How to fill in the contents of the daily care record form for the elderly

The core principle of filling in the daily care record form for the elderly is "real-time and factual, corresponding to needs, and traceable." Don't fill it out in advance to save trouble. Each record must correspond to the actual care actions you do and the actual state of the elderly. There is no room for confusion.

I used to help sort out the nursing records for half a year at a community nursing home. I saw many nurses who were quick to fill in the blood pressure and eating status for a week as "normal" in advance. As a result, an old man with long-term hypertension suddenly felt dizzy and sent him to the hospital one day. He wanted to look up the previous blood pressure fluctuation records for reference. They were all uniform 130/80mmHg, which had no reference value at all, but delayed the doctor's judgment of the cause.

Don't think that this watch is just a showpiece to deal with inspections by superiors. It is the most solid evidence when you encounter trouble. For example, for basic vital signs, just write down the measured value. If the old person just finished the test after drinking hot porridge, or went downstairs for a walk, mark "just after activity" on the back, so that people who read the record later will not regard physiological fluctuations as abnormal. Don't always write a vague "appetite" when eating. If an old man has a bad appetite today and only drank less than half a bowl of millet porridge and vomited two mouthfuls, he must write it down clearly. If a diabetic old man secretly eats half an extra piece of moon cake brought by his family, he must also write it down. If the blood sugar is high later, he can directly find out the cause without guessing.

Nowadays, the industry has different opinions on the details of records. Many front-line nursing workers feel that the daily nursing tasks are already very heavy, and there is no need to write down every detail, which will delay the nursing time. Some people think that all changes in the elderly's condition must be recorded, and even if they sneezed twice today, they will leave traces. In fact, both statements are a bit extreme. Just find a good balance and adhere to the principle of "remember exceptions and keep routines concise." An old man who can usually walk independently staggered twice while walking today. Even if he can rest for two minutes, he still needs to remember. If the blood pressure has been stable in the normal range for a week, just write the numerical value directly. No need to write extra words.

Last time a family member came to visit on the weekend and asked how the old man's appetite was recently. I looked through the records and told him that the old man caught a cold last Wednesday and his appetite decreased for two days. We adjusted the liquid diet and added his favorite pumpkin puree. In the past three days, he has recovered to being able to eat less than half a bowl of soft noodles at one meal. It is much more convincing than saying "very good" in vain, and the family is particularly relieved. If you encounter an elderly person who is disabled and bedridden, the records of turning over and skin examination must not be missed. On any day when the sacrococcyx is touched and there is a little redness, you must clearly write down the approximate extent of the redness, whether you have applied decubitus ointment, and check the records during the next care to see if they have disappeared. This is equivalent to leaving a dynamic timeline for the elderly person's condition, so whoever comes to take over can quickly catch up.

You need to be more careful when you meet an elderly person with cognitive impairment. If the elderly person is inexplicably irritable and throws a cup today, don't just ignore it as a tantrum. You must also write it down. Many elderly people with dementia cannot express themselves when they are not feeling well, and they will only show it through abnormal emotions. When the doctor consults later, these detailed records are important references for judging the condition. To put it bluntly, this form is not filled out for others to see, but to support the care of the elderly. When you fill it out, you must use your conscience and compare it with what you actually did that day, and you will not make any mistakes.