Observation, Documentation, and Reporting to the RN

Observation, Observation, Documentation, and Documentation, and Reporting to the RNReporting to the RN

Subjective and Objective Subjective and Objective ObservationsObservations

SignsSigns – Seen by using your senses; usually indicate Seen by using your senses; usually indicate

disease or abnormalitiesdisease or abnormalities SymptomsSymptoms

– What patients tell you about their conditionsWhat patients tell you about their conditions– Cannot be seen by others or detected by using Cannot be seen by others or detected by using

your sensesyour senses

Subjective and Objective Subjective and Objective ObservationsObservations

SubjectiveSubjective– Observations may or may not be factualObservations may or may not be factual– Based on what you think Based on what you think – Based on information the patient gives you Based on information the patient gives you

(may or may not be true)(may or may not be true) ObjectiveObjective

– Factual and can be observed by othersFactual and can be observed by others

PainPain

Pain means that something is wrongPain means that something is wrong– It is never normalIt is never normal

Patients display their pain through body Patients display their pain through body language and behaviorlanguage and behavior– Culture affects their responseCulture affects their response

PainPain

Never make assumptions about pain even if Never make assumptions about pain even if the patient is laughing, talking, or sleepingthe patient is laughing, talking, or sleeping

PainPain

Patient and RN establish a pain Patient and RN establish a pain management goal using a pain-rating scale.management goal using a pain-rating scale.

Become familiar with the pain scales used in Become familiar with the pain scales used in your facilityyour facility

Pain Rating ScalePain Rating Scale


0-10 Scale0-10 Scale


Pain ScalePain Scale

Questions to askQuestions to ask Where does it hurt?Where does it hurt? When did it start? or How long has it When did it start? or How long has it

persisted?persisted? What word would you use to describe the What word would you use to describe the

pain? (sharp or dull)pain? (sharp or dull) Determine intensity – use pain scaleDetermine intensity – use pain scale What makes it worse?What makes it worse? What makes it better?What makes it better? Does it affect your ability to carry out routine Does it affect your ability to carry out routine

ADLs or important tasks?ADLs or important tasks?

Golden Rule for Pain ReliefGolden Rule for Pain Reliefin Childrenin Children

Whatever is painful to adults is painful to Whatever is painful to adults is painful to childrenchildren

Pain control should be based on scientific Pain control should be based on scientific facts, not personal opinions facts, not personal opinions

Never lieNever lie– Admit that a procedure will hurtAdmit that a procedure will hurt– Make the child as comfortable as possibleMake the child as comfortable as possible

Health Insurance Portability and Health Insurance Portability and Accountability Act (HIPAA)Accountability Act (HIPAA)

1996 Law1996 Law– Increases patient control over medical recordsIncreases patient control over medical records– Restricts use and disclosure of informationRestricts use and disclosure of information– Makes facilities accountable for protecting Makes facilities accountable for protecting

patient datapatient data– Protects all individually identifiable health Protects all individually identifiable health

information information


Patient information provided to staff on a Patient information provided to staff on a “need to know”“need to know” basis basis

Facilities analyze how and where patient Facilities analyze how and where patient information is usedinformation is used


Procedures for protecting confidential dataProcedures for protecting confidential data– Areas where charts are storedAreas where charts are stored– Places patients are discussedPlaces patients are discussed– How personal information is distributedHow personal information is distributed

DocumentationDocumentation

Means of communicationMeans of communication Health care maxim:Health care maxim:

“ “If it’s not charted, it wasn’t done!”If it’s not charted, it wasn’t done!” Information on the medical record is used by Information on the medical record is used by

many individualsmany individuals Record must be objective, accurate, and Record must be objective, accurate, and

completecomplete

DocumentationDocumentation Document onlyDocument only your your care and observations care and observations Never document in advanceNever document in advance

– Avoid documenting care that is supposed to be Avoid documenting care that is supposed to be given (turning every two hours)given (turning every two hours)

If you forget to documentIf you forget to document– Follow facility policies for making a late entryFollow facility policies for making a late entry


Nursing personnel cannot legally choose Nursing personnel cannot legally choose between giving care and keeping recordsbetween giving care and keeping records– Sometimes patient care is put ahead of Sometimes patient care is put ahead of

documentationdocumentation– Results in incorrect or incomplete Results in incorrect or incomplete

documentation documentation


Nursing personnel focus on treating the Nursing personnel focus on treating the human response to illnesshuman response to illness

Physicians focus on the disease, illness, or Physicians focus on the disease, illness, or injuryinjury

Access to nursing information, observations, Access to nursing information, observations, and procedures is criticaland procedures is critical


Is part of patient’s care, as well as validation Is part of patient’s care, as well as validation that care was giventhat care was given

Computers are commonly used for Computers are commonly used for documentation in health care facilitiesdocumentation in health care facilities


HIPAA HIPAA – Affects all health care communication, Affects all health care communication,

especially information technology (IT)especially information technology (IT) Information is limited to essential careInformation is limited to essential care

– IT can track who is accessing any patient's IT can track who is accessing any patient's recordrecord

– Can identify misuse of the systemCan identify misuse of the system


When using a computer:When using a computer:– Use password that is not easily decipheredUse password that is not easily deciphered

