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Caregiving Documents & Records (Reading Care Records, Handover Notes, Manuals, and Schedules)

Nursing Care · 介護 - Kaigo · Written by Tokutei Pass based on the official study texts; not copied verbatim.

Role of Caregiving Documents, the 8 Document Types, and Reading Fundamentals

In long-term care facilities, many staff members work in rotating shifts, so user conditions, work rules, and schedules are shared accurately through written documents (records and tables). Reading documents accurately is the foundation of safe caregiving.

The Caregiving Japanese Evaluation Test features 8 types of documents: (1) User's Condition (Riyousha no joukyou), (2) Work Procedures / Manuals (Shigoto no yarikata), (3) Facility Notices / Posters (Keiji / Oshirase), (4) Menu Charts (Kondatehyou), (5) Event Plans (Gyouji no keikaku), (6) Work Schedules (Shigoto no yotei: day/night shifts), (7) Accident Reports (Jiko no houkoku), and (8) Handover Notes & Care Records (Moushiokuri / Kaigo kiroku).

When reading any document, carefully verify: When (date, time, day of the week, daytime or nighttime), Where (location, floor number), Who (user, care worker, nurse, cooking staff, family), and What / How things are done.

Pay special attention to Left vs. Right, Daytime vs. Nighttime, Independent vs. Needs Assistance, exact numbers of participants, and step-by-step order (1 -> 2 -> 3 -> 4), as distractors frequently swap these details.

Key points


  • Exam documents fall into 8 types: User Condition, Work Procedures, Notices, Menu Charts, Event Plans, Work Schedules, Accident Reports, and Handover Notes.

  • Always cross-check Date/Time, Location, Person in Charge, Target User, and Specific Actions word-for-word against the document.

  • Watch out for common distractor traps: swapping Left/Right, Day/Night, Independent/Assisted, and the sequence of steps.
WordMeaning
Caregiving documents (Kaigo no bunsho) and Care records (Kaigo kiroku)
User's condition (Riyousha no joukyou) and Work procedures (Shigoto no yarikata)
Posted notice (Keiji / Oshirase) and Menu chart (Kondatehyou)
Event plan (Gyouji no keikaku) and Work schedule (Shigoto no yotei)
Accident report (Jiko no houkoku) and Shift handover (Moushiokuri)
Confirmation (Kakunin), Observation (Kansatsu), and Watching over (Mimamori)

User's Condition 1: Records of Communication Abilities (Seeing, Hearing, Speaking)

In a User's Condition (Riyousha no joukyou) table, alongside the user's name, age, and care level, communication abilities are listed under three categories: Miru (Seeing / Vision), Kiku (Hearing), and Hanasu (Speaking / Conversation).

Under Seeing (Miru), the record specifies which eye sees well or poorly and when glasses are used—for example: The right eye sees well, but the left eye is hard to see with due to cataracts (Hakunaishou); uses glasses (Megane) when reading the newspaper.

Under Hearing (Kiku), details such as: Hard of hearing in the left ear, but hears well in the right ear, Can hear if spoken to slowly in a slightly loud voice, or Uses a hearing aid (Hochouki) are recorded.

Incorrect choices often reverse the facts—such as stating the right eye sees poorly (when it is the left eye) or that the user cannot hear at all even in a loud voice (when they can hear if spoken to loudly)—so always verify left/right sides and conditions.

Key points


  • Communication tables organize user status into three sections: Miru (Seeing), Kiku (Hearing), and Hanasu (Speaking).

  • For vision and hearing records, accurately read Right (Migi) vs. Left (Hidari) and whether glasses (Megane) or a hearing aid (Hochouki) are used.

  • Distinguish carefully between being able to hear when spoken to loudly versus not being able to hear at all.
WordMeaning
Communication (Seeing Miru, Hearing Kiku, Speaking Hanasu)
Right eye (Migime), Left eye (Hidarime), Hard to see (Mienikui)
Wear glasses (Megane wo kakeru)
Right ear (Migimimi), Left ear (Hidarimimi), Hard to hear (Kikoenikui)
Hearing aid (Hochouki - device that assists hearing)
Speak slowly in a loud voice (Ookii koe de yukkuri hanasu)

User's Condition 2: Records of Mobility, Excretion, Meals, Bathing, and Family Visits

In records of daily living activities, Mobility (Idou), Excretion (Haisetsu), Meals (Shokuji), and Bathing (Nyuuyoku) describe methods by time of day and the level of assistance required. Questions frequently test the difference between daytime (Hiruma) and nighttime (Yakan / Yoru).

