08/22/2021
Disclaimer: I am not an expert, just a former caregiver sharing my personal opinions formed by my personal experiences) - The Caregiver's Notebook:
One of the things that I and some of the caregivers that I worked with did, was create a personalized caregiver's notebook to use for each client.
This notebook was kept at the client's home as a caregiving tool, and its information only shared with the client's approved caregiving team.
Inside on the first page was a copy of the client intake page that we created based on our initial visit with the client. It included client's address and phone number, age, marital status and whether the client lived alone or with someone. Next was the client's contact information, including who was the POA. It had other contact information such as doctor's name, address, and phone number. If we were providing transportation, then we also included names and phone numbers of hair salon, and other social places a client might attend, such as, the local Senior Center.
An important section included the client's primary medical diagnosis and any important secondary diagnosis, as well as whether or not the client had a DNR (Do Not Resuscitate) order.
Below that would be a list specific to the client, such as whether or not a client was a fall risk, had hearing aids or glasses or dentures, used a walker or a cane or wheel chair, needed assistance with ambulating or transfers, on oxygen and at what level, breathing treatments, etc.
On a separate page, would be a list of any prescriptions or other Over the Counter medicines, and Vitamins and Supplements that the client was taking, along with their schedule and doses.
On a separate page is a monthly calendar that includes any appointments for doctors or social events, etc. If there are multiple caregivers, then there would be a second caregivers' schedule calendar, with each day marked with a caregiver's name and scheduled arrival and departure time.
Inside the notebook was blank notebook paper to use as a daily log of any information relevant to the client's care. If more than one caregiver, each caregiver would identified their arrival time and departure time so that family members, or others on the authorized caregivers list, would know whom to speak with, if there were any questions regarding the notes.
As I grew more experienced, my team of caregivers and I, realized that there was a lot of important information that needed to be noted but was time-consuming to write out. So, we then created a form where you only needed to check off if that task was done or if necessary write in the time. Examples would be, Daily Personal care: Brushed teeth, brushed hair, Washed face and hands, Bath day, Washed bedding, Changed bedding, Client's laundry done, Daily meds taken, Input and Output, etc. The example below is for a bedridden Hospice patient which requires 24/7 care and rotations. The form is just to give a visual example of how you can reduce writing time and yet ensure that this information is recorded daily. Anything specific to the day, that may not be routine, can be added in the summary notes below. It all depends on each client what information might be pertinent to have on this daily sheet. A separate sheet can be used if there are multiple shifts with multiple caregivers each day. You could use the summary notes for the meals information and how much was consumed 25%, 50% or 100% as well as what liquids were consumed and how many ounces. It can also include a specific incident that happened, such as a fall, or that the client seemed especially tired or had a cold or congestion, or seemed more anxious than usual, etc. Anything noteworthy that was not part of the usual routine.
