You are the early warning system. Know each person's normal, spot changes and emergency signs, report with SBAR, and write it down right.
ForNursing home, Home health, Hospice staff
TimeAbout 78–79 minutes
Lessons10, each with a quick check
FinishA quiz (80% to pass) and a printable certificate of completion
What you will learn
Explain why aides are often the first to notice a change.
Explain what a baseline is.
Name the body changes AHRQ lists as top changes to watch.
Name the non-physical changes AHRQ lists as top changes.
Use F.A.S.T. to spot a stroke and know to get help at once.
Recognize the signs of sepsis and act fast.
Use SBAR to give a clear, short report.
Write notes with facts, numbers, times and the person's own words.
Know when the facility must notify the doctor and the resident's representative.
Report changes to the agency during the visit.
Written by Pact Compliance from federal rules and CDC, CMS, OSHA and NIH guidance (sources under each lesson), checked October 2026. Where your facility's policy is different, follow your facility's policy.
Lesson 1: You Are the Early Warning System
In this lesson you will:
Explain why aides are often the first to notice a change.
Know that small changes can be early signs of serious illness in older adults.
Know the federal reporting duty for your setting.
Eyes and ears
Of the team
In a hospital, nurses and doctors are there almost all the time. In a nursing home, doctors and nurse practitioners are there much less. AHRQ says nursing assistants are the staff who see residents most often. Residents depend on you to notice when something changes. AHRQ calls nursing assistants the eyes, ears, and hands of the care team.
Small signs
Can mean a lot
In older adults, signs of illness may be mild, or different from what you expect. AHRQ says that sometimes feeling or acting tired is the only clue. In a younger person, the same illness might cause a fever or another clear sign. So it is important to notice and report changes in an older person sooner than you would for a younger person.
Show the answer
Illness in older adults can show up with mild signs, like being tired. AHRQ says signs may be mild or different, so report sooner.
One thing
Leads to another
Picture a frail resident who gets diarrhea. Over a week, she eats less. Her pulse is faster than her usual. Then she gets a high fever and ends up in the intensive care unit. AHRQ uses a case like this to make a point. When one thing goes wrong, it can lead to another. Noticing a change early, and acting fast, can stop that chain.
Nursing homes
The rule
Federal rules say a nursing home must immediately consult the resident's doctor and notify the resident's representative when there is a significant change, or an accident with an injury that may need a doctor. CMS says a key skill for every CNA is to spot a change in condition and act on it. For example, you write it on a short form and tell the RN. The RN checks the resident and calls the doctor.
Home health and hospice
The rule
Federal rules say home health aides must report changes in a patient's condition to a registered nurse or other skilled professional. Hospice aides must report changes in the patient's medical, nursing, rehab, and social needs to a registered nurse. Aides in both settings must also complete records as their agency's policies say. Their training covers observing, reporting, and documenting, and changes in body function to report.
Speak up
No blame
AHRQ lists things that get in the way of reporting. One is fear that someone will be blamed. Another is thinking someone else will act. A third is thinking someone else knows the person better than you do. AHRQ says residents are safest when everyone expects to report anything that might affect their well-being. Your report is never a bother. It is your job.
On your shift
Something's off
Mr. Reyes always walks to breakfast with his walker. Today he asks for a wheelchair. He says he is just tired. There is no fever. Nothing looks wrong. But this is a change from his normal. You tell your nurse: 'Mr. Reyes walks to breakfast every day. Today he asked for a wheelchair and says he's tired. It started this morning.' That small report could catch an illness early.
Quick review
Notice early
Let's review. You see the people in your care more than almost anyone, so you often see changes first. In older adults, a small change, like being tired, may be the only early sign of illness. Federal rules in every setting expect aides to notice and report changes. Don't wait for someone else. Speak up. Early reports save lives.
Your facility's policy (ask your supervisor):
Who aides report changes to on each shift (title and how to reach them)
Learn a person's baseline from the person, family, coworkers and records.
Compare shift to shift to spot changes.
Baseline
Their normal
A baseline is what is normal for one person. It is how they usually move, eat, talk, sleep, and act. AHRQ says the best way to spot a change is to know what is normal for that person. One resident may always nap after lunch. For another, a nap is a big change. You can only see a change if you know the starting point.
Learn it
From others
When you meet a new person, find out all you can. AHRQ says to talk with your team. Coworkers may have learned things from family, visitors, or other caregivers. Shift report is another good way to learn a person's baseline. Spend time with a new resident, just getting to know them. Talk with the person and the family every day you are there.
