copyright © 2008 delmar learning. all rights reserved. unit 8 observation, reporting, and...

Copyright © 2008 Delmar Learning. All rights reserved.

Unit 8

Observation,

Reporting, and Documentation


Objectives

• Spell and define terms.• List the components of the nursing

process.• Explain the responsibilities of the

nursing assistant for each component of the nursing process.


Objectives

• Describe two observations to make for each body system.

• Describe the purpose of the care plan.• List three times when oral reports are

given.


Objectives

• Describe the information given when reporting.

• State the purpose of the HIPAA laws.• Describe the purpose of the patient’s

medical record.


Objectives

• Explain the rules for documentation.• List at least ten guidelines for

computerized documentation.


Introduction

• One of the responsibilities of the nursing assistant: – To collect and communicate information

about patients

• Information is collected:– By making observations of the patients


Introduction

• Information is communicated to other team members by reporting and documenting

• Nursing process– The mechanism used to carry out these

actions


Diagnoses

• Physicians collect information– Make medical diagnoses and treat illness

• Nurses collect information– Use it to diagnose and treat the human

response to illness– Refer to Figure 8-1


Diagnoses


Nursing Process

• Registered nurse– Responsible for achieving patient-focused

care by using the nursing process


Nursing Process

• Nursing process consists of five steps:– Assessment– Problem identification– Planning– Implementation– Evaluation


Importance of the Nursing Process

• Nursing process is a key element in health care delivery

• Nursing units run more efficiently and effectively if all staff understand and use the nursing process



• If the nursing process breaks down:– Patients are at high risk of injury – Facility and its personnel are at high risk of

legal exposure



• Understanding and fulfilling your role in the nursing process is an important responsibility


Critical (Clinical) Pathways

• DRG method of payment has affected many health care practices and shortened hospital stays

• Many hospitals are using critical (clinical) pathways to direct care


Making Observations

• An observation – Information that is obtained by using one’s

senses

• Two types of observations:– Subjective– Objective


Making Initial Observations

• To make accurate observations:– You must first know what is expected or

normal for an individual– For this reason, baseline information is

collected when each patient is admitted to the facility


Making Initial Observations

• To make accurate observations:– If you help admit a patient, make

observations while you are completing your assignment

– It is especially important to note any possible signs of injury or skin breakdown


Pain

• It is very important that you be factual in reporting observations of pain and behavior

• Never try to judge whether a patient really has pain or how severe the pain is


Pain

• Pain is never normal• Always report patient complaints of pain

to the nurse


Confidentiality and Privacy

• Health Insurance Portability and Accountability Act (HIPAA) of 1996– Increase patient control over personal

medical records– Restrict use and disclosure of patient

information– Make facilities accountable for protecting

patient data



• HIPAA rules:– Require facility to implement and monitor

their information release policies and procedures



• HIPAA rules:– Protect all individually identifiable health

information in any form– Apply to paper, verbal, and electronic

documentation, billing records, and clinical records


Reporting

• Giving an oral report – One method used to relay information from

one person to another

• Nursing assistant may participate in oral reports several times on a shift


Documentation

• In some facilities:– You may be expected to record your

observations on the patient’s medical record

– The medical record is a document – A document is a legal record


Documentation

• In some facilities:– The process of recording a patient’s care,

response to treatment, and progress in the patient’s chart is called charting


Charting Guidelines

• A patient’s medical record – Legal document that may be used in court

as evidence– It is important that everything be correct

and legible– All charting and records must be in clear,

simple, and accurate language

copyright © 2008 delmar learning. all rights reserved. unit 8 observation, reporting, and...

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