observation & charting module 15. observation use of senses to collect information –senses...
TRANSCRIPT
Observations that should be made
Skin color & temp Mood & mental status Behavior & movement Unusual odors Respirations Responsiveness Appetite Ability to perform ADLs Elimination Pain or discomfort
Observation
Learn to observe through daily contacts- note any changes or needs & REPORT
ABCs of observation– Appearance– Behavior– Communication
Observation
Objective – Signs that you can see, hear, feel, smell – Factual, measurable, & observable
Subjective – what the resident or family tells you– Not directly seen or observed by CNA– Symptoms reported by resident
Types of Charting Documents
Resident Record & Chart– Communicates & records health history, status, &
treatment– Legal record
Kardex– Summarizes dr’s orders– Identifies critical data – allergies, code status, diet,
activity, etc.– Gives medication & treatment info
Types of Charting Documents
Nursing Care Plan– Lists resident’s need & provides specific nursing
activities that address needs– Guide for the CNA providing care
Graphic sheet– VS, I & O, Weight
ADLS sheet– Documents care at each shift for ADLs– Record on which most facilities have the care work
chart
Charting Procedures
Correct chart or ADL sheet Write legibly & neatly
– Write notes on paper first– Check for spelling & accuracy
Place events in proper sequence Chart according to facility standards Be concise, use appropriate terms & abbreviations Always use ballpoint pen – black ink
– No felt tip, fountain pens, pencils, gel pens– Use color only if approved by facility
Charting Procedures (cont)
Errors – cross out, one line– DO NOT ERASE OR USE WHITE OUT– Write “error” above the line– Initial the entry
Include resident’s complete info on each page– Some facilities have imprint stampers– If no stamper, write in name & info
Never skip lines Signature, B. McGrory, CNA
Charting Procedures (cont)
Always date & time entries Make sure you are charting on correct
date & time Chart only procedures YOU have
performed Never chart for someone else Chart only AFTER you have performed
the procedure
Charting Procedures (cont)
Chart only observations you know to be true (objective data)– Do not chart opinions– Subjective data must be in “quotation
marks” & exactly as stated
Computers & Charting
Basic principles – confidentiality & privacy
Systems are password protected– Each user has a personal password– Never share passwords– Sharing/using others’ passwords may be
grounds for termination
Legal Issues of Charting
Resident record is a legal document– Can be used in a court of law
All information in chart is confidential Information should be accurate,
objective, & truthful Have access only to charts of the
resident you are caring for
Summary of Charting Guidelines
Safety– Note safety measures done to protect him
from harm.– Restraints – type, exact time in & out,
activity done when in restraint, condition of skin, resident’s response to care given
Charting Guidelines
Emotions– Mood – angry, withdrawn, crying, etc.– Unusual symptoms showing anxiety –
picking at sheets, stuttering, tenseness, restlessness, VS changes
– Quotes “I’m afraid”– What decreases anxiety– Changes in orientation
Charting Guidelines
Range of Motion– Active vs. passive– Problem areas – pain or restricted
movement– Progress made
Charting Guidelines
Positioning– Time of position changes– Observation of skin condition– Reddened areas & what treatment given– How resident tolerated position
Charting Guidelines
Pressure Sores– Factual observations – location, condition– Special treatment used – positioning,
special equipment
Charting Guidelines
Personal hygiene– Type of treatment or care given (bath, grooming,
back care, lotion, make-up)– Why care was NOT given– Skin, mouth, hair, nails, feet descriptions– What resident can do for self– Emotional state – use own words– C/o pain, discomfort– Observe any previous problem area & make a
factual statement of current condition
Charting Guidelines
Nutrition & Fluid– Amount of food eaten (percentage)– Type & amount of food NOT eaten– Appetite– Self feed vs. fed– Problems with eating– Special diets– Intake record for residents with catheter or on
bladder training– Weekly or monthly weight
Charting Guidelines
Elimination– Record urine color, odor, amount, clarity, presence of
sediment, mucus– Time of voiding if more freq than every 2 hours– Stool size,number, & characteristics– Unusual occurrences – bright red blood, mucus, dark or
strong-smelling urine, burning, voiding small amounts, smeary or liquid feces
– Estimating incontinence • 9 in. diameter – 50 –75 cc• 12 in. diameter – 100 –125 cc• 18 in. diameter – 150 –175 cc• 24 in. diameter – 200 –300 cc
Charting Guidelines
Vital Signs– Febrile vs. afebrile– Pulses – strong, regular, weak, irregular,
thready– Respirations – regular, shallow, deep,
irregular, Cheyne-Stokes, dyspnea, orthopnea, apnea
– Blood pressure – strong, poor, HTN, hypotension
Charting Guidelines
Oxygen– Exact times on/off O2– How O2 administered– Number of liters flow per minute– Resident condition & comfort– Care given to prevent irritation to skin,
nose, mouth
Charting Guidelines
Death– Exact time of death & what observations
you made– Postmortem care – time & date body was
taken to mortuary or morgue. Record what was done with resident valuables & have a witness co-sign.
Medical terminology & Abbrev
Abbreviations are– Shortened form of words/phrases– Commonly used in health care– Designates medical specialty areas – ER,
OR, OB– Shortened forms of word or first letters –
amb, BRP, lab, etc– Shortened form of Latin or Greek word –
ad lib, prn, po, etc.
24 hour clock
Greenwich time vs. Military time One value for each minute of the day Expressed in 4 digits No colon Midnight can be expressed as 0000 or
2400
24 hour clock
12 MN 0000 2400 6:00 AM 0600
1:00 AM 0100 7:00 AM 0700
2:00 AM 0200 8:00 AM 0800
3:00 AM 0300 9:00 AM 0900
4:00 AM 0400 10:00 AM 1000
5:00 AM 0500 11:00 AM 1100
24 hour clock
12:00 PM 1200 6:00 PM 1800
1:00 PM 1300 7:00 PM 1900
2:00 PM 1400 8:00 PM 2000
3:00 PM 1500 9:00 PM 2100
4:00 PM 1600 10:00 PM 2200
5:00 PM 1700 11:00 PM 2300