What to learn
Moving and ADLs
Notice how the person moves around. How do they get from bed to chair? Do they need to sit in the shower? Notice how they do with daily activities, like dressing, eating, and using the toilet. Learn what they like for activities, food, and clothes. AHRQ says a change in a person's routine, or in the parts of the day they enjoy, can be a sign of a medical change.
Show the answer
What is normal for that one resident. Baseline means the person's usual condition, so you can spot change.
Ask about pain
Then share
Watch for signs that the person is uncomfortable. AHRQ says many older adults won't talk about pain unless you ask. So ask. When you learn something important about a person, share it with your coworkers. Help float staff and new staff too. They don't know the person's normal yet. A tip from you can help them catch a change.
Same staff
Same people
AHRQ says many leaders in nursing home care believe that having the same staff care for the same residents leads to better care. It also leads to happier staff. When you care for the same people again and again, you learn their normal. You notice small changes faster. The same is true when you visit the same patients at home.
Dementia
Watch closely
AHRQ says to take special care to learn the baseline of people with dementia. Changes in these residents can be sudden, and they may not be able to tell you what's wrong. Many residents are confused at baseline. But a new level of confusion can mean pain, a medicine problem, or a new illness. Know how confused is normal for this person, so you can see when it gets worse.
Shift to shift
Compare
Your workplace has a place to record things like bowel movements, urine, temperature, daily care, and behavior. AHRQ says to record your shift, and also read what the shifts before you wrote. Then compare. Ask yourself, 'Is there a change I should watch or report?' If something needs watching, write it in your notes. If something has changed, report it.
On your shift
A new resident
Mrs. Ochoa moved in yesterday. You don't know her yet. You read the notes from last night. You ask the night aide how she slept. You ask her daughter what a good day looks like for her mom. Her daughter says, 'Mom always does her own hair and loves the morning news.' Now you know her normal. If she stops doing these things, you'll notice.
Quick review
Know the normal
Let's review. A baseline is a person's normal. You need it to see a change. Learn it from the person, family, coworkers, shift report, and the record. Notice how they move, do daily care, and what they enjoy. Ask about pain. Learn the baseline of people with dementia with extra care. Compare shift to shift, and share what you learn.
Your facility's policy (ask your supervisor):
Where aides record shift observations (flow sheet, kiosk, app) and how to read prior shifts
Name the body changes AHRQ lists as top changes to watch.
Recognize signs of dehydration.
Report vital signs outside the care plan range if measuring them is your job.
Top changes
Body first
AHRQ lists twelve top changes to watch for. Six are physical, or body, changes. They are walking, urine and bowel patterns, skin, weakness, falls, and vital signs. You can check many of these while you give daily care. If your workplace uses a checklist or card for changes, use it. This lesson walks through the body changes one at a time.
Walking
Balance
Watch how the person walks. Do they have trouble getting started? Is their balance poor? Are their steps smaller, or shuffling? Do they favor one side? Watch how much help they need, and whether they use the hand rails more. AHRQ says these changes raise the risk of a fall. They may also mean a fall that nobody saw, more arthritis pain, a small stroke, or a medicine problem.
Urine and bowels
New patterns
AHRQ says new loss of bladder control should always be checked by a clinician. Less urine, or no urine, is also important. Notice if the person goes more often, or if urine smells different. Constipation and diarrhea need early attention. Watery stool can sometimes leak around hard stool that is stuck. So report it. Don't assume it's just diarrhea.
Show the answer
Tell the nurse what you saw and where it is. Report skin changes. The nurse checks the skin and decides what it is.
Skin
Look and tell
You see more of a person's skin than anyone. Look while you bathe and dress them. Report red or darker skin over a bony spot. Report any skin breakdown. Report skin that is swollen, puffy, or red, and any new rash. Dry or cracked lips can be a sign of dehydration or a mouth infection. Describe what you see. The nurse checks the skin and decides what it is.
Weakness
Sudden or slow
Weakness can be all over, or in one area, like one arm. AHRQ says weakness that comes on suddenly might be a sign of a stroke or a serious illness. Watch when the person lifts their arms to eat, brush their hair, or wash. Is it harder than usual? Sudden weakness on one side is an emergency. You'll learn what to do in the emergency lessons.
