Observation, Documentation, and Reporting to the RN

1. Observation, Documentation, and Reporting to the RN

2. 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

3. Subjective and Objective Observations • Subjective • 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

4. Pain • Pain means that something is wrong • It is never normal • Patients display their pain through body language and behavior • Culture affects their response

5. Pain • Never make assumptions about pain even if the patient is laughing, talking, or sleeping

6. Pain • Patient and RN establish a pain management goal using a pain-rating scale. • Become familiar with the pain scales used in your facility

7. Pain Rating Scale

8. Pain Rating Scale • 0-10 Scale

9. Pain Rating Scale • Pain Scale

10. Questions to ask • Where does it hurt? • When did it start? or How long has it persisted? • What word would you use to describe the pain? (sharp or dull) • Determine intensity – use pain scale • What makes it worse? • What makes it better? • Does it affect your ability to carry out routine ADLs or important tasks?

11. Golden Rule for Pain Reliefin 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. Rules of Charting • Denote date and time • Never leave blank spaces • Clearly describe what you observe • Articles such as a, an, and the are omitted • Omit the word “patient” from sentences • Begin each sentence with a capital letter • End each statement with a period

24. Charting example • Thought: The patient ate all of the soft diet. Bed bath was given to the patient by the nurse. • Chart: 8/24/07 10:50 Ate all of soft diet. Bed bath given. --------------------------N. Jones CNA

25. RESIDENT CARE CONFERENCES • OBRA requires two types of resident care conferences: • Interdisciplinary care planning (IDCP) conference • Problem-focused conference • The person has the right to take part in these planning conferences.

26. REPORTING AND RECORDING • Reporting is the oral account of care and observations. • Recording (charting) is the written account of care and observations. • During end-of-shift report, information is shared about: • The care given • The care that must be given • The person’s condition

27. Anyone who reads your charting should know: • What you observed • What you did • The person’s response

28. Recording Time (24 hr. Clock)

29. MEDICAL TERMINOLOGY • Prefixes, roots, and suffixes • A prefix is a word element placed before a root. • The root is the word element that contains the basic meaning of the word. • A suffix is a word element placed after a root. • Medical terms are formed by combining word elements. • Prefixes always come before roots. • Suffixes always come after roots. • A root can be combined with prefixes, roots, and suffixes.

30. The abdomen is divided into the following regions: • Right upper quadrant (RUQ) • Left upper quadrant (LUQ) • Right lower quadrant (RLQ) • Left lower quadrant (LLQ)

31. Directional terms give the direction of the body part when a person is standing and facing forward. • Anterior (ventral)—at or toward the front of the body or body part • Distal—the part farthest from the center or from the point of attachment • Lateral—away from the midline; at the side of the body or body part • Medial—at or near the middle or midline of the body or body part • Posterior (dorsal)—at or toward the back of the body or body part • Proximal—the part nearest to the center or to the point of origin

32. ABBREVIATIONS • Abbreviations are shortened forms of words or phrases. • Use only those accepted by the center.

33. COMPUTERS IN HEALTH CARE • Computer systems collect, send, record, and store information. • Computers do the following: • They save time. • They increase quality care and safety. • Fewer errors are made in recording. • Records are more complete. • Staff is more efficient.

34. PHONE COMMUNICATIONS • Good communication skills are needed when answering phones. • Be professional and courteous. • Practice good work ethics. • Follow the center’s policy.

35. The End