Observations

An observation is written from the resident’s sheet, with the Observation button, or from a care, with the Observation button of its detail.

Writing an observation

  1. Choose the type at the top: General, Behaviour, Pain, Fall, Change, Wound or Family.

  2. Write what you saw, in your words.

  3. Switch on Someone must read this if the team must know.

  4. Answer the extra questions, if the type asks for them.

  5. Tap Save.

Extra questions by type

The app only asks what the record needs for that type.

  • Pain — How bad, 0 to 10: tap the score.

  • Fall — see below.

  • Change — What kind, and How often the first time only: the answer is then kept in the continence register.

  • Wound — see below.

Fall

  • What happened — a fall without injury, with a minor, moderate or major injury, or another incident.

  • Where — tap a usual place (the resident’s room, the places the house often records, bedroom, bathroom, corridor, dining room…) or type it under Somewhere else? Type it here.

  • Witnesses — who saw it, if anyone.

  • Where on the body — for a fall with an injury, tap the zone on the drawing.

  • Photos — up to three. Take a photo opens the camera; Remove takes one off.

The fall is recorded in the fall register, where the head nurse reads it.

Wound

Under Which wound, choose a wound already followed, A new wound, or Skin watched, no wound.

For a new wound:

  • What kind of wound;

  • Where on the body — tap the zone on the drawing, or Elsewhere, not on the drawing and say where;

  • Where it comes from.

A Wound observation on the phone: the choice of the wound, the type of wound and the body drawing to tap the zone

Then, for a new wound as for a wound followed:

  • Photo — Take a photo, Retake to replace it;

  • Measured today, in cm — length, width, depth;

  • Stage when the type of wound has one, Exudate and Edges.

For a wound already followed, And now records the decision of the day.

Reading an observation

Tap an observation on the resident’s sheet or in the bell: it opens whole, with its type, its time, its author, the measures it carries, the body drawing, the photos (tap one to enlarge it) and the attached files.

  • Newer and Older — or a swipe — go to the resident’s other observations.

  • Tap the resident’s name to open the sheet.

  • For an observation marked Someone must read this, tap I have read it once it is read. The observation then says who read it.

An observation opened whole on the phone, with its text, its author and the read button

The observations also appear in the back office, in the resident’s nursing notes. See Observations and vital signs.