Fluids
Dehydration signs
MedlinePlus says older adults have a higher risk of dehydration. Early signs include thirst, a dry or sticky mouth, not passing much urine, darker urine, dry skin, headache, and cramps. Severe signs include very dark urine or none, confusion, dizziness, a fast heartbeat, fast breathing, and sunken eyes. Report when a person drinks less than usual, and report any of these signs.
Falls
Always report
AHRQ says falls should always be reported, even when no one seems hurt. Many things can cause a fall: the room, the lighting, the floor, medicines, illness, or the person's state of mind. A report helps the team find the cause and make changes. Also watch for near misses, like a person who leans out of a wheelchair to reach for things.
Vital signs
If it's your job
Vital signs are temperature, pulse, breathing rate, and blood pressure. Home health and hospice aide training covers reading and recording temperature, pulse, and breathing. Take them only if it is your job and you were trained. AHRQ says compare them with the person's baseline. Fast breathing with a fever and a fast pulse could mean an infection. If a number is outside the range in the care plan, tell the nurse right away.
Quick review
Body changes
Let's review. Watch for changes in walking, urine and bowels, skin, weakness, falls, and vital signs. Watch for dehydration, like dark urine, dry mouth, and new confusion. Report every fall. Describe skin changes. Don't label them. If vital signs are your job, compare them to the person's normal and report numbers outside the care plan range right away.
Your facility's policy (ask your supervisor):
Your change-in-condition card or checklist, if you use one (insert your own licensed tool)
Which aides may take vital signs and where the care-plan ranges are found
Lesson 4: What to Watch: Mind, Mood, Eating, Sleep and Pain
In this lesson you will:
Name the non-physical changes AHRQ lists as top changes.
Recognize delirium as sudden confusion that needs a report.
Know that it is better to report too much than too little.
Six more
Changes to watch
AHRQ's top twelve changes also include six that are not about the body. They are how the person acts, appetite, sleep, speech, confusion or agitation, and complaints of pain. AHRQ says many of these may show up when a person has delirium. Delirium is sudden confusion that comes from another illness or problem.
Delirium
Sudden confusion
MedlinePlus says delirium is sudden, severe confusion. It comes from fast changes in the brain caused by illness. It is often short-term and can get better with treatment. Causes include infections, like a bladder infection or pneumonia, some medicines, and lack of sleep. The person may switch from sleepy to upset and back. They may not know where they are, or talk in ways that don't make sense.
New confusion
Report fast
MedlinePlus says to contact a health care provider if there is a fast change in mental status. So if a person becomes newly confused, more confused than their normal, or very sleepy, tell your nurse right away. Delirium can look quiet, too. A person may just be slower and hard to wake. Quiet confusion is easy to miss.
Show the answer
Possible delirium. Tell the nurse right away. Delirium is sudden confusion from illness. A fast change in mental status needs a report.
How they act
Mood changes
AHRQ says illness can change a person's mood or behavior. A bloodstream infection or a stroke can do this. Watch for a person who pulls back, won't get out of bed, or skips usual activities. They may talk less, or seem not to pay attention. They may also talk much more, talk loudly, or refuse care. Some people see or hear things that are not there.
Appetite
Watch the tray
AHRQ says changes in appetite should always be reported. Look at the tray after meals. How much did they eat and drink? Many things can cause a poor appetite. Medicines can change taste. Mouth pain or tooth problems can make eating hard. Nausea, depression, and delirium can do it too. The nurse finds the cause. You report what you see.
Sleep and speech
Unusual changes
Watch for a person who says they don't feel rested, falls asleep in odd places, or is hard to wake. Poor sleep can be a sign of pain, worry, depression, or breathing trouble at night. Listen to speech, too. AHRQ says new slurred or garbled speech, trouble finding words, or new trouble chewing or swallowing needs a check. If speech changes suddenly, it may be a stroke. That is an emergency.
Pain
New pain matters
People know their own bodies. Even a person with dementia may be able to tell you something hurts. Watch for a grimace or wince when they move or when you help them transfer. AHRQ says new pain can be a sign of something serious, like a heart attack. Tell your nurse about new pain right away. Old pain still needs to be reported, too.
How much to report
When in doubt
You may wonder if a change is big enough to report. AHRQ gives a rule of thumb. If you report three to five changes for every one that leads to a full nurse check, you are probably getting it right. AHRQ says it is more important to report anything that might matter than to get the amount perfect. Newer staff should report more, not less. When in doubt, report.
