Advanced Skills for Health Care Providers, Second Edition Barbara Acello Thomson Delmar Learning, 2007 Chapter 2 Observation, Documentation, and Reporting to the RN

OBJECTIVES: Spell and define key terms Spell and define key terms Differentiate between signs and symptoms Differentiate between signs and symptoms Differentiate between subjective and objective observations Differentiate between subjective and objective observations Describe how to report and record patient information (continued) Describe how to report and record patient information (continued)

Objectives (continued) Describe how to identify pain by making observations of facial expressions, gestures, movement, and body language Describe how to identify pain by making observations of facial expressions, gestures, movement, and body language State the purpose of the medical record State the purpose of the medical record List 10 guidelines for documenting in the medical record List 10 guidelines for documenting in the medical record

Terms to Know HIPAA HIPAA Signs Signs Symptoms Symptoms Objective Objective Subjective Subjective Chart Chart Medical Record Medical Record PDAs PDAs TPCs TPCs

COMMUNICATING WITH OTHER MEMBERS OF THE HEALTH CARE TEAM Good communication is one of the keys to team success the keys to team success Communication can be verbal or written Communication can be verbal or written Reporting is usually verbal Reporting is usually verbal Recording / Documenting is written Recording / Documenting is written

Confidentiality and Privacy THE MEDICAL RECORD IS A PRIVATE AND CONFIDENTIAL DOCUMENT THE MEDICAL RECORD IS A PRIVATE AND CONFIDENTIAL DOCUMENT ALL STAFF ARE RESPONSIBLE FOR PROTECTING PATIENT INFORMATION FROM ACCESS BY UNAUTHORIZED PERSONS ALL STAFF ARE RESPONSIBLE FOR PROTECTING PATIENT INFORMATION FROM ACCESS BY UNAUTHORIZED PERSONS

More on Confidentiality & Privacy You should never read the patient charts out of curiosity You should never read the patient charts out of curiosity Medical records and other patient data should be accessed only by those with a need to know the information Medical records and other patient data should be accessed only by those with a need to know the information Privacy of patient information is protected by the 1996 law HIPAA Privacy of patient information is protected by the 1996 law HIPAA

HIPAA – Health Insurance Portability and Accountability Act Passed in 1996 by Congress, it concerns privacy, confidentiality, and medical records. The HIPAA rules: Increase patient’s control over their medical records Increase patient’s control over their medical records Restrict use and disclosure of pt info Restrict use and disclosure of pt info Make facilities accountable for protecting patient data Make facilities accountable for protecting patient data Require the facility to implement and monitor info release policies and procedures Require the facility to implement and monitor info release policies and procedures

HIPAA Protects all identifiable health information: Paper Paper Verbal Verbal Electronic documentation Electronic documentation Billing records Billing records Clinical records Clinical records

Patient information is given to staff on a “need to know” basis Staff members need that info to carry out their duties, ex., dietary needs to know if patient is on a special diabetic diet or has food allergies, they would not need to know why the patient is in the hospital Staff members need that info to carry out their duties, ex., dietary needs to know if patient is on a special diabetic diet or has food allergies, they would not need to know why the patient is in the hospital Policies must protect patient information which includes charts, verbal communication, faxes & other disclosure Policies must protect patient information which includes charts, verbal communication, faxes & other disclosure

HIPAA rules ask providers: To analyze how and where patient information is used To develop procedures for protecting confidential data which includes Where patient charts are kept Places where patient information is discussed Ways that patients’ health info is distributed

OBSERVING THE PATIENT You are responsible for Making observations Making observations Reporting observations to the RN Reporting observations to the RN PCTs spend most of their time providing direct patient care and will notice changes that need to be reported immediately

Use Your Senses to Make Observations Many changes are things you can see Changes in movement / position Facial expression Skin color change These changes may suggest pain or other serious problems

Use Your Senses to Make Observation (continued) You will hear some changes like noisy breathing and things the patient tells you You will smell some changes that give unusual odors You will feel some changes like temperature change or moisture

