Basics of Record Keeping in an Assisted Living Facility

As a caregiver you are responsible for record keeping and documentation. As such, you must keep any and all resident records confidential and in a safe and secure area.  You are not permitted to release confidential resident information to any unauthorized parties. You have an obligation to the resident, the assisted living home and yourself to document properly and adequately, and to keep resident records private. Specific states will vary with respect to “what’ is required documentation. Here, we provide you with the most universally common required documentation in care homes across the United States.

Most universally required documentation includes, but is not limited to the following:   

  • Changes in level of care
  • Incidents
  • Doctor’s Communication
  • Pharmacy Communication
  • Representatives/Relative Communication
  • Actions taken to ensure continuous and consistent care
  • ADL’S (Activities of Daily Living)

While the above is generally required documentation keep in mind that you may be delegated to document additional things such as environmental controls, fire drills, other facility records and any other documentation that you would reasonably consider to be important to document.  Finally, always bear in mind that as a caregiver you will never hurt anyone by ‘over documenting’.