✨ Why Documentation Matters

Documentation protects the individual, supports consistent care, and helps the team respond correctly. Communication issues (refusals, distress, boundary concerns, misunderstandings) should be documented clearly and objectively.

 

✨ Document Facts, Not Opinions

Write what you observed and what you did.

Do not write:

• “He was rude.”

• “She was being difficult.”

Write instead:

• “He raised his voice and said, ‘Leave me alone.’”

• “She stepped back, crossed her arms, and repeated ‘no’ three times.”

 

✨ What to Include

• Date and time

• What happened (facts)

• What the individual said (quotes if needed)

• Signs of distress (tense, pulling away, etc.)

• What you did to support

• Outcome (what helped / what didn’t)

• Who was notified, if required

 

✨ When to Report Immediately

Follow policy and report if you observe:

• Staff not respecting consent or boundaries

• Possible rights violations

• The person appears unsafe or pressured

• Sudden behavior changes that could indicate pain, illness, or trauma

• Any incident that requires escalation per your organization’s rules