Observation & Charting

1. Observation & Charting Module 15

2. Observation • Use of senses to collect information • Senses • Sight • Touch • Hearing • Smell

3. 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

4. Observation • Learn to observe through daily contacts- note any changes or needs & REPORT • ABCs of observation • Appearance • Behavior • Communication

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Charting Guidelines • Range of Motion • Active vs. passive • Problem areas – pain or restricted movement • Progress made

17. Charting Guidelines • Positioning • Time of position changes • Observation of skin condition • Reddened areas & what treatment given • How resident tolerated position

18. Charting Guidelines • Pressure Sores • Factual observations – location, condition • Special treatment used – positioning, special equipment

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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.

25. 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.

26. Abbreviations

27. Abbreviations

28. Abbreviations

29. Abbreviations

30. Abbreviations

31. Abbreviations

32. 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

33. 24 hour clock

34. 24 hour clock

35. 24 hour clock • Each value has one hour value & one minute value • 5:03 a.m. = 0503 • 5:03 PM = 1703 • 11:57 AM = 1157 • 11:57 PM = 2357 • 12:00 midnight = 2400 or 0000 • 12:05 AM = 0005