The Dangers of Unrecorded Care

If an elderly loved one is receiving care from a family member or hired caregiver, how do you know their needs are consistently being met? Can you be sure they are safe? Do you know they are being well taken care of?

When care is recorded, the answers to these questions are ensured. Hopefully, for the caregivers helping seniors in your families, documenting their care is a habit. Documented care means detailed written and oral communication between caregivers, health professionals, agencies, insurance agents and families about the treatment of a senior citizen receiving long-term care. Under the supervision of caregivers, seniors are helped with activities of daily living (ADLs) that are necessary for healthy and safe independent living. Without documentation proving that these tasks are performed which help seniors eat, dress, bathe, toilet, stay tidy and take medication, it’s difficult to know what care is provided and how regularly.

Why does documentation matter?

The obvious: The health and safety of senior care recipients hinges on the assurance that caregivers are providing ALL tasks necessary for long-term care. Harm and even death are risks of unrecorded care. One small detail, like documentation that says a senior was reminded to take an important medication, can be the key to their survival through the night.

Also, your money’s worth is only met when care meets all requirements and expectations. If you are a senior citizen paying for care, good documentation will show whether or not the level and quality of care is worth what you are paying. If you are a family member monitoring the coverage of a senior loved one’s care, you do not want your loved one’s assets to be taken advantage of. Long-term care is expensive. Documentation of care tells you that your investment is worthwhile.

When it comes to paying for long-term care, you may be fortunate to have a long-term care insurance policy. Once a claim is started, documentation of senior care is necessary to keep it active. Long-term care insurance representatives need thorough reports of what care a senior with a policy receives to make sure the policy is actually paying for long-term care. With a long-term insurance policy, you will only maintain your funding if you can provide documentation.

Care providers are regulated by law to ensure the safety of seniors they care for. Poor documentation of senior care can cause a number of legal problems. If it looks like a caregiver gave poor care, which can easily happen when a caregiver forgets to document a task, they or their agencies can be blamed for any health problems that could have stemmed from that care lapse. A lack of documentation may also convey that a senior is neglected, and caregivers or their agencies can be accused of causing harm to the client. Documentation protects against and exposes poor care that should be punished by law.

Since documenting care can guarantee proof of seniors’ wellbeing, of the soundness of your care investment, the coverage of long-term care insurance, and protection against poor care, it can also provide you with peace of mind. Nothing is more reassuring than hearing or seeing a report of job well done.

Types of Documentation

Assessments are initial surveys of the state of a long-term care recipient’s health needs and environment before care is received. This type of documentation details exactly what kinds of care- and how much of it- a senior needs. By communicating written and oral assessments, health professionals and providers establish expectations of care to be performed later on. This also informs providers, seniors and families about the cost of the care that will be needed.

Caregiver Credibility is key to the guarantee of quality care. When a caregiver is reliable and trustworthy, you can expect them to be good providers for the seniors they will care for. Before caregivers are hired and placed into seniors’ homes, they must be fully vetted to be credible. Amada Senior Care documents this through criminal and background checks, reference checks, phone and in-person interviews and orientations. Documented certifications also add to caregivers’ credibility. When elder abuse is a real risk, families and seniors must pay attention in selecting the right people to entrust with long-term care. If caregiver credibility cannot be proven and documented, which can be the case with some family and hired caregivers who might have wrong intentions, seniors you love might become vulnerable to harm.

Care Plans take a step forward from assessments and establish the number, sequence and quality of tasks that must be performed by caregivers. These plans outline exactly what a caregiver will do for a senior every day. Perhaps a senior needs certain medications at particular times. The care plan will clarify this. If a doctor orders an hour of exercise for a senior every day, caregivers can refer to the care plan to see when and how it should happen. Care plans make logging tasks after they are performed easier, and lets caregivers know everything they need to accomplish before their shift is done.

Reports can be written or oral. When a caregiver finishes providing care to a senior, they must document what they did in a report. This can take the form of a list of tasks performed and notes regarding them, or conversations caregivers have with their supervisors about their work. Especially with a written report, it is easy to relay documentation of a senior’s care to families and long-term care insurance representatives. Reports are made only after care is provided.

What should caregivers document?

In all types of documentation mentioned above, certain things must be reported. These are details essential to proving that quality care is provided for seniors under caregiver supervision. Caregivers should pay close attention to the seniors they care for in order to ensure that care is sufficient and errors are prevented. Caregivers should document these things:

  • Observations of facts and events caregivers notice as they go about their daily work. Are there certain things the seniors need that were not acknowledged in their assessment? Does the senior take part in activities that affect their health or other people around them? Is the senior displaying signs of a new illness? Observations that report answers to questions like these must be communicated constantly.
  • Measurements of a senior’s diet, medication, duration of activities and weight are important to document because they may change at any time. Changes in these measurements signal health adjustments, and even illnesses. When caregivers track these important measurements, they’ll be able to react in order to maintain the senior’s wellbeing.
  • Client Comments are also important because a senior’s direct feedback on the quality of their care reports more than any other kind of documentation. It gives caregivers, families and providers insight into the effect that the long-term care has on the senior from a first-person point of view. Reporting client comments, whether they are good or bad, tells providers when and how to adjust to seniors’ needs and preferences.
  • Environment Issues concerning seniors’ homes or the people around them must be documented in order to ensure their safety. It is common for seniors to have limited control over the environments around them. Maybe their house has a safety issue that might harm them or inhibit their movement. Maybe there is a family member around who bothers the senior emotionally or physically. It is up to caregivers to report these things that may go unsaid. As guardians of the seniors they care for, caregivers who look out for threatening issues will contribute to their resolution.

Rules of Documentation

DO be complete and accurate.

DO NOT document care that was not provided.

DO be consistent.

DO NOT simply copy documentation that was made from past days.

DO be timely.

DO NOT document and report care before it is provided, but immediately after.

How Technology can Help

By the power of the internet, families can monitor the care of their elderly loved ones remotely. For families that live far away from senior loved ones, technology offers a way for them to access documentation of their long-term care. Sensors, like movement detectors, can be placed strategically throughout seniors’ homes to track seniors’ activity during the day. Activity patterns can be logged and relayed to family members via a smartphone app as well.

To keep in touch with their elderly loved ones, families can also take advantage of Amada Senior Care’s Transparent technology. Transparent is an online portal system where families can log on at any time of the day to see exactly what duties caregivers have performed. Did Mom take her medication today? Did Dad make it to his doctor’s appointment? Did Grandma eat a healthy meal? These are things that can be tracked with Transparent.

Through a combination of these various forms of documentation, you and the seniors you love will avoid the dangers of unrecorded care. Caregivers and providers will thrive and maintain quality work performing the aid that seniors need, while documenting a long record of good service. This is a benefit to you and anyone else involved in the long-term care of elderly loved ones.

Learn more about Transparent and the importance of documented care by calling an Amada Senior Care location near you.



“The Dangers of Undocumented Care,” by Michelle Mendoza, Amada Blog contributor.





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