PRINCIPLES OF CAREGIVING:

FUNDAMENTALS
CHAPTER 6 OBSERVING,
REPORTING AND DOCUMENTING
CONTENTS
A. Purpose and Importance of Observing and Reporting
B. Observing and Monitoring
1. Recognizing Changes The DCW as Detective
2. Signs and Symptoms of Illness and Injury
3. Changes in Mental or Emotional Status
4. Changes in Home Environment
C. Care Plans and Support Plans
D. Reporting
E. Documenting
1. Significance of Documentation
2. Documentation Guidelines
3. Documenting and Reporting Facts
4. Documentation Activity
5. Standardized Medical Abbreviations and Acronyms

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OBJECTIVES
1. Explain the purpose of reporting and documentation.
2. Describe the purpose of care and support plans.
3. Explain the importance of observing changes in a person and describe observation
techniques.
4. Identify and explain signs and symptoms that need to be reported.
5. Prepare written documentation following documentation guidelines.

KEY TERMS
Care plan

Sign

Charting

Reporting

Documentation

Support plan

Progress notes

Symptom

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A. PURPOSE AND IMPORTANCE OF OBSERVING AND REPORTING

The purpose of observing, reporting, and documenting is to
communicate any changes or status that may be occurring with an
individual and/or the family. Since the individual may even be
unaware of changes, it is vitally important for the DCW to
communicate with other team members (including the persons
family, as appropriate). This can be accomplished through
observing and monitoring for any changes, and reporting and
documenting those changes.
Report and document only things that you saw or did YOURSELF. The information that is
communicated will help the supervisor act appropriately. The DCW becomes the eyes and
ears for the supervisor. The DCWs accurate input is vitally important.

B. OBSERVING AND MONITORING

1. Recognizing Changes The DCW as Detective

Early identification of changes in an individuals daily routines, behavior, ways of

communicating, appearance, general manner or mood, or physical health can save
his or her life.

You get to know a person by spending time with him or her and learning what is
usual for them. If you dont know what is normal for a person, you wont know when
something has changed.

Tools the DCW may use

Observation: Use all of your senses: sight, hearing, touch and smell.

Communication: Ask questions and listen to answers. A good listener hears the
words and notices other ways of communicating, including behavior.

2. Signs and Symptoms of Illness or Injury

Signs are what can be observed; symptoms are what the person experiences or feels.
Physical Health: Changes in physical health are often identified by changes in a
particular part of the body. Some are changes you may observe, and others are changes
an individual may tell you. For example, you may observe that an individual is pulling his
ear or an individual may tell you that his ear hurts.
Ask yourself: Is there any apparent change to the individuals skin, eyes,
ears, nose, or any other part of the body?

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Physical changes to pay attention to include:

Skin: Redness, cut, swelling, rash.

Eyes: Redness, yellow or green drainage, swelling of the eyelid, excessive tearing, or
the individual reports pain and/or that eyes are burning.

Ears: Pulling at ear, ringing in the ears, redness, fever, diminished hearing, and
drainage from the ear canal, the individual reports dizziness or pain.

Nose: Runny discharge (clear, cloudy, colored), rubbing of nose.

Mouth and throat: Refusing to eat, redness, white patches at the back of the
throat, hoarse voice, fever or skin rash, toothache, facial or gum swelling, gum
bleeding, fever, individual reports pain when swallowing.

Muscles and bones: Inability to move a leg or an arm that the individual could
previously move, stiffness, limited range of motion, individual reports pain in the
arms, legs, back.

Breathing (lungs): Chest pain, cough, phlegm (mucous), shortness of breath or

wheezing, fever, rash, stiff neck, headache, chills, nasal congestion, individual
reports pain in nose or teeth, dizziness.

Heart and blood vessels: Numb or cold hands or feet, swelling of ankles, chest pain,
shortness of breath.

Abdomen, bowel, and bladder (stomach, intestines, liver, gallbladder, pancreas,

urinary tract): Constant or frequent abdominal pain, bloating, vomiting, loose stools
or diarrhea, constipation, blood in vomit or stools, fever, fruity smelling breath,
difficult, painful and/or burning urination, changes in urine color (clear to cloudy or
light to dark yellow), fruity smelling urine, nausea, pain on one or both sides of the
mid-back, chills.

Womens health: Vaginal discharge, itching, unusual odor, burning, changes in

menses, such as change in frequency, length, and flow.

