Care documentation
CareHere you keep the care diary per client – each entry chronologically records what was observed and done during the shift.
What you do here
Use „New entry“ to document an observation or measure: pick the client, the category (e.g. vitals, care, mobility, nutrition, mood, incident) and the shift (early, late or night) and write your note. The timeline shows the course chronologically, the list lets you filter and search all entries.
Tips
Document promptly and factually – the „Incident“ category highlights critical entries in red. Carers may amend their own entries afterwards, even without full management rights. Filter by client and category to prepare a handover quickly.
Legal requirements
The care documentation fulfils the documentation and proof-of-service duty under SGB XI §113. For each entry, record which service was provided – use „Service code“ and „Duration (minutes)“ – and have the care recipient confirm the proof via „Confirmed by recipient“ together with the confirmation time. For MDK audit-readiness every entry must be traceable: who wrote it and who last changed it is logged automatically, so amendments stay identifiable. Do not delete or overwrite existing entries – amend instead. Care documentation must be retained for ten years; the „Retain until“ field records the deadline per entry.
Data protection
Care entries contain health data and thus special categories of personal data under Art. 9 GDPR. They are subject to heightened protection: collect and document only what is necessary for care, phrase it factually and share entries only with authorised persons. Access is governed by the permission matrix; a per-carer restricted read access will be added separately. The ten-year retention period is at the same time the deletion limit – once it expires the data must be deleted or anonymised.
What you can do here
- ✓Care entries
- ✓Timeline
- ✓Care entry
- ✓New entry
- ✓Edit
- ✓Delete
- ✓Set category
- ✓Set shift
Live preview — real view with sample data