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 name and title Errors – cross out neatly with straight line, “error” and initials c/o pain in nek neck error KS

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