Observation, Documentation, and Reporting to the RN Chapter 2 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 Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

Subjective and Objective Observations 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 Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. Pain Pain means that something is wrong It is never normal Patients display their pain through body language and behavior Culture affects their response Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. Pain Never make assumptions about pain even if the patient is laughing, talking, or sleeping Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. Pain Patient and RN establish a pain management goal using a pain-rating scale. Become familiar with the pain scales used in your facility Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. Pain Rating Scale Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. Pain Rating Scale 0-10 Scale Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. Pain Rating Scale Pain Scale Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

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 Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

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 Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

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 Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

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 Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

Documentation Means of communication Health care maxim: “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 Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 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 Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 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 Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 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 Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 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 Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 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 Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 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 Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.

Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 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 Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED.