It’s natural to be a little wary of documentation. We’ve all seen how bureaucracy and paperwork can slow processes down, turning straightforward and intuitive tasks into complex and difficult ones. While caregiving is certainly not simple and straightforward, it does fit within our area of expertise, and so we know how to manage these tasks and execute them effectively.
Until recently, documentation has been focused on problems — for instance, maladaptive behaviors, or anything that is going wrong for the caree. Frankly, it is unrewarding to focus only on these negative aspects. Unfortunately, many care providers have been influenced by this approach, and have become aware that they could lose their supports if they begin to show improvements or if they begin to move closer to the goals — positive action results in a reduced support priority.
There has been a profound shift in the modern care environment. Person-centered thinking has become the focus. Support plans now must include what is important to and for the individual receiving the support. With this in mind, we need to update our understanding of what documentation must show.
To ensure the supports we are providing are continued, or to get adequate compensation for our work, we may feel that simply verbalizing our situation is enough — to tell external personnel about what we have done and how we’ve done it. Unfortunately, this may not always be enough.
The Documentation Dilemma: Why No One Believes Your Lived Experience: They First Need to Understand It
Why is ‘telling’ not enough? Because your caregiving experience is your own experience, your lived experience. Those who do not have this shared understanding — those who have not carried out the same tasks you have — may find it difficult to understand.
At best, this is frustrating and annoying. We all like to feel that our efforts are appreciated, that the magnitude of what we have achieved is fully understood. When other people don’t show this appreciation or understanding, we may feel unseen, undervalued, or just unappreciated.
At worst, however, it’s dangerous. A lack of understanding and appreciation can lead to difficult situations, particularly regarding funding and continuity of supports. Simply ‘telling’ a third party about the work you do may not be enough to secure the resources and supports you need. You can’t assume that the people who are assigning budgets and making decisions in government share your lived experience or understand how to value it.
This is the #DocumentationDilemma. You don’t want to be distracted by paperwork and bureaucracy while you do what you do, but you certainly don’t want to go unappreciated, undervalued, or unsupported. You definitely don’t want all the progress you have accomplished to disappear because the person who takes your place isn’t as knowledgeable as you have become. A balanced approach to documentation is necessary.
How Documentation Improves the Care Process
Why is this documentation needed at all? In many cases, caregiving is a largely personal and unique process. It depends upon the caregiver’s own style of delivery, their relationship with the person needing care, and the specific supports needed for optimum outcomes. Do some people require the same care? Yes. Does requiring the same care make documentation redundant? No. In fact, documentation can improve the care process in a number of different ways.
Let’s start with the delivery of the care itself. It’s easy to become overwhelmed by the experience of delivering care, and this is certainly not something that caregivers should be ashamed of. Such an intensive, vital and often difficult process takes its toll on the caregivers themselves. Caregivers need support too and often the same ones they are providing for others. When we factor in all the different things you and your fellow caregivers need to keep track of — care schedules, progress reports, A.D.L.s, medications, achieving development goals, etc. — the process becomes even more complex.
When you are documenting your progress as a caregiver, you are recording the supports necessary for someone to live a successful life, as well as the activities that are detrimental to that success. Keeping digital and written records helps you to organize and gain an understanding of the supports you are providing. This insight becomes vital in the ongoing delivery of care.
Evaluations are stressful. No one wants to have everything they have done questioned by someone who wasn’t living the experience with them. No one wants to feel like they have failed in their care duties or that they were not doing a good job. However, evaluations are necessary in the caregiving field. They are not designed to increase stress and strain for the caregiver, but to ensure that the caree is receiving all the supports they need. At the same time, evaluations can help caregivers by providing them with new information on supports available and education that increases their knowledge and encourages new skill development.
Managing Evaluation Goals
Goals and targets are always key to an evaluation and provide caregivers with the framework they need to develop and grow. Documentation helps you to manage these goals and targets, keeping you on track. In the day-to-day work of delivering care, it is extremely easy to get caught up in the routine of life. Reminding ourselves of our ongoing goals is important to achieving them. This is why classes such as CPR and First Aid need to be recertified every two years. In order to learn new advancement to the technique and to refresh the caregiver on things they already know how to do.
Your evaluation target might be based on feedback from your previous session. In this case, a written evaluation document gives you something to refer to — a concrete resource to draw upon beyond just what you have to remember everyday. Meanwhile, you may also have a document outlining specific goals for your next evaluation. When you achieve this goal, it can be removed from the list.
Evaluations are fluid and ongoing. While you tick off previously set goals, you may find new targets appearing. Documentation helps you to keep a record of the goals you have already completed while adding targets to focus on for the next evaluation. Documentation also shows you relapses so that you can address them before they become overwhelming issue.
