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Documentation and reporting



Content Reviewers:

Lisa Miklush, PhD, RNC, CNS

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.

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.

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.