Effective Techniques for Health Care Observation Recording

Recording and Reporting Personal Qualities of a Health Care Worker

Making Observations • Sense of sight • Color of skin • Swelling, edema • Rash, sores • Color of urine, stool • Amount of food eaten • Etc.

Making Observations • Sense of smell • Body odor • Unusual odors of breath, wounds, urine or stool

Making Observations • Sense of touch • Pulse • Skin dryness or temperature • Perspiration • Swelling

Making Observations • Sense of hearing • Used while listening to respirations, abnormal body sounds, coughs, speech

Two Types of Observations • Subjective • “symptoms”, cannot be seen or felt • statements by patient • Objective • “signs” that can be seen or measured • bruise, cut, rash, B/P

Basic Rules for Recording • Recorded information should be accurate, concise and complete • Writing should be neat and legible • Spelling and grammar must be correct • Only objective observations should be noted

Basic Rules for Recording • Record statements in patient’s own words, in quotation marks • Sign with name and title • Errors – cross out neatly with straight line, “error” and initials c/o pain in nek neck error KS

HIPAA • Strict standards for maintaining confidentiality of health care records • Patients must be able to see/obtain their records, and control who sees them • Health care workers must protect privacy of patient records

Effective Techniques for Health Care Observation Recording