For example, an excretion and mobility record may state: During the daytime, goes to the restroom using a walker (or wheelchair), but at night uses a bedside portable toilet; requires slight assistance, has no incontinence (Shikkin wa nai), and eats meals independently.

For users recently discharged from the hospital or with chronic conditions, precautions are noted: Discharged (Taiin) last month; sometimes experiences chest tightness (Mune ga kurushiku naru) during bathing, so assistance and watching over (Kaigo to mimamori) are required when bathing.

In Family and Visitation (Gokazoku to menkai) records, distinguish each family member's situation: The daughter lives nearby but works on weekdays (Heijitsu), so she visits on Saturdays or Sundays; the son lives in a distant prefecture and rarely visits.

User's Condition 2: Records of Mobility, Excretion, Meals, Bathing, and Family Visits

Key points


  • In excretion records, check the difference between daytime (restroom) and nighttime (portable toilet) methods, and whether incontinence (Shikkin) is present.

  • Note health precautions during bathing—such as occasional chest tightness—and the requirement for assistance and watching over (Mimamori).

  • In family visitation (Menkai) records, match each relative (daughter, son) with where they live and which days they visit (weekdays vs. weekends).
WordMeaning
Difference between Daytime (Hiruma / Hiru) and Nighttime (Yakan / Yoru)
Can do independently (Jiritsu) / Requires slight caregiving assistance
No incontinence (Shikkin wa nai)
Hospital discharge (Taiin), Hospitalization (Nyuuin), Chest tightness (Mune ga kurushiku naru)
Requires caregiving assistance and watching over (Kaigo to mimamori ga hitsuyou)
Family (Gokazoku), Visitation (Menkai), Weekdays (Heijitsu) and Saturday / Sunday

Work Procedures (Manuals) 1: Wheelchair Safety and Emergency Fire Procedures

Work Procedures (Shigoto no yarikata) are operational manuals that care workers must follow. In a Wheelchair Safe Usage manual, the first rule is: Before use, check the brakes (Brake) and tires (air pressure).

Next are the rules: Always apply the brakes when the user gets on or off and whenever the wheelchair is stopped, and Always say 'I am going to push the wheelchair now' (Kurumaisu wo oshimasuyo) before moving.

In an Emergency Procedure in Case of Fire (Kaji ga okita baai) document, questions directly test the exact order of actions (1 -> 2 -> 3 -> 4). The correct sequence begins with: (1) Alert people nearby in a loud voice that there is a fire -> (2) Press the emergency alarm bell button (Hijou bell).

Then proceed with: (3) Call 119 on the telephone -> (4) Guide users to a safe location (Anzen na basho ni yuudou suru - never use elevators). When asked to choose the option matching the document's sequence, trace steps 1 through 4 accurately.

Key points


  • The three core rules in a wheelchair manual are: Check brakes and tires before use, Lock brakes when stopped or transferring, and Speak before pushing.

  • The four steps in case of fire are: (1) Shout to alert others nearby -> (2) Press the emergency alarm bell -> (3) Call 119 -> (4) Guide users to a safe place.

  • For sequence questions, carefully check the numbers and arrows (->) to spot options where steps are reversed.
WordMeaning
Check the brakes and tires (Brake to tire wo kakunin suru)
Always apply the brakes when stopped
In case a fire breaks out (Kaji ga okita baai - emergency response)
Alert people nearby in a loud voice (Ookii koe de mawari no hito ni shiraseru)
Press the emergency bell button (Hijou bell) / Call 119 (119-ban)
Guide to a safe location (Anzen na basho ni yuudou suru) / Emergency exit (Hijouguchi)

Work Procedures (Manuals) 2: Manuals for Excretion, Bathing, and Meal Assistance

In an Excretion Assistance Procedure document, the sequence is: (1) Check what the user can do by themselves -> (2) Go to the restroom together -> (3) Confirm the user is seated stably on the toilet seat (Benza) -> (4) Explain the call button -> (5) Wait outside the restroom.

In a Bathing Assistance Precautions document, the rules specify: check physical condition (vital signs) before bathing, have the user use the restroom beforehand, and avoid bathing immediately after a meal (Shokuji no sugu ato no nyuuyoku wa sakeru).

Furthermore, to prevent heat shock caused by sudden temperature changes in winter, warm up the changing room (Datsuishitsu) and bathroom (Yokushitsu) beforehand, and always provide fluid intake (Suibun hokyuu) after bathing to replace fluids lost through sweat.

