Sharing information through records
A record is a written (or digital) note of what happened in the care of a person. It lets every worker know the person's condition without asking again, shows what care was given, and protects the person and the worker if something goes wrong.
A good record is:
- Fact-based: what you saw, heard, measured or did, not guesses ("ate 2 of 4 spoons", not "was lazy").
- Timed and dated, and signed with your name.
- Clear and short: simple words, no hard abbreviations.
- Written soon: do not wait until you forget.
- Private and safe: only the care team may read it; keep papers locked and passwords secret.
If you must write what the person said, put it in quotation marks. If you make a mistake, cross it out with one line and sign it, never rub out.
Handover and reporting
Handover is when one shift passes information to the next. Give the most important things first: changes in the person, anything to watch, things to do. Read the record before you start your shift.
Use Report, Contact, Consult: Report what happened to your supervisor soon and clearly. Contact the people who must know (nurse, doctor, family). Consult when you are not sure what to do. Tell early: a small problem told early stays small.
Teamwork and coordination
Care is shared by many: care worker (daily support), nurse (health care), doctor (treatment), therapist (movement, speech), social worker or care manager (plans and services), and the family. Each knows a different part of the person's life.
Coordination means agreeing on one plan: who does what, and when. The team meets, shares what each has seen, and agrees on the aim. Respect each role: ask your own questions about your own role and pass medical questions to the nurse or doctor. Keep the person at the centre and listen to what they want.
Try it
At home: choose a family member as "the person". Write a fact record of their breakfast (time, what they ate, how much). Hand it to a second family member as "the evening shift". Can they tell what happened without asking? Now rewrite one line with an opinion and notice how it loses meaning.
Key formulas and definitions
- Record = facts + time + signature
- FACT: Fine details, Accurate time, Clear words, Tell the team
- Report, Contact, Consult
- Care team = care worker + nurse + doctor + family + others
- Tell early, tell clearly
Worked examples
1. Rewrite "Mr. Rao was grumpy at tea" as a fact record.
"4:00 pm. Mr. Rao said, 'I do not want tea.' He pushed the cup away and did not drink." (time, what he said, what he did).
2. At 8 am the person had 38.5 °C fever. Whom do you tell and in what order?
The nurse straight away, then your supervisor, then the family. Record the time and temperature.
3. A person ate 3 of 4 portions of lunch. What fraction and percentage did they eat?
3/4 = 75%. Record "ate 3 of 4 portions (75%) at 12:30".
Common mistakes
- Writing opinions like "lazy" or "rude" instead of facts.
- Forgetting the time or your signature.
- Waiting for "the right moment" to report a problem.
- Leaving records where visitors can read them.