1. Observations, Recording, and Reporting
Nursing Fundamentals
Unit 2.02

2. General Observations General appearance and position Skin
Eyes, ears, nose, and mouth
Breathing
Abdomen “belly”, bowels, bladder
Mobility and function, movements
Activities of daily living

3. General Observations Activities of daily living Mental condition, mood
Nutrition / hydration level
Sleeping habits
Pain, discomfort, complaints

4. What do you see? Examples using sight:
Rash, skin color, bruising, swelling
Presence of blood or discharge
Condition of the resident’s environment

5. What do you hear? Wheezing, moans
Words spoken by the resident, friends, or family
Water dripping in the sink, toilet running over

6. What do you feel?
Lumps
Temperature of skin
Change in pulse

7. What do you smell? Odor of breath or body Odor of urine or feces
Diabetes-Fruity
Odor of urine or feces
Trash cans with soiled under pads

8. What do you taste?
JK!!

9. Documentation Facts
Observations made by the nurse aide must be shared with the health care team through verbal communication or written communication for continuity of care

10. Reporting Facts
Reporting - Verbal sharing of resident information Abnormal observations must be REPORTED immediately to the nurse in addition to being recorded/documented

11. Recording
Writing resident information is also called charting or documenting

12. Nurse Aide documentation of observations are an essential part of the Minimum Data Set (MDS)
The MDS is a detailed form used by nurses for resident assessment
Observations reported and documented by the nurse aide may indicate illness or “trigger” the need for additional resident assessment by the nurse
A new MDS must be done when there is any major change in resident condition

13. Record/document using the tool specified by the nursing care facility
Hardcopy “check-off” sheet for recording/documenting resident care (also called ADL or flow sheet)
Electronically on portable devices or touch screen input devices (example: CareTracker®)

14. Documentation is given to insurance companies to receive payment for services

15. Documentation papers become a part of the resident’s medical record or chart
Medical records/charts are legal records and may be used in court
Documentation on medical records provide legal proof that something has been done or observed
If it isn’t recorded, it did not happen

16. Documentation on Hard Copy
Information can be recorded on a notepad at the bedside and used later for official reporting and recording/documenting
Do not rely on memory alone
Avoid using little pieces of paper to write information on
Avoid writing on gloves
Destroy all notes after official documentation is completed
Don’t confuse data from one resident to another

17. Documentation
Record/document AFTER care is given
Be careful, clear, and concise in your documentation
Record facts not opinions
Write neatly, legibly, using a black pen
Sign your full name, title, and write the correct date
You may need to document time using the 24-hour clock or military time

18. Correcting mistakes Draw one line through it
Write the correct word or words, put your initials and date
Never erase what you have written
Do not use correction fluid

19. Electronic Charting
The nursing facility will provide hands on training for the specific type of electronic charting system used
Make sure nobody can see patient information on the computer screen

20. Electronic Charting Basics
Caregiver uses biometric thumbprint or password for secure access
Caregiver goes to their home page
Selects “resident charting”
Select “category” or “resident” to begin to enter the data observed and tasks performed
Each entry is time and date stamped and signed digitally by the nurse aide
Tasks icons are highlighted at the beginning of the shift
As tasks are completed and documented in the system, the icons change color

21. Specific events requiring reporting and documentation
Incident report
An accident or an unexpected event during the course of care is considered an “incident” and must be reported
State and federal guidelines require incidents to be recorded in an incident report
Protect everyone involved; resident, your employer, and you
Complete the incident as soon as possible and give it to the charge nurse

22. The following occurrences are considered Incidents
A resident falls (all falls must be reported, even if the resident says he or she if fine
You or a resident break or damage something
You make a mistake in care
A resident or a family member makes a request that is our of your scope of practice

23. A resident or family member makes sexual advances or remarks
Anything happens that makes you feel uncomfortable, threatened, or unsafe
You get injured on the job
You are exposed to blood or body fluids

24. Guidelines for Incident Reports
Tell what happened. State the time, and the mental and physical condition of the person
Tell how the person tolerated the incident
State the facts; do not give opinions
Do not write anything in the incident report on the medical record (incident reports are confidential)
Describe the action taken to give care
Include suggestions for change
Never place any blame or liability within the report

25. Resident abuse
Nurse aides have ethical and legal responsibility to observe for and report suspected resident abuse, it is the law, not an option
Support residents who want to make a complaint themselves
Give as much information as possible when reporting abuse

26. Must follow the chain of command when reporting abuse
Report suspected abuse to nurse first
If action is not taken, keep reporting up the chain of command
Report up the of command until action is taken

27. If no appropriate action is taken at the facility level
Call the complaint hotline at within NC
Hotline operates 8:30am to 4:00pm weekdays, except holidays
Call the County Department of Social Services – Adult Protective Services Section
If life or death situation witnessed, remove the resident to a safe place if possible, get help immediately or send for help, do not leave the resident

28. Observations that may indicate abuse and neglect
Suspicious injuries
Unexplained change in behavior, example withdrawal