Why documentation matters

Documentation is what bridges the gap between what you experience at home every day and what the CLSC assessor learns in a single 90-minute visit. Specific, organized evidence supports a more accurate evaluation and a stronger care plan.

You do not need all of the items below. Gather what is relevant and available. Even partial documentation is better than none.

Core documents

• Current medication list — all medications, dosages, and who manages them (see Medication Lists article)
• Recent hospital discharge summaries — from any hospitalization in the past 12–24 months
• Family doctor letter or note — confirming diagnosis, functional limitations, or need for increased care
• Specialist reports — neurologist, cardiologist, physiatrist, psychiatrist, or other relevant specialists
• Occupational therapy assessment report — if an OT evaluation has been done
• Physiotherapy assessment or discharge report
• Previous CLSC care plan — to compare with current needs

Functional documentation

• Falls record — dates, location, circumstances, injuries (even informal)
• Caregiver journal — dated observations of daily challenges (see Caregiver Journal article)
• Written description of functional changes — specific tasks the person now struggles with or can no longer do
• Near-miss log — situations that were unsafe but didn't result in injury

Caregiver documentation

• Brief written account of caregiver hours and tasks — how many hours per week, what you do
• Description of any change in caregiver situation — illness, returning to work, no longer available

Supporting context

• List of current CLSC services — what has been approved and what is actually happening
• Contact information for the care coordinator
• Date of the last formal assessment

How to organize it

A simple file folder (paper or digital) with tabbed sections works well. You do not need a binder with colour-coded dividers. The goal is to be able to find what you need quickly during the visit.

Before the assessment, review what you have and identify the one or two most important pieces of evidence. Lead with those in your conversation.

What should I gather next?

Each article in this Documentation section walks through one item on this checklist in detail. Start with the items most relevant to your situation.