Documentation and reporting

As a nursing assistant, you represent a connection between your clients and other healthcare professionals. So, a major part of your job is to report and document, or record, all the relevant information that’s related to the clients under your care.

Now, for this, you need to make observations, which are defined as something you notice about your client, especially any changes in the client’s physical or mental condition. There are two types of observations: objective and subjective.

Objective observations are typically detected with your senses. For example, you can see a skin rash; you can hear a client’s noisy breathing or coughing; you can smell unpleasant odors; and finally, you can touch a client's skin and feel if it’s cold, warm, wet, or dry.

In addition, objective observations can also be measured. For example, you can measure the client’s vital signs, such as body temperature, blood pressure, and pulse. Objective observations provide objective data called signs.

On the other hand, subjective observations cannot be directly detected or measured. Instead, they include any information reported to you by clients, such as discomfort, dizziness, or weakness.

As an example, a client may complain about nausea or bloating. You can’t see, hear, smell, feel, or measure their discomfort, but the client can describe it to you. Subjective observations provide subjective data, which are called symptoms.

Now, switching gears and moving on to communication among healthcare team members. The most common way of communication is reporting.

This is a verbal form of communication about the client’s condition. As a nursing assistant, there are several things that you should always report to the nurse.

The first thing to keep in mind are observations that suggest changes in the client’s condition as well as observations concerning the client’s response to a new procedure or therapy.

Next, make sure you report when a client complains of symptoms, like pain and discomfort, or refuses therapy. In addition, one of your clients may have specific requests, such as requesting a clergy, and you should report that as well.

As part of the healthcare team, remember that you should always report when you are taking a break or need to leave the unit for some reason.

Now, when reporting to the nurse, keep in mind that there are several general rules you must follow. First, you should only report what you did yourself or observed during your shift.