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Advanced Skills for Health Care Providers, Second Edition Barbara Acello

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Chapter 2 Observation, Documentation, and Reporting to the RN. Advanced Skills for Health Care Providers, Second Edition Barbara Acello Thomson Delmar Learning, 2007. OBJECTIVES:. Spell and define key terms Differentiate between signs and symptoms

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Presentation Transcript
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Chapter 2 Observation, Documentation, and Reporting to the RN

Advanced Skills for Health Care Providers, Second Edition

Barbara Acello

Thomson Delmar Learning, 2007

objectives
OBJECTIVES:
  • Spell and define key terms
  • Differentiate between signs and symptoms
  • Differentiate between subjective and objective observations
  • Describe how to report and record patient information (continued)
objectives continued
Objectives (continued)
  • Describe how to identify pain by making observations of facial expressions, gestures, movement, and body language
  • State the purpose of the medical record
  • List 10 guidelines for documenting in the medical record
communicating with other members of the health care team
COMMUNICATING WITH OTHER MEMBERS OF THE HEALTH CARE TEAM

Good communication is one of

the keys to team success

  • Communication can be verbal or written
  • Reporting is usually verbal
  • Recording / Documenting is written
confidentiality and privacy
Confidentiality and Privacy

THE MEDICAL RECORD IS A PRIVATE AND CONFIDENTIAL DOCUMENT

ALL STAFF ARE RESPONSIBLE FOR PROTECTING PATIENT INFORMATION FROM ACCESS BY UNAUTHORIZED PERSONS

more on confidentiality privacy
More on Confidentiality & Privacy
  • You should never read the patient charts out of curiosity
  • Medical records and other patient data should be accessed only by those with a need to know the information
  • Privacy of patient information is protected by the 1996 law HIPAA
hipaa health insurance portability and accountability act
HIPAA – Health Insurance Portability and Accountability Act

Passed in 1996 by Congress, it concerns privacy, confidentiality, and medical records.

The HIPAA rules:

  • Increase patient’s control over their medical records
  • Restrict use and disclosure of pt info
  • Make facilities accountable for protecting patient data
  • Require the facility to implement and monitor info release policies and procedures
hipaa
HIPAA

Protects all identifiable health information:

  • Paper
  • Verbal
  • Electronic documentation
  • Billing records
  • Clinical records
patient information is given to staff on a need to know basis
Patient information is given to staff on a “need to know” basis
  • Staff members need that info to carry out their duties, ex., dietary needs to know if patient is on a special diabetic diet or has food allergies, they would not need to know why the patient is in the hospital
  • Policies must protect patient information which includes charts, verbal communication, faxes & other disclosure
hipaa rules ask providers
HIPAA rules ask providers:
  • To analyze how and where patient information is used
  • To develop procedures for protecting confidential data which includes
      • Where patient charts are kept
      • Places where patient information is discussed
      • Ways that patients’ health info is distributed
observing the patient
OBSERVING THE PATIENT

You are responsible for

  • Making observations
  • Reporting observations to the RN

PCTs spend most of their time providing direct patient care and will notice changes that need to be reported immediately

use your senses to make observations
Use Your Senses to Make Observations

Many changes are things you can see

  • Changes in movement / position
  • Facial expression
  • Skin color change

These changes may suggest pain

or other serious problems

use your senses to make observation continued
Use Your Senses to Make Observation (continued)

You will hear some changes like noisy breathing and things the patient tells you

You will smell some changes that give unusual odors

You will feel some changes like temperature change or moisture

observing the patient is a continuous process
Observing the Patient is a Continuous Process
  • If you see, feel, hear, or smell anything that seems abnormal, report it to the RN
  • Even changes that seem insignificant may indicate a problem
  • The nurse will select the course of action
  • Also observe for safety, comfort and other environmental factors
for example
For Example
  • A red area on the skin may seem minor but the area can quickly turn into a pressure sore
  • A patient receiving blood can state he feels cold. Your first reaction may be to get a blanket. Chilling is a sign of transfusion reaction which is very serious and must be reported immediately
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