Observation & Charting

Module 15

Observation

Use of senses to collect information – Senses

• Sight• Touch• Hearing• Smell

Observations that should be made

Skin color & temp Mood & mental status Behavior & movement Unusual odors Respirations Responsiveness Appetite Ability to perform ADLs Elimination Pain or discomfort

Observation

Learn to observe through daily contacts- note any changes or needs & REPORT

ABCs of observation– Appearance– Behavior– Communication

Observation

Objective – Signs that you can see, hear, feel, smell – Factual, measurable, & observable

Subjective – what the resident or family tells you– Not directly seen or observed by CNA– Symptoms reported by resident

Types of Charting Documents

Resident Record & Chart– Communicates & records health history, status, &

treatment– Legal record

Kardex– Summarizes dr’s orders– Identifies critical data – allergies, code status, diet,

activity, etc.– Gives medication & treatment info

Types of Charting Documents

Nursing Care Plan– Lists resident’s need & provides specific nursing

activities that address needs– Guide for the CNA providing care

Graphic sheet– VS, I & O, Weight

ADLS sheet– Documents care at each shift for ADLs– Record on which most facilities have the care work

chart

Charting Procedures

Correct chart or ADL sheet Write legibly & neatly

– Write notes on paper first– Check for spelling & accuracy

Place events in proper sequence Chart according to facility standards Be concise, use appropriate terms & abbreviations Always use ballpoint pen – black ink

– No felt tip, fountain pens, pencils, gel pens– Use color only if approved by facility

Charting Procedures (cont)

Errors – cross out, one line– DO NOT ERASE OR USE WHITE OUT– Write “error” above the line– Initial the entry

Include resident’s complete info on each page– Some facilities have imprint stampers– If no stamper, write in name & info

Never skip lines Signature, B. McGrory, CNA

Charting Procedures (cont)

Always date & time entries Make sure you are charting on correct

date & time Chart only procedures YOU have

performed Never chart for someone else Chart only AFTER you have performed

the procedure

Charting Procedures (cont)

Chart only observations you know to be true (objective data)– Do not chart opinions– Subjective data must be in “quotation

marks” & exactly as stated

Computers & Charting

Basic principles – confidentiality & privacy

Systems are password protected– Each user has a personal password– Never share passwords– Sharing/using others’ passwords may be

grounds for termination

Legal Issues of Charting

Resident record is a legal document– Can be used in a court of law

All information in chart is confidential Information should be accurate,

objective, & truthful Have access only to charts of the

resident you are caring for

Summary of Charting Guidelines

Safety– Note safety measures done to protect him

from harm.– Restraints – type, exact time in & out,

activity done when in restraint, condition of skin, resident’s response to care given

Charting Guidelines

Emotions– Mood – angry, withdrawn, crying, etc.– Unusual symptoms showing anxiety –

picking at sheets, stuttering, tenseness, restlessness, VS changes

– Quotes “I’m afraid”– What decreases anxiety– Changes in orientation

Charting Guidelines

Range of Motion– Active vs. passive– Problem areas – pain or restricted

movement– Progress made

Charting Guidelines

Positioning– Time of position changes– Observation of skin condition– Reddened areas & what treatment given– How resident tolerated position

Charting Guidelines

Pressure Sores– Factual observations – location, condition– Special treatment used – positioning,

special equipment

Charting Guidelines

Personal hygiene– Type of treatment or care given (bath, grooming,

back care, lotion, make-up)– Why care was NOT given– Skin, mouth, hair, nails, feet descriptions– What resident can do for self– Emotional state – use own words– C/o pain, discomfort– Observe any previous problem area & make a

factual statement of current condition

Charting Guidelines

Nutrition & Fluid– Amount of food eaten (percentage)– Type & amount of food NOT eaten– Appetite– Self feed vs. fed– Problems with eating– Special diets– Intake record for residents with catheter or on

bladder training– Weekly or monthly weight

Charting Guidelines

Elimination– Record urine color, odor, amount, clarity, presence of

sediment, mucus– Time of voiding if more freq than every 2 hours– Stool size,number, & characteristics– Unusual occurrences – bright red blood, mucus, dark or

strong-smelling urine, burning, voiding small amounts, smeary or liquid feces

– Estimating incontinence • 9 in. diameter – 50 –75 cc• 12 in. diameter – 100 –125 cc• 18 in. diameter – 150 –175 cc• 24 in. diameter – 200 –300 cc

Charting Guidelines

Vital Signs– Febrile vs. afebrile– Pulses – strong, regular, weak, irregular,

thready– Respirations – regular, shallow, deep,

irregular, Cheyne-Stokes, dyspnea, orthopnea, apnea

– Blood pressure – strong, poor, HTN, hypotension

Charting Guidelines

Oxygen– Exact times on/off O2– How O2 administered– Number of liters flow per minute– Resident condition & comfort– Care given to prevent irritation to skin,

nose, mouth

Charting Guidelines

Death– Exact time of death & what observations

you made– Postmortem care – time & date body was

taken to mortuary or morgue. Record what was done with resident valuables & have a witness co-sign.

Medical terminology & Abbrev

Abbreviations are– Shortened form of words/phrases– Commonly used in health care– Designates medical specialty areas – ER,

OR, OB– Shortened forms of word or first letters –

amb, BRP, lab, etc– Shortened form of Latin or Greek word –

ad lib, prn, po, etc.

Abbreviations

Drsg Dx ECG EEG

ER F FBS FF

Fld Ft Gal GI

Hr or h H20 HS ht

Abbreviations

Ht ICU In I & O

IV L Lab Lb

Liq LLQ LMP LVN

Lt LUQ Meds MN

Abbreviations

Min ml NA CNA

Neg Nil Noc NPO

O2 OB OJ OOB

OR OT Oz pc

Abbreviations

Peds Per PM po

Postop Preop Prep Prn

Pt PT Q qd

qh qhs qid qod

Abbreviations

R RLQ RN ROM

RR RUQ S SSE

Stat Tbsp tid TLC

TPR U/A VS WBC

Abbreviations

W/c Wt

tsp

24 hour clock

Greenwich time vs. Military time One value for each minute of the day Expressed in 4 digits No colon Midnight can be expressed as 0000 or

2400

24 hour clock

12 MN 0000 2400 6:00 AM 0600

1:00 AM 0100 7:00 AM 0700

2:00 AM 0200 8:00 AM 0800

3:00 AM 0300 9:00 AM 0900

4:00 AM 0400 10:00 AM 1000

5:00 AM 0500 11:00 AM 1100

24 hour clock

12:00 PM 1200 6:00 PM 1800

1:00 PM 1300 7:00 PM 1900

2:00 PM 1400 8:00 PM 2000

3:00 PM 1500 9:00 PM 2100

4:00 PM 1600 10:00 PM 2200

5:00 PM 1700 11:00 PM 2300

24 hour clock

Each value has one hour value & one minute value– 5:03 a.m. = 0503– 5:03 PM = 1703– 11:57 AM = 1157– 11:57 PM = 2357– 12:00 midnight = 2400 or 0000– 12:05 AM = 0005