Observing the Patient is a Continuous Process If you see, feel, hear, or smell anything that seems abnormal, report it to the RN Even changes that seem insignificant may indicate a problem The nurse will select the course of action Also observe for safety, comfort and other environmental factors

For Example A red area on the skin may seem minor but the area can quickly turn into a pressure sore A red area on the skin may seem minor but the area can quickly turn into a pressure sore A patient receiving blood can state he feels cold. Your first reaction may be to get a blanket. Chilling is a sign of transfusion reaction which is very serious and must be reported immediately A patient receiving blood can state he feels cold. Your first reaction may be to get a blanket. Chilling is a sign of transfusion reaction which is very serious and must be reported immediately

LEGAL ALERT Reporting and recording your observations of patients are key PCT responsibilities Reporting and recording your observations of patients are key PCT responsibilities Pay attention to details Pay attention to details Practice good communication skills Practice good communication skills (continued) (continued)

Legal Alert (continued) Learn which observations must be reported immediately Learn which observations must be reported immediately Learn which observations can wait until the end of the shift Learn which observations can wait until the end of the shift An alert, observant PCT is invaluable in protecting patients’ safety and well-being.

Subjective and Objective Observations Signs are things seen or observed by using your senses. The red area you notice on a patient’s skin during bathing is a sign. Signs are things seen or observed by using your senses. The red area you notice on a patient’s skin during bathing is a sign. Symptoms are things patients notice about their condition and tell you. These things cannot be seen or detected by others. Nausea is an example. Symptoms are things patients notice about their condition and tell you. These things cannot be seen or detected by others. Nausea is an example.

Subjective and Objective Observations Objective observations are factual, and can be made by others. They are made by seeing, hearing, feeling, touching, and smelling. Objective observations are factual, and can be made by others. They are made by seeing, hearing, feeling, touching, and smelling. Subjective observations are based on what you think or information the patient gives you that may or may not be true. Subjective observations are based on what you think or information the patient gives you that may or may not be true.

PAIN IS NOT NORMAL Inform the RN if the patient complains of pain Inform the RN if the patient complains of pain Determining whether pediatric or cognitively impaired patients are in pain may be difficult Determining whether pediatric or cognitively impaired patients are in pain may be difficult Know that different cultures react differently to pain Know that different cultures react differently to pain

Pain Scale Use for pediatrics & cognitively impaired

Pain – Signs and Symptoms Body language may be the first clue Look for: Pain on movement Pain on movement Facial expressions Facial expressions Crying Crying Moaning Moaning Guarded positioning Guarded positioning

When in pain the patient usually acts the opposite of “normal” Always suspect pain if the patient’s behavior changes Always suspect pain if the patient’s behavior changes Report your observations to the RN compared to the normal behavior for the patient Report your observations to the RN compared to the normal behavior for the patient

REPORTING OBSERVATIONS Information must be objective Report observations and changes in condition promptly Report observations and changes in condition promptly You are responsible for reporting the information You are responsible for reporting the information RNs are responsible for interpreting it based on their further assessment RNs are responsible for interpreting it based on their further assessment If the patient changes further, report again, do not assume the RN knows If the patient changes further, report again, do not assume the RN knows (continued) (continued)

REPORTING (continued) Report to the RN when you leave the unit Report to the RN when you leave the unit Report to the RN when you return Report to the RN when you return Report off at the end of the shift Report off at the end of the shift Receive a report at the start of your shift Receive a report at the start of your shift Report during your shift when patients’ conditions changes Report during your shift when patients’ conditions changes

RECORDING OBSERVATIONS ON THE MEDICAL CHART Documentation on the medical record is also a means of communication Documentation on the medical record is also a means of communication Many departments care for the patient Many departments care for the patient Physicians and others read the medical record and use it to plan patient care Physicians and others read the medical record and use it to plan patient care The information advises of the patient’s problems, needs, solutions, and progress The information advises of the patient’s problems, needs, solutions, and progress

Common Rule in Health Care IF IT IS NOT DOCUMENTED, IT WAS NOT DONE !!!

