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Observation, Documentation, and Reporting to the RN.

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Presentation on theme: "Observation, Documentation, and Reporting to the RN."— Presentation transcript:

1 Observation, Documentation, and Reporting to the RN

2 Subjective and Objective Observations  Signs –Seen by using your senses; usually indicate disease or abnormalities  Symptoms –What patients tell you about their conditions –Cannot be seen by others or detected by using your senses

3 Subjective and Objective Observations  Subjective –Observations may or may not be factual –Based on what you think –Based on information the patient gives you (may or may not be true)  Objective –Factual and can be observed by others

4 Pain  Pain means that something is wrong –It is never normal  Patients display their pain through body language and behavior –Culture affects their response

5 Pain  Never make assumptions about pain even if the patient is laughing, talking, or sleeping

6 Pain  Patient and RN establish a pain management goal using a pain-rating scale.  Become familiar with the pain scales used in your facility

7 Pain Rating Scale

8  0-10 Scale

9 Pain Rating Scale  Pain Scale

10 Questions to ask  Where does it hurt?  When did it start? or How long has it persisted?  What word would you use to describe the pain? (sharp or dull)  Determine intensity – use pain scale  What makes it worse?  What makes it better?  Does it affect your ability to carry out routine ADLs or important tasks?

11 Golden Rule for Pain Relief in Children  Whatever is painful to adults is painful to children  Pain control should be based on scientific facts, not personal opinions  Never lie –Admit that a procedure will hurt –Make the child as comfortable as possible

12 Health Insurance Portability and Accountability Act (HIPAA)  1996 Law –Increases patient control over medical records –Restricts use and disclosure of information –Makes facilities accountable for protecting patient data –Protects all individually identifiable health information

13 Health Insurance Portability and Accountability Act (HIPAA)  Patient information provided to staff on a “need to know” basis  Facilities analyze how and where patient information is used

14 Health Insurance Portability and Accountability Act (HIPAA)  Procedures for protecting confidential data –Areas where charts are stored –Places patients are discussed –How personal information is distributed

15 Documentation  Means of communication  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 many individuals  Record must be objective, accurate, and complete

16 Documentation  Document only your care and observations  Never document in advance –Avoid documenting care that is supposed to be given (turning every two hours)  If you forget to document –Follow facility policies for making a late entry

17 Documentation  Nursing personnel cannot legally choose between giving care and keeping records –Sometimes patient care is put ahead of documentation –Results in incorrect or incomplete documentation

18 Documentation  Nursing personnel focus on treating the human response to illness  Physicians focus on the disease, illness, or injury  Access to nursing information, observations, and procedures is critical

19 Documentation  Is part of patient’s care, as well as validation that care was given  Computers are commonly used for documentation in health care facilities

20 Documentation  HIPAA –Affects all health care communication, especially information technology (IT)  Information is limited to essential care –IT can track who is accessing any patient's record –Can identify misuse of the system

21 Documentation  When using a computer: –Use password that is not easily deciphered  Never share your password –Turn the monitor so it is not visible to others –Access only information you are authorized to obtain

22 Documentation  When using a computer –Make sure your documentation is objective, accurate, and complete –Always wash your hands after using a computer even if it has a plastic cover

23 Rules of Charting  Denote date and time  Never leave blank spaces  Clearly describe what you observe  Articles such as a, an, and the are omitted  Omit the word “patient” from sentences  Begin each sentence with a capital letter  End each statement with a period

24 Charting example  Thought: The patient ate all of the soft diet. Bed bath was given to the patient by the nurse.  Chart: 8/24/07 10:50 Ate all of soft diet. Bed bath given N. Jones CNA

25  RESIDENT CARE CONFERENCES –OBRA requires two types of resident care conferences:  Interdisciplinary care planning (IDCP) conference  Problem-focused conference –The person has the right to take part in these planning conferences. Slide 25

26  REPORTING AND RECORDING –Reporting is the oral account of care and observations. –Recording (charting) is the written account of care and observations. –During end-of-shift report, information is shared about:  The care given  The care that must be given  The person’s condition Slide 26

27 –Anyone who reads your charting should know:  What you observed  What you did  The person’s response Slide 27

28 Slide 28 Recording Time (24 hr. Clock)

29  MEDICAL TERMINOLOGY –Prefixes, roots, and suffixes  A prefix is a word element placed before a root.  The root is the word element that contains the basic meaning of the word.  A suffix is a word element placed after a root. –Medical terms are formed by combining word elements.  Prefixes always come before roots.  Suffixes always come after roots.  A root can be combined with prefixes, roots, and suffixes. Slide 29

30 –The abdomen is divided into the following regions:  Right upper quadrant (RUQ)  Left upper quadrant (LUQ)  Right lower quadrant (RLQ)  Left lower quadrant (LLQ) Slide 30

31 –Directional terms give the direction of the body part when a person is standing and facing forward.  Anterior (ventral)—at or toward the front of the body or body part  Distal—the part farthest from the center or from the point of attachment  Lateral—away from the midline; at the side of the body or body part  Medial—at or near the middle or midline of the body or body part  Posterior (dorsal)—at or toward the back of the body or body part  Proximal—the part nearest to the center or to the point of origin Slide 31

32 Slide 32  ABBREVIATIONS –Abbreviations are shortened forms of words or phrases.  Use only those accepted by the center.

33 Slide 33  COMPUTERS IN HEALTH CARE –Computer systems collect, send, record, and store information. –Computers do the following:  They save time.  They increase quality care and safety.  Fewer errors are made in recording.  Records are more complete.  Staff is more efficient.

34 Slide 34  PHONE COMMUNICATIONS –Good communication skills are needed when answering phones.  Be professional and courteous.  Practice good work ethics.  Follow the center’s policy.

35 The End Slide 35


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