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Understand nurse aide observations, recording, and reporting.Understand nurse aide observations, recording, and reporting. Nursing Fundamentals HN431 2.02.

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Presentation on theme: "Understand nurse aide observations, recording, and reporting.Understand nurse aide observations, recording, and reporting. Nursing Fundamentals HN431 2.02."— Presentation transcript:

1 Understand nurse aide observations, recording, and reporting.Understand nurse aide observations, recording, and reporting. Nursing Fundamentals HN Unit A Nurse Aide Workplace Fundamentals Nurse Aide Workplace Fundamentals Essential Standard NA2.00 Apply communication and interpersonal skills and physical care that promote mental health and meet the social and special needs of Apply communication and interpersonal skills and physical care that promote mental health and meet the social and special needs of residents in long-term care. residents in long-term care. Indicator 2.02 Understand nurse aide observations, recording, and reporting. Understand nurse aide observations, recording, and reporting.

2 Nursing Fundamentals HN YOU …the nurse aide, have many opportunities to observe the resident!

3 Nursing Fundamentals HN433 Examples using SIGHT : Rash Skin color Bruising Methods of Observation 2.02

4 Nursing Fundamentals HN434 Examples using HEARING : Wheezing Moans Moans Words spoken by resident Words spoken by resident Methods of Observation 2.02

5 Nursing Fundamentals HN435 Methods of Observation TOUCH Examples using TOUCH : Lump Temperature of skin Change in pulse 2.02

6 Nursing Fundamentals HN436 SMELL Examples using SMELL : Odor of breath or body Odor of urine or feces Trash cans with soiled under pads Methods of Observation 2.02

7 Nursing Fundamentals HN DOCUMENTATION

8 Nursing Fundamentals HN438Reporting 2.02 Reporting is the verbal sharing of resident information Reporting is the verbal sharing of resident information ABNORMAL OBSERVATIONS MUST BE REPORTED IMMEIDATELY TO THE NURSE in addition to being recorded or documented ABNORMAL OBSERVATIONS MUST BE REPORTED IMMEIDATELY TO THE NURSE in addition to being recorded or documented

9 Nursing Fundamentals HN439Recording 2.02 Recording is the writing of resident information and is also called charting or documenting. Currently much of the documentation done by nurse aides is done electronically.

10 Nursing Fundamentals HN4310 Guidelines for Written Documentation on Hard Copy 2.02 Information can be recorded on a notepad at the bedside

11 Nursing Fundamentals HN4311 Guidelines for Written Documentation on Hard Copy 2.02 Record or document AFTER care is given!

12 Nursing Fundamentals HN4312 Guidelines for Written Documentation on Hard Copy 2.02 Careful, Clear, ConciseCareful, Clear, Concise Just the FACTS ma’amJust the FACTS ma’am

13 Nursing Fundamentals HN4313 Guidelines for Written Documentation on Hard Copy 2.02 Write neatly, legibly, using a black penWrite neatly, legibly, using a black pen Sign your full name, title, and correct date.Sign your full name, title, and correct date.

14 Nursing Fundamentals HN4314 Guidelines for Written Documentation on Hard Copy hour clock or military time24-hour clock or military time Correcting mistakesCorrecting mistakes

15 Nursing Fundamentals HN4315 Guidelines for Electronic Documentation The link below leads to a video prepared by Care Tracker. This video gives the nurse aide student an overview of electronic charting.

16 Nursing Fundamentals HN4316 Special Events to Report and Document Incident Report 2.Resident Abuse – Types of Abuse were discussed in a previous indicator 3.Resident Grievances – More details discussed in a previous indicator

17 Nursing Fundamentals HN4317 Special Events to Report and Document Incident Report An unexpected event must be reportedAn unexpected event must be reported Complete asapComplete asap Examples of “incidents”Examples of “incidents”

18 Nursing Fundamentals HN4318 Guidelines for Incident Reports What happened 2. State facts 3. Describe care given 4. Never place blame

19 Nursing Fundamentals HN4319Reporting 2.02 Report only facts, not opinionsReport only facts, not opinions –objective data - that observed using senses –subjective data - that told to nurse aide by the resident

20 Nursing Fundamentals HN4320Reporting 2.02 Observe resident’s environment and report safety hazards!

21 Nursing Fundamentals HN4321Reporting 2.02 When reporting, consider:When reporting, consider: –care or treatment given –time of treatment –resident’s response to care

22 Nursing Fundamentals HN4322Reporting 2.02 When reporting, consider: –observations helpful to other health care workers –information resident has given that would affect his or her treatment –anything unusual about resident

23 Nursing Fundamentals HN Communicating with other Staff Members

24 Nursing Fundamentals HN4324 Body language Reporting or communicating orally Written communications 2.02 Forms of Communication