Quick review
Mind and mood
Let's review. Watch how the person acts, eats, sleeps, and talks. Watch for confusion, agitation, and pain. Delirium is sudden confusion caused by illness. It can be loud or quiet. Report it fast. Always report appetite changes and new pain. Sudden speech changes may mean a stroke. Not every report will be a big problem. That's OK. When in doubt, report.
Lesson 5: Emergency Signs, Part 1: Stroke, Heart Attack and Breathing
In this lesson you will:
Use F.A.S.T. to spot a stroke and know to get help at once.
Recognize heart attack signs, including mild ones.
Know which breathing problems are an emergency.
Get help now
Don't wait
Some changes cannot wait for a report later. CMS says the doctor should be told when a resident has chest pain, passes out, or has other signs of a heart attack or stroke. In a facility, call for your nurse at once and follow your emergency steps. Stay with the person. At home, call 911 for these signs, then call your agency. If the person is on hospice, follow the care plan for who to call.
Stroke
F.A.S.T.
NINDS says stroke signs appear suddenly. It teaches a test called F.A.S.T. F is for face. Ask the person to smile. Does one side of the face droop? A is for arms. Ask them to raise both arms. Does one arm drift down? S is for speech. Ask them to repeat a simple phrase. Is speech slurred or strange? T is for time. If you see any of these signs, call 911 right away.
Show the answer
These are stroke signs. Get emergency help right away. NINDS says if you see any F.A.S.T. sign, call 911 right away.
More stroke signs
All sudden
NINDS lists other sudden signs. Numbness or weakness of the face, arm, or leg, often on one side. Confusion, or trouble speaking or understanding. Trouble seeing in one or both eyes. Trouble walking, dizziness, or loss of balance. A severe headache with no known cause. Note the time the signs started. Doctors need it to choose treatment.
Signs went away?
Still report
NINDS says a person having a stroke may not know it. They may not be able to call for help. That is why the people around them matter so much. Sometimes stroke signs go away after a few minutes. This may be a mini-stroke. NINDS says it is a sign of a serious problem. Tell the health care team right away, even if the person now seems fine.
Heart attack
Many signs
NHLBI says not every heart attack starts with crushing chest pain. Signs include chest pain, pressure, or discomfort. Pain in one or both arms, the back, shoulders, neck, jaw, or upper belly. Shortness of breath, which is more common in older adults. Sweating, unusual tiredness, nausea, light-headedness, or a fast or uneven heartbeat. Older adults and people with diabetes may have mild signs, or none.
Heart attack
Act fast
NHLBI says to call 911 even if you are not sure it is a heart attack. Every minute matters. An ambulance is the best and safest way to get to the hospital. Don't drive the person yourself. In a facility, get your nurse at once and follow your emergency steps. Don't wait to see if it passes.
Breathing
Trouble now
MedlinePlus says to call 911 if trouble breathing comes on suddenly, or is so bad the person can hardly talk. Call 911 if someone stops breathing. Tell the nurse right away about other breathing changes. These include short of breath at rest or while talking, needing to sit up to breathe at night, new wheezing, or choking. Also report breathing that is worse than the person's normal.
On your shift
A sudden change
At lunch, Mrs. Lin's words come out slurred. Her right hand drops her cup. One side of her mouth droops. You look at the clock. It is 12:10. You press the call light and call out for the nurse. You stay with her and keep her safe. When the nurse comes, you say: 'Slurred speech, right hand weak, face drooping. It started at 12:10.'
Quick review
F.A.S.T.
Let's review. For a stroke, think F.A.S.T.: face, arms, speech, time. Note when it started. For a heart attack, watch for chest pain and the milder signs, like shortness of breath, sweating, and nausea. For breathing, sudden or severe trouble is an emergency. Get help at once. Use your emergency steps, or call 911 at home. Stay with the person.
Your facility's policy (ask your supervisor):
Your emergency code or call steps (who calls 911, who calls the doctor and family)
Home health/hospice: agency 24/7 number and the hospice's instructions on when to call 911
Lesson 6: Emergency Signs, Part 2: Sepsis, Low Blood Sugar and Falls
In this lesson you will:
Recognize the signs of sepsis and act fast.
Recognize signs of low blood sugar and tell the nurse right away.
Respond safely to a fall and watch for head injury signs.
