1. Observation, Documentation, and Reporting to the RN
Chapter 2
Observation, Documentation, and Reporting to the RN

2. Subjective and Objective Observations
Signs
Seen by using your senses; usually indicate disease or abnormalities
Symptoms
What patients tell you about their conditions
Cannot be seen by others or detected by using your senses
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3. Subjective and Objective Observations
Observations may or may not be factual
Based on what you think
Based on information the patient gives you (may or may not be true)
Objective
Factual and can be observed by others
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Pain
Pain means that something is wrong
It is never normal
Patients display their pain through body language and behavior
Culture affects their response
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Pain
Never make assumptions about pain even if the patient is laughing, talking, or sleeping
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Pain
Patient and RN establish a pain management goal using a pain-rating scale.
Become familiar with the pain scales used in your facility
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Pain Rating Scale
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Pain Rating Scale
0-10 Scale
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Pain Rating Scale
Pain Scale
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10. Golden Rule for Pain Relief in Children
Whatever is painful to adults is painful to children
Pain control should be based on scientific facts, not personal opinions
Never lie
Admit that a procedure will hurt
Make the child as comfortable as possible
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11. Health Insurance Portability and Accountability Act (HIPAA)
1996 Law
Increases patient control over medical records
Restricts use and disclosure of information
Makes facilities accountable for protecting patient data
Protects all individually identifiable health information
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12. Health Insurance Portability and Accountability Act (HIPAA)
Patient information provided to staff on a “need to know” basis
Facilities analyze how and where patient information is used
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13. Health Insurance Portability and Accountability Act (HIPAA)
Procedures for protecting confidential data
Areas where charts are stored
Places patients are discussed
How personal information is distributed
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14. Documentation Means of communication Health care maxim:
“If it’s not charted, it wasn’t done!”
Information on the medical record is used by many individuals
Record must be objective, accurate, and complete
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Documentation
Document only your care and observations
Never document in advance
Avoid documenting care that is supposed to be given (turning every two hours)
If you forget to document
Follow facility policies for making a late entry
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Documentation
Nursing personnel cannot legally choose between giving care and keeping records
Sometimes patient care is put ahead of documentation
Results in incorrect or incomplete documentation
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Documentation
Nursing personnel focus on treating the human response to illness
Physicians focus on the disease, illness, or injury
Access to nursing information, observations, and procedures is critical
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Documentation
Is part of patient’s care, as well as validation that care was given
Computers are commonly used for documentation in health care facilities
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Documentation
HIPAA
Affects all health care communication, especially information technology (IT)
Information is limited to essential care
IT can track who is accessing any patient's record
Can identify misuse of the system
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Documentation
When using a computer:
Use password that is not easily deciphered
Never share your password
Turn the monitor so it is not visible to others
Access only information you are authorized to obtain
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Documentation
When using a computer
Make sure your documentation is objective, accurate, and complete
Always wash your hands after using a computer even if it has a plastic cover
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