The patient’s chart Notebook or binder Notebook or binder Containing the medical record Containing the medical record It is a legal document It is a legal document Record of patient’s condition, progress, and care Record of patient’s condition, progress, and care

Policies vary regarding Who is responsible for recording information on the chart Who is responsible for recording information on the chart Who is responsible for documenting information on various medical records Who is responsible for documenting information on various medical records

Never document in advance Documentation on the medical record should be objective Know and follow your facility policies on charting

CHARTING TIME on the 24-Hour Clock

The 24-hour Clock No need to use AM and PM No need to use AM and PM The day starts at Midnight The day starts at Midnight 15 minutes after Midnight is minutes after Midnight is minutes after Noon is minutes after Noon is minutes after 1:00am is minutes after 1:00am is minutes after 1:00pm is minutes after 1:00pm is 1315 Hours after Noon is added to 12 Hours after Noon is added to 12

Legal Considerations Accountability Accountability Timeliness Timeliness Accuracy of the Medical Record Accuracy of the Medical Record

Accountability Each person documents what he or she did for the patient Each person documents what he or she did for the patient Ask the RN if you do not know how to describe the patient’s condition Ask the RN if you do not know how to describe the patient’s condition You are responsible for what you write You are responsible for what you write Every entry is evidence that care was given Every entry is evidence that care was given NEVER CHART FOR SOMEONE ELSE !!! NEVER CHART FOR SOMEONE ELSE !!!

Timeliness Document your care as soon as possible Document your care as soon as possible NEVER CHART BEFORE CARE IS GIVEN NEVER CHART BEFORE CARE IS GIVEN Carry a small notebook Carry a small notebook Follow facility policy regarding late-entry documentation Follow facility policy regarding late-entry documentation

Accuracy of the Medical Record Avoid opportunities for records to be altered Never use pencil or erasable ink Never use pencil or erasable ink Do not leave blank lines or spaces Do not leave blank lines or spaces Follow facility policy for correcting errors Follow facility policy for correcting errors Most facilities want one line through the error, Most facilities want one line through the error, With “error” and your initials written above it With “error” and your initials written above it

REMINDER: IF IT WAS NOT DOCUMENTED IT WAS NOT DONE

Computers in Health Care Facilities Large amounts of information can be recorded, stored and retrieved Large amounts of information can be recorded, stored and retrieved Departments can communicate Departments can communicate Information is easy to read Information is easy to read NEVER GIVE YOUR PASSWORD TO ANYONE ELSE NEVER GIVE YOUR PASSWORD TO ANYONE ELSE Some information will not be available to all users (See HIPAA Need to Know) Some information will not be available to all users (See HIPAA Need to Know)

Handheld Computers Charting and communication can be done at the patient’s bedside Charting and communication can be done at the patient’s bedside Two major classes of portable computers Two major classes of portable computers PDAs – personal digital assistants PDAs – personal digital assistants TPCs – tablet personal computers TPCs – tablet personal computers

Radio Frequency Emitting Devices Personal Cell Phones and PDAs Personal Cell Phones and PDAs KNOW YOUR FACILITY’S POLICIES REGARDING KEEPING YOUR CELL PHONE ON AND USING YOUR CELL PHONE KNOW YOUR FACILITY’S POLICIES REGARDING KEEPING YOUR CELL PHONE ON AND USING YOUR CELL PHONE The frequency of your cell phone may interfere with hospital electronic equipment or communication devices The frequency of your cell phone may interfere with hospital electronic equipment or communication devices

Computers and HIPAA Compliance HIPAA affects Information Technology (IT) You will only be able to access You will only be able to access Your patients Your patients Only information on your patients that you “need to know” Only information on your patients that you “need to know” Hospitals have “firewalls” to prevent patient information being broadcast into cyberspace Hospitals have “firewalls” to prevent patient information being broadcast into cyberspace

Advantages of Using Computers Information access is rapid Information access is rapid Data is easy to read Data is easy to read Provide warning alerts regarding patient drug and food allergies Provide warning alerts regarding patient drug and food allergies Bedside data entry Bedside data entry Team communication is improved Team communication is improved Charges for supplies and services Charges for supplies and services