Sepsis
An emergency
CDC says sepsis is the body's extreme response to an infection. It is a life-threatening emergency. Sepsis can quickly lead to organ damage and death without fast treatment. The infections that lead to sepsis most often start in the lungs, the urinary tract, the skin, or the gut. Adults 65 and older, and people with long-term illnesses like diabetes or lung disease, are at higher risk.
Sepsis signs
Know them
CDC lists these signs of sepsis. Clammy or sweaty skin. A fast heart rate, or low blood pressure. New confusion, or more confusion than usual. Extreme pain or discomfort. Fever, shivering, or feeling very cold. Shortness of breath. CDC tells nursing assistants to watch for any change from a resident's baseline.
Show the answer
Tell the nurse right away. These can be signs of sepsis. CDC says act fast and alert the nurse at once for possible sepsis.
Sepsis
Act fast
If you think a person might have sepsis, act fast. CDC says to tell the nurse or clinician in charge right away. Most residents who may have sepsis need to go to a hospital quickly. Know your workplace's sepsis steps. At home, call your agency right away. If the person is very sick, call 911.
Low blood sugar
Diabetes
MedlinePlus says low blood sugar can happen to people with diabetes who take insulin or some diabetes medicines. Signs include shaking, sweating, hunger, a fast heartbeat, and headache. The person may be cranky or act aggressive. They may have blurry vision, unclear thinking, or feel tired and weak. Severe low blood sugar can cause seizures. Some people have no warning signs at all.
Low blood sugar
Tell the nurse now
MedlinePlus says severe low blood sugar is a medical emergency. If you see these signs in a person with diabetes, tell the nurse right away. Stay with them. Follow the care plan. Don't give insulin or any medicine. If the person can't wake up or has a seizure, use your emergency steps. At home, call 911.
After a fall
Don't rush
AHRQ says when someone falls, your first job is to make sure they get the care they need, fast. Always alert the nurse as your policy says. MedlinePlus says keep the person still and calm. Don't move a person who may have a hurt hip, pelvis, upper leg, neck, or back unless it is truly necessary. Stay with them and call for help.
Head injury
Watch closely
If the person hit their head, watch for danger signs. MedlinePlus says get help right away if the person becomes very sleepy, acts strange, or talks in a way that doesn't make sense. Also for a severe headache, a seizure, pupils of different sizes, trouble moving an arm or leg, passing out even briefly, or throwing up more than once. Signs can show up later, so keep watching as the care plan says.
On your shift
A fall at night
At 2 a.m., you find Mr. Hall on the floor by his bed. He has a bump on his forehead. His left leg looks turned out. You don't lift him. You press the call light and keep him still and warm. You tell the nurse what you found, the time, and his words: 'I tried to go to the bathroom.' Later, you help with the incident report, as your policy says.
Quick review
Act fast
Let's review. Sepsis is an emergency. Watch for fever or chills, clammy skin, fast heartbeat, new confusion, extreme pain, and shortness of breath. Low blood sugar can cause shaking, sweating, confusion, and seizures. Tell the nurse now. Never give medicine. After a fall, don't move the person if they may be hurt. Get help. Watch for head injury signs. Report every fall.
Your facility's policy (ask your supervisor):
Your facility's sepsis steps (CDC asks staff to know them)
Your fall response and incident report process
Diabetes care plan instructions for aides (who to call; what aides may and may not do)
Use CUS and report again when a concern is not heard.
SBAR
A memory aid
SBAR is a simple way to organize a report. It stands for Situation, Background, Assessment, and Recommendation, or Request. AHRQ teaches it to nursing assistants for reporting to nurses. Nurses use it to report to doctors. AHRQ says SBAR helps team members speak up and share a concern in a short, clear way. It is most useful when a person's condition is getting worse.
S: Situation
What's happening
Start with the situation. Say who you are, who the person is, and what is going on right now. Keep it short. AHRQ's TeamSTEPPS program reminds you to introduce yourself. Don't assume everyone knows who you are. That matters most on the phone. For example: 'This is Ana, the aide on the east hall. I'm calling about Mr. Patel in room 14. He's breathing fast.'
Show the answer
Situation and background: what you saw and how they were before. AHRQ says these are the most important parts for nursing assistants.
B: Background
Before the change
Next, give the background. For an aide, AHRQ says this is how the person was before the change. For example: 'He's usually up in his chair and talking at this time.' Add what you noticed, and when it started. AHRQ says that for nursing assistants, the situation and background are the most important parts of SBAR. Those parts are what you see best.
