Documentation and reporting

Definitions & Key takeaways

Documentation and reporting are important in any field, especially in the medical field. As a medical professional, you are required to keep accurate records of your patients' conditions and treatments. This information can help assess the patient's progress and determine the best course of treatment. In addition, good documentation can also help protect you from potential malpractice lawsuits. So it's essential to ensure your documentation is clear and concise and that you are up-to-date on the latest reporting requirements.

Chapters:

Watch video only

Introduction0:00–0:25

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.

Observations0:25–1:43

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.

Reporting1:43–4:41

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. Next, always give the client’s full name and room and bed number.
Be sure to report the changes in a client’s condition as often as their condition requires or whenever the nurse asks you to do so.
Try to be prompt, thorough, and accurate. With objective observations, you should be specific and avoid giving your opinion.
For example, you shouldn’t say, “The client was probably tired, so he got out of the bed at noon.” Instead, you should say, “The client didn’t get out of bed until noon.” On the other hand, when reporting subjective observations, you should repeat them the exact same way the client said them to you.
For example, you shouldn’t say, “The client couldn’t walk.” Instead, you should say, “The client said that he felt too weak to walk.” Additionally, report any specific requests or needs that the client may have.
For example, the client may require assistance with grooming. Also, report any expected or unexpected changes in the client’s condition.
For example, the client may experience dizziness in the evening. A tip to make sure you give a concise and clear report is to write everything down.
Finally, it’s important to always report the time of your observations or the care that was given. You should report the time according to your facility’s policy by using a 24-hour clock format or a conventional time format, which specifies AM or PM.One form of reporting is the end-of-shift report, which is also known as the change-of-shift report.
As the name implies, in this type of the report, the healthcare workers on duty meet with the workers that will be on the next shift to inform and update them about the client’s condition, possible changes, the care given, and any procedures or therapy performed during the previous shift.Another type of communication among the healthcare team members is documentation, which is also known as charting or recording.

Documentation4:41–9:19

Documentation is the written form of communication about the client’s condition. The goal of documentation is to allow everyone on the healthcare team to know the client's status, any special needs or concerns, and plans for ongoing care.
This can be done on paper or electronically.Now, documentation requires tools, such as medical records and the Kardex. First, let’s focus on a medical record, which is also known as a client’s chart.
The client’s medical record contains information about the client's current condition as well as diagnostic and treatment procedures that have been performed and the client’s response to care.
It’s important to note that a medical record is a legal document that can be used as evidence in court, so it must be clear, concise, and accurate.A medical record is subdivided into several sections.
Each section contains specific forms, and the most important ones are admission records, medical history, nursing history, physician’s order sheet, medication administration record, physician’s progress notes, narrative nurse’s notes, graphic sheet, and finally, miscellaneous documents.
First, let’s focus on the admission record, which is obtained at the time of admission to the facility. The client’s admission record contains personal information, including the client’s name, gender, date of birth, age, address, marital status, and advance healthcare directive.
Moreover, this form contains the date and time of admission and the doctor’s name. The admission record also includes the client’s social security number, insurance and employment information, known allergies, and previous diagnosis.
Finally, it’s important to note that the admission record contains the client’s identification, or ID, number, which must match with their ID bracelet.
The client’s healthcare provider then completes the second part of the medical record, which is the medical history. This part contains details about the client’s previous and current conditions, procedures, and medications.
Next, the nurse completes the nursing history and obtains information about physical limitations or disabilities; use of assistive devices, like ambulation aids, dentures, eyeglasses, or hearing aids; diet, lifestyle habits, occupation, and hobbies; and bowel or bladder habits.
The next part of the medical record is the physician’s order sheet, which is used by the client’s healthcare provider to establish requirements for care, including lab tests, medications, diet, and activity.
Next comes the medication administration record, or MAR for short, which covers all medications prescribed to your client along with the date; time; dosage; and the member of the healthcare team who gave the medication, which is usually the nurse.
Moving on: The physician’s progress notes is a form that is used by the client’s doctor to write down their observations and track the client’s progress and response to the treatment.
Next, we have the narrative nurse’s notes. The nurse uses this form to record details about interventions done on behalf of the client and the client's response.
Now, as a nursing assistant, you’ll most commonly use the part of the medical history called the graphic sheet, which is used to document information such as vital signs, intake and output, as well as the client's weight.
The last part of the medical history are miscellaneous documents, which include lab reports, radiology reports, and other diagnostic or therapeutic reports.
Alright, then! Another tool used for documentation is the Kardex, which is a summary of the client’s current diagnosis; diagnostic tests; treatments; special needs; and routine care measures, like diet and bathing schedule.
The Kardex card should be constantly updated if there are any changes in the client’s condition or doctor’s orders. Keep in mind that the Kardex is not part of the permanent medical record, but it’s meant to help healthcare workers find the information they need quickly and more efficiently.Now, when you’re documenting a client’s information, there are several general guidelines to keep in mind.
If you’re documenting on paper, make sure you write as legibly as possible and use the correct ink color indicated by your facility, which is usually blue or black ink.
Be sure to always include the date, time, and client’s name; you should also sign your entry. You should only document your own observations or care that you’ve personally given.
Finally, document information in a timely manner and only after observing or giving care. It’s also important to make sure you’re using appropriate terminology or abbreviations that are approved in your facility.

Abbreviations9:19–10:30

This will help avoid confusion and miscommunication between your co-workers. Here’s a list of some common abbreviations in the healthcare field.
Be sure to double-check with your facility before using them, though! Okay, when documenting vital signs, you may find TPR as an abbreviation for temperature, pulse, and respirations and BP for blood pressure.
Cath is short for catheter. PO stands for per os, which means by mouth and is often used when talking about the route of administration of certain medications.
NPΟ is short for nil per os, meaning nothing by mouth in which case no foods or fluids can be taken orally. PRN.
stands for pro re nata, which means when necessary. PC stands for post cibum, which means after meals, while AC stands for ante cibum, which means before meals.
OOB stands for out of bed. I&O refers to intake and output.
UTI stands for urinary tract infections. And finally, OT stands for occupational therapy.Alright, as a quick recap… As a nursing assistant, you must report and record your observations using appropriate terminology or abbreviations.

Recap10:30–11:49

Now, observations can be objective, including anything you can see, hear, smell, touch, or measure or subjective, including any complaints and symptoms reported to you by clients.
Now, as a nursing assistant, you should report your observations to the nurse. Reporting is a verbal form of communication about the client’s condition, symptoms, or requests.
End-of-shift report is when the healthcare workers on duty meet with the workers on the next shift to update them about the clients.
Next, there’s documentation, which is written and allows everyone on the healthcare team to know the client’s condition.
Documentation requires medical records or charts, which contain information about the current condition as well as diagnostic and treatment procedures.
Medical records are subdivided into several sections that contain specific forms, including admission record, medical history, nursing history, physician’s order sheet, medication administration record, physician’s progress notes, narrative nurse’s notes, graphic sheet, and miscellaneous documents.
All medical records are legal documents, except the Kardex card, which is a condensed version of