In a Meal Assistance Procedure document, the care worker sits on a chair at the same eye level as the user, first explains the menu and offers tea or soup to moisten the mouth, and after eating provides oral care (Koukuu care) and has the user rest seated for about 30 minutes.

Key points


  • Toilet assistance sequence: Check what the user can do -> Guide to toilet -> Confirm stable seating -> Explain call button -> Wait outside.

  • Bathing manuals emphasize: Avoid bathing right after meals, Warm the changing room and bathroom, and Rehydrate (Suibun hokyuu) after bathing.

  • Meal manuals emphasize: Sit at eye level to assist, Explain the menu, Perform post-meal oral care, and Maintain a sitting posture for 30 minutes.
WordMeaning
Check what the user can do by themselves
Confirm seating on the toilet seat / Wait outside the restroom
Avoid bathing immediately after a meal
Pay attention to the temperature of the changing room and bathroom
Provide fluid intake after bathing (Nyuuyoku no ato ni suibun hokyuu wo suru)
Sit on a chair at eye level to provide meal assistance

Facility Notices and Posters (Visitation Rules, Food Poisoning Prevention, and Handwashing Steps)

Notices (Keiji / Oshirase) posted at the entrance, hallways, or washbasins communicate rules for visiting families and staff. Read them carefully to identify prohibited actions, applicable locations, and dates.

In notices titled To All Visitors (Menkai no minasama e), common rules include: Smoking is prohibited everywhere in this facility (Doko mo kinen desu) and Mobile phones are prohibited inside the building; please make phone calls outside the building.

In notices titled To All Family Members (Summer Food Poisoning Prevention), specific dates and requests are stated: From June 1 to August 31, to prevent food poisoning (Shokuchuudoku), please do not bring food into the facility, and Please disinfect your hands at the entrance (Genkan).

At washbasins, a How to Wash Hands (Te no araikata) poster shows 6 steps: (1) Wet hands with water -> (2) Apply soap and wash palms (Tenohira) and backs of hands (Tenokou) -> (3) Wash fingertips and under nails (Yubisaki) -> (4) Wash between fingers and wrists (Tekubi) -> (5) Rinse thoroughly with water -> (6) Wipe dry with a paper towel.

Facility Notices and Posters (Visitation Rules, Food Poisoning Prevention, and Handwashing Steps)

Key points


  • In visitor notices, verify rules and locations such as No smoking anywhere on the premises and Use mobile phones outside the building.

  • In food poisoning and infection notices, check the exact period (start and end dates), prohibition on bringing food, and hand disinfection at the entrance.

  • For handwashing posters, follow the exact order of washing palms, backs of hands, fingertips, between fingers, and wrists as written.
WordMeaning
To All Visitors (Menkai no minasama e) / To All Family Members
No smoking anywhere (Doko mo kinen)
Prohibited inside the building (Tatemono no naka dewa shiyou kinshi)
Food poisoning (Shokuchuudoku) / Outbreak of infectious disease (Kansenshou no ryuukou)
Disinfect hands at the main entrance (Genkan de te no shoudoku wo suru)
How to wash hands (Palm Tenohira, Back of hand Tenokou, Fingertips Yubisaki, Wrist Tekubi)

Reading Menu Charts (Kondatehyou) and Event Plans (Birthday Parties, Summer Festivals)

A Menu Chart (Kondatehyou) lists Breakfast (Choushoku), Lunch (Chuushoku), Snack (Oyatsu), and Dinner (Yuushoku) across multiple dates and days of the week. Read the intersection of the vertical column (date/meal) and horizontal row (staple food Shushoku, side dish Fukushoku, soup Shirumono, Dessert).

For example: Tuesday's lunch staple food is beef udon (Niku udon) and dessert is yogurt; Wednesday's dinner side dishes are grilled fish (Yakizakana) and simmered vegetables (Yasai no nimono). Cross-check carefully so you do not confuse days or meals.

An Event Plan (Gyouji no keikaku—such as a Birthday Party Tanjoubikai or Summer Festival Natsumatsuri) table lists Date and Time (Nichiji), Location (Basho: 2nd-floor hall or 3rd-floor hall), Number of Participants (Sankasha), and Preparations / Person in Charge (Junbi / Tantousha).

Carefully distinguish participant numbers by group (e.g., 20 users, 15 family members, 5 care workers, 1 nurse, 1 cook) and who is responsible for each task (e.g., the nurse buys birthday gifts, the cook prepares drinks, and care workers set up the hall and guide users).

Key points


  • On a Menu Chart, always align all three elements: Date/Day of the week, Meal (breakfast/lunch/dinner), and Dish category (staple/side/dessert).