A: Assessment
Your concern
Then give your assessment. For a nurse, this is a clinical judgment. For an aide, it is simply your concern. You don't diagnose. AHRQ gives examples an aide might say: 'I think you might want to check him.' Or, 'I don't know what this means, but I hope you will take a look.' That is enough.
R: Request
What you need
Last, say what you need and when. TeamSTEPPS says the recommendation, or request, states what is needed and when. An aide might say, 'Can you come see him as soon as possible?' If the nurse gives you a task, like 'keep him sitting up and check him in ten minutes,' say it back so you both agree.
CUS
When not heard
Sometimes you feel your concern is not getting through. AHRQ teaches a tool called CUS for these times. You say: 'I am Concerned.' 'I am Uncomfortable.' 'This is a Safety issue.' For example: 'I'm concerned about Ms. Cole. I'm uncomfortable with how she's acting. I think she's not safe.' AHRQ says to use CUS only when the situation is urgent, not for every report.
Report again
If nothing changes
AHRQ says if the person still has a problem, and there was no response to your report, or the response didn't help, report again. Nurses do the same thing with doctors. If you still can't get help for a serious problem, go to the next person in charge, as your policy says. Don't give up on a person who needs help.
On your shift
A full SBAR
Here is a full SBAR from an aide. 'This is Sam, the aide on B hall. Mrs. Ruiz in 22 is very sleepy and hard to wake.' That's the situation. 'She's usually up for lunch and chatting. This started after breakfast.' That's the background. 'I'm worried something is wrong.' That's the assessment. 'Can you see her now?' That's the request.
Quick review
S, B, A, R
Let's review. SBAR stands for Situation, Background, Assessment, and Recommendation or Request. Say who you are, who the person is, and what's happening. Tell how they were before. Share your concern without diagnosing. Say what you need and when. If you are not heard in an urgent case, use CUS. If the problem continues, report again.
Your facility's policy (ask your supervisor):
Your reporting format or card (if you use INTERACT, insert your licensed SBAR or change-in-condition form)
Write notes with facts, numbers, times and the person's own words.
Chart only care you gave, after you gave it, and fix mistakes the right way.
Protect the record: your own login, no copying, no sharing.
The record
Tells the story
CMS says the medical record must give an accurate picture of what really happened to the resident. Staff must write down a person's status when any change happens, good or bad. Nursing home records must be complete and accurate. Home health records must be accurate. Hospice records must be correct. Your notes are part of that story, and the next caregiver depends on them.
Facts you saw
Not labels
Write what you saw, heard, and measured. Use numbers. Write 'ate two bites of lunch,' not 'poor appetite.' Write 'red area the size of a quarter on left heel,' not 'bedsore.' Write 'yelled and pushed my hand away during bath,' not 'combative.' Facts help the nurse. Labels can be wrong, and they can follow a person for a long time.
Their words
In quotes
When a person tells you something important, write their exact words in quotes. For example: Resident said, "My chest feels tight." If a family member tells you something, write who said it. Also write who you reported to, and when. For example: Told nurse Kim at 10:15.
Show the answer
'Drank 1 cup of juice at lunch. Said, "I'm not thirsty." Told nurse Kim 12:30.' It gives facts, the person's words, who you told, and when.
Date, time, name
Every entry
Home health rules say every entry must be clear, complete, dated, timed, and signed with your name and title, or your secure computer ID. Hospice rules say entries must be clear, complete, signed, and dated as hospice policy says. For electronic records in nursing homes, CMS says each person needs their own ID, and the computer records the date and time.
After, not before
Only what you did
Chart care only after you give it. Plans change. A resident may refuse a bath. You may get called away. If you charted ahead, the record would be wrong. Never chart care you didn't give, and never chart for a coworker. If a person refused care, write that they refused, and tell your nurse. An accurate record shows what really happened.
Late or wrong?
Fix it right
If you forget to chart something, add it as soon as you can. Follow your policy for late entries. Usually you label it as late, and give the time it happened. If you make a mistake, fix it the way your policy says. Never erase, white out, or delete. For electronic records, CMS says an entry is not changed after it is recorded.
No copying
Today's facts
Don't copy yesterday's note, or another aide's note, into today's record. The person may have changed. A copied note can hide the very change you were supposed to catch. Each entry should show what you saw today. Keep records private. Use only your own login, and never share it. Records must be kept confidential and safe from misuse.
