Recording and Reporting

Personal Qualities of a Health Care Worker

Making Observations

• Sense of sight Color of skin Swelling, edema Rash, sores Color of urine, stool Amount of food eaten Etc.

Making Observations

• Sense of smell Body odor Unusual

odors of breath, wounds, urine or stool

Making Observations

• Sense of touch Pulse Skin dryness or

temperature Perspiration Swelling

Making Observations

• Sense of hearing Used while

listening to respirations, abnormal body sounds, coughs, speech

Two Types of Observations

• Subjective “symptoms”, cannot be seen or

felt statements by patient

• Objective “signs” that can be seen or

measured bruise, cut, rash, B/P

Basic Rules for Recording

• Recorded information should be accurate, concise and complete

• Writing should be neat and legible

• Spelling and grammar must be correct

• Only objective observations should be noted

Basic Rules for Recording

• Record statements in patient’s own words, in quotation marks

• Sign with your name and title

• Errors – cross out neatly with straight line, “error” and initials

Use blue or black ink ONLY

c/o pain in nek neck

HIPAA

• Strict standards for maintaining confidentiality of health care records

• Patients must be able to see/obtain their records, and control who sees them

• Health care workers must protect privacy of patient records