What is the capability observation for?

It records what a resident can still do in everyday situations — finding their way, everyday gestures, reading and writing, understanding, social interactions — and, for each situation, the action or alternative that would let them do it anyway.

Is the capability observation an assessment of dependency?

No. It observes preserved capacities; it does not replace the dependency assessment.

Where do I open a capability observation?

In Nursing Care → Care → Observations → Capability Observations, from the + button of the care dashboard, from the multidisciplinary meeting, or on the care app with the Capacities button of the resident.

How does an observation reach the care plan?

From a situation where an alternative is written, click Make it an objective or Add to the care plan. The synthesis then lists each alternative and what became of it.

Can several people fill the same observation?

Yes. Each situation keeps its own observer and date; the observation lists every observer and is closed by the observer in charge.

When is the next observation due?

Closing an observation proposes the next one a year later. The team can set an earlier date. Once that date has passed, the observation is to renew and comes up in the multidisciplinary meeting.

Capability observation (Potentia)¶

The capability observation looks at what a person still can do, rather than at what they can no longer do. It is filled situation by situation, by several members of the team over days or weeks, then closed with a synthesis. Its real purpose is the last column of the grid: the actions or alternatives that become objectives of the care plan.

The application is optional: an establishment that does not install it sees neither its menu nor its line in the multidisciplinary meeting.

In Belgium

The grid delivered is Potentia, the observation grid proposed by the AViQ and the CARD to Walloon nursing homes. It is a recommendation, not a duty, and it does not replace the Katz scale. The observation opened on entry into an adapted unit, and its place on the meeting’s agenda after the first month, follow the Walloon standards for adapted units (Annexe 120).

The grid¶

The grid delivered covers seven domains: spatial cues, temporal cues, everyday gestures, reading, writing, understanding and social interactions. For each situation the observer chooses how the person came through it:

Independent;
With help;
By the observer.

What each level means is written for each domain (“finds the way alone”, “reads alone”…) and shown next to the choice. Some situations are only noted, never graded; for some, the observer writes the question they asked.

Administrators read the grids in Nursing Care → Configuration → Observation Grids: domains, situations, the meaning of the three levels and the category an objective made from a domain gets. Add your own situations rather than changing those of the grid.

1. Open an observation¶

Open Nursing Care → Care → Observations → Capability Observations and click New, or use Capability observation on the + button of the care dashboard, where a Capacities (Potentia) tile also sits in the follow-up.

Fill in Who and why:

Resident and Grid;
Reason — Admission or entry into the unit, Periodic observation, After an event (a fall, a hospital stay, a change noticed), Asked by the multidisciplinary meeting or Other, with a Reason detail;
under When and by whom, the Opened on date and the Observer in charge, who closes it.

Mother tongue and Other languages spoken help read the understanding domain; they are taken over from the previous observation.

Only one observation per resident and grid can be in progress.

Tip

When a resident moves into a sector marked Adapted Unit (on admission or from another wing), WideCare opens an empty observation on its own, with the reason Admission or entry into the unit, unless one is in progress or the last one is still current. The team fills it during the first month.

2. Document the situations¶

Click Next situation: the first situation still to document opens.
Read the instruction and the caution of the grid.
Under How did the person come through it?, choose the level.
Write the Observation notes and, above all, the Actions or alternatives: what would let the person do it anyway.
Click Save and next.

Each situation records its own Observer and Observed on date. The Situations tab lists them all with their level and state (To document / Documented); the Progress block counts the situations documented and the alternatives written. Add a situation adds one of the resident’s own, beside those of the grid.

3. Turn the alternatives into care¶

From a situation with an alternative:

Make it an objective — opens a care plan objective already filled in (the situation, the category of the domain, the notes, the alternative as the intervention), on the resident’s current care plan, or on a draft plan opened for the purpose;
Add to the care plan — adds a care line carrying the alternative.

The objective keeps a link to the situation it comes from. The Objectives and Care lines buttons at the top of the observation open what was made of it. See Care plans.

4. Close with the synthesis¶

Click Close with its synthesis. At least one situation must be documented. The Synthesis tab — also posted in the history — sums up each domain, lists every alternative and what became of it (objective, care line, or not on the care plan yet) and compares the result with the previous observation (more autonomous, less autonomous, unchanged). The Next observation is proposed a year later; set it earlier if needed.

Print the grid prints the observation laid out as the official grid, with its synthesis and the comparison.
Cancel stops an observation in progress; what was written stays readable.
Reopen (head nurse) reopens a closed observation. A closed observation is part of the clinical record and cannot be deleted.

The multidisciplinary meeting¶

Each resident reviewed in the multidisciplinary meeting gets a line Capacities (observation grid): never observed, in progress (with Continue), closed with the next date, or to renew when that date has passed. New observation opens one with the reason Asked by the multidisciplinary meeting.

The meeting’s agenda also brings up, on its own:

an observation whose next date has passed;
an observation left open for more than 45 days;
a resident of a sector marked Adapted Unit with no observation one month after entering it.

On the care app¶

When the care app is used, the resident’s sheet has a Capacities button (for the roles allowed to read the observations):

with no observation in progress, it shows the last one and Start an observation (choose the reason);
otherwise, the observation in progress domain by domain, with the filter To document / All; tap a situation, choose the level, write the notes and the alternative, then Save.

What is recorded at the bedside works without a connection and is sent when it comes back. Closing the observation, with its synthesis, is done at the desk.