On your shift
A busy morning
A coworker says, 'I'm behind. Just chart that I gave Mr. Long his shower. I'll do it after lunch.' You say, 'I can't chart care I didn't see. When you give it, you can chart it.' Later, you notice you forgot to chart Mrs. Lee's 9 a.m. intake. You add it now, labeled as a late entry, with the real time, as your policy says.
Quick review
Clear, true, timed
Let's review. Write facts and numbers, not labels. Use the person's own words in quotes. Date, time, and sign every entry. Chart only care you gave, and only after you give it. Fix late entries and mistakes the way your policy says. Never erase or delete. Don't copy old notes. Use only your own login. Keep records private.
Your facility's policy (ask your supervisor):
Your late-entry and correction policy (paper and electronic)
Where aides chart and who to call for login problems
Lesson 9: Nursing Homes: Notification, Follow-Through and Handoffs
For: Nursing home
In this lesson you will:
Know when the facility must notify the doctor and the resident's representative.
Know your part in starting that notice.
Give a safe handoff and include visitors' observations.
The facility
Must notify
Federal rules say a nursing home must immediately tell the resident, consult the resident's doctor, and notify the representative when certain things happen. These include an accident with an injury that may need a doctor. They include a significant change for the worse in physical, mental, or emotional health. They also include a need to change treatment in a big way, or a decision to transfer the resident.
Your part
Start the chain
The nurse or facility makes these calls. Your job is to start the chain. CMS says a CNA who sees a change in condition may write it on a short form and report it to the RN. The RN then checks the resident and calls the doctor. If you wait, the facility can't notify on time. A fast, clear report from you makes the whole system work.
Family too
Even if alert
CMS says the family or representative should be told about a significant change, even when the resident can make their own decisions. The resident may be too sick to call them. And the resident must still be told what is happening to them. If a family member asks you to call them about changes, tell the nurse. Follow your policy on who makes the call.
Show the answer
Her family or representative should still be told, and she must be told too. CMS says the resident may not be able to notify them, so the facility should.
Your tools
Know them well
CMS says facilities may use tools to help staff spot and report changes. Examples are AHRQ's training modules, or the INTERACT program. But CMS says just naming a tool is not enough. Staff must show they can use the tool to find and report changes. So learn your facility's form or card, and practice it.
Handoffs
Pass it on
A handoff is when care moves from you to the next person, like at shift change. TeamSTEPPS says a handoff passes on both the facts and the responsibility. Include recent changes in condition and the plan. You are still responsible until the next person knows and accepts the handoff. Don't assume they will read a note without checking.
At handoff
What to say
At shift change, tell the next aide what you saw, what you reported, who you told, and what you were asked to watch. For example: 'Mr. Long ate half his dinner. I told the nurse at 5. She wants him checked every two hours.' TeamSTEPPS says handoffs are a time for questions and a fresh set of eyes. Ask questions when you receive a handoff, too.
Everyone watches
Ask visitors
AHRQ says other staff, like housekeepers, dietary staff, clerks, and volunteers, notice changes too. They should be encouraged to tell clinical staff. AHRQ says visitors can be very important observers. If a visitor says, 'Dad isn't himself,' ask what is different and when it started. Then tell the nurse, using the visitor's words.
On your shift
A daughter's worry
Mrs. Bell's daughter stops you. 'Mom didn't know my name today. That's never happened.' You ask, 'When did you first notice?' She says, 'Just now.' You tell the nurse right away: 'Mrs. Bell's daughter says her mom didn't know her name today. That's new.' The nurse checks Mrs. Bell and calls the doctor. The facility then updates the daughter.
Quick review
Start the chain
Let's review. The facility must quickly consult the doctor and notify the representative about injuries and significant changes. Your fast report starts that chain. Learn and practice your facility's reporting tool. At handoff, pass on changes, reports, and the plan, and make sure the next person accepts it. Listen to visitors and other staff, and pass their concerns to the nurse.
Your facility's policy (ask your supervisor):
Your change-in-condition form or card and where it is kept
Who notifies the doctor and family, and how aides pass on family requests
Lesson 10: Reporting From the Home: Home Health and Hospice
For: Home health, Hospice
In this lesson you will:
Report changes to the agency during the visit.
Know when to call 911, and follow the hospice plan of care for who to call.
Listen to the patient and family and report what they say.
