Every note you write becomes part of a client's medical record. It protects them, protects you, and helps the entire care team stay on the same page. Documentation is not busy work — it is essential care.
Golden Rules of Documentation
- Be factual. Write what you observed, not what you think or assume.
- Be timely. Document as soon as possible after the event.
- Be clear. Use simple language; avoid jargon.
- Be specific. Instead of "client is confused," write "client did not recognize family member who visited at 2 PM."
- Never erase. If you make a mistake, draw one line through it, write "error," and initial and date. Never use white-out.
What to Document
- Activities of daily living (bathing, toileting, eating).
- Mood, behavior, and any changes.
- Intake and output.
- Skin condition and any sores or redness.
- Client complaints and your response.
- Anything unusual or concerning.
Communication at Handover
At shift change, report important findings face-to-face. Do not assume the next person will read your notes. Be concise and clear about urgent concerns.
Privacy and Confidentiality
Never discuss a client's care on social media or with family members not involved in their care. Records are confidential. Keep them secure.
🔑 Key Takeaways
- Factual, timely, clear, specific — always.
- Document ADLs, mood, changes, and concerns.
- Never erase — use a single line and initial.
- Report at handover face-to-face.
- Maintain confidentiality always.