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Recording and Reporting

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

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Recording and Reporting

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  1. Recording and Reporting Personal Qualities of a Health Care Worker

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

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

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

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

  6. 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

  7. 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

  8. 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

  9. 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

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