Mens health: Discharge from penis, pain, itching, redness, burning.

Warning signs of injury that require medical attention:

Joint deformity: Limb is out of alignment with the rest of the extremity.

Joint pain or tenderness: Finger pressure to the area causes pain.

Swelling: Swelling within a joint causes pain and can even cause a clicking noise as
the structural tendons and ligaments get pushed into new positions.

Decreased range of motion of the affected joint or limb.

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Numbness or tingling: This may be a sign of nerve compression.

For treatment of injuries, refer to Chapter 9, Fire, Safety and Emergency Procedures.

3. Changes in Mental or Emotional Status

Behavior: An individual who is usually calm starts hitting and kicking; appears more
or less active than usual.
Ask yourself: Does the individual appear more or less active than usual?
Is the individual acting aggressively to himself or to others?

Ways of communicating: An individual who usually talks a lot stops talking; speech
becomes garbled or unclear.
Ask yourself: Has the individuals ability to talk or communicate changed?

Appearance: An individual who is usually very neat in appearance now has

uncombed hair; is wearing a dirty, wrinkled shirt. There are changes in color or appearance (a sudden redness on the hands or an ashy tone and clammy feel to the
skin); any changes in weight, up or down.
Ask yourself: Does it seem like the individual has lost interest in things?
Is the individual taking less care in his or her dress?

General manner or mood: Someone who is usually very talkative and friendly
becomes quiet and sullen; an individual who usually spends her free time watching
TV with others suddenly withdraws to her room and wants to be alone.
Ask yourself: Has the individuals mood changed? Does the individual want to
be alone all the time?

Family/social relationships: The individual may act distant or afraid when family
members or visitors are around.
Ask yourself: Is there someone interacting with the person who appears to
causing emotional distress? If you notice any signs of drug activity, or verbal
or physical abuse, inform your supervisor immediately.

4. Changes in Home Environment

Finances: Are there unpaid bills? Have utilities been cut off? Is there sufficient food
on hand?

Cleanliness: Has there been a change in housekeeping routines? Can the individual
continue doing household chores?

Home maintenance/safety: Are there repairs that need to be done that could cause
a health or safety hazard?
Source: The section on observing and monitoring was adapted from: Direct Care Worker Training,
California Department of Developmental Services.

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Reporting Equal Win/Win for Client and Caregiver

Learning to communicate effectively with an individual and your supervisor is key to
maintaining a good caregiving relationship. As a caregiver, you learn to adapt and respect each
clients daily routine; however, as a clients level of care may begin to change, there may need to be
adjustments to ensure the safety of the person and the caregiver are not compromised. As a caregiver, your communication and reporting is very valuable to identify any changes so that your
supervisor can respond with a plan of action and also communicate with clients case manager.
As a caregiver supervisor working in this field over eight years, I recall a win/win situation
for one client and caregiver based on effective communication and reporting.
My story begins with the caregiver who has been providing care for her client for over four
years. Over time Mary began noticing that managing the daily routine began taking longer and
longer as her clients abilities were lessening. The caregiver reported her concerns with her
supervisor, and the supervisor scheduled a home visit to meet with the client and caregiver to observe
the morning routine. Upon completing the home visit, it was apparent to the supervisor that the
caregiver did not have the tools and time necessary to meet the clients needs. The supervisor
contacted the clients case manager. Another visit was scheduled with the case manager, supervisor,
client, clients daughter, and caregiver to meet together in clients home to discuss face to face what
changes could be implemented into the clients routine, so both client and caregiver were safe and the
client would be receiving good care. The case manager completed a new assessment and submitted
orders for the client to receive a hospital bed, Hoyer lift, new wheelchair and cushion and a new
shower chair. The clients hours of service were increased to have coverage seven days a week, with
a morning and evening schedule. Communication and reporting got this snowball going and it all
paid off in the end with the win / win for both client and caregiver.
Bonnie Zanardi, caregiver supervisor

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C. CARE PLANS AND SUPPORT PLANS

A care plan or support plan (depending on the agency terminology) is a written plan
created to meet the needs of the person. It may also be called a service plan.

The plan is usually created during an in-home assessment of the individuals situation,
the strengths and care being provided by family and friends.

The plan defines the needs and objectives/goals for care.

The plan lists the actions to be provided by the DCW.

