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  • Writer's pictureMarie

Dear Marie: I walked into my patient’s room and the family member was writing down everything in a n

Updated: May 23, 2020

You should not be alarmed BUT you should be informed. As Occupational Therapists it is our job to encourage family members to be advocates for their loved ones. Here are some basic typical documentation tips that are given to families.

Family Documentation Tips:

“Documenting what you see when visiting the nursing home/hospital/etc. is a key component to being a good advocate. The notes are helpful when looking for breakdowns in good care. An isolated incident might actually be a pattern upon further analysis of a situation over a period of time.

  1. Carry a small notebook when you visit, small enough to conveniently carry in your purse or pocket.

  2.  Make a habit of always writing at least one thing in the notebook during each visit or immediately afterward.

  3.  Don’t use the book as a weapon against the staff.

What Should Be Documented?

Some entries might only require a date and a few words describing the general tone of the visit, while others may require more detailed note taking. Not every entry will require answering all of the following questions.

1. Who? Who did you visit and who was with you? Make note of the staff on duty when an incident or care issue occurred. Who said what? (use direct quotes) If someone else witnessed an incident, try to get their name and telephone number. 2. What? What did you see and hear happen? Be specific. How long did it last? (ie. Mom waited one hour to be toileted) 3. How? How did you find out this information? (Did someone tell you, did you see it, etc.?) 4. When? What day and time did an incident occur? 5. Where? The exact location of an incident or conversation can be important later in identifying witnesses and jogging memories.

Sample Documentation Entries: Thursday, January 1, 2018 at 2:15 p.m.: Mom seemed disoriented and did not recognize me immediately. Mom complained of mild chest pain since lunch time. I spoke with Mrs. X, head nurse evening shift; she checked mom’s medications and blood pressure. Appeared to be okay. No note from afternoon shift about her pain. Mrs. X will make a note in mom’s file and contact Dr. S.

Tuesday, October 7, 2007 at 1:04 p.m.: Mom was not taken down to bingo today (I was attending the family council meeting). When I asked Mr. Y (Mom’s aide) about this, he informed me that Mrs. H (the activities director – and family council liason) told him that perhaps in the future I spend less time at council meetings and more time with my mother.”

Do you have any tips for your fellow OTs?

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