1. Recording and Reporting
Personal Qualities of a Health Care Worker

2. Making Observations Sense of sight Color of skin Swelling, edema
Rash, sores
Color of urine, stool
Amount of food eaten
Etc.
If pt expresses the worse pain in their life but they are talking and smiling what would you be thinking? What do you see? Does what you see match what they are telling you?

3. Making Observations Sense of smell Body odor
Unusual odors of breath, wounds, urine or stool
You can smell ETOH, marijuana, or wounds. Wounds smell awful as do urine or stool.

4. Making Observations Sense of touch Pulse Skin dryness or temperature
Perspiration
Swelling

5. Making Observations Sense of hearing
Used while listening to respirations, abnormal body sounds, coughs, speech

6. Two Types of Observations
Subjective
“symptoms”, cannot be seen or felt
statements by patient
Objective (Observed)
“signs” that can be seen or measured
bruise, cut, rash, B/P
Measurable
vital signs
weight and height
test result
Disease symptoms that can be observed by somebody other than the person who is ill
OBJECTIVE:
perceived to exist only by the patient and is not recognizable to anyone else
Example: Headache (H/A), Stomach pain, muscle ache

7. Basic Rules for Recording
Recorded information should be accurate, concise and complete
Writing should be neat and legible
Spelling and grammar must be correct
Only objective observations should be noted
What did we say your medical record is? (Legal Document) Therefore, the information in that chart could be used in a court of law at ANY TIME. Information has to be correct, legible, complete, and concise. You can put subjective information in the chart and you will but you will also indicate things like “Pt c/o h/a.. Pt states that he has had back pain for months”. It will be clear that it the pt’s view or thoughts.

8. Basic Rules for Recording
Record statements in patient’s own words, in quotation marks
Sign with name and title
Errors – cross out neatly with straight line, “error” and initials
c/o pain in nek neck
error KS

9. HIPAA
Strict standards for maintaining confidentiality of health care records
Patients must be able to see/obtain their records, and control who sees them
Health care workers must protect privacy of patient records