  • On an Event Plan table, accurately read Date/Time, Location (which floor hall), and Participant counts for each group.

  • Under Preparation and Person in Charge (Tantousha), verify what tasks are assigned to Care Workers, Nurses, Cooks, and Users.
WordMeaning
Menu chart (Kondatehyou: Breakfast Choushoku, Lunch Chuushoku, Snack Oyatsu, Dinner Yuushoku)
Staple food (Shushoku), Side dish (Fukushoku), Soup (Shirumono), Dessert
Event plan (Gyouji no keikaku: Birthday party Tanjoubikai, Summer festival Natsumatsuri)
Date and time (Nichiji), Location (Basho: 2nd-floor hall / 3rd-floor hall)
Participants (Sankasha: number of users, family members, and staff)
Preparation and Person in charge (Junbi / Tantousha - role assignment)

Reading Work Schedules (Day Shift Schedule and Night Shift Schedule)

A Work Schedule (Shigoto no yotei) shows a care worker's daily duties in chronological order. Two schedules frequently appear on the exam: Day Shift (Nikkin, e.g., 9:00 to 18:00) and Night Shift (Yakin, e.g., 17:00 to 10:00 the next morning).

On a Day Shift schedule: 9:00 report to work (Shukkin) and morning meeting, 10:00 hydration assistance, 11:30 lunch and medication assistance (Fukuyaku), 13:00 60-minute break (Kyuukei), 14:00 bathing assistance, 16:00 hydration, 17:00 evening meeting, 17:30 writing records (Kiroku), and 18:00 finish work (Taikin).

On a Night Shift schedule: 17:00 report to work, 18:00 dinner/medication assistance and handover (Moushiokuri) from the day shift, 20:00 bedtime care (Shuushin no kaigo: face washing, oral care, changing into sleepwear), and night rounds (Junshi) once every 2 hours starting at 23:00.

The next morning: 6:00 wake-up care (Kishou no kaigo), 8:00 breakfast and medication assistance, 9:00 morning meeting (handover), 9:30 writing records, and 10:00 finish work. Pay attention to what task occurs at what time, break duration in minutes, and patrol frequency.

Key points


  • On a Day Shift (Nikkin) schedule, track each timed duty from clock-in to clock-out (meals, medication, break duration, bathing, recording).

  • On a Night Shift (Yakin) schedule, verify 20:00 bedtime care (Shuushin), night rounds (Junshi: once every 2 hours), and 6:00 morning wake-up care (Kishou).

  • Watch out for options testing the order of events, such as whether recording (Kiroku) happens before or after the meeting.
WordMeaning
Work schedule (Shigoto no yotei / Schedule chart)
Day shift (Nikkin: 9:00 - 18:00) and Night shift (Yakin: 17:00 - 10:00)
Report to work (Shukkin), Finish work (Taikin), Break (Kyuukei), Meeting
Meal and medication assistance (Shokuji / Fukuyaku no kaigo)
Bedtime care (Shuushin no kaigo) and Wake-up care (Kishou no kaigo)
Night patrol rounds (Junshi - checking rooms once every 2 hours)

Reading Accident Reports (Jiko Houkokusho and Near-Miss / Hiyari-Hatto Records)

When a fall, aspiration, or property damage occurs in a facility, an Accident Report (Jiko no houkoku / Jiko houkokusho) is created with the User's Name, Date/Time (Nichiji), Location (Basho), Incident Details (Naiyou), Cause (Genin), and Future Preventive Measures (Korekara dou suru ka).

A classic exam example is: In the washroom (Senmenjo), while Mr. A was washing his dentures (Ireba / Gishi) by himself, they slipped from his hand, fell to the floor, and broke.

Under Cause (Genin), the report notes: The strength in his fingertips (Yubisaki no chikara) has weakened, and his hands were wet and slippery. Under Future Measures (Korekara dou suru ka), specific preventive steps are written.

Preventive measures still respect independence support: Mr. A will continue removing his dentures by himself, while a care worker will wash them and put them away in their storage case (Case). Read carefully to distinguish what the user does versus what the care worker does.

Key points


  • An Accident Report consists of 5 core items: Date/Time, Location, Incident Details, Cause, and Future Preventive Measures (Korekara dou suru ka).

  • Identify the direct Cause written in the document (such as weak fingertip grip or wet, slippery hands).

