Health and Wellbeing Documentation in Disability Support: Holistic Care

Health as a Foundation for Wellbeing

Participants' ability to achieve their goals depends partly on their health — both physical and mental. Documentation should track health status and how it affects goal progress.

Physical Health Documentation

Document ongoing health observations:

• Chronic conditions: Diabetes, asthma, hypertension — how are they controlled? Any changes?
• Pain and discomfort: Does the participant report pain? Where? How does it affect activity?
• Medication: Are they taking medications as prescribed? Any side effects?
• Appointments: Are health appointments attended? What did healthcare providers recommend?
• Preventive care: Dental visits, eye exams, vaccinations — are they up to date?
• Lifestyle factors: Sleep, nutrition, exercise — how do these affect wellbeing?

Recognizing Health Changes

Document any changes that might indicate health problems:

• Changes in appetite, sleep, energy, or mood
• New pain or discomfort
• Changes in mobility or function
• Increased toileting frequency
• Confusion or concentration difficulties
• Changes in behavior (withdrawal, agitation, unusual requests)

Example: "Jake has been more withdrawn this week. Sleeping longer. Less interested in activities he normally enjoys. Asked about his arm pain assessment — he said his shoulder hurts. Will contact GP to check. Health change may be affecting mood."

Coordination With Healthcare Providers

Document health coordination:

• What did the GP/specialist recommend?
• Are you implementing recommendations? How?
• What observations will help the GP understand how the participant is doing?
• Have you shared your concerns or observations with healthcare providers?

This article was written by AccuNote's Health & Wellbeing Team, which helps disability support providers recognize health changes and coordinate with healthcare systems.