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Module 15 Observing and Charting
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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
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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
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Observation – Gathering information by using the main 4 senses
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After bed bath be sure to document how res tolerated bath and her skin condition. (any skin tears, red areas, etc)
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Objective- Objective is measurable, can be seen, smelt, heard or touched Examples- temperature, # ccs of fluid output, cloudy urine, pulse #.
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Subjective Subjective is not measurable, for example res. states ……..
that she is sick to her stomach. c/o chest pain c/o being depressed
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Part B. Patient Care Plan
Ch 2 pg 16
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Care Plans- Plan-A list of resident’s needs and specific nursing activities to address those needs would be found here
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Care Plans
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ADL Sheet-Form where routine daily CNA tasks performed are charted.
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Kardex- -A quick easy resource that includes critical data, many are computer generated now
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Part C. Patient Care Documentation
Ch 4 pg 42-45
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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
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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
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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
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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
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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
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Legal Issues of Charting
Part D- Ch 4 pg 42-45
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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.
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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.
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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.
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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
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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:
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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:
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Documenting in Military Time Review military time conversions
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Medical Terminology and abbreviations
Part E- Ch 4 pg pg Medical Terminology and abbreviations
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Abbreviations from “Diversified Health Occupations” Text Book Abbreviations from local healthcare providers 2014
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