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Chapter 2
Observation, Documentation, and Reporting to the RN
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 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
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 3
Subjective and Objective Observations
• Subjective– 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
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 4
Pain
• Pain means that something is wrong– It is never normal
• Patients display their pain through body language and behavior– Culture affects their response
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 5
Pain
• Never make assumptions about pain even if the patient is laughing, talking, or sleeping
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 6
Pain
• Patient and RN establish a pain management goal using a pain-rating scale.
• Become familiar with the pain scales used in your facility
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 7
Pain Rating Scale
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 8
Pain Rating Scale
• 0-10 Scale
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 9
Pain Rating Scale
• Pain Scale
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Golden Rule for Pain Reliefin 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
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 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
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 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
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 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
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 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
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 15
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
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 16
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
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 17
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
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 18
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
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 19
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
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 20
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
Copyright © 2007 Thomson Delmar Learning. ALL RIGHTS RESERVED. 21
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