Each client will receive a Client Home Journal upon start-up of services which will be kept at the client’s home during the provision of services. Caregivers will document all activities related to the care and wellbeing of clients. Proper, consistent documentation by the caregiver is encouraged after each shift. This valuable communication tool will allow many parties to see the client’s care including multiple caregivers, family members, healthcare professionals, and our office.
The Client Home Journal’s page entries are listed below. While each page has purpose and value, some may not be appropriate to the care plan. During the evaluation, each client at their discretion can determine which pages they feel are needed and will be helpful in the service plan.
FIVE THINGS YOU SHOULD KNOW ABOUT MOM
We want to learn about our new client! What did they do for a living? Did they work outside the home? Where were they raised? What are their hobbies? How many children and grandchildren do they have? What are their likes and dislikes? What are their frustrations? What makes them laugh? What is their favorite TV show? What is their favorite snack? Answers allow us to understand our client, meet their needs better, foster conversation, and help us get to know our clients!
CLIENT FACT SHEET
This document contains the client’s name and address along with their doctor(s) contact information and a current medicine list. Please keep us updated on any medicine changes. This document is taken along on all outings should the client have a health episode and 911 is called.
This two-sided document includes the client’s brief medical history, questions about assistance needed, assistive devices used, nutritional needs, and days and times of service along with the caregiver(s)’s name(s). The service plan includes services needed, checked off with frequency to be performed (daily, weekly, per visit) with special instructions as needed.
Please include home, work and cell and list names in order to be called.
After each shift, caregivers write a few lines about the services performed for the client, This document is particularly helpful for cases with multiple caregivers allowing them to see when certain tasks were performed that need not be done daily, ie., changing the bed sheets. In addition, it is here where the caregivers record the client’s mood, how the day went and any changes in the client. Caregivers are instructed to call the office immediately with any significant or concerning changes.
MEDICATION REMINDER LOG
Caregivers can remind clients to take their meds from pre-poured pillboxes, recording date and time with initials. We are happy to ensure specific instructions like clients consuming meds in front of their caregivers as well as storing meds out of sight and reach of clients.
Weight loss and gain is a common area of concern for clients. Caregivers document not only what the client has consumed but how much. We are able to follow dietary restrictions and recommendations and record meals allowing family members and healthcare professionals to review and modify as needed.
Upon hospital or rehabilitation discharge, the client’s home can be a revolving door with Visiting Nurse Services coming which may include the Registered Nurse, home health aide, physical therapist, occupational therapist, speech therapist, and social worker. It can be confusing for clients to remember who is visiting and report to their family members when asked. Caregivers can request all visitors to sign the Visitors’ Log.
Caregivers record their mileage when using their own cars to transport clients or run errands. Mileage is from the client’s house to the destination and back, not the caregivers’ commute to the clients’ houses. All entries include destination and miles driven.
FINANCIAL TRANSACTION LOG
Before services start, the method of payment (cash or credit) for any purchases will be established. The caregiver will document all purchases and store all receipts here unless otherwise instructed.