30.6: Key Concepts in Creating Documentation

Accuracy and Completeness

How important is accurate observation and documentation? If you were asked to write down one thing you did yesterday, how well would you remember the details of that moment? What if you were asked to write down a moment from one week ago today? Which of those memories would have more accurate details? Most would answer that recording a memory from yesterday would be more accurate and detailed than the record of an event from a week ago. Yet many caregivers try to document observations days or weeks after an event. Upcoming deadlines, such as a family conference or assignment due date, often prompt caregivers to sit down and create documentation from past observations. Unfortunately, waiting to record information diminishes accuracy and clarity.

Let's take this exercise further. What if you needed to write down a conversation from yesterday? From last week? From last month? Can you recall the details of what you said? Which memory would be most accurate: the one from yesterday, last week, or last month? How confident could you be of the accuracy of what was said?

Observation notes need to be accurate, objective and factual. Accurate observation notes include facts and details about the order in which they occur. Consider the following story about Gabriel (33 months), which occurs during a home visit. Here is the entire exchange:

"Gabriel and his mom are next to each other. Each one is building a tower using large plastic blocks. Gabriel builds his tower as tall as he is. He bumps into the tower with his arm. The tower falls over and knocks down the block tower that his mother built. Gabriel laughs and jumps up and down while clapping his hands. His mom laughs, claps her hands, and hugs Gabriel."

Here is what the caregiver documented:

"Gabriel builds a tower as tall as he is using large plastic blocks. He starts to laugh, jump up and down, clap his hands, and bumps into his tower, knocking it down and his mom's tower down, too."

This observation note created by the caregiver is not accurate. It contains facts out of order (laugh, jump up and down, clap his hands, and bump into his tower). It is also missing information (Gabriel and his mother are next to each other, each one is building a tower, Gabriel's mom laughs, claps her hands, and hugs Gabriel). Accuracy matters. Over time, inaccurate observation notes may lead to erroneous interpretations or misunderstandings of what an infant or toddler can do.

Here are additional tips to write accurate observation notes:

• Note the infant or toddler's name and the person making the observation.
• Note the date/time of the observation, setting (e.g., indoor/outdoor, routine, play experience), and other infants, toddlers, or adults involved.
• Use abbreviations, short phrases, symbols, drawn pictures, and other shorthand inventions to capture information quickly.
• Use phonetic spellings to capture vocalizations (e.g., buh-buh-buh-mmmm) and word attempts (e.g., "peez" for "please").
• Observe with a partner and then compare observations.[1]

Caregivers often document a behavior, but miss what happened before (antecedent) and what happened after (consequence). To capture an entire event, caregivers need to include the ABCs.

• Antecedents – Environmental events or stimuli that trigger a behavior
• Behavior – What people do, say, think or feel
• Consequence – Outcome of a behavior [2]

A Word About the Word Play

Educators love the word play, and it needs to be a more significant part of the vocabulary when teaching and planning the days with young infants and toddlers. However, play should rarely be part of documentation. What comes to mind if asked to describe an infant or toddler at play? It could include a few toddlers in the sociodramatic area pretending to cook dinner, an infant or toddler digging a hole in the sandbox, or a single infant stacking blocks or investigating a piece of fabric. If the word play were used to document each scene, information would be limited by saying “the infant played” because the details are missing. The word “play” might fit as a generalization, but it doesn't provide curriculum development or assessment details. If a caregiver writes, "Javier was playing house," many details for later analysis are missing. However, if the caregiver writes, “Javier grasped the pot with his left hand. He clutched a wooden spoon firmly with his right hand and slowly mixed the pretend soup in a clockwise circle. Sarina walked over and handed Javier the spices and stated, ‘make the soup better,’” more visual details and information for assessment or curriculum development purposes are included. The second statement proves most effective because it describes the specific behaviors observed.

---

[1] U.S Department of Health and Human Services ECLKC Child observation: The heart of individualizing responsive care for infants and toddlers is in the public domain

[2] Daffin, L. W. (2022). Module 5: Determining the ABCs of Behavior via a Functional Assessment . In Principles of Behavior Analysis and Modification (4th ed.) licensed under a CC BY NC SA