Any deviations from a care or support plan may put the DCW at risk for disciplinary
action. Therefore, any changes need to be approved by the supervisor.

Care/support plans are reviewed by the care team. The DCW may be asked for input as
to how the plan is working. Reporting and documenting are very critical in evaluating
whether the plan is working or if it needs revision.

D. REPORTING
Now that you have observed changes or monitored the persons status the DCW needs to
report the changes. Reporting is the verbal communication of observations and actions
taken to the team or supervisor, usually in person or over the phone. A verbal report is
given to a supervisor when the need arises, or for continuity of care (for example, giving a
verbal report to the next shift).
It is always better to report something than to risk endangering the person, the agency, and
yourself by not reporting it.
Reporting helps your supervisor act accordingly.

E. DOCUMENTING
Documenting, also called charting, is the written communication of observations and
actions taken in the care of the individual.

1. Significance of Documentation

A record of what was done, observed, and how the person reacted.

Used for evaluation by other team members of the care plan.

Used to clarify complaint issues.

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Remember two important phrases:

If it wasnt documented, it wasnt done.
The job is not over until the paperwork is finished.

Always remember that the client record is a

legal document.

2. Documentation Guidelines
Your agency will tell you about policies and procedures you need to know. Some
agencies have specific forms you need to use. You may learn specific rules for reporting
information and incidents. The following is a list of general guidelines.

Always use ink.

Sign all entries with your name and title, if any, and the date and time.

Make sure writing is legible and neat.

Use correct spelling, grammar, and punctuation and abbreviations (Refer to the
Standardized Medical Abbreviations list on the following pages).

Never erase or use correction fluid. If you make an error, cross out the incorrect
part with one line, write error over it, initial it, and rewrite that part.

Do not skip lines. Draw a line through the blank space of a partially completed line or
to the end of a page. This prevents others from recording in a space with your
signature.

Be accurate, concise, and factual. Do not record judgments or interpretations.

Make entries in a logical and sequential manner.

Be descriptive. Avoid terms that have more than one meaning.

Document any changes from normal or changes in the persons condition. Also
document that you informed the persons physician or your supervisor as indicated.

Do not omit any information.

Try to relate your charting to the objectives/goals on the persons plan. For example,
if walking more is a goal, write walked 3 times today without assistance from
bedroom to kitchen instead of had a good day today.

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3. Documenting and Reporting Facts

When you document or report your observations and actions, it is important that you
are objective. Write down facts and describe exactly what happened. What exactly did
you see or hear? What exactly did the client say? Write down the words that the client
said, not what you think he or she meant. Opinions are less useful because you may
interpret a situation one way, but another person may have a different opinion.
Example: Mrs. Jones said: I dont want to eat anything. She did not touch the chicken
sandwich I prepared for lunch; she only drank ice tea.
Dont try to explain why you think she does not want to eat. Just write what she said
and did. When you dont stick to the facts, your opinion may cause a client to lose his or
her much-needed services.

4. Documentation Activity
Practice documentation, using the documentation guidelines. Here is an example:
Sara (client) has not been eating much lately so the goal is to increase her intake. During
your shift today, she ate all of her lunch.
The documentation may look something like this:

What would your documentation look like in these situations? What would you report?
You can use the form on the next page.

When you arrived at Saras house today she stated that she had fallen during the
night. She is not complaining of pain except for a bruise on her leg.

While you were washing dishes you broke a plate.

During your shift Sara had an episode of chest pain. She took a nitroglycerin tablet
and the pain went away.

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XYZ Agency
Client Name:
Date / Time

Action / Observation

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5. Standardized Medical Abbreviations and Acronyms

Every agency has different needs. For some positions you may have to learn some of
these abbreviations. Use this table as a reference.
A
abd
ac
AD
ADL
ad lib
AM
AP
AROM
AS
ASAP
ASHD
as tol
AU
ax

abdomen
before meals
right ear
activities of daily living
as desired
between 12 midnight & noon
apical pulse
active range of motion
left ear
as soon as possible
arteriosclerotic heart disease
as tolerated
both ears
axillary

B
bid
BM
BP
BRP
BS

two times a day

bowel movement
blood pressure
bathroom privileges
bowel sounds

COPD

C
CAD
Cal
cap
CBC
cc
C & DB
CHF
Chol
CNS

with
coronary artery disease
Calorie
Capsule
complete blood count
cubic centimeter
cough and deep breath
congestive heart failure
cholesterol
central nervous system

