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

The key to filling out this form is to put the word "real" first. Write exactly what you actually observed and performed. Don't embellish the content for the sake of beauty, and don't fill it out blindly by remembering it after two or three days. This form is essentially a "barometer" of the elderly's physical condition. In the event of an emergency, flipping through the record can directly help the medical staff find out the cause of the disease, which is more effective than family members telling them in half a day.

Not long ago, the 82-year-old Grandpa Wang who was cared for in our community had a low-grade fever for three consecutive days for no apparent reason. No obvious infection was found after taking blood tests. I looked through the previous nursing records and found that three days before he had a low-grade fever, the nurse noted that "there was a small red patch on his left heel, and the old man complained of pain when he pressed it." He didn't take it seriously at the time. In the end, it was diagnosed as a low-grade fever caused by pressure ulcers in the early stages. If he paid attention to the abnormal signals in the records earlier, the old man would not have to suffer so much.

For example, for vital signs that everyone often fills in, write down as many as you have measured. If your blood pressure and heart rate are measured just after rehabilitation training, just after eating, or just after an awkward fight with someone, just add a small note at the end. Otherwise, if the values ​​are too high or too low, people who look at the records next time will not be sure whether they are normal fluctuations.

In addition to these cold numerical values, don't vaguely write "normal" or "average" for seemingly trivial matters such as daily diet, excretion, and sleep. For example, if the old man choked twice while eating today, you have to write it down. Don't just write "eating is normal." Otherwise, the next time the nurse will change, he will not know that he is at risk of choking, and feeding too fast can easily lead to aspiration. There was a family member who came to the inn to make a fuss, saying that the nursing staff treated the elderly man harshly and complained that he was hungry. When he checked the previous records, he always said "eat enough". Later, when he stayed and checked, he found out that the elderly man had lost all his teeth. The vegetables given by the nursing staff were not chopped and he couldn't chew and vomited most of them. If the records had added a sentence of "half a bowl of vegetables left and the chief complaint was that he could not chew", there would be no such misunderstanding.

There are a lot of debates in the nursing circle now. Some people say that nursing records must be written down in detail to be responsible. Some nursing workers complain that they are busy taking care of the elderly and cannot spend more than ten minutes writing records. In fact, there is no contradiction between the two. You can just abbreviate the normal state, such as "blood pressure 130" /80, normal." "Slept 6 hours, peacefully." Only write two more sentences if there are abnormal situations. For example, "I tripped over the threshold in the corridor at 3 o'clock in the afternoon. I sat on the ground. There was no redness or swelling in my hip, and I said it didn't hurt."

If the elderly person in your family has cognitive deterioration, you should also take note of his mood and cognitive status. For example, if he couldn't recognize people today, if he lost his temper for no reason, if he went out and couldn't find his home, after two months of recording, you can figure out his emotional pattern. When he is prone to losing his temper, just follow the instructions in advance, and it will save a lot of trouble in taking care of him.

To put it bluntly, this record sheet is not a showpiece for outsiders to see. When you write it, think more about the health of the elderly, and you will naturally know what to write. Don't deal with it. What you are dealing with is actually the safety of the elderly and your own conscience.