Copyright © 2008 Delmar Learning. All rights reserved. Unit 8 Observation, Reporting, and Documentation

Copyright © 2008 Delmar Learning. All rights reserved. Objectives Spell and define terms. List the components of the nursing process. Explain the responsibilities of the nursing assistant for each component of the nursing process.

Copyright © 2008 Delmar Learning. All rights reserved. Objectives Describe two observations to make for each body system. Describe the purpose of the care plan. List three times when oral reports are given.

Copyright © 2008 Delmar Learning. All rights reserved. Objectives Describe the information given when reporting. State the purpose of the HIPAA laws. Describe the purpose of the patient’s medical record.

Copyright © 2008 Delmar Learning. All rights reserved. Objectives Explain the rules for documentation. List at least ten guidelines for computerized documentation.

Copyright © 2008 Delmar Learning. All rights reserved. Introduction One of the responsibilities of the nursing assistant: –To collect and communicate information about patients Information is collected: –By making observations of the patients

Copyright © 2008 Delmar Learning. All rights reserved. Introduction Information is communicated to other team members by reporting and documenting Nursing process –The mechanism used to carry out these actions

Copyright © 2008 Delmar Learning. All rights reserved. Diagnoses Physicians collect information –Make medical diagnoses and treat illness Nurses collect information –Use it to diagnose and treat the human response to illness –Refer to Figure 8-1

Copyright © 2008 Delmar Learning. All rights reserved. Diagnoses

Copyright © 2008 Delmar Learning. All rights reserved. Nursing Process Registered nurse –Responsible for achieving patient-focused care by using the nursing process

Copyright © 2008 Delmar Learning. All rights reserved. Nursing Process Nursing process consists of five steps: –Assessment –Problem identification –Planning –Implementation –Evaluation

Copyright © 2008 Delmar Learning. All rights reserved. Importance of the Nursing Process Nursing process is a key element in health care delivery Nursing units run more efficiently and effectively if all staff understand and use the nursing process

Copyright © 2008 Delmar Learning. All rights reserved. Importance of the Nursing Process If the nursing process breaks down: –Patients are at high risk of injury –Facility and its personnel are at high risk of legal exposure

Copyright © 2008 Delmar Learning. All rights reserved. Importance of the Nursing Process Understanding and fulfilling your role in the nursing process is an important responsibility

Copyright © 2008 Delmar Learning. All rights reserved. Critical (Clinical) Pathways DRG method of payment has affected many health care practices and shortened hospital stays Many hospitals are using critical (clinical) pathways to direct care

Copyright © 2008 Delmar Learning. All rights reserved. Making Observations An observation –Information that is obtained by using one’s senses Two types of observations: –Subjective –Objective

Copyright © 2008 Delmar Learning. All rights reserved. Making Initial Observations To make accurate observations: –You must first know what is expected or normal for an individual –For this reason, baseline information is collected when each patient is admitted to the facility

Copyright © 2008 Delmar Learning. All rights reserved. Making Initial Observations To make accurate observations: –If you help admit a patient, make observations while you are completing your assignment – It is especially important to note any possible signs of injury or skin breakdown

Copyright © 2008 Delmar Learning. All rights reserved. Pain It is very important that you be factual in reporting observations of pain and behavior Never try to judge whether a patient really has pain or how severe the pain is

Copyright © 2008 Delmar Learning. All rights reserved. Pain Pain is never normal Always report patient complaints of pain to the nurse

Copyright © 2008 Delmar Learning. All rights reserved. Confidentiality and Privacy Health Insurance Portability and Accountability Act (HIPAA) of 1996 –Increase patient control over personal medical records –Restrict use and disclosure of patient information –Make facilities accountable for protecting patient data

Copyright © 2008 Delmar Learning. All rights reserved. Confidentiality and Privacy HIPAA rules: –Require facility to implement and monitor their information release policies and procedures

Copyright © 2008 Delmar Learning. All rights reserved. Confidentiality and Privacy HIPAA rules: –Protect all individually identifiable health information in any form –Apply to paper, verbal, and electronic documentation, billing records, and clinical records

Copyright © 2008 Delmar Learning. All rights reserved. Reporting Giving an oral report –One method used to relay information from one person to another Nursing assistant may participate in oral reports several times on a shift

Copyright © 2008 Delmar Learning. All rights reserved. Documentation In some facilities: –You may be expected to record your observations on the patient’s medical record –The medical record is a document –A document is a legal record

Copyright © 2008 Delmar Learning. All rights reserved. Documentation In some facilities: –The process of recording a patient’s care, response to treatment, and progress in the patient’s chart is called charting

Copyright © 2008 Delmar Learning. All rights reserved. Charting Guidelines A patient’s medical record –Legal document that may be used in court as evidence – It is important that everything be correct and legible –All charting and records must be in clear, simple, and accurate language