Signs and Symptoms of Illness or Injury

Outcomes

• Identify changes that may be signs and symptoms of illness or injury.

• Know when to call 911, the doctor, or to provide treatment at home.

• Know how to document signs and symptoms and your response.

Key Words:

• Medical Emergency: An unexpected illness or injury that is life threatening.

• Routine Treatment: Providing first aid or following the doctor’s orders for the signs or symptoms of illness that were reported.

• Signs and Symptoms: Possible disease, illness, or injury which has been seen (sign) by the DSP or reported by the individual (symptom).

• Urgent Call to Doctor: An urgent call to the doctor to report possible serious signs or symptoms of illness or injury.

• Descriptive Documentation: Tells what you actually see, hear, or physically feel. (For example, you may feel that the person is warm when you touch them, you may feel a lump.)

Recognizing Changes

This training will help you recognize when an individual may be ill. All of the individuals you work with will have different ability levels. You must learn how each person communicates how they are feeling. You have many opportunities throughout the day to identify changes that may be signs of illness or injury. Get to know the person and learn as much as possible about them. By spending time with the person you will learn what is usual for that individual. You will learn what is normal for each person by observing daily routines, behavior, ways of communicating, appearance, general manner or mood, and overall physical health. You should review each individual’s information sheet to learn about known medical and health conditions, health history, allergies, likes, and dislikes. As you learn about each person make sure you use all your senses: sight, hearing, touch, and smell. You may see a physical change, such as a tear streaked face, redness or swelling of the skin, or cloudy urine. You may hear labored or noisy breathing, crying, moaning, coughing or screaming. You may feel hot, moist, or cool skin. You may smell an unusual or unpleasant odor coming from an individual’s mouth, body or body fluids. If the individual is unable to use words to tell you what is wrong, it is important to ask questions and watch for facial expressions, and body language. You must “hear” both words and behaviors to determine what the person is telling you.

What to do when you learn about a change

Once you have identified a change you must make a decision on what action you should take. Making the right decision involves using all of your knowledge about the person, and his or her health history, current medications, and doctors’ orders. Signs and symptoms of illness will have different levels of response, which include the following:

Levels of Emergency Response:

• 911 Call: Medical emergencies that require immediate medical attention.

• Urgent Call to Doctor: Potentially serious signs or symptoms that require an urgent report to the individual’s doctor.

• Routine Treatment: Signs or symptoms that are addressed by simple First Aid or written doctor’s orders.

A 911 call involves medical emergencies that require immediate medical attention.

o If you think you need to call 911, do it!

o Don’t call someone to ask if you should.

o If you have any question in your mind, make the call. 

Timeliness in recognizing signs and symptoms that require emergency medical treatment can be the difference between life and death.

Reporting and Documentations 

Reporting and Documenting Changes

Regardless of what action you, as the DSP take, you must report (tell it) and document (write about it) in some way. Medical emergencies must be:

(1) Documented in the individual’s record and

(2) Documented on an incident report form.

Any call to the doctor must be documented in the individual’s record and may require an incident report. Any treatment provided in accordance with a written doctor’s order or simple First Aid must also be documented in the individual’s record. 

**Refer to AFC administrative rules [400.14311 (1-7)] for Investigation and reporting of incidents, accidents, illnesses, absences, and death**

Sometimes the correct response is simply to document the change that you have identified. This is important as over time, you and other DSPs may identify a pattern or trend and provide valuable information in the diagnosing of a health problem. For example, through continuous documentation of your observations, you may discover that an individual is losing interest in activities, which may be a sign or symptom of illness or injury. Many changes occur slowly over time and will only be identified if you and other DSPs consistently document and share observations. You may be reporting changes (or signs and symptoms) to a number of different people, including a doctor, dentist, support services coordinator, behavior specialist, and your supervisor. All of these contacts must be documented.

Remember that signs and symptoms may be an indication of possible abuse or neglect that you are mandated to report to the Recipient Rights office. Always report and document changes as soon as possible. Some types of documentation, such as an incident report, have timelines that must be followed. For example, an incident report must be completed within 24 hours.

Here are some guidelines to follow when reporting and documenting changes that may be signs or symptoms of illness or injury:

1. Write down what the individual said or did to communicate the change: 

   • For example, Bill said, “My stomach hurts,” or “Fred walked up to me and pointed to his stomach, frowning and moaning.” 

     • Do not try to make a diagnosis. The DSP is not a health care professional!

2. Describe identified changes only. Do not document your personal opinion: 

   • For example, “Bill said his arm hurt, but I don’t think there is anything really wrong.” 

     • This type of documentation is called “evaluative”.

3. Be specific when reporting and documenting observed changes: 

   • For example, “I heard Jane screaming. She was sitting on the couch in the living room. The screaming lasted for about two minutes.”

4. When reporting and documenting answers to questions, report and document both the question and the response: 

   • For example, “Bill told me my stomach hurts.” I asked him, ‘how long has it hurt?’ Bill said, ‘Since breakfast, and it really hurts bad.’

5. In the case where an individual does not verbally respond, the DSP should report and document the individual’s response: 

   • For example, “I heard Jane screaming. When I asked Jane, ‘What’s wrong?’ she put her hands on her head and began rocking.”

Now that you have completed the Signs and Symptoms module, please proceed to take the test. To successfully complete the course, you must achieve a passing score of 80% or higher.