Why evidence matters

A CLSC assessor typically spends 60–90 minutes in the home. They cannot observe everything, and they depend significantly on what families describe. Evidence — concrete documentation of what has changed — makes that description more reliable, specific, and persuasive.

This does not mean families need to "build a legal case." It means arriving at the assessment with specific facts rather than general impressions.

Most useful types of evidence

A record of falls

Falls are one of the most objective and impactful indicators of change. If you have written down the dates, circumstances, and any injuries from each fall, bring that record. Even a simple handwritten note is valuable.

What to include:

• Date of each fall
• Where it happened (bathroom, bedroom, outdoors)
• What the person was doing at the time
• Whether there was an injury, and how severe
• Whether emergency services were called

Medication list

A current, complete list of medications — including dosage and frequency — helps the assessor understand the medical context. It also supports a case for medication management assistance if the person is struggling to take medications correctly.

Hospital discharge summaries

After any hospitalization, the hospital provides a discharge summary. This document describes the reason for admission, treatments received, the person's condition at discharge, and follow-up instructions. It is one of the most credible pieces of evidence that functional status has changed.

Request a copy from the hospital or ask your care coordinator to obtain one.

Physician or specialist letters

A letter from the person's family doctor, neurologist, cardiologist, or other specialist can carry significant weight. It does not need to be elaborate — a note confirming a diagnosis, describing functional limitations, or recommending increased care is sufficient.

If the physician is aware of the challenges you are facing at home, ask them to document it.

Occupational therapy (OT) reports

If an OT assessment has been conducted — either through the CLSC or privately — bring the report. OT reports provide a functional capacity assessment that directly maps to the kinds of decisions the CLSC makes.

A caregiver journal

A written record of daily observations — what tasks the person needed help with, close calls, behaviours that seem unsafe — is highly useful. It does not need to be formal. A dated notebook is sufficient.

See the Caregiver Journals article for guidance on what to record.

Caregiver situation statement

If caregiver circumstances have changed — more hours of care required, health problems, work demands, no other family available — write it down briefly. A short written summary of your own situation as a caregiver helps the assessor understand the full picture.

What to do with this evidence

Bring it to the home visit. If you have documents, have them organized. If you have a journal, have a summary ready so you can speak to the key points without having to read through everything in the meeting.

You can also share materials with your care coordinator before the visit, which gives them context before the assessment begins.

What should I gather next?

The Documentation section of this Knowledge Centre covers each of these categories in detail.