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CVA

chronic obstructivepulmonary disease

cardiopulmonary
resuscitation
cerebrovascular accident

D
dc,d/c
dias
DM
DOA
Dx

discontinued
diastolic
diabetes mellitus
dead on arrival
diagnosis

E
ECF
ECG, EKG
EEG
EENT
EMG
ER

extended care facility

electrocardiogram
electroencephalogram
eyes, ears, nose, & throat
electromyogram
emergency

F
FBS
Fe
Fib
ft
Fx
FWB

fasting blood sugar

iron
fibrillation
feet
fracture
full weight bearing

G
GI
gm
gr
gtts
GU
Gyn

gastrointestinal
gram
grain
drops
Genitourinary
Gynecology

CPR

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H
H2O
H2O2
hgb
hr
hs
ht
Hx
I
ICU
I&O
IPPB

water
hydrogen peroxide
Hemoglobin
Hour
hour of sleep
Height
History

I/S

intensive care unit

Intake and output
intermittent positive
pressure breathing device
instruct and supervise

K
K

potassium

L
lab
lb, #
liq

laboratory
pound
liquid

M
MD
med
mEq
mg
MI
min
mi
mm
MOM
MS
MSW

medical doctor
medication
milliequivalents
milligram
myocardial infarction
minute
mile
millimeter
milk of magnesia
multiple sclerosis
medical social work, or
Master of Social Work

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N
Na
Neg
Neuro
No.#
NPO
NS
nsg.
N&V
NWB

sodium
negative
neurology
number
nothing by mouth
normal saline
nursing
nausea and vomiting
no weight bearing

O
O2
OD
OR
ortho
os
OS
OT
OU
oz

oxygen
right eye
operating room
orthopedics
oral
left eye
occupational therapy
both eyes
ounce

P
pc
peri
PM
po
pre op
pm
PROM
pt
PT
PVD

after meals
perineal
after 12 noon
by mouth
preoperative
as necessary
passive range of motion
patient
physical therapy
peripheral vascular disease

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Q
q
qd
qh
qid
qod
qt
quad

every
everyday
every hour
four times a day
every other day
quart
quadriplegic

R
RBC
reg
ROM
Rx

red blood count

regular
range of motion
prescription

S
s
SO
ST
Stat.
SQ/subq
syst
Sx

without
significant other
speech therapy
at once/immediately
subcutaneous
systolic
symptoms

T
TB
Tbsp
temp
TIA
tid
TPR
Tx

U
UA
URI
UTI

urinalysis
upper respiratory infection
urinary tract infection

V
via
VS

by way of
vital signs

W
WBC
W/C
wk
WNL
wt

white blood count

wheelchair
week
within normal limits
weight

Y
yr

year

Symbol
one of something
two of something

tuberculosis
tablespoon
temperature
transient ischemic attack
three times a day
temperature, pulse,
respirations
treatment

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Mix and Match Exercise: Medical Abbreviations

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.

a.c.
A.M.
b.i.d.
cc
DC
gtts
h.s.
NPO
OD
OS
OU
p.c.
P.M.
PO
p.r.n.
q.d.
q2H
q4H
q.i.d.
q.o.d.
stat
t.i.d.
tsp
ml
mg
gr

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twice a day
before meals
four times a day
immediately
right eye
morning
cubic centimeter
every 2 hours
teaspoon
three times a day
every other day
as needed
drops
discontinue
every day
after meals
both eyes
by mouth
hour of sleep
left eye
nothing by mouth
every 4 hours
afternoon
milligram
grain
milliliter
two
one

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Did you know?

1. Mr. Chang seems different. He normally reads the paper or watches TV; today he just
sits quietly.
a. You ask him how he is feeling.
b. You dont disturb him.
2. Mrs. Green does not want to eat lunch. You remember that she did not eat lunch the
last time you were there.
a. You are not concerned; sometimes people are not hungry.
b. You document that she did not eat lunch and also report it to your supervisor.
c. You document that she did not eat lunch.
3. Mrs. Brown complains she always feels cold.
a. You write in your notes Mrs. Brown stated she always feels cold.
b. You write in your notes Mrs. Brown is cold.
4. Mr. Jones did not want to get out of bed.
a. You write in your notes: Mr. Brown stayed in bed; I think he is sick.
b. You write in your notes: Mr. Brown stayed in bed.

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