Healthcare English 4 — Reporting & Documentation Vocabulary BE

The language of care documentation — accurate reporting protects residents, protects staff, and keeps the whole team informed.

Vocabulary in context

In care work, if it isn't documented, it didn't happen. Accurate, clear reporting is a professional and legal requirement, and the vocabulary of documentation is something every care worker needs to own confidently. This exercise covers the key terms used in care records, handover notes, and incident reporting.

Ready to practice! Let's go!

Fill in each blank with the correct word from the list:

accurate
body map
confidential
deterioration
fluid balance chart
legible
next of kin
observe
referral
safeguarding

1. All care records must be — never guess or approximate when documenting observations.

2. Document any skin marks or bruises on the at the start of every shift.

3. If you notice any in a resident's condition, report it to the nurse immediately.

4. Please keep all resident information strictly — do not discuss it in public areas.

5. Record every drink the resident takes on the to monitor their daily fluid intake.

6. Ensure all written entries are — if it can't be read, it may as well not exist.

7. Contact the if there is a significant change in the resident's health or wellbeing.

8. A to the GP was made after the resident reported persistent chest pain.

9. Any concern about a resident's safety must be raised immediately under the policy.

10. Continue to closely the resident and record any changes every 15 minutes.