Advanced Skills for Health Care Providers, Second Edition Barbara Acello Thomson Delmar Learning, 2007 Chapter 2 Observation, Documentation, and Reporting to the RN

OBJECTIVES: Spell and define key terms Spell and define key terms Differentiate between signs and symptoms Differentiate between signs and symptoms Differentiate between subjective and objective observations Differentiate between subjective and objective observations Describe how to report and record patient information (continued) Describe how to report and record patient information (continued)

Objectives (continued) Describe how to identify pain by making observations of facial expressions, gestures, movement, and body language Describe how to identify pain by making observations of facial expressions, gestures, movement, and body language State the purpose of the medical record State the purpose of the medical record List 10 guidelines for documenting in the medical record List 10 guidelines for documenting in the medical record

COMMUNICATING WITH OTHER MEMBERS OF THE HEALTH CARE TEAM Good communication is one of the keys to team success the keys to team success Communication can be verbal or written Communication can be verbal or written Reporting is usually verbal Reporting is usually verbal Recording / Documenting is written Recording / Documenting is written

Confidentiality and Privacy THE MEDICAL RECORD IS A PRIVATE AND CONFIDENTIAL DOCUMENT THE MEDICAL RECORD IS A PRIVATE AND CONFIDENTIAL DOCUMENT ALL STAFF ARE RESPONSIBLE FOR PROTECTING PATIENT INFORMATION FROM ACCESS BY UNAUTHORIZED PERSONS ALL STAFF ARE RESPONSIBLE FOR PROTECTING PATIENT INFORMATION FROM ACCESS BY UNAUTHORIZED PERSONS

More on Confidentiality & Privacy You should never read the patient charts out of curiosity You should never read the patient charts out of curiosity Medical records and other patient data should be accessed only by those with a need to know the information Medical records and other patient data should be accessed only by those with a need to know the information Privacy of patient information is protected by the 1996 law HIPAA Privacy of patient information is protected by the 1996 law HIPAA

HIPAA – Health Insurance Portability and Accountability Act Passed in 1996 by Congress, it concerns privacy, confidentiality, and medical records. The HIPAA rules: Increase patient’s control over their medical records Increase patient’s control over their medical records Restrict use and disclosure of pt info Restrict use and disclosure of pt info Make facilities accountable for protecting patient data Make facilities accountable for protecting patient data Require the facility to implement and monitor info release policies and procedures Require the facility to implement and monitor info release policies and procedures

HIPAA Protects all identifiable health information: Paper Paper Verbal Verbal Electronic documentation Electronic documentation Billing records Billing records Clinical records Clinical records

Patient information is given to staff on a “need to know” basis Staff members need that info to carry out their duties, ex., dietary needs to know if patient is on a special diabetic diet or has food allergies, they would not need to know why the patient is in the hospital Staff members need that info to carry out their duties, ex., dietary needs to know if patient is on a special diabetic diet or has food allergies, they would not need to know why the patient is in the hospital Policies must protect patient information which includes charts, verbal communication, faxes & other disclosure Policies must protect patient information which includes charts, verbal communication, faxes & other disclosure

HIPAA rules ask providers: To analyze how and where patient information is used To analyze how and where patient information is used To develop procedures for protecting confidential data which includes To develop procedures for protecting confidential data which includes Where patient charts are kept Where patient charts are kept Places where patient information is discussed Places where patient information is discussed Ways that patients’ health info is distributed Ways that patients’ health info is distributed

OBSERVING THE PATIENT You are responsible for Making observations Making observations Reporting observations to the RN Reporting observations to the RN PCTs spend most of their time providing direct patient care and will notice changes that need to be reported immediately

Use Your Senses to Make Observations Many changes are things you can see Changes in movement / position Changes in movement / position Facial expression Facial expression Skin color change Skin color change These changes may suggest pain or other serious problems

Use Your Senses to Make Observation (continued) You will hear some changes like noisy breathing and things the patient tells you You will smell some changes that give unusual odors You will feel some changes like temperature change or moisture

Observing the Patient is a Continuous Process If you see, feel, hear, or smell anything that seems abnormal, report it to the RN If you see, feel, hear, or smell anything that seems abnormal, report it to the RN Even changes that seem insignificant may indicate a problem Even changes that seem insignificant may indicate a problem The nurse will select the course of action The nurse will select the course of action Also observe for safety, comfort and other environmental factors Also observe for safety, comfort and other environmental factors

For Example A red area on the skin may seem minor but the area can quickly turn into a pressure sore A red area on the skin may seem minor but the area can quickly turn into a pressure sore A patient receiving blood can state he feels cold. Your first reaction may be to get a blanket. Chilling is a sign of transfusion reaction which is very serious and must be reported immediately A patient receiving blood can state he feels cold. Your first reaction may be to get a blanket. Chilling is a sign of transfusion reaction which is very serious and must be reported immediately

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