Medical & Health Services

Best practices for monitoring health, coordinating care, communicating with physicians, and maintaining documentation for individuals receiving HCBS services.

Monitoring Health Changes

Direct Support Professionals are often the first to observe a change in an individual's health. Early recognition and prompt response can prevent minor issues from becoming serious medical events.

Health changes that should be documented and reported include:

• Changes in appetite, eating habits, or unexplained weight loss or gain
• New or worsening pain — location, intensity, and frequency
• Changes in behavior, mood, or cognitive function that are out of character
• Skin integrity issues — new wounds, redness, bruising, or pressure injuries
• Changes in sleep patterns or energy levels
• Bowel or bladder changes — frequency, consistency, or incontinence
• Respiratory changes — shortness of breath, coughing, wheezing
• Any fall, near-fall, or change in balance or mobility
• Signs of infection — fever, redness, swelling, unusual discharge

Communicating with Physicians

Know the physician contacts: 

Every individual's support plan should include primary care physician information,    specialist contacts, and emergency contact procedures.

Use the SBAR framework: 

Situation — Briefly describe what changed. Background — Relevant history and context. Assessment — What you think is happening. Recommendation — What you are requesting (appointment, advice, prescription review).

Document every communication: 

Log the date, time, who you spoke with, what was communicated, and what the outcome or follow-up instruction was.

Respect individual rights: 

Individuals have the right to participate in their own healthcare decisions. Never communicate with a physician on someone's behalf without their knowledge and consent.

Follow up on instructions: 

When a physician provides instructions, document and act on them promptly. Log follow-through.

Documentation Expectations

In Colorado HCBS settings, if it isn't documented, it didn't happen. Health-related documentation must be accurate, timely, and objective.

Daily Notes: Record relevant health observations in daily service notes — not just incidents, but general status and any deviations from baseline.

Health Logs: Maintain any required health monitoring logs (blood pressure, blood glucose, seizure logs, weight tracking) as specified in the support plan.

Appointment Records: Document when appointments occur, who attended, the physician's findings, and any instructions given.

Refusal of Care: If an individual refuses medical care, document the refusal factually, notify your supervisor, and follow agency protocol.

Emergency Response: After any medical emergency, complete an incident report and document the sequence of events, response taken, and outcome.

Corrections: Never erase or backdate documentation. Corrections should be made with a single line through the error, initialed and dated, with the corrected entry added.

Health and Safety Monitoring

• Conduct and document regular health and safety checks as specified in the support plan
• Ensure the home environment is free of hazards — clutter, unsafe flooring, unsecured chemicals or medications
• Know and follow emergency procedures for each individual's specific health conditions
• Maintain emergency contact lists that are current and accessible
• Follow infection control practices — handwashing, PPE when appropriate, food safety
• Review and follow all physician orders related to physical activity, diet, positioning, and mobility

Coordinating Care

Case Manager Communication: Keep the case manager informed of significant health changes, hospitalizations, and any events that may affect the service plan.

Family and Guardian Updates: Notify authorized family members or guardians as specified in the support plan, especially for medical events.

Therapy Integration: If an individual receives physical, occupational, or speech therapy, follow therapist recommendations within daily support activities.

Hospital Transitions: When an individual is hospitalized, coordinate with the hospital team and ensure continuity of support plan information at discharge.

Best Practices

• Review the support plan at the start of each service period — know the individual's current health status and any active physician orders
• Never provide medical advice or diagnose — your role is to observe, document, and report
• Treat each individual as the expert on their own body and preferences
• When uncertain about a health concern, always err on the side of caution and contact your supervisor
• · Maintain confidentiality — health information is protected and should only be shared with authorized individuals
• · Complete required training on health monitoring topics specific to the individuals you support

Need Help? Contact Extended Care Services Education

Extended Care Services Education offers consulting, staff training, mock audits, and compliance support tailored for Colorado HCBS providers.

📞 720-532-0907 · info@extendedcareservices.com · extendedcareservices.com