Presentation on theme: "Observation, Documentation, and Reporting to the RN."— Presentation transcript:
Observation, Documentation, and Reporting to the RN
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
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
Pain Pain means that something is wrong –It is never normal Patients display their pain through body language and behavior –Culture affects their response
Pain Never make assumptions about pain even if the patient is laughing, talking, or sleeping
Pain Patient and RN establish a pain management goal using a pain-rating scale. Become familiar with the pain scales used in your facility
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?
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
–Anyone who reads your charting should know: What you observed What you did The person’s response Slide 27
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
–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
–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
Slide 32 ABBREVIATIONS –Abbreviations are shortened forms of words or phrases. Use only those accepted by the center.
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.
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.