Contents of daily care record sheet for the elderly

There is no unified template for the specific content of basic physiological indicators, daily activity support records, special care tracking, and traces of abnormal events. They must be adjusted according to the health status of the elderly and the care scene. There is no need to rigidly apply standardized online templates.

Let me tell you a real story that I encountered when I was working as a care supervisor in a community nursing home: There was a 72-year-old Aunt Zhang last year. Her family members printed out the online care form, took her blood pressure every day, and filled it out neatly. The values ​​were normal for half a month. It wasn’t until the old lady suffered from hypoglycemia at home that she fell and was sent to the hospital. Only then did she realize that the aunt had been having a bad appetite for that half month and only ate half a bowl of porridge at each meal. There was no column for her eating status at all on the form, and her family members didn’t even think of recording it. Later, I looked at the 2023 home care survey data of the China Association on Aging and found that only 17% of home caregivers regularly record the status of the elderly, and 80% of the record sheets only have two items: blood pressure and blood sugar, missing many key warning items.

Interestingly, there is currently no consensus in the nursing community on what should be recorded in the record sheet. One group is often referred to as the "minimalist group" in the industry. They advocate recording quantifiable hard indicators: body temperature, blood pressure, heart rate, medication time, food intake, and frequency of excretion. They feel that content such as emotions and social interactions are too subjective, and the judgment standards of different caregivers are far different. Memorizing them can easily mislead. For example, if you think the old man is smiling happily today, another caregiver may think he is depressed and has no reference at all. This model is especially suitable for the elderly who are in good health and only need routine monitoring of chronic diseases. It takes two or three minutes for family members to complete the form after get off work every day. It is not easy to give up halfway. Many working children choose this form for their parents who live alone.

The other school is the "whole-person care school", which advocates that in addition to hard indicators, soft content such as emotional state, social activities, and completion of interests should also be included. For example, did you go downstairs to play cards with your old friend today, did you have a tantrum, and did you actively watch TV and listen to the radio. Especially for the disabled and demented elderly, these soft indicators are the first signs of changes in the condition. Grandma Wang, an elderly person with dementia who was cared for by our inn before, had gone missing before. Her exclusive record sheet specifically added a column for "Signature of the person accompanying her when she went out that day." Later, even if a new temporary caregiver was replaced, she did not dare to take her out casually, and there were no mistakes again. There are also elderly people who are bedridden with pressure sores. We will leave blanks on the form to record the time of turning over each time and the subsidence of skin redness and swelling. It is much more practical than simply filling in "normal/abnormal".

If you really want to implement the specific content, it can actually be "customized" without having to stick to a template. For example, for an elderly person with prostatic hyperplasia, adding a column for the number of nocturia is better than recording anything else. Uncle Li from our inn was embarrassed to say that he got up five or six times a night. After adding this column to the form, he was seen by the community doctor within three days of filling it out. After adjusting the medicine, his sleep quality improved a lot. Elderly people with dysphagia should note down whether they coughed or not and what level of liquid food they were eating every time they were fed. Don’t wait until they get pneumonia before they realize they had choked and coughed several times before, but they just didn’t take it seriously and didn’t remember it.

Don’t make the record sheet a burden. I’ve had family members ask me for templates before, and there are more than a dozen items at the beginning. I said you try it first. You’ll be exhausted after get off work every day and have to fill in ten items. If you can persist for three days, I’ll lose. I usually give advice to family members taking care of themselves at home, so I create a small whiteboard hanging on the refrigerator, and record the three or four most important items. For example, if the elderly have diabetes, record blood sugar + food intake, and if the elderly have high blood pressure, record blood pressure + medication status. If there is any abnormality, I will use a small notebook to record the details separately. It is easier to use than any fancy template. I have seen records in some institutions that were filled out beautifully, with "normal" and "no abnormality" in them. However, the old man secretly told me that he had not had a bowel movement for three days, and the caregiver was too lazy to fill in the abnormal items because it was too troublesome. This kind of record made to cope with the examination is more harmful than not remembering it.

To put it bluntly, this thing is essentially a tool for caring for scars. There is no absolute standard answer. Even if you just mark it on the calendar, circle it on a day when your blood pressure is high or mark a day when you have no appetite. It can help you discover hidden dangers in advance and can be used as a reference for doctors when seeking medical treatment. It is a useful record sheet.