Let's talk about daily restorative documentation. It's the bane of many care professionals' existence. What exactly *should* you write down? I have some thoughts. Prepare for some potentially unpopular opinions.
The Obvious Stuff (That's Still Missed!)
First, the easy stuff. Resident's name. It's helpful, trust me. Date and time, obviously. We're not time travelers (yet).
Did Mrs. Higgins actually participate in the restorative activity? Circle "yes" or "no." Don't guess. She'll rat you out later.
What activity did you do? Walking, range of motion, maybe some bingo. Be specific! "Stuff" isn't descriptive enough.
The "Important" Vitals (Maybe?)
Okay, pulse and blood pressure. Are they drastically different from yesterday? Note it. Otherwise? Maybe skip it. Unless your boss is watching, then definitely write it down.
Weight-bearing status. Partial? Full? Did Mr. Johnson attempt to fly again? (This happens more than you think.)
Assist level. Independent? Minimal? Did you practically carry them? Honesty is key. (Mostly.)
The Subjective Gold (That No One Wants to Write)
Here's where things get interesting. Resident's mood. Happy? Grumpy? Contemplating world domination? Write it down!
Did they complain about pain? Location? Intensity? "My everything hurts!" counts as pain. Document it! And offer comfort, of course.
Engagement level. Were they actively participating? Or just staring blankly at the wall, dreaming of warmer climates? It matters! Document the dreams (metaphorically, of course).
A Note on "Goals"
Goals. The dreaded "G" word. Did we make progress towards the goal of "stand independently for 30 seconds?" If so, celebrate! If not, document why.
Maybe Mr. Henderson decided he'd rather nap. That's a valid reason. Adjust the goal accordingly. Napping is important!
Don't be afraid to say "no progress due to resident refusal." It's honest. And saves you from making up fantastical stories about spontaneous hamstring injuries.
The "Extra Credit" Section (For the Truly Dedicated)
Personal preferences. Does Mrs. Gable hate Tuesdays? Does Mr. Abernathy only respond to polka music? This is gold! Write it down!
Family visits. Did a loved one come by? Did it brighten their day? Note it! It shows you care. (Even if you're just pretending. Kidding! Mostly.)
Anything unusual. Did Mr. Davies suddenly start speaking fluent Klingon? Did Mrs. Peabody try to escape using a walker? This is documentation worthy!
Ultimately, the goal is to paint a picture. Not just of their physical abilities, but of their overall well-being.
What NOT to Document (My Unpopular Opinion)
Excessive details. We don't need a play-by-play of every single rep of every single exercise. Keep it concise.
Blame. "Resident uncooperative" without explanation is useless. Explain *why* they were uncooperative.
Gossip. "Mrs. Rodriguez is having an affair with the mailman." Leave it out. Seriously. That's just bad karma.
The Bottom Line
Document what's relevant. What tells the story of the resident's day and their progress. Be honest. Be specific. And maybe, just maybe, add a little bit of humor. It makes the process slightly less painful.
And remember, a happy resident makes for a happier documenter. So spread some joy! (And document it, of course.)
Now go forth and document! (And maybe take a nap afterwards. You deserve it.)
