How to Write a Field Note Mrs. Kimberly Petronella New Visions Health Professions

Purpose 1. Provides documentation of what you witnessed and learned 2. Allows others to learn from your experience 3. Allows you the opportunity to reflect on your learning activities Provides an opportunity for you to use your medical terminology you are learning and actively engage in medical documentation

How Do I Write This? 1. You should take notes of the things you are witnessing, although you must be aware of HIPAA laws and regulations Never take notes in front of a patient, it will cause them to grow uneasy of you and may cause them to wonder what your motives are for writing down this information. Write your notes once you are away from the patient, but never use names, room numbers or identifying information 2. On the next few slides we will go step by step though the process of writing your field notes. Some highlights include : Always complete your field notes thoroughly : Always use proper spelling and medical terminology

Example Function/Activity Performed/Observation Procedure/Reasons New Visions Health Professions Field Notes Name: __Student Sally____________________________________ Date: _10/20/2016___________________ Department: ____AC 3 St. Luke’s Hosptial_______________________________________________________________ Function/Activity Performed/Observation Procedure/Reasons Reactions  I observed a patient care technician prepare measure a blood pressure on an 82-year-old male patient.  The care technician first identified herself to the patient, she then asked the patient to state their name and state their birth date. Once she was sure of proper identification, she washed her hands and explained the procedure to the patient. She then asked the patient which arm they preferred to have their blood pressure taken in, the patient stated they didn’t care. The care technician then, exposed the patients bare skin on their arm. She then placed the blood pressure cuff over the upper arm, above the elbow. She used her fingers to palpate a brachial pulse, she then cleaned the stethoscope before placing on the patient, once cleaned she placed the diaphragm of the stethoscope over the pulse site. She began to inflate the cuff, then she turned the valve to open it slowly to let air escape while she was listening, and viewing the gauge. She then removed the stethoscope and blood pressure cuff and cleaned up all her equipment, she asked the patient if he needed anything, gave the call light, washed her hands then documented and stored equipment.  I was so shocked to see how many steps there were involved with taking a blood pressure , and how quickly she was able to read the blood pressure reading.  

Example findings From the example I showed you what do you see? Is anything missing, should things be added? Discuss this with your group and we will review your findings.

Connections/Parallels/Reminds Me of…..  This reminded me of when I have my blood pressure taken when I go to the doctors for my appointments.   Scrap Book- Clippings, poems, cartoons, reactions   This is an example of a blood pressure cuff and someone inflating the cuff to attempt to perform a blood pressure reading. Identify any economic issues evident in this department or with this skill. (Budgeting, supplies, demands, etc.…)  I noticed while performing this procedure, the care technician used several alcohol prep pads, so the hospital must go through a large amount of these throughout the day/shift, I also noticed that the blood pressure cuffs were reusable, which would be cost effective in a hospital environment. Document any government involvement pertaining to your experience in this department or with this procedure documented. (Laws, regulations, etc.…)  I noticed that the care attendant identified the patient not only by name but verified their date of birth and hand verified the name band also. This triple checks allows for the care attendant to know they are performing the procedure on the correct patient, which would follow the HIPAA laws and patient rites acts.

Example Findings From the example I showed you what do you see? Is anything missing, should things be added? Discuss this with your group and we will review your findings.

Dos and Don’ts In your groups complete the chart before you, we will discuss this together.

Okay, Now it’s time to write one https://www.youtube.com/watch?v=DHuOIcxJTIY Using the video clip above we will be watching a venipuncture being performed. This is a very common procedure done at the clinical sites. Once the video clip is completed you will work with your groups to complete the field notes on what you observed, just as you would with any observation you would make at your sites. We will discuss this as a class once everyone is through.