1. Recording and Reporting
Charting
Recording and Reporting

2. Recording and Reporting
Health care workers must listen carefully AND make observations
They use their senses to make certain observations about their patient and report them.

3. Use your senses to See Smell Color of skin, swelling, edema
Presence of rash or sore
Color of urine or stool
Amount of food eaten
Smell
Body odor
Unusual odors of breath, wounds, urine or stool

4. Use your senses Touch Hearing Pulse Dryness or temp of skin
Perspiration
swelling
Hearing
Respirations
Abnormal body sounds
Coughs
speech

5. Charting and Reporting
Observations should be reported accurately – use facts and report what you say, not the reasons.
NOT – Mr. Ruiz is in pain
INSTEAD – Mr. Ruiz is moaning and holding his left side.
Observations on a patient’s health record should be accurate, concise, and complete.

6. Charting Objective observations – what was seen.
DO NOT record what you feel or think.
If a patient’s statement is recorded, use the pt’s own words and quotation marks.
Sign entries with name and title of the person recording information.
Cross out errors neatly with a straight line, write “error” and initial error.

7. Subjective Data What you think or feel. May or may not be accurate.
Based on assumptions.
Not advisable to use on medical charts.

8. Subjective (continued)
Example: Ms. Jones is visiting with family and laughing. She is not in pain right now.

9. Subjective example…….
Ms. Smith has a bad headache.

10. Objective Data What is actually seen. Only facts documented
Best way to document on medical record.

11. Example
Ms. Jones is sitting on couch with family and friends surrounding her, smiling and looking at camera.

12. Example
Ms. Smith has her eyes closed and is holding her forehead with both hands.

13. Record your observations

14. Record Your Observation

15. Record your observations