Contents of daily care record sheet for the elderly

The core content of the daily care record form for the elderly can be summarized into five modules: basic physiological indicators, daily activity ability, medical intervention execution, emotional and social status, and special event records. However, there is no universal standardized template and must be flexibly adjusted based on the elderly's care level, basic disease conditions, and care scenarios (home/community/institution).

When I worked as a care supervisor in a community nursing home two years ago, I encountered many family members filling out the form using a uniform template that I randomly searched on the Internet. The elderly person in the family had a history of diabetes for more than 20 years, and there was no registration column for pre-meal blood sugar in the form. There were also people who cared for severely disabled elderly people. The form also left an option for "assessment of ability to go up and down stairs", which was completely useless.

Nowadays, there are actually two voices in the nursing industry regarding the precision of record sheets. One is the "extremely detailed school", which advocates that even the amount of water consumed in a single session, the amount of urine, and every bite of food eaten should be recorded. It is suitable for the elderly who have just been transferred from the ICU to recover after surgery, the elderly who are severely disabled or have severe metabolic diseases, and can help doctors accurately adjust the treatment plan.； The other is the "minimalist and practical", who feel that there is no need to take up care time just to fill in the form. Apart from the indicators that must be monitored, other content can be omitted. It is more suitable for the mildly disabled and healthy elderly people with stable physical conditions. This prevents the caregiver from focusing on filling out the form and neglecting the needs of the elderly. There is actually nothing wrong with both of these statements. The core point is to look at the actual situation of the elderly.

Don’t underestimate the details of physiological index records. The same blood pressure is 140/90. The meaning of the pre-test and the post-test of taking antihypertensive drugs are completely different. Elderly people with gout are best to add additional uric acid monitoring and a remarks column for the intake of high-purine foods on the day. Our station There used to be a 68-year-old Aunt Zhang who suddenly suffered from gout and was in so much pain that she couldn't get out of bed. Looking through her records for the past half month, she discovered that she secretly ate the butter crabs given by her son for three days in a row. Her family always thought that she had good food taboos, and if she had kept records earlier, she could have avoided this crime.

In addition to the well-known daily activities such as eating, dressing, and moving, the most easily missed ones are the records of toileting and coughing. Many elderly people are embarrassed to say that they cannot pass stool for several days. By the time their family members find out, they have already had to have an enema. If you simply write down "1 bowel movement today/constipation" every day, you can preemptively use sterilization or adjust dietary intervention. If there is an elderly person with cognitive impairment at home, it is best to add a small directional note, such as "I recognized my granddaughter today" and "I couldn't find my room at noon." This can visually see the changes in the condition, which is much more effective than going to the hospital for evaluation once a month.

When it comes to medical intervention, don’t just check the “Medicine Already Taken” column. If the elderly person misses a dose, or has minor reactions such as dizziness or rash after taking the medicine, be sure to write it down. Previously, we had a 72-year-old Uncle Li. His feet were a little swollen after taking a newly prescribed Sartan antihypertensive drug. The caregiver casually wrote it down in the note. When he checked with the doctor next time, he immediately adjusted the medicine, saving a lot of additional examinations. If you are an elderly person who has recovered from a stroke, remember clearly how high you can raise your hand today, how many steps you have taken, and whether you have any joint pain. This is a hundred times more useful than telling the doctor "It seems better than before" during your follow-up visit.

Many people think that emotional and social records are useless. I have met many family members in the past who said, "Just take care of food, drink, and toilet, and there is no time to care about whether he is happy or not." However, we have done statistics before and found that the risk of depression for the elderly who insist on recording their emotional states for a long time is 32% lower than those who do not record. There was a 76-year-old Grandpa Wang who for three days in a row recorded that he "didn't want to talk or go downstairs for a walk." After talking to him, we found out that his old comrade had left last week. We were so upset that we quickly arranged psychological counseling for him. We also contacted his old colleagues from the factory to visit him. Within a week, he went to play croquet with everyone again. If he hadn't remembered this, he might have developed problems after holding it in for a long time.

As for the record of special events, it is more practical. For example, the elderly accidentally fell or touched, and suddenly had a headache and panic. Don't just write "I fell today." You should clearly remember the time, where you fell, what you were doing at the time, whether there was any break, and whether you went to the hospital. If there are any problems later, this record is not only a reference for the doctor, but also to avoid quarrels between caregivers and family members. After all, a good memory is not as good as a bad pen.

In fact, to put it bluntly, the nursing record form is an auxiliary tool. Don’t make it fancy just to make up the content, and don’t fill it in just to meet errands. Home care does not have to be as complicated as in a nursing home. It only takes three to five minutes to fill it out every day. The core is that it can help you discover the unspoken needs of the elderly. If it can really help the elderly, this form will not be in vain.