Maintaining Skill Levels
Having a written record of supports delivered also helps caregivers maintain consistency in the care they provide. With this record, you will be able to keep track of your own skills and achievements, ensuring that these are applied consistently during your work.
This is where documentation requires the right approach. It can be stressful to feel that you are being “checked up on” or “micromanaged” all the time. However, if you view the support record as both a care resource and a personal resource for professional improvement, the experience becomes much more positive.
Communicating with the Circle of Support
This is something we have already discussed at the beginning of this article — the difficulty of communicating your own lived experience to those outside of this experience. In an ideal world, your more qualified and more expert view would simply be trusted. However, in reality, it’s always best to have a record of documentation to back up your communication.
This is critical in a number of different situations, such as:
- Communicating with Community Partners
Community partners offer valuable supports to caregivers, particularly at-home caregivers who may otherwise find themselves isolated or have difficulty connecting with others. These partners include non-profit organizations that work with caregivers and carees, charities focused on supporting care and well-being, or religious and social groups aimed at developing and improving the local area. Typically, the representatives of these partner organizations will not share your own experience, and you will have to communicate precisely what you do, how you do it, and what you need in the way of assistance. Documentation provides the foundation for this communication.
- Communicating with Governments
Local and national government departments can provide assistance to caregivers — including payments for services, financial assistance, and supports of other kinds. However, personnel in these government departments will need to sign off on the supports they provide, which involves making a value judgment based on how much support to grant or whether to grant it at all. Just because these personnel work in the field of care does not mean they are experienced in the same way you are. Being able to refer to the support record can help as you communicate your needs — and the value of the supports you provide — to government personnel.
- Communicating with Fellow Providers
This is an interesting area of communication for caregivers. You might think that a fellow provider would automatically share your own experience and therefore be very easy to communicate with. However, the provision of care is such a varied and largely personal field that this is often not the case. It may be difficult for these fellow providers to put themselves into your shoes and view the process in the way you do. Again, documentation offers a way to quantify the supports you provide and demonstrate your value to other caregivers.
Maintaining support documentation helps caregivers to achieve a more person-centered approach. There are so many unique elements of care — the duration of supports, for example, their frequency and their intensity — that a general approach is not going to be enough. Instead, you need to focus your efforts on the individual, creating a person-centered system of care.
While documentation may seem like a rigid and impersonal way to record care, this does not need to be the case. A caregiver’s documentation needs to be about how you supported the person in your care. How you helped them and why that was necessary. You can include participant feedback into the documentation system, tailoring the records you keep to meet the specific needs of the caree themselves.
Training New Team Members
Documentation is a valuable resource that demonstrates how care is provided and what form it should take according to different case studies and situations. During team member training, the full diversity and variation of the caregiving process must be communicated. While face-to-face trainings and practical training are important in delivering this understanding, there is no way to communicate a lifetime of care in one or two educational events.
With strong documentation, training becomes easier to deliver. The face-to-face meetings and practical elements mentioned above are still required, but this is supported by a resource that the trainee can draw upon as they learn and develop. Documentation new providers can access at all times prevents interruptions to the much-needed time off of other caregivers.
Creating a Robust Care History in Case of Transition
It’s not just new caregivers who can benefit from this written support record. There may come a time at which the caree needs to be transferred between case workers and care providers. The well-being of this caree must be the priority during this transitional period, and all efforts must be made to achieve it smoothly.
Documentation provides information on care history, all of which will be crucial as this transition is completed. With a well-structured and well-organized care history, the incoming care provider has all the resources they need as they implement a new regimen of care.
Prevention of Abuse or Exploitation
We saved this point for last on the list, not because it is less important than the others, but because it needs its own space in this article. Abuse and exploitation of vulnerable individuals is a very real concern here in the United States and across the world. While you yourself provide responsible and valuable care to the individuals you work with, you must also recognize the importance of systematic protection for those who may be at risk of abuse.
This is a very important point when it comes to documentation and makes this resource vital for caregivers. With proper evaluation and strong documentation, care monitoring and assessment becomes easier to achieve. Regulatory bodies can draw upon the same centralized record as they monitor caregiver/caree relationships and identify potential instances of abuse or exploitation.
The result is protection for all parties. The caree is protected from possible abuse, the caregiver is protected from allegations of abuse, and the bodies themselves are protected from charges of negligence and dereliction of duty.
Embracing a New Approach to Caregiver Documentation
Documentation does not need to be an obstacle and is not something you need to shy away from. Instead, it can be a valuable resource — something that can help you deliver the best possible care while also supporting your own well-being. MyDoDad exists to assist caregivers in solving the documentation dilemma by putting person-centered documentation at your fingertips, and providing you the personal support required to improve outcomes for your caree.