Charting Recording and Reporting Recording and Reporting Health

Charting Recording and Reporting

Recording and Reporting • Health care workers must listen carefully AND make observations They use their senses to make certain observations about their patient and report them.

Use your senses to • See – Color of skin, swelling, edema – Presence of rash or sore – Color of urine or stool – Amount of food eaten • Smell – Body odor – Unusual odors of breath, wounds, urine or stool

Use your senses • Touch – – Pulse Dryness or temp of skin Perspiration swelling • Hearing – – Respirations Abnormal body sounds Coughs speech

Charting and Reporting • Observations should be reported accurately – use facts and report what you say, not the reasons. • NOT – Mr. Ruiz is in pain • INSTEAD – Mr. Ruiz is moaning and holding his left side. • Observations on a patient’s health record should be accurate, concise, and complete.

Charting • Objective observations – what was seen. • DO NOT record what you feel or think. • If a patient’s statement is recorded, use the pt’s own words and quotation marks. • Sign entries with name and title of the person recording information. • Cross out errors neatly with a straight line, write “error” and initial error.

Subjective Data • • What you think or feel. May or may not be accurate. Based on assumptions. Not advisable to use on medical charts.

Subjective (continued) • Example: Ms. Jones is visiting with family and laughing. She is not in pain right now.

Subjective example……. • Ms. Smith has a bad headache.

Objective Data • What is actually seen. • Only facts documented • Best way to document on medical record.

Example • Ms. Jones is sitting on couch with family and friends surrounding her, smiling and looking at camera.

Example • Ms. Smith has her eyes closed and is holding her forehead with both hands.

Record your observations

Record Your Observation

• Record your observations