SeizureSafe™ Documentation
Module 3: Document – How to Record and Report What Matters
In long-term care, the phrase “if it’s not documented, it didn’t happen” isn’t just a cliché; it’s a policy, a liability protection, and a clinical continuity all in one. After a seizure or suspected seizure, your documentation becomes the official record. Clear, accurate notes guide clinical decisions, prevent repeat events, and protect the facility and staff during audits, surveys, or legal reviews.
This module teaches you how to document seizure-related events with precision, using simple, direct language that ensures your observations are both useful and defensible.
Lesson 3.1: Why Documentation Matters
Why Documentation Matters
Seizure-related events are among the most under-documented incidents in residents with dementia. Without accurate notes, clinical teams may miss patterns that could prevent harm.
Why Is This a Problem?
- Unclear Notes Lead to Inaction: “Resident seemed tired” = no follow-up. “Resident stared unresponsive 25 seconds, head droop, confusion” = clinical review.
- No Record = No Clinical Review: If an event isn’t documented, clinical teams may never be aware of it.
- Poor Documentation = Compliance Risk: SNFs risk F-tag citations; ALFs risk survey deficiencies and reputational damage.
- Legal and Family Review: Families and lawyers review notes. Missing or vague entries increase legal exposure.
Why Your Role Matters
As direct care staff, your notes tell the story. You don’t need medical jargon, but you must describe exactly what you saw in clear, factual terms.
What you’ll learn:
- What to write and how to structure it.
- How to describe observations clearly and objectively.
- What language to avoid (e.g., assumptions or diagnoses).
- How to ensure others take the next step based on your notes.
Done well, documentation protects residents, staff, and the community.
Lesson 3.2: How to Document What You Saw
What You Should Document
- Time and Duration: Record when the episode began and how long it lasted (estimate if exact timing isn’t possible).
- Resident Behavior During the Event: Describe specific behaviors – staring, jerking, unresponsiveness, or repetitive motion.
- Responsiveness: Note whether the resident was able to speak, follow commands, or respond to verbal cues.
- Staff Actions: Record what you did during the event (e.g., moved hazards, called for help, supported recovery).
- Resident Condition After the Event: Document observations such as confusion, fatigue, or unusual silence.
- Notifications Made: Note who you informed (nurse, supervisor, or family) and the time of notification.
Sample Language
“At 10:35 AM, the resident became unresponsive during dressing. Blank stare lasted about 25 seconds, no verbal response. Appeared confused and tired afterward. Charge nurse notified at 10:40 AM.”
Language to Avoid
- “Weird episode”
- “Acted out again”
- “Probably sundowning”
- “Had a seizure” (unless told by the clinical team)
Instead, describe:
“Unresponsive for approximately 30 seconds, eyes fixed, no verbal response, appeared confused afterward.”
Closing the Loop
- Confirm if the care plan was updated based on your note.
- Ensure a provider or family member was notified if required.
- Follow up to see if the event was reviewed by clinical staff.
Even if you are not in a leadership role, your documentation initiates the chain of care. See the Seizure Response and Seizure Documentation modules for related steps and examples.
Lesson 3.3: Closing the Loop: What Happens After You Document
What Should Happen After Documentation
Your note is the starting point for follow-up care and risk prevention. Once documentation is complete, the following steps typically occur:
- Clinical review by nursing or medical staff
- Care plan updates to reflect any changes in risk or needs
- Family notification if required by policy
- Handoff to the next shift with clear, factual reporting
- QAPI or incident log review for tracking and quality improvement
What You Can Do to Close the Loop
- Verbally report the event at shift change to ensure nothing is missed
- Ask if the care plan was updated based on your observation
- Confirm that the event is tracked in the incident log.
- Notify a supervisor if the resident experiences a similar episode later
For Communities Using QAPI or Incident Logs
Ask yourself:
- Would someone understand this note three months from now?
- Does it clearly show what happened, what actions were taken, and what follow-up is needed?
Protecting Residents and Staff
Most seizures go unrecognized, not due to lack of care, but because signs are subtle and training is limited. Accurate documentation ensures patterns are caught early, protecting residents from harm and staff from liability or survey deficiencies.
Your Role
Your documentation transforms an observed risk into a controlled, actionable response.
Module 3 Wrap-Up: Documenting Suspected Seizure Activity
What You Learned
- Why seizure documentation is often incomplete or unclear
- What to include in your note for accuracy and clarity
- How to describe observations without making assumptions
- How clear notes drive follow-up and prevent repeat events
- Why your notes matter to clinical teams, families, surveyors, and legal teams
Key Takeaway
You’re not just writing a note—you’re building the official record. What you document may determine whether the resident receives a clinical review or whether the risk is missed until it happens again.
- Good documentation protects residents.
- Clear documentation protects staff.
- Strong documentation protects the organization.
Next Steps
- Review sample case notes in the Case Examples section.
- Download the Seizure Documentation Checklist from the Downloads section.
- Revisit Seizure Response if you need a refresher on post-event reporting.
- Return to Hub Landing Page