chapter 2 observation, documentation, and reporting to the rn

Chapter 2

Observation, Documentation, and Reporting to the RN

Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 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


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


Pain

• Pain means that something is wrong– It is never normal

• Patients display their pain through body language and behavior– Culture affects their response


Pain

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


Pain

• Patient and RN establish a pain management goal using a pain-rating scale.

• Become familiar with the pain scales used in your facility


Pain Rating Scale


Pain Rating Scale

• 0-10 Scale


Pain Rating Scale

• Pain Scale


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


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



• Patient information provided to staff on a “need to know” basis

• Facilities analyze how and where patient information is used



• Procedures for protecting confidential data– Areas where charts are stored– Places patients are discussed– How personal information is distributed


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


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


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


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


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


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


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


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

chapter 2 observation, documentation, and reporting to the rn

Documents

thomson delmar learning

pain rating scalecopyright

pain scales

pain rating scale0

painrating scale

pain reliefin childrenwhatever

pain management goal

health insurance portability