If you’ve worked in a healthcare environment before, you already know that documentation is a major part of everyone’s job. You might have even heard the common phrase, “if you didn’t document it, it didn’t happen.” Here at Easy Living, caregiver documentation is the foundation of how we communicate with one another and how we provide the best care for our clients.
Your documentation is your way of telling us what is going on with the clients you serve. When you document your day, you are giving us crucial information.
When you document, it’s important to remember that you only document what you observe. Never document what you think happened or what you guess happened. Think of it in the old saying, “just the facts, ma’am”. Here are some things you might observe:
Things you SEE:
You might notice Mr. Jenkins is limping today or that Harriett’s legs are swollen when you help her put on her socks.
Things you HEAR:
You might notice that Thomas has a new dry cough or that Ms. Anderson is asking more repetitive questions than usual.
Things you TOUCH:
You might feel Mr. Lettington’s head and notice that he has a fever or that Iris has clammy skin.
Things you SMELL:
You might notice that Betsy has a strong urine smell or that Mr. Yost’s bowel movements are particularly odorous.
Each of your observations give us insight to the overall health of your patients. The more we know, the better we can follow up and perhaps prevent an emergency room visit or a serious illness.
For example, we talked about noticing Harriett’s legs were swollen when you helped put on her socks. If you check her care plan, you see that she has a history of heart disease and that swollen legs can mean she needs to get her medicine adjusted. If we notice that change right away, we can assist in getting Harriett the help she needs before she ends up in the emergency room or in the cardiac unit of the hospital.
When you document, make sure you are clear and concise about the facts. You should also never leave any requested documentation blank.
Your notes and observations matter to us, so document them.
