REPORTING AND RECORDING

REPORTING & RECORDING 1) Developing observational skills You may be the first one to notice a change in the client’s condition. You have to be able to make accurate observations and provide feedback for other health care professionals. Observation is the act of noticing a truth or fact. Observations can be objective (signs) - things you can see or subjective (symptoms) - things the client tells you they are feeling. When you report subjective data you must use the clients exact words “I have a dull aching pain in my back today”. Be alert to changes in a person’s condition or behaviours.

REPORTING & RECORDING 2) Describing your observations Your observations are critical. Your observations are used for the assessment and evaluation of a client Be precise and accurate- provide details Do not interpret or make assumptions

REPORTING & RECORDING VERBAL REPORTING A verbal report is the spoken account of care provided and observations made. Know your employers policies and procedure regarding who to report to, how often and what to report. Client information is confidential. Some reports are given to a group and some are tape-recorded.

REPORTING & RECORDING IN A FACILITY 2) IN THE COMMUNITY report your actions and observations to your supervisor prompt and accurate include client’s name, room # and bed # the time you made the observation always report a change in the clients condition 2) IN THE COMMUNITY most agencies do not require you to make a verbal report. Call your supervisor if there is any change in the clients condition

REPORTING & RECORDING CHARTS Also known as a record, a chart is a written account of a client’s condition or illness and responses to care. A chart is a legal document. Charts are used for the following: Communication Currency Accountability Continuity of care

REPORTING & RECORDING TYPES OF DOCUMENTS USED IN CHARTS Charts vary depending on the employer. You will see several types of documents within the charts including: Data forms Assessment forms Home assessment forms Care plans Progress notes ADL check lists Task sheets Graphic sheets Other flow sheets

REPORTING & RECORDING RECORDING Recording or charting is documenting care and observations. Know your employers policies and procedures for charting. You should be charting: What you observed What you did When you did it The clients response Use the acronym DAR (Data, Action, Response) Always use the 24 hr clock , medical terminology and abbreviations when charting. CHARTING CAN TAKE PLACE IN 1) In a facility 2) In the community