrs. Smith said about her situation, and what she did to respond. The documentation is also dated and signed.
There comes a point where a change in a client’s baseline, or other concerns you may have, need to be reported to the appropriate person in your care setting.
For in-home clients, report changes to the case manager. If you work in a boarding home or an adult family home, there will be communication procedures on how, when, what, and to whom you are to report. If these procedures are unclear to you, ask your supervisor to explain them.
Reporting
There comes a point where a change in a client’s baseline, or other concerns you may have, need to be reported to the appropriate person in your care setting.
For in-home clients, report changes to the case manager. If you work in a boarding home or an adult family home, there will be communication procedures on how, when, what, and to whom you are to report. If these procedures are unclear to you, ask your supervisor to explain them.
The following are some guidelines for when to report to the client’s case manager or your supervisor. Use any documentation notes you have to report what you observed.
Document afterwards what you have reported and to whom.
- You have worries or questions about changes in a client’s condition.
- The client develops a new problem and 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 have suggestions or 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.
- You are asked to perform tasks not outlined in the care plan and cannot resolve this with the client.
- The client continues to refuse services.