Never share your passwordNever share your password– Turn the monitor so it is not visible to othersTurn the monitor so it is not visible to others– Access only information you are authorized to Access only information you are authorized to

obtainobtain


When using a computerWhen using a computer– Make sure your documentation is objective, Make sure your documentation is objective,

accurate, and completeaccurate, and complete– Always wash your hands after using a computer Always wash your hands after using a computer

even if it has a plastic covereven if it has a plastic cover

Rules of ChartingRules of Charting

Denote date and timeDenote date and time Never leave blank spacesNever leave blank spaces Clearly describe what you observeClearly describe what you observe Articles such as a, an, and the are omittedArticles such as a, an, and the are omitted Omit the word “patient” from sentencesOmit the word “patient” from sentences Begin each sentence with a capital letterBegin each sentence with a capital letter End each statement with a periodEnd each statement with a period

Charting exampleCharting example

Thought: The patient ate all of the soft diet. Thought: The patient ate all of the soft diet. Bed bath was given to the patient by the Bed bath was given to the patient by the nurse.nurse.

Chart: Chart: 8/24/07 10:50 Ate all of soft diet. Bed bath 8/24/07 10:50 Ate all of soft diet. Bed bath

given. --------------------------N. Jones CNAgiven. --------------------------N. Jones CNA

RESIDENT CARE CONFERENCESRESIDENT CARE CONFERENCES– OBRA requires two types of resident care OBRA requires two types of resident care

conferences:conferences: Interdisciplinary care planning (IDCP) conferenceInterdisciplinary care planning (IDCP) conference Problem-focused conferenceProblem-focused conference

– The person has the right to take part in these The person has the right to take part in these planning conferences.planning conferences.

Slide Slide 2525

REPORTING AND RECORDINGREPORTING AND RECORDING– Reporting is the oral account of care and Reporting is the oral account of care and

observations.observations.– Recording (charting) is the written account of care and Recording (charting) is the written account of care and

observations. observations. – During end-of-shift report, information is shared about:During end-of-shift report, information is shared about:

The care givenThe care given The care that must be givenThe care that must be given The person’s conditionThe person’s condition

Slide Slide 2626

– Anyone who reads your charting should know:Anyone who reads your charting should know: What you observedWhat you observed What you didWhat you did The person’s responseThe person’s response

Slide Slide 2727

Slide Slide 2828

Recording Time (24 hr. Clock)Recording Time (24 hr. Clock)

MEDICAL TERMINOLOGYMEDICAL TERMINOLOGY– Prefixes, roots, and suffixes Prefixes, roots, and suffixes

A prefix is a word element placed before a root.A prefix is a word element placed before a root. The root is the word element that contains the basic The root is the word element that contains the basic

meaning of the word.meaning of the word. A suffix is a word element placed after a root.A suffix is a word element placed after a root.

– Medical terms are formed by combining word Medical terms are formed by combining word elements.elements. Prefixes always come before roots.Prefixes always come before roots. Suffixes always come after roots.Suffixes always come after roots. A root can be combined with prefixes, roots, and A root can be combined with prefixes, roots, and

suffixes.suffixes.

Slide Slide 2929

– The abdomen is divided into the following The abdomen is divided into the following regions:regions: Right upper quadrant (RUQ)Right upper quadrant (RUQ) Left upper quadrant (LUQ)Left upper quadrant (LUQ) Right lower quadrant (RLQ)Right lower quadrant (RLQ) Left lower quadrant (LLQ)Left lower quadrant (LLQ)

Slide Slide 3030

– Directional terms give the direction of the Directional terms give the direction of the body part when a person is standing and body part when a person is standing and facing forward.facing forward. Anterior (ventral)—at or toward the front of the Anterior (ventral)—at or toward the front of the

body or body partbody or body part Distal—the part farthest from the center or from Distal—the part farthest from the center or from

the point of attachmentthe point of attachment Lateral—away from the midline; at the side of the Lateral—away from the midline; at the side of the

body or body partbody or body part Medial—at or near the middle or midline of the Medial—at or near the middle or midline of the

body or body partbody or body part Posterior (dorsal)—at or toward the back of the Posterior (dorsal)—at or toward the back of the

body or body partbody or body part Proximal—the part nearest to the center or to the Proximal—the part nearest to the center or to the

point of originpoint of origin

Slide Slide 3131

Slide Slide 3232

ABBREVIATIONSABBREVIATIONS– Abbreviations are shortened forms of words or Abbreviations are shortened forms of words or

phrases.phrases. Use only those accepted by the center.Use only those accepted by the center.

Slide Slide 3333

COMPUTERS IN HEALTH CARECOMPUTERS IN HEALTH CARE– Computer systems collect, send, record, and Computer systems collect, send, record, and

store information.store information.– Computers do the following:Computers do the following:

They save time.They save time. They increase quality care and safety.They increase quality care and safety. Fewer errors are made in recording.Fewer errors are made in recording. Records are more complete.Records are more complete. Staff is more efficient.Staff is more efficient.

Slide Slide 3434

PHONE COMMUNICATIONSPHONE COMMUNICATIONS– Good communication skills are needed when Good communication skills are needed when

answering phones.answering phones. Be professional and courteous.Be professional and courteous. Practice good work ethics.Practice good work ethics. Follow the center’s policy.Follow the center’s policy.

The EndThe End

Slide Slide 3535

Documents

Observation, Documentation, and Reporting to the RN