In the home
Plan ahead
In the home, you may be the only staff member there. Federal rules say home health aides must report changes in a patient's condition to a registered nurse or other skilled professional. Hospice aides must report changes to a registered nurse. Aide training covers recognizing emergencies and what to do. Before your first visit, save your agency's phone numbers, including after hours.
Call the agency
During the visit
When you notice a change, call your agency during the visit. Don't wait for the nurse's next visit, or for the end of your day. Use SBAR: who you are, who the patient is, what changed, how they were before, your concern, and what you need. Then write it in your visit note. Home health entries must be dated, timed, and signed.
Call 911
Home health
Some signs need 911 first, then a call to your agency. Call 911 for stroke signs, like a drooping face, a weak arm, or slurred speech. Call 911 for heart attack signs, even if you are not sure. Call 911 for sudden, severe trouble breathing, or if someone stops breathing. Call 911 if the person is not responding. Stay with the patient until help comes.
Show the answer
From the plan of care and your hospice nurse's instructions. Hospice aides give care as ordered in the plan of care. Ask before you need it.
Hospice
Follow the plan
Hospice care focuses on comfort. MedlinePlus says a do-not-resuscitate order may be part of a hospice care plan. Hospice aides give the care the hospice team ordered in the plan of care, and the hospice record includes any advance directives. So learn the plan for each patient. Know when your hospice wants you to call the hospice, and when to call 911. Ask your nurse before you need it.
Expected changes
Still report
Near the end of life, some changes are expected. NIA says loss of appetite is common and normal near death. Breathing may change, with pauses or noisy breaths. Hands and feet may feel cool or look bluish. Even so, tell the hospice nurse what you see. NIA says to tell the team if pain is not controlled. Signs of pain include trouble sleeping, restlessness, and crying.
Listen
Patient and family
Family members see the patient every day. AHRQ says visitors and family are important observers. When a family member says something has changed, ask what is different and when it started. Home health aide training covers reporting clinical information to patients, families, caregivers, and staff. In your report and your note, use their words and say who said it.
No answer?
Keep trying
If you can't reach the nurse, don't give up. Call the agency's backup or after-hours number. Follow your agency's steps. If the patient is in danger and you can't reach anyone, call 911 as your agency's policy says. Don't leave a patient alone who is not safe. Tell your agency what happened as soon as you can.
On your shift
A home call
You arrive at Mr. Gray's home. His wife says, 'He hasn't eaten since yesterday, and he's sleeping all the time.' He wakes up but doesn't know what day it is. That's new for him. You call the agency nurse: 'This is Rosa, the aide at Mr. Gray's. His wife says he hasn't eaten since yesterday. He's very sleepy and confused. That's new. Can you come today?'
Quick review
Call, then chart
Let's review. In the home, report changes to your nurse during the visit. Use SBAR, then chart it. In home health, call 911 for emergencies, then call your agency. In hospice, follow each patient's plan for who to call. Expected changes still get reported. Listen to the family, and use their words. If you can't reach anyone, keep trying and follow your agency's steps.
Your facility's policy (ask your supervisor):
Agency daytime, after-hours and backup phone numbers
Your hospice's exact instructions on when to call the hospice and when to call 911
Answer every question. You need 80% to pass. You can try again as many times as you like.
Your quiz covers the lessons for: Nursing home ( questions). Change your setting
Please read
This free course gives you a certificate of completion from Pact Compliance. It is not continuing education (CE) credit and is not approved by any state.
Your employer decides whether it counts toward required in-service hours. Home health and hospice aide training must be given or supervised by the agency's registered nurse.
California: it does not count toward CNA or HHA renewal hours.
Your name and quiz answers stay in your browser and are never sent to Pact.
Pact Compliance LLC, Cordova, TN
Certificate of Completion
This certifies that
completed the online in-service course
Observe, Document and Report Changes in Condition
Setting
Completed
Seat time
Quiz score
Certificate ID
This free course gives you a certificate of completion from Pact Compliance. It is not continuing education (CE) credit and is not approved by any state. Your employer decides whether it counts toward required in-service hours. Home health and hospice aide training must be given or supervised by the agency's registered nurse. California: it does not count toward CNA or HHA renewal hours.
Part of this topic needs a hands-on check with your supervisor; this online course does not cover that part.
Pact does not keep a record of this certificate. Print it or save it as a PDF and give a copy to your supervisor. pactcompliance.com/free-training/change-in-condition-reporting/
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