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Documentation

2017-11 FTHC In-Service:

Documentation



Part 1: Client Note Structure
  • Heading -- for each entry you should record

    1.  Client name
    2.  Date
    3.  Caregiver name
    4.  Start time
    5.  Finish time


  • Note: If you are working through 2 shifts, stop your first note at end of shift and start a new note for your second shift. (Example: 11PM-7AM and 7AM-3PM ￿ you should create separate notes even though shifts are contiguous)

  •  Body -- the body of the note needs to include -

    1. 1. Tasks completed
    2. 2. Concerns noted throughout shift
    3. 3. Any discussions held with Care Director, Family, or Facility staff
    4. 4. Any changes on client
    5.  5. Notes on daily function (eating %, drinking %, etc.)
    6. 6. Bowel movements if important to particular case
    7. 7. Behavior of client throughout shift
    8. 8. Info to help aide easier transition for next caregiving shift
    9. 9. Medication reminders given and what meds client takes (dosage/time-of-day)


  • Note: Documenting does not exonerate you from showing concern about a client and notifying Care Director immediately when there is any question about a client￿s health or welfare

Continue To Part 2

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