Writing Care Notes Successfully

 

Caregiving Professionals in Documenting Care Notes

Care notes are an essential part of the documentation required. They are a tool for clients, families, and staff to record changes that impact the delivery of care and track client progress or declination. This information is used to review and update care plans. Progress and Care notes provide an essential means of communication among staff and reflect the soundness of care delivery in any organization. They are legal documents and should be accurate, plausible, and clearly written.

Interaction with clients for a large part of their day allows us to observe subtle and major changes in their health, demeanor, cognitive and physical strength, and diminishing abilities.

Examples of key concerns and details to include in Care notes if applicable: (not limited to)

·     Condition upon arrival/departure from client (alert and oriented? Did you leave them better than how you found them?)

·     Food intake, (what, when, how much?)

·     Activities

·     Medication reminders

·     Incontinent care checks (every 2 hours, changings documented)

·     ADL’s

·     Skin appearance

·     Any bruising, cuts, etc.

·     Client suddenly having difficulty to eat independently

·     Change in level of assistance required by staff in physical support

·     Change in level of support required by staff

·     Clients having difficulty swallowing

·     Clients having confrontations/altercations with peers

·     Emotional distress

·     Changes in moods (weeping, anger outbursts, apathy)

·     Aggressiveness - Physical and Verbal

·     Falls

NOTE: In the case of a fall, make your client as comfortable as possible (do not lift or help client to stand up), call office immediately for report and further directions

Essential Elements of Care Notes

Care Notes entries must consider the following:

*Caregivers are required to document care notes for EACH shift worked

1.  Objective – How was your client today? How is the client affected, refer to care plan

2.  Concise - Use fewer words to convey the message.

3.  Relevant - Consider the facts

4.  Well written - Sentence structure, spelling, straightforward writing is important

Use your critical thinking to analyze, assess, and document your care notes. Consider that others, including family, management, and staff, view your notes to support your client. 

Structuring entries: caregivers can use a structured template or summarizing paragraph

Tips for Writing Care and Progress Notes:

1.  Care Notes should be read at the start of each shift so staff know what kind of support will be required.

2.  Keep your entries professional and clear to understand

3.  Refer to previous entries for continuity.

4.  Keep your entries relevant to the care you are providing

5.  Sign off upon completion of your entry

6.  Acknowledge that Care Notes contain confidential information and should be handled as such

7.  Record your times and conditions of checks with your client (incontinent care, skin condition, etc.) Remember - if it is not written down, it didn’t happen.

Examples of Care Note Entries:

EXAMPLE 1- Shift from 11am-8pm

11am-arrived to receive report, Lola is in bed sleeping soundly.

11:15am-Facility staff gave meds which made Lola very sleepy

12pm-Facility staff brought lunch for Lola, encouraged her to eat but she refused and wanted to continue napping

1pm-Lola is awake and more alert than earlier, assisted her to bathroom and back to bed. She picked at her lunch a little bit ate maybe 10% of her meal and drank an 8oz Ensure. Lola was not very interested in much activity, we sat and chatted while I tidied her room and made her comfortable.

2pm-Facility staff gave next dosage of medication, but Lola wanted to wait for dinner to take all of them

430pm-Lola refused dinner again even after encouragement. She did drink 4oz more Ensure

5pm-Lola tried to use restroom, false alarm

530pm-Lola is restless and stating she “just doesn’t feel good” but unable to tell me where or how. I offered her different ways I could support her to make her more comfortable. Changed her into her pjs, adjusted her pillows and blankets, and read a book together.

6pm-Lola drank another 4oz Ensure but refused soup and rice. We continued to chat for a little bit and then had some quiet time.

745pm-Lola is resting her eyes, laying in bed. Overnight caregiver arrived for report and shift change. 

8pm-clock out and departure

 

EXAMPLE 2-Shift from 6am-10am

When I arrived at 6am Betty was sitting in her recliner. She said she's been out here since 3:30am states she’s been in a lot of pain with her feet. For breakfast I scrambled her 2 eggs, and a cutie made her some hot tea. I've got the laundry started. The cats have been fed. Cleaned out a med bm from bedside commode. Betty checked her O2 level, one of her readers was steadily dropping and ended up being in the low 80s but she used her other reader and said low 90s to high 80s. I moved the laundry from washer to dryer. I peeled some banana and put them in a baggie and into the freezer. I've washed the dishes and finished tidying the house. Betty was feeling a little tired so she decided to take a nap. Last check before leaving and everything is good.