What are the contents of the daily care record form for the elderly?

At present, the daily care record form for the elderly commonly used in domestic elderly care institutions and community home care generally covers four modules: basic vital sign monitoring, daily living status tracking, medical care operation traces, and special event archiving. Elderly people with different physical conditions will flexibly add and delete items according to their needs, and there is no completely unified fixed template.

The most basic body temperature, heart rate, blood pressure, and blood sugar are universally required items in all record forms. For the elderly with underlying diseases such as COPD, heart failure, and chronic kidney disease, blood oxygen and daily weight items will also be measured as needed. The industry has previously discussed whether ordinary healthy elderly people should include daily weight monitoring. One group of people believes that once a week is enough for healthy elderly people. Frequent measurements will make the elderly feel "sick" and add psychological burden. The other group believes that many elderly people have latent edema without obvious symptoms. A daily weight fluctuation of more than 1 kilogram is a clear warning sign. Monitoring is necessary even if they appear to be healthy. The current common practice in the industry is to conduct a health assessment for the elderly before making a decision, and there will be no one-size-fits-all approach. The 82-year-old Granny Zhang who was under our care before the station had coronary heart disease, so we added her daily weight to her exclusive record sheet. Last month, she gained 2 kilograms in weight for three consecutive days. We discovered in time that it was water and sodium retention, and adjusted the dosage of diuretics to prevent the situation from developing to the point of requiring hospitalization.

In addition to the physical signs data directly linked to health, the most important things on the record sheet are seemingly fragmentary daily details. You will remember how much water you drank that day, how much you ate, whether you coughed, whether your bowel movements were normal, how many hours you slept at night, how long you walked out, whether you played chess with your old friends downstairs, and whether your mood was good that day. Don't underestimate these scattered contents. Last month, Grandpa Li in our jurisdiction recorded in his records for two consecutive days that "he ate less than half of what he usually eats, and he didn't want to go out for a walk. When asked, he said he felt uncomfortable." The nurse came to check that he had an oral ulcer that was so painful that he couldn't eat. He prescribed medicine in time and it took two days, but it didn't lead to infection. Some family members have mentioned before that it is unnecessary to record these details of daily life in such detail, which wastes the time of the caregiver. Many family members also said that by looking through these records every day, they can know how the elderly person is doing that day, and they can rest assured that they are far away. Now many record forms have these contents in a check-box format. Just check the boxes and it does not take time, which just takes into account efficiency and needs.

Contents related to diagnosis, treatment and nursing operations are also required. Did you take the medicine on time, did you miss it, and did you have any suspicious adverse drug reactions such as rash or dizziness? If you performed operations such as pressure ulcer dressing changes, atomized inhalation, and physical rehabilitation training that day, you should also clearly remember the operation time and the elderly person's reaction after completion. There are also small temporary requests made by the elderly or family members, such as wanting a softer pillow or making an appointment to go to the hospital to check blood sugar next week. You can also write them down in the notes column to avoid forgetting them later.

Another very important thing is the record of special events. Even if the old man accidentally knocked his skin without breaking the skin, or suddenly became dizzy for two minutes and recovered, this may not seem like a big thing. The time of the incident, the situation at the time, how to deal with the follow-up, and whether there has been any improvement must be clearly written down. This is not only responsible for the health of the old man, but also an important basis for avoiding disputes. A colleague I met before failed to write down the old man's transient dizziness. Later, the old man suffered a cerebral infarction. His family members questioned that the symptoms had not been dealt with before, and they could not produce effective records of the conflict that had been going on for a long time, which was particularly troublesome.

In fact, there is no unified national recording form standard. Each institution and nursing station adjusts it according to the situation of the elderly they serve. The core is to truly reflect the daily status of the elderly and facilitate the connection between doctors, family members, and caregivers. It does not need to be too complicated, which will make it difficult to use.