More effective way of documenting…

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Presentation transcript:

More effective way of documenting… Caregiver Log More effective way of documenting…

Care Log… In this presentation we will be reviewing and explaining the fields on the care log form that are required to fill out. At the top of the care log you must fill out: Consumer Name Caregiver Name Date & Shift. Ensure that you use black ink when filling out the form. Make sure that your writing is legible.

Personal Care… Check off the services that you have provided to the consumer. Ex. If you have given a tub bath, shave, wash hair, mouth care, and assisted with dressing. Make sure you check each box. Important: You must read your CARE PLAN to see what services that the consumer requires.

Nutrition… In this section you will check off if you prepared a meal (breakfast, lunch, supper) or if you have given a snack. You also will provide how much was eaten and what was provided. You must read your CARE PLAN to see what the consumer requires. If the consumer is on a fluid restriction or if we are to encourage the consumer to drink. Also you may be required to list the fluid intake while you were at the consumer’s residence.

Elimination… In this section you are required to indicate if the consumer was incontinent of bowel or bladder. If the consumer used adult briefs, the amount of times the adult briefs where changed? If you assisted the consumer to the bathroom, commode, bedside commode, bedpan, or urinal. If you assisted the consumer with any appliance, urinary catheter bag or an ostomy bag. If the consumer had a bowel movement, and if so how many? How many times or how much the consumer urinated during your shift.

Medication Reminder… In this section you are to indicate that you reminded the consumer to take their medication or did you assist the consumer with self-administered medications. Also, did the consumer take their medication or did they refuse after you reminded them to take the medication. This section also reminds you; Aides are only to remind consumer to take medication, aides are not allowed to administer medications such as, over the counter medication, breathing treatments, patches, eye drops, ear drops, insulin, or blood sugars, any questions call the office.)

Other Services… In this section you must indicate if there is an alteration in mobility such as; Turn and reposition every 2 hours. If you changed the consumers position. If you elevated the head of the bed for the consumer. Remember if there is an alteration in mobility and it is not listed on the care plan you must notify the office. Also, you must indicate the consumer’s ambulation or walking; Did you assist/supervise the consumer while they were walking? Did the consumer use any assistive devices such as a cane, walker, or wheelchair? Did the consumer require assistance with transfers or where they independent? Remember, Family Care is a no lift agency. If a consumer needs assistance with lifting you must notify the office immediately.

Light Housekeeping… In this section you must indicate the services that you provided while at the consumer’s residence. Refer to the CARE PLAN to see if the consumer has a duty list that the aides must complete while at the residence.

Caregiver Signature… Remember to sign at the bottom of the caregiver log form. Upon signing this form you are stating that everything on this form is true and factual.