Observations, Recording, and Reporting Nursing Fundamentals Unit 2.02

General Observations General appearance and position Skin Eyes, ears, nose, and mouth Breathing Abdomen “belly”, bowels, bladder Mobility and function, movements Activities of daily living

General Observations Activities of daily living Mental condition, mood Nutrition / hydration level Sleeping habits Pain, discomfort, complaints

What do you see? Examples using sight: Rash, skin color, bruising, swelling Presence of blood or discharge Condition of the resident’s environment

What do you hear? Wheezing, moans Words spoken by the resident, friends, or family Water dripping in the sink, toilet running over

What do you feel? Lumps Temperature of skin Change in pulse

What do you smell? Odor of breath or body Odor of urine or feces Diabetes-Fruity Odor of urine or feces Trash cans with soiled under pads

What do you taste? JK!!

Documentation Facts Observations made by the nurse aide must be shared with the health care team through verbal communication or written communication for continuity of care

Reporting Facts Reporting - Verbal sharing of resident information Abnormal observations must be REPORTED immediately to the nurse in addition to being recorded/documented

Recording Writing resident information is also called charting or documenting

Nurse Aide documentation of observations are an essential part of the Minimum Data Set (MDS) The MDS is a detailed form used by nurses for resident assessment Observations reported and documented by the nurse aide may indicate illness or “trigger” the need for additional resident assessment by the nurse A new MDS must be done when there is any major change in resident condition

Record/document using the tool specified by the nursing care facility Hardcopy “check-off” sheet for recording/documenting resident care (also called ADL or flow sheet) Electronically on portable devices or touch screen input devices (example: CareTracker®)

Documentation is given to insurance companies to receive payment for services

Documentation papers become a part of the resident’s medical record or chart Medical records/charts are legal records and may be used in court Documentation on medical records provide legal proof that something has been done or observed If it isn’t recorded, it did not happen

Documentation on Hard Copy Information can be recorded on a notepad at the bedside and used later for official reporting and recording/documenting Do not rely on memory alone Avoid using little pieces of paper to write information on Avoid writing on gloves Destroy all notes after official documentation is completed Don’t confuse data from one resident to another

Documentation Record/document AFTER care is given Be careful, clear, and concise in your documentation Record facts not opinions Write neatly, legibly, using a black pen Sign your full name, title, and write the correct date You may need to document time using the 24-hour clock or military time

Correcting mistakes Draw one line through it Write the correct word or words, put your initials and date Never erase what you have written Do not use correction fluid

Electronic Charting The nursing facility will provide hands on training for the specific type of electronic charting system used Make sure nobody can see patient information on the computer screen

Electronic Charting Basics Caregiver uses biometric thumbprint or password for secure access Caregiver goes to their home page Selects “resident charting” Select “category” or “resident” to begin to enter the data observed and tasks performed Each entry is time and date stamped and signed digitally by the nurse aide Tasks icons are highlighted at the beginning of the shift As tasks are completed and documented in the system, the icons change color

Specific events requiring reporting and documentation Incident report An accident or an unexpected event during the course of care is considered an “incident” and must be reported State and federal guidelines require incidents to be recorded in an incident report Protect everyone involved; resident, your employer, and you Complete the incident as soon as possible and give it to the charge nurse

The following occurrences are considered Incidents A resident falls (all falls must be reported, even if the resident says he or she if fine You or a resident break or damage something You make a mistake in care A resident or a family member makes a request that is our of your scope of practice

A resident or family member makes sexual advances or remarks Anything happens that makes you feel uncomfortable, threatened, or unsafe You get injured on the job You are exposed to blood or body fluids

Guidelines for Incident Reports Tell what happened. State the time, and the mental and physical condition of the person Tell how the person tolerated the incident State the facts; do not give opinions Do not write anything in the incident report on the medical record (incident reports are confidential) Describe the action taken to give care Include suggestions for change Never place any blame or liability within the report

Resident abuse Nurse aides have ethical and legal responsibility to observe for and report suspected resident abuse, it is the law, not an option Support residents who want to make a complaint themselves Give as much information as possible when reporting abuse

Must follow the chain of command when reporting abuse Report suspected abuse to nurse first If action is not taken, keep reporting up the chain of command Report up the of command until action is taken

If no appropriate action is taken at the facility level Call the complaint hotline at 1-800-624-3004 within NC Hotline operates 8:30am to 4:00pm weekdays, except holidays Call the County Department of Social Services – Adult Protective Services Section If life or death situation witnessed, remove the resident to a safe place if possible, get help immediately or send for help, do not leave the resident

Observations that may indicate abuse and neglect Suspicious injuries Unexplained change in behavior, example withdrawal