4.2 Where and What to Document

We want documentation to be as easy as possible for you to complete. You can access your documentation on your ClearCareGo app.

Here are common items you will need to document when you work as a caregiver here at Easy Living.

First, you will need to document the tasks you completed during your shift. You will document if the task was completed during your shift or not. If you did not complete a task, you must document why. For example, if Mr. Everett refused his shower today, you will report that task was not completed. You will also note that he refused his shower because his daughter was coming over to visit and he didn’t want to be late.

You’ll be prompted to document tasks completed on your app or via telephony when you clock out.

Next, you’ll document any notes. These are general observations you want to share about your shift or about the client but that do not have to do with your daily tasks. For example, you might want to note that Mrs. Rivers spent the majority of the morning crying today, which is unusual for her.

Finally, you want to document any noticeable changes in condition. This means anything you observe that is different about the patient. For example, you might note that Evelyn was very confused today or that Ms. Raymond’s cough is worse than yesterday.

You might also need to document additional information such as in an incident report if something unusual happens during your shift.

Take some time now to review how to document on ClearCareGo with your agency representative. I’ll see you again soon as we begin chapter 5 of our orientation, which is all about care expectations.

Making Notes Using Task

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