Advanced Skills for Health Care Providers, Second Edition Barbara Acello

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

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

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

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

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

6. More on Confidentiality & Privacy • 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 • Privacy of patient information is protected by the 1996 law HIPAA

7. 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 • Restrict use and disclosure of pt info • Make facilities accountable for protecting patient data • Require the facility to implement and monitor info release policies and procedures

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

9. 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 • Policies must protect patient information which includes charts, verbal communication, faxes & other disclosure

10. 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

11. OBSERVING THE PATIENT You are responsible for • Making observations • 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

12. 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

13. 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

14. 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

15. For Example • 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

16. LEGAL ALERT Page 40