Contents of daily care record sheet for the elderly

Basic vital signs, daily living status, dietary and nutritional intake, medication compliance, excretion status, emotional and cognitive status, special event notes, there are no bells and whistles and superfluous items, they are all the rigid needs of front-line nursing.

Last week, I went to inspect a community nursing home near my home, and I saw the new nurse being trained by the station manager because she took down the blood pressure of an 82-year-old man with high blood pressure, Uncle Li, and only wrote 130/80mmHg without adding a word of remark. Uncle Li's blood pressure has been maintained at around 145/90mmHg all year round. The value that day seemed normal, but it was actually an abnormal fluctuation caused by missing half a tablet of antihypertensive medicine in the morning. The colleague who took over in the afternoon did not take it seriously and almost missed the process of taking a replacement dose, which shocked everyone into a cold sweat.

Speaking of this, we have to mention a disagreement in the industry that has never reached a conclusion: one group believes that vital signs records only need to fill in the numerical values, which saves the time of the caregivers. After all, the front-line manpower is already tight.； The other group insists that "basic value comparison + exception reason remarks column" must be added. Even if you write three or five more words, you can avoid many unnecessary risks. I have been training in nursing care for the elderly for almost 9 years. To be honest, I am on the latter side. After all, numbers are dead and people are alive. Especially for the elderly with basic diseases, it is much more important to compare with their own basic values ​​than with the universal normal range.

Many people think that medication recording is just a matter of checking a box. If the elderly take it, they will mark it √, and if they do not take it, they will mark it ×. This is not true. Last year I provided home care for a family. The live-in aunt initially gave the elderly patient with Alzheimer's disease medicine as required, and she checked the boxes on time every time. However, the old man complained of dizziness for a week in a row. When I went to the hospital for a review, I found out that the aunt was afraid that the old man would not be able to swallow it, so she broke up the sustained-release antihypertensive medicine and gave it to her every time. The effect of the medicine was concentrated and the blood pressure was naturally unstable. Later, we added a half-column for "Medication Methods/Abnormal Reaction Remarks" to their record sheet. We don't need to fill it out every time. If there are special circumstances, just mention it. Since then, there have been no similar problems. Of course, some family members feel that this column is redundant. Originally, the aunt has to do a lot of work every day, and it is too troublesome to write additional things. Our current processing method is semi-open. If there is anything, just write it down, and if there is no situation, leave it blank. There is no need to force the content, so everyone can worry less.

Don’t think that remembering what time you got up and how many hours you slept is a waste of time. 76-year-old Aunt Wang always told her family that she had insomnia, waking up before dawn every day and sleeping for a maximum of 4 hours. Her children were so anxious that they bought her a bunch of sleep-aid products, but they were useless. Later, the nurse detailed her daily life records and added an entry for "fragmented sleep," and discovered that she sat on the sofa and watched TV every afternoon, squinting for more than two hours, which was equivalent to sleeping half a night earlier. I adjusted her afternoon activity schedule and took her to the yard to water the flowers and chat with old neighbors. In less than half a month, her sleep at night increased to more than 6 hours, and she no longer complained of insomnia.

The same goes for the records of diet and excretion. Don’t just remember useless things like “eating a bowl of rice” or “defeating once”. Remember whether you choked, whether you were picky about food, and whether the stool was dry and hard. These small details hide a lot of body signals. I once met an old man who marked "eat only soft foods and refuse hard dishes" in his food record for three consecutive days. The nurse didn't take it seriously. When his family came to visit, they found that the old man's gums were so swollen that he couldn't bite. Later, we required that whenever the old man changes his dietary preference for two consecutive meals, he must mention it in the notes to prevent minor problems from turning into big problems.

Oh, yes, emotion recognition recording is a module that has only been added in recent years, and it is also the most controversial. Many nursing staff feel that they are only responsible for food, drinking, and toileting, and managing emotions is just extra work. I used to think it was a bit useless until I encountered an incident in a nursing home last year: the nursing staff wrote in the record for three consecutive days, "Aunt Zhang Guiying did not want to go downstairs to participate in activities and did not answer questions." After seeing this, the social worker took the initiative to chat with the aunt, only to find out that her son, who was far away in Shenzhen, had not called her for almost half a month. She thought that her son was too busy at work and had forgotten about her, and was secretly upset. The social worker contacted her son that day and made a half-hour video call in the evening. The next day, the aunt carried a small fan and went downstairs to dance in the square. To be honest, the physical condition and emotions of the elderly are much tighter than those of the young. Sometimes just writing one more sentence can help the elderly solve big troubles.

I have customized record sheets for many institutions and families over the years. To be honest, there is no "standard universal template". The seven core contents are pretty much the same, but how to set them up and how detailed they are to be filled in all depends on the actual situation. If the elderly person living alone at home has only a little high blood pressure, then it is okay to make the record sheet simple. If the elderly person has cognitive impairment and is paralyzed in bed, then all the remarks columns should be added. In the past two years, many institutions have begun to use electronic record forms. After measuring blood pressure, the values ​​are automatically uploaded, and family members can view them on their mobile phones at any time. It is convenient. Many family members feel that paper signatures are more reliable, and they are afraid that there will be problems in the system and the records will be missed. There is no wrong choice, and the one that suits them is the best.