1. Module 15 Observing and Charting

2. Module & Chapter Guides
Part A-Ch 4 pg 42, ch 9*, ch18*, ch 17*, Ch 18 pg , ch 16 pg , ch 17 pg
Observation of patients and reporting responsibility
Part B-Ch 2 pg 16
Patient care plan
Part C- Ch 4 pg 42-45
Patient Care Documentation
Part D- Ch 4 pg 42-45
Legal Issues of Charting
Part E- Ch 4 pg pg
Medical Terminology and abbreviations

3. Part A. Observation of Patients and Reporting Responsibility
A-Ch 4 pg 42, ch 9*, ch18*, ch 17*, Ch 18 pg , ch 16 pg , ch 17 pg

4. Observation – Gathering information by using the main 4 senses

5. After bed bath be sure to document how res tolerated bath and her skin condition. (any skin tears, red areas, etc)

6. Objective- Objective is measurable, can be seen, smelt, heard or touched Examples- temperature, # ccs of fluid output, cloudy urine, pulse #.

7. Subjective Subjective is not measurable, for example res. states ……..
that she is sick to her stomach.
c/o chest pain
c/o being depressed

8. Part B. Patient Care Plan
Ch 2 pg 16

9. Care Plans- Plan-A list of resident’s needs and specific nursing activities to address those needs would be found here

10. Care Plans

11. ADL Sheet-Form where routine daily CNA tasks performed are charted.

12. Kardex- -A quick easy resource that includes critical data, many are computer generated now

13. Part C. Patient Care Documentation
Ch 4 pg 42-45

14. Accurate report of a residents status
The following occurrences should be reported immediately:
Falls Severe Headaches
Chest Pain
Difficulty Breathing
Abnormal Pulse, Respirations or BP
Changes in mental status

15. Accurate report of a resident’s status (cont’d):
Occurrences to be reported immediately (cont’d):
Sudden weakness or loss of mobility
High fever
Loss of or change in consciousness
Bleeding
Change in condition
Signs of abuse

16. List qualities of urine and identify signs and symptoms about urine to report
The following are normal characteristics of urine:
Adults produce about 1200 to 1500 mL of urine, although the elderly may produce less.
Light, pale yellow, or amber color.
Clear or transparent
Faint smell

17. Urine to Report Report these signs and symptoms related to urine:
Cloudy urine
Dark or rust-colored urine
Strong, offensive, or fruity smelling urine
Pain, burning, or pressure when urinating
Blood, pus, mucus, discharge
Protein or glucose in urine
Incontinence

18. Documentation Forms and Terms
A medical chart is a legal record of a residents care. It contains:
Admission Chart
Residents medical history
Doctor’s orders
Progress notes
Lab/test results
Graphic results
Nurses notes
Flow chart/ ADL sheet

19. Legal Issues of Charting
Part D- Ch 4 pg 42-45

20. Must use black ink, Correct errors using “SLIDE” rule
Must use black ink, Correct errors using “SLIDE” rule! Draw a single line through the entry, write the word error above the line, date it and initial the entry, then write correct entry. Documentation gives you an up to date record of each residents care.

21. Documentation Res. medical chart is a legal document.
In court what is written in the chart is what is considered to have actually happened.
If it was not charted, it did
not happen, legally speaking.
Failing to document could
cause you serious legal problems.

22. 24-hr Clock “Military Time”
The 24-hour clock, or military time, has been used for decades in the medical field as a concise method of demonstrating time. This method begins at midnight, or 0000 hour, and runs consecutively until 2359,
or 11:59 Greenwich time. This method
uses a special two-digit system so
a.m. and p.m. are not needed.
Military time is used to eliminate the confusion regarding time of day for medical records.

23. 24-hr Clock “Military Time”
Regular Time
Military Time
Midnight
0000 or 2400
Noon
1200
1:00 a.m.
0100
1:00 p.m.
1300
2:00 a.m.
0200
2:00 p.m.
1400
3:00 a.m.
0300
3:00 p.m.
1500
4:00 a.m.
0400
4:00 p.m.
1600
5:00 a.m.
0500
5:00 p.m.
1700
6:00 a.m.
0600
6:00 p.m.
1800
7:00 a.m.
0700
7:00 p.m.
1900
8:00 a.m.
0800
8:00 p.m.
2000
9:00 a.m.
0900
9:00 p.m.
2100
10:00 a.m.
1000
10:00 p.m.
2200
11:00 a.m.
1100
11:00 p.m.
2300

24. Convert the following times:
1:15 am 1
2:35 pm 2
1210 3
2:45 am 4
0414 5
1800 6
8:25 am 7
11:30 pm 8
12:00 pm 9
0110 10
3:25 pm 11
9:15 pm 12
2125 13
1505 14
10:40 pm 15
2400 16
11:35 am 17
8:55 pm 18
2300 19
0845 20
Convert the following times:

25. Convert the following times:
Greenwich
Military 1
1:15 am 2
2:35 pm 3
1210 4
2:45 am 5
0414 6
1800 7
8:25 am 8
11:30 pm 9
12:00 pm 10
0110 11
3:25 pm 12
9:15 pm 13
2125 14
1505 15
10:40 pm 16
2400 17
11:35 am 18
8:55 pm 19
2300 20
0845
Convert the following times:

26. Documenting in Military Time Review military time conversions

27. Medical Terminology and abbreviations
Part E- Ch 4 pg pg
Medical Terminology and abbreviations

28. Abbreviations from “Diversified Health Occupations” Text Book
Abbreviations from local healthcare providers 2014