25 Nursing Fundamentals HN4325 Resident Care Plans Written Communications: Resident Care Plans Resident care plans prepared by nurse One for each resident Kept at nurses’ station 2.02

26 Nursing Fundamentals HN4326 Written Communications: Resident Care Plans (continued) Working record to provide consistent, well-planned care on a daily basis Changed and updated as needed by licensed nurse 2.02

27 Nursing Fundamentals HN4327 Written Communications: Resident Care Plans (continued) Information included: –Resident’s level of independence in ADL –Treatments –Statement of problems 2.02

28 Nursing Fundamentals HN4328 Written Communications: Resident Care Plans (continued) Information included (continued): –Short-term and long-term goals –Plan to attain goals –Date plan initiated and reevaluated 2.02

29 Nursing Fundamentals HN4329 Written Communications: Resident Care Plans (continued) Nurse aides contribute by: –Helping to identify problems –Attending care conferences 2.02

30 Nursing Fundamentals HN4330 Written Communications: Resident Care Plans (continued) Nurse aides contribute by (continued): –Directing questions about plan to supervisor –Reporting resident response to treatment and activities 2.02

31 Nursing Fundamentals HN4331 Written Communications: Resident‘s Medical Record Includes information from all disciplines providing direct service to residents 2.02

32 Nursing Fundamentals HN4332 Written Communications: Resident’s Medical Record (cont.) A record of: –assessments, implementations, evaluations –management plans –progress notes Permanent legal record 2.02

33 Nursing Fundamentals HN4333 Written Communications: Resident’s Medical Record (cont.) Purpose –Organizes all information on care in one document –Accountability so care can be evaluated –Documentation so there is knowledge of what each discipline is doing 2.02

34 Nursing Fundamentals HN4334 Written Communications: Resident’s Medical Record (cont.) Confidential information available only to health care workers involved in care of resident 2.02

35 Nursing Fundamentals HN4335 Guidelines For Charting Guidelines For Charting As Allowed By Facility Make sure entries are accurate and easy to read Always use ink Print, unless script is accepted form Do not use the term “resident” 2.02

36 Nursing Fundamentals HN4336 Guidelines For Charting As Allowed By Facility (continued) Use short, concise phrasesUse short, concise phrases Always chart after care is performedAlways chart after care is performed Make sure writing legible and neatMake sure writing legible and neat 2.02

37 Nursing Fundamentals HN4337 Guidelines For Charting As Allowed By Facility (continued) Use only abbreviations accepted by facility Make sure spelling, grammar and punctuation are correct Do not record judgments or interpretations 2.02

38 Nursing Fundamentals HN4338 Guidelines For Charting As Allowed By Facility (continued) Record in a logical and chronological manner Be descriptive Make sure all forms added to the chart contain identifying information 2.02

39 Nursing Fundamentals HN4339 Guidelines For Charting As Allowed By Facility (continued) Avoid using words that have more than one meaning Use resident’s exact words in quotation marks whenever possible Always indicate the time of care 2.02

40 Nursing Fundamentals HN4340 Guidelines For Charting As Allowed By Facility (continued) Leave no lines blank Sign each entry with first initial, last name and title Correct errors using facility procedure 2.02

41 Nursing Fundamentals HN4341 Electronic Charting 2.02

42 Nursing Fundamentals HN4342 Electronic Charting 2.02 The following slides are used with permission of CareTracker. CareTracker is a computer program designed to make it easy for nurse aides and other staff members to accurately document resident care and observations on the spot, using wall- mounted and portable touch screens, in just minutes.

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49 Nursing Fundamentals HN4349 Electronic Charting 2.02 Visit ngTermCare/CareTracker.aspx ngTermCare/CareTracker.aspx

50 Nursing Fundamentals HN Medical Terminology

51 Nursing Fundamentals HN4351 Medical Terminology Medicine has a language of its own –Historical development –Composed mainly of Greek and Latin word parts –Consistent and uniform 2.02

52 Nursing Fundamentals HN4352 Medical Terminology Medical Terminology (cont.) Three components –Prefixes –Root words –Suffixes Medical dictionary –Used for reference –Spelling is important 2.02

53 Nursing Fundamentals HN Abbreviations

54 Nursing Fundamentals HN4354 Abbreviations Help health care workers communicate quickly and effectively Are shortened forms of words Reduce time needed to chart important information 2.02

55 Nursing Fundamentals HN4355 Abbreviations (cont.) Conserve space on medical recordConserve space on medical record Used primarily in written communicationUsed primarily in written communication Some abbreviations are no longer used to prevent confusion and protect residents from harmSome abbreviations are no longer used to prevent confusion and protect residents from harm 2.02

56 Understand nurse aide observations, recording, and reporting. 56  END  Nursing Fundamentals HN43


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