Observation, Reporting, and Documentation

1. Observation, Reporting, and Documentation Unit 8

2. Nursing Process • Steps of Nursing Process: • Assessment • Planning • Implementation • Evaluation

3. Nursing Process • Assessment: learning about the patient • Nursing assistant actions include: • Observing carefully during admission process • Listening carefully to what the patient and family say • Measuring vital signs • Reporting findings to the nurse

4. Nursing Process • Assessment: learning about the patient • Nursing assistant actions include: • Reporting changes in the patient’s condition, response, and behavior promptly • If permitted, charting or documenting • Charting: vital signs, intake/output (objective) • Documenting: observations (subjective/objective)

5. Nursing Process • Planning: preparing the nursing plan • Nursing assistant actions include: • Being informed of, and following the nursing care plan • Participating in the planning conference • Contributing information and observations that will help the team develop a plan

6. Nursing Process • Implementation: seeing that the care plan is followed • Nursing assistant actions include: • Carrying out assignments correctly • Being willing to cooperate and help other team members

7. Nursing Process • Evaluation: determine how well care plan goals have been met • Nursing assistant actions include: • Reporting your observations • Inform the nurse if an approach cannot be implemented • Informing the nurse if the patient has problems with a listed approach

8. Making Observations • Observing is an important part of the nursing assistant's job, which includes: • Using all of your senses when making observations • Noting anything unusual or extraordinary • Reporting your observations to your team leader in an accurate, timely manner

9. Making Observations • Observations of normal values: • The nursing assistant must have basic knowledge of the range of normal observations • Anything outside the range of normal should be reported to the nurse

10. Making Observations • Observations of specific body systems: • Integumentary system: • Color, temperature, flexibility (turgor), dryness, moisture, redness, open areas, bruises, swelling, scars, rashes • Musculoskeletal system: • Deformities, ability to walk, sit, or move, pain, posture, or abnormal movements • Circulatory system: • Skin color, heart rate, pulse, blood pressure, nails, lower extremities

11. Making Observations • Observations of specific body systems: • Respiratory system: • Difficulty breathing, blueness of skin, shortness of breath, rate of respirations, noisy respiration, cough • Nervous system: • Level of consciousness, response to questions, paralysis, orientation to time & place, condition of eyes & ears

12. Making Observations • Observations of specific body systems: • Urinary system: • Frequency, amount and character of urine, inability to hold urine, drainage, color of urine, blood in urine, pain during urination • Digestive system: • Appetite, tolerance to certain foods, diarrhea, constipation, gas, difficulty chewing or swallowing, unusual color or consistency of stool, nausea, vomiting

13. Making Observations • Observations of specific body systems: • Endocrine system: • Signs and symptoms of hypo/hyperglycemia • Reproductive system: • Abnormalities of the breasts, menstrual cycle, and vaginal discharge, lumps in testes, abnormal drainage from the penis • Other observations: • Pain, behavior, ability to function

14. Making Observations • Observations of pain: • Pain is never normal • Body language and facial expressions may provide clues to the presence of pain, particularly in children and cognitively impaired adults • The patient’s self-report of pain is always the most accurate; avoid making assumptions about pain (subjective) • Pain scales are used to help patients communicate level/intensity of pain

18. Reporting • A “report” is given by staff going off duty to the oncoming shift • Oral Reporting: • Most accurate because it is “up to the minute” • Face to face • Allows for questions • Allows for review of medical records, lab results, etc.

19. Reporting • A “report” is given by staff going off duty to the oncoming shift • Written report: • Less accurate • Writing can be illegible • Details can be omitted for sake of brevity • Events that occur after report is written may not be updated on report for oncoming shift • Can be “misplaced” • Can be HIPPA violation if not secured

20. Documentation • General guidelines for charting: • PRINT entries as neatly as possible, unless cursive entries are allowed – must also be neat and legible • Use BLACK ink for all entries • Use short, concise, factual phrases – no opinions • Always chart after the event – NEVER before • Always enter time of event in entry

21. Documentation • General guidelines for charting: • Leave no blank spaces when documenting • Sign EACH entry with first initial, last name and your title • NEVER, ever (next slide please…..)

22. Documentation • General guidelines for charting: • NEVER

23. Documentation • General guidelines for charting: • Leave no blank spaces when documenting • Sign EACH entry with first initial, last name and your title • NEVER, ever erase, use “white-out,” or repeatedly cross through an error. • Draw single line through error, print word “error,” and initial. Single line • Use medical terms appropriately and spell them correctly error CER

24. Documentation • General guidelines for charting: • Use international (military) time when you document, or follow your facility’s policy • 1:00 PM = 1300 Hours • 12:00 AM (midnight) = 0000 Hours