> ## Documentation Index
> Fetch the complete documentation index at: https://docs.bizaxl.com/llms.txt
> Use this file to discover all available pages before exploring further.
# Patient Monitoring and Observations
> How to record structured observations during home visits - wound photos, dressing status, feeding ability, and mobility level - to track patient progress over time.
Observations are structured checks recorded during each home visit. Unlike free-text notes, observations use a defined format (a photo, a yes/no answer, or a selection from a fixed list). This structured format makes it possible to track how a patient is doing over time - is the wound healing? Is the patient becoming more mobile? Are they eating on their own?
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## The Four Observation Templates
The system has four pre-configured observation templates for home care. Each captures a specific aspect of the patient's condition.
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### 1. Wound Photo
| Detail | Value |
| ------------------ | ------------------------------------------------- |
| What it captures | A photo of the wound |
| How it is recorded | Attach an image file (taken on a phone or tablet) |
| When to use it | At every wound dressing visit |
The wound photo is the most powerful monitoring tool for wound care patients. A photograph taken before and after each dressing change creates a visual timeline of healing. The care team and the supervising doctor can look back through the photo history to see whether the wound is getting smaller, cleaner, and healing well - or whether it is getting worse and needs a different treatment approach.
**Best practice:** Take the photo before removing the old dressing (to show the wound environment) and again after the new dressing is applied (to confirm a clean, well-applied dressing). Attach both to the same observation record.
***
### 2. Dressing Changed
| Detail | Value |
| ------------------ | ---------------------------------------------- |
| What it captures | Whether the dressing was changed at this visit |
| How it is recorded | Yes or No |
| When to use it | At every wound dressing visit |
Sometimes the nurse arrives and the dressing does not need to be changed yet (the wound is clean and the previous dressing is intact). Recording this as "No" is just as important as recording "Yes" - it shows the team that the nurse did assess the wound and made a clinical decision about the dressing.
***
### 3. Feeding Ability
| Detail | Value |
| ------------------ | --------------------------------------------------------------------------------------- |
| What it captures | How the patient is eating |
| How it is recorded | Select one: Self Feeding / Assisted Feeding / Tube Feeding |
| When to use it | At visits for patients with eating difficulties, elderly patients, post-stroke patients |
| Option | What It Means |
| ---------------- | ------------------------------------------------------------------------------------------- |
| Self Feeding | Patient can eat and drink on their own without any help |
| Assisted Feeding | Patient needs someone to help - cutting food, feeding them with a spoon, guiding their hand |
| Tube Feeding | Patient cannot eat by mouth and is being fed through a nasogastric or PEG tube |
A change in this observation is clinically significant. If a patient who was self-feeding at the last visit is now needing assistance, the nurse should report this to the supervising doctor.
***
### 4. Mobility Level
| Detail | Value |
| ------------------ | ------------------------------------------------------ |
| What it captures | How well the patient can move around |
| How it is recorded | Select one: Independent / Needs Assistance / Bedridden |
| When to use it | At every visit for patients with mobility concerns |
| Option | What It Means |
| ---------------- | --------------------------------------------------------------------------------------------------- |
| Independent | Patient can stand, walk, and move around the home without any help |
| Needs Assistance | Patient can move but needs someone to hold their arm, use a walker, or help them get out of a chair |
| Bedridden | Patient cannot get out of bed without full support; they spend most of their day in bed |
A patient who was walking with assistance at the last visit and is now bedridden is a concern that needs to be reported immediately. Declining mobility often signals a worsening of the underlying condition.
***
## How to Record an Observation
During a home visit:
1. Go to Home Care workspace → Orders section → **Observation** → New
2. Fill in the details:
| Field | What to Enter |
| -------------------- | -------------------------------------------------------------------------------------------------- |
| Patient | The patient you are visiting |
| Observation Template | Select the type of observation (Wound Photo, Dressing Changed, Feeding Ability, or Mobility Level) |
| Practitioner | Your name (auto-fills) |
| Service Request | Link to the relevant service request if this observation was ordered by the doctor |
| Date | Today's date |
3. Enter the value based on the observation type:
* For **Wound Photo**: Click the attach button and upload the photo from your phone or tablet
* For **Dressing Changed**: Select Yes or No
* For **Feeding Ability**: Select Self Feeding, Assisted Feeding, or Tube Feeding
* For **Mobility Level**: Select Independent, Needs Assistance, or Bedridden
4. Add any extra notes in the free-text notes field if something unusual was observed.
5. Click **Submit**.
The observation is now part of the patient's permanent record and appears in their history timeline.
***
## Viewing a Patient's Observation History
To see how a patient's condition has changed over time:
1. Go to the **Patient History** (Healthcare workspace → Records and History → Patient History)
2. Search for the patient
3. Look for Observation records in the timeline
4. Compare the same observation type across different dates
For example, to track wound healing:
* Find all "Wound Photo" observations
* Open each one and view the photo
* Compare photos from week 1, week 2, week 3, and week 4
This visual comparison is far more informative than written descriptions alone.
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## Compiling a Diagnostic Report
If the doctor wants to compile multiple observations into a formal report (for example, to send to the patient's GP or hospital), they can create a Diagnostic Report:
1. Go to Home Care workspace → Orders section → **Diagnostic Report** → New
2. Link to the patient
3. Add the relevant Observations to the report
4. Write an overall summary or impression
5. Submit the report
The Diagnostic Report can be printed and sent to the referring doctor or shared with the patient through the portal.
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## Field Guide: Observation
| Field | What It Contains |
| -------------------- | ---------------------------------------------------------------------------------------- |
| Patient | The patient being observed |
| Observation Template | The type of observation (Wound Photo, Dressing Changed, Feeding Ability, Mobility Level) |
| Practitioner | Who recorded the observation |
| Service Request | The order that prompted this observation (if applicable) |
| Date | When the observation was recorded |
| Value | The recorded data (photo, yes/no, or selection) |
| Notes | Additional free-text details |
| Status | Draft → Submitted |
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## Best Practices
* Record observations at every relevant visit, not just when something has changed - a "no change" observation is still important information because it shows the team that the nurse looked and assessed the situation
* For wound patients, always photograph the wound before removing the dressing, not just after - the state of the old dressing (soaked through, clean, stuck to the wound) tells the doctor important information about the wound's behaviour
* When recording Mobility Level or Feeding Ability, also add a note if you noticed anything that influenced the reading (e.g., "Mobility Level: Needs Assistance - patient says right knee is more painful today than last week")
* Never alter an observation after submission - if you recorded the wrong value, add a new observation with the correct value and a note explaining the correction
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## Troubleshooting
**I cannot attach a photo to the Wound Photo observation**
Make sure you are using a device with a camera or file access. The system supports image file uploads (JPG, PNG). If the file size is very large, reduce the photo resolution before uploading.
**The observation is not appearing in the patient's history**
Check that the observation has been submitted. Draft observations do not appear in the history timeline.
**I recorded the wrong mobility level for a patient**
Do not try to edit a submitted observation. Instead, create a new observation with the correct value and add a note: "Correction to \[date] observation - correct Mobility Level is \[value]."
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## Related Features
* [Nursing Care](/health-wellness/homecare-services/nursing-care): Wound photo observations are typically taken alongside wound dressing procedures
* [Home Visit Record](/health-wellness/homecare-services/home-visit): Observations are linked to the visit encounter
* [Laboratory](/health-wellness/homecare-services/laboratory): Blood test results are a separate type of monitoring data