  • Under Future Measures, distinguish which action the user continues doing independently and which action the care worker takes over.
WordMeaning
Accident report (Jiko no houkoku / Jiko houkokusho)
Location (Basho: Washroom Senmenjo, Private room Kyoshitsu, Dining hall Shokudou)
Incident details (Naiyou: dropped and broke dentures / fell down Tentou)
Cause (Genin: weak fingertip strength / hands were wet with water)
What to do from now on (Korekara dou suru ka - recurrence prevention)
Put into a storage case and keep safely (Case ni irete hokan suru)

Handover Notes and Timed Care Records (Short Stay, Hospital Visits, and Night Records)

A Handover Note (Moushiokuri note) passes important messages to the next shift. For example, a Short Stay handover note states arrivals and departures by floor: Tomorrow, 2 users will arrive on the 2nd floor, and 1 user will return home from the 4th floor.

It also specifies departure times and transportation methods: Mr. A will return home on the 15:00 shuttle van (Sougeisha); Ms. B's family will pick her up at 14:00. Organize who leaves at what time and by which method.

A hospital visit (Tsuuin) handover note often requires simple time calculation: Tomorrow at 10:30 (10-ji han), Ms. C will go to the hospital in the facility car accompanied by a Nurse. Please bring Ms. C to the main entrance (Genkan) 10 minutes before departure (by 10:20).

Timed night Care Records (Kaigo kiroku) track changes chronologically: 18:00 Ate all of dinner, drank 200 ml of tea, no nausea -> 02:45 Nurse call rang; felt unwell and vomited slightly (Sukoshi outo shita) -> 03:10 Feeling settled, vital signs normal, reported to the Nurse.

Handover Notes and Timed Care Records (Short Stay, Hospital Visits, and Night Records)

Key points


  • In Short Stay handover notes, distinguish how many users arrive or leave on each floor, and whether they leave by shuttle van (Sougeisha) or family pickup.

  • In hospital visit handovers, calculate times carefully: 10 minutes before 10:30 means arriving at the entrance (Genkan) by 10:20.

  • In timed night records (18:00, 02:45, 03:10), match each timestamp with meal/fluid intake (ml), vomiting, vital signs, and reporting to the Nurse.
WordMeaning
Handover notebook (Moushiokuri note) and Communication items (Renraku jikou)
Short stay, Shuttle vehicle (Sougeisha), Family pickup
Go to the hospital in the facility vehicle (Shisetsu no kuruma de byouin e iku)
Come to the entrance 10 minutes before 10:30 (at 10:20)
Drink 200 ml of tea / Vomited slightly (Sukoshi outo shita)
No abnormalities in vital signs / Reported to the Nurse

Frequently Tested Points & Memory Tips

In 'Documents & Records', questions test reading comprehension of care records, meal/fluid intake charts, excretion check sheets, handover notes, shift schedules, and notices.

When reading tables, always check the 'date, time slot, user name, and unit (ml, g, times, tenths/wari)' first. Adding up total fluid intake (ml) and distinguishing staple food (Shushoku) from side dishes (Fukushoku) are tested constantly.

When reading medication bags, you must distinguish: 'Shokuzen = before meals (~30 min before)', 'Shokugo = after meals (within 30 min)', 'Shokkan = between meals (~2 hours after a meal, NOT during a meal!)', and 'Tonpuku = as needed when symptoms appear'.

Key points


  • Medication timing: 'Shokuzen = before meals', 'Shokugo = after meals', 'Shokkan = between meals (never confuse with during meals!)', 'Shuushinmae = before bed', 'Tonpuku = as needed for symptoms'.

  • Meal & fluid charts: Distinguish 'Shushoku (staple: rice/bread)' from 'Fukushoku (side dishes)', and carefully add up fluid intake (ml) by time slot or full day.

  • Excretion check sheets: Match time slots with urination (Hainyou) / bowel movement (Haiben) counts and stool types (Futsuuben = normal, Nanben = soft, Suiyouben = watery, Kouben = hard).

  • Shift table terms: 'Nikkin = day shift, Hayaban = early shift, Osoban = late shift, Yakin = night shift, Koukyuu = scheduled day off'.

  • Handover & Near-miss (Hiyari-hatto) reports: Cross-check 'When, Where, Who, What happened, Cause, and Prevention measures' against the question options.
WordMeaning
Shokuzen (before meal), Shokugo (after meal), Shokkan (between meals), Tonpuku (as needed)
Shushoku (staple food), Fukushoku (side dish), and Fluid intake
Futsuuben (normal stool), Nanben (soft stool), Suiyouben (watery stool)
Hayaban (early shift), Nikkin (day shift), Osoban (late shift), Yakin (night shift)

Caregiving Documents & Records

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