Behaviour documentation for personal care workers

What happened? → What did the resident do or say? → Who or what was affected? → What did you do? → What happened afterwards?

Below are examples written in language a personal care worker could realistically use.

Wandering

At approximately 2:15 pm, Mrs Jones entered three other residents' rooms without permission. One resident became upset and asked her to leave. Mrs Jones was redirected back to the lounge and offered a cup of tea. She remained settled afterwards.

Interfering with Objects

Mr Smith removed another resident's glasses from the dining table and placed them in his pocket. The owner was unable to locate their glasses and became distressed. Glasses were returned to the owner and Mr Smith was redirected to his seat.

Interfering with Others

Mrs Brown repeatedly attempted to assist another resident to stand despite staff advising her not to. The other resident became anxious and stated, "Leave me alone." Mrs Brown was redirected to a nearby activity and no further incidents occurred.

Verbal Aggression

During personal care, Mr Lee raised his voice and repeatedly said, "Get out! Leave me alone!" while pointing at staff. Care was paused for five minutes before re-approaching. Mr Lee accepted care on the second attempt.

Verbal Calling Out

Mrs Green called out "Help me!" approximately every 2-3 minutes for 20 minutes while in the lounge. Other residents appeared distressed and several asked staff to stop the shouting. Mrs Green was reassured, pain assessed and offered one-to-one support. Calling out reduced after staff remained with her.

Repeated Buzzer Use

Mr White activated the call bell 12 times between 8:00 am and 9:00 am. On each occasion he requested reassurance about the time of breakfast despite staff providing the information. Frequent call bell use delayed staff responding to other residents' requests. Mr White was provided with reassurance and a visible clock was placed within view.

Physical Aggression

While staff were assisting with dressing, Mrs Taylor attempted to hit the care worker with an open hand and kicked towards staff twice. No injuries occurred. Care was stopped and re-attempted after allowing time for the resident to settle. Care was completed without further incident.

Depression Symptoms

Mr Wilson remained in his room throughout the day and declined invitations to attend morning tea and lunch with other residents. He stated, "I don't feel like seeing anyone today." He ate only a small amount of lunch. This reduced his usual participation in social activities. RN notified.

Memory Loss Symptoms

Mrs Harris asked where her husband was six times within one hour, despite being reminded he had passed away several years ago. She appeared tearful after each reminder. Staff redirected the conversation to family photographs, which reduced her distress.