What are the contents of the daily care record form for the elderly?

At present, whether it is a daily care record form for home care, elderly care institutions, or community care, the core content is basically adapted to three directions: basic physical sign monitoring, daily care, and special event traces. There is no universal template at all. They are all adjusted according to the care level and health status of the elderly.

When I was doing elderly care services in the community, I met Aunt Wang, who lived in Building 3. Her daughter was working out of town and hired a live-in caregiver. At first, the caregiver took a small notebook and jotted it down. Today she wrote "I ate a bowl of porridge" and tomorrow she wrote "I slept well." Last month, Aunt Wang suddenly suffered from hypoglycemia and fainted at home and was sent to the doctor. The doctor asked her about her recent blood sugar and diet status. The nurse couldn't explain anything clearly, or the community later provided her with a standardized nursing chart, which lasted only half a month. Last week, Aunt Wang had a cough. The nurse recorded her body temperature and coughing frequency as required on the chart. When the community doctor came to her home and saw that the temperature was 37.3°C for three consecutive afternoons, she directly suggested taking a lung X-ray, which checked for pneumonia early on, and it was very effective.

Many people think that the nursing chart is just a formality. In fact, it is not. There are many tricks in it. Let’s talk about the basic physical signs that everyone is most familiar with, such as blood pressure, blood sugar, heart rate, and body temperature. The frequency of monitoring is based on the doctor’s instructions. For example, an elderly person with high blood pressure should remember clearly whether the test was taken in the morning on an empty stomach or after taking antihypertensive medicine. It is best to note whether you climbed stairs or walked before taking the test, otherwise it will be useless to remember the values. Oh, by the way, there is still a little controversy in the industry: one group thinks that if the indicators of the elderly are stable for a long time, it is completely possible to "no records without abnormalities", which saves the nursing staff from filling in a bunch of useless content every day, but it is easy to fill in perfunctorily. ； The other group, especially those who work in institutional elderly care, believe that even if the required inspection items are normal, they should be checked and left traces. In case something goes wrong with the elderly one day or there is a dispute between the family members, these records are the most direct evidence. Now that both sides have practices, it is impossible to say who is right and who is wrong. It still depends on the usage scenario.

As for the content of daily life, there is greater flexibility. The disabled elderly must remember clearly how much they ate at each meal, whether they choked or coughed, and the frequency and characteristics of defecation. Don’t feel embarrassed to remember such details. I have encountered cases where a nurse failed to remember that an elderly person had not had a bowel movement for three days. By the time his family found out, the elderly person was constipated to the point of sweating due to stomach pain, and had to go to the hospital for an enema.； For the elderly who are semi- or fully able to take care of themselves, there is no need to be so detailed. At most, you can just record whether you go out for exercise every day, whether you sleep well, and whether you take medicine on time. When communities developed templates before, they did not differentiate between levels of care. The forms issued to the elderly who can take care of themselves are the same as those for the disabled elderly. They have to fill out more than 20 items every day. The nursing staff found it troublesome and filled them all in vain, which made it meaningless.

In addition to these regular contents, there must always be an empty space on the table to record special things, such as whether the elderly fell or bumped today, whether he took too much or missed medicine, whether he was in a bad mood and lost his temper, or even when family members came to visit, or if relatives gave him any favorite food, you can write down a few sentences. There was an old man with Alzheimer's disease in our former care center. One day he suddenly made a fuss and wanted to "go back home." The nurse looked through the records and saw that his grandson had just visited the day before. He immediately understood that he missed his child, so he made a video call and immediately became quiet, which saved a lot of guesswork.

To be honest, many people always think that the more comprehensive the better when making a nursing form, which only lasts for three or four pages. In fact, half a page of A4 paper is often enough for a useful form. It is focused and matches the actual needs of the elderly, which is more effective than any flashy template.