Use this section for specific events that need to be formally reported — a fall, a near-fall, an injury, a medication error, a choking episode, or any behavioral crisis that required calling a physician or family member. These are events where something happened that someone else needs to know about officially.

Examples: Found on floor · Refused all medications · Struck caregiver · Elopement attempt · Injury during personal care · Sudden change in condition. For repeated behaviors and mood patterns — agitation, restlessness, refusal of care — use the Behavior Patterns section instead.

Late-day confusion and agitation in dementia patients is often called "sundowning." Document every episode — patterns across multiple entries reveal far more than a single log.

⚠️ Sundowning can mask other causes. Before attributing behavioral changes to sundowning, consider whether the patient may have an undiagnosed UTI, untreated pain, constipation, dehydration, a medication timing issue, or overstimulation. These causes are treatable — sundowning progression is not.

Document: exact time, behaviors observed, possible triggers, what helped, and how long the episode lasted.

Call the physician if: the episode is significantly worse than usual, the patient has a fever, shows signs of pain, has not urinated in 8+ hours, or the behavior change is sudden rather than gradual. Sudden change is a medical signal, not a dementia symptom.

Document every incident immediately. A wandering log is only clinically useful when entries are consistent and complete. Time of incident, duration, location found, and what the patient was doing are all essential.

Wandering vs. Leaving Unsupervised: Wandering is movement within a supervised space. Leaving unsupervised — clinically called elopement — means the patient has left or attempted to leave without authorization. This is a medical emergency. If a patient leaves or attempts to leave, call 911 immediately, then notify the family and supervisor.

Before logging, verify safeguards are in place: door alarms active, bed sensor functioning, ID bracelet on patient, family notified of risk level.

Call the physician if: wandering episodes are new or suddenly increasing in frequency, the patient appears in pain or distressed during episodes, or the patient is found in an unsafe location. A sudden increase in wandering behavior can signal a UTI, pain, medication reaction, or disease progression.

Use this section to document repeated or pattern-based behaviors — agitation, restlessness, refusal of care, verbal outbursts, mood changes, or sundowning episodes. The ABC format captures three things: what happened before the behavior (the trigger), what the behavior looked like, and what helped resolve it.

Why it matters: A single behavior entry tells you little. Ten entries showing agitation occurs every afternoon when visitors arrive tells you everything. The pattern is where the clinical value lives. Use the Incident Report section instead for one-time events like falls, injuries, or medication errors that need to be formally reported.

The 0–10 face scale is for patients who can communicate their pain verbally or by pointing. For patients with moderate to advanced dementia who cannot self-report, this scale alone is not reliable. A patient who scores 0 may still be in significant pain — they simply cannot express it.

For non-verbal dementia patients, observe behavior instead of asking. Signs of unrecognized pain include: facial grimacing, bracing or guarding a body part, moaning or calling out during movement, resisting care, increased agitation or confusion, changes in breathing, or refusing to bear weight.

When documenting pain: Record what you observed, not what you assumed. "They grimaced and pulled their arm away during dressing" is more useful than "pain score 4." Specificity helps the physician make better decisions.

Call the physician if: pain appears sudden or severe, the patient shows signs of pain at rest (not only during care), pain seems to come from a new location, or behavioral changes are unexplained. Pain in dementia patients is consistently underdiagnosed and undertreated.