Observation &
Charting
Module 15
Observation
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Use of senses to collect information
– Senses
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Sight
Touch
Hearing
Smell
Observations that should be made
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Skin color & temp
Mood & mental status
Behavior & movement
Unusual odors
Respirations
Responsiveness
Appetite
Ability to perform ADLs
Elimination
Pain or discomfort
Observation
Learn to observe through daily contactsnote any changes or needs & REPORT
 ABCs of observation
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– Appearance
– Behavior
– Communication
Observation
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Objective – Signs that you can see,
hear, feel, smell
– Factual, measurable, & observable
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Subjective – what the resident or family
tells you
– Not directly seen or observed by CNA
– Symptoms reported by resident
Types of Charting Documents
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Resident Record & Chart
– Communicates & records health history, status, &
treatment
– Legal record
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Kardex
– Summarizes dr’s orders
– Identifies critical data – allergies, code status, diet,
activity, etc.
– Gives medication & treatment info
Types of Charting Documents
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Nursing Care Plan
– Lists resident’s need & provides specific nursing
activities that address needs
– Guide for the CNA providing care
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Graphic sheet
– VS, I & O, Weight
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ADLS sheet
– Documents care at each shift for ADLs
– Record on which most facilities have the care
work chart
Charting Procedures
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Correct chart or ADL sheet
 Write legibly & neatly
– Write notes on paper first
– Check for spelling & accuracy
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Place events in proper sequence
 Chart according to facility standards
 Be concise, use appropriate terms &
abbreviations
 Always use ballpoint pen – black ink
– No felt tip, fountain pens, pencils, gel pens
– Use color only if approved by facility
Charting Procedures (cont)
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Errors – cross out, one line
– DO NOT ERASE OR USE WHITE OUT
– Write “error” above the line
– Initial the entry
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Include resident’s complete info on each page
– Some facilities have imprint stampers
– If no stamper, write in name & info
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Never skip lines
 Signature, B. McGrory, CNA
Charting Procedures (cont)
Always date & time entries
 Make sure you are charting on correct
date & time
 Chart only procedures YOU have
performed
 Never chart for someone else
 Chart only AFTER you have performed
the procedure
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Charting Procedures (cont)
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Chart only observations you know to be
true (objective data)
– Do not chart opinions
– Subjective data must be in “quotation
marks” & exactly as stated
Computers & Charting
Basic principles – confidentiality &
privacy
 Systems are password protected
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– Each user has a personal password
– Never share passwords
– Sharing/using others’ passwords may be
grounds for termination
Legal Issues of Charting
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Resident record is a legal document
– Can be used in a court of law
All information in chart is confidential
 Information should be accurate,
objective, & truthful
 Have access only to charts of the
resident you are caring for
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Summary of Charting Guidelines
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Safety
– Note safety measures done to protect him
from harm.
– Restraints – type, exact time in & out,
activity done when in restraint, condition of
skin, resident’s response to care given
Charting Guidelines
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Emotions
– Mood – angry, withdrawn, crying, etc.
– Unusual symptoms showing anxiety –
picking at sheets, stuttering, tenseness,
restlessness, VS changes
– Quotes “I’m afraid”
– What decreases anxiety
– Changes in orientation
Charting Guidelines
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Range of Motion
– Active vs. passive
– Problem areas – pain or restricted
movement
– Progress made
Charting Guidelines
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Positioning
– Time of position changes
– Observation of skin condition
– Reddened areas & what treatment given
– How resident tolerated position
Charting Guidelines
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Pressure Sores
– Factual observations – location, condition
– Special treatment used – positioning,
special equipment
Charting Guidelines
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Personal hygiene
– Type of treatment or care given (bath, grooming,
back care, lotion, make-up)
– Why care was NOT given
– Skin, mouth, hair, nails, feet descriptions
– What resident can do for self
– Emotional state – use own words
– C/o pain, discomfort
– Observe any previous problem area & make a
factual statement of current condition
Charting Guidelines
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Nutrition & Fluid
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Amount of food eaten (percentage)
Type & amount of food NOT eaten
Appetite
Self feed vs. fed
Problems with eating
Special diets
Intake record for residents with catheter or on
bladder training
– Weekly or monthly weight
Charting Guidelines
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Elimination
– Record urine color, odor, amount, clarity, presence
of sediment, mucus
– Time of voiding if more freq than every 2 hours
– Stool size,number, & characteristics
– Unusual occurrences – bright red blood, mucus,
dark or strong-smelling urine, burning, voiding
small amounts, smeary or liquid feces
– Estimating incontinence
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9 in. diameter – 50 –75 cc
12 in. diameter – 100 –125 cc
18 in. diameter – 150 –175 cc
24 in. diameter – 200 –300 cc
Charting Guidelines
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Vital Signs
– Febrile vs. afebrile
– Pulses – strong, regular, weak, irregular,
thready
– Respirations – regular, shallow, deep,
irregular, Cheyne-Stokes, dyspnea,
orthopnea, apnea
– Blood pressure – strong, poor, HTN,
hypotension
Charting Guidelines
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Oxygen
– Exact times on/off O2
– How O2 administered
– Number of liters flow per minute
– Resident condition & comfort
– Care given to prevent irritation to skin,
nose, mouth
Charting Guidelines
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Death
– Exact time of death & what observations
you made
– Postmortem care – time & date body was
taken to mortuary or morgue. Record what
was done with resident valuables & have a
witness co-sign.
Medical terminology & Abbrev
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Abbreviations are
– Shortened form of words/phrases
– Commonly used in health care
– Designates medical specialty areas – ER,
OR, OB
– Shortened forms of word or first letters –
amb, BRP, lab, etc
– Shortened form of Latin or Greek word –
ad lib, prn, po, etc.
Abbreviations
Drsg
Dx
ECG
EEG
ER
F
FBS
FF
Fld
Ft
Gal
GI
Hr or h
H20
HS
ht
Abbreviations
Ht
ICU
In
I&O
IV
L
Lab
Lb
Liq
LLQ
LMP
LVN
Lt
LUQ
Meds
MN
Abbreviations
Min
ml
NA
CNA
Neg
Nil
Noc
NPO
O2
OB
OJ
OOB
OR
OT
Oz
pc
Abbreviations
Peds
Per
PM
po
Postop
Preop
Prep
Prn
Pt
PT
Q
qd
qh
qhs
qid
qod
Abbreviations
R
RLQ
RN
ROM
RR
RUQ
S
SSE
Stat
Tbsp
tid
TLC
TPR
U/A
VS
WBC
Abbreviations
W/c
tsp
Wt
24 hour clock
Greenwich time vs. Military time
 One value for each minute of the day
 Expressed in 4 digits
 No colon
 Midnight can be expressed as 0000 or
2400
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24 hour clock
12 MN
0000 2400 6:00 AM
0600
1:00 AM
0100
7:00 AM
0700
2:00 AM
0200
8:00 AM
0800
3:00 AM
0300
9:00 AM
0900
4:00 AM
0400
10:00 AM
1000
5:00 AM
0500
11:00 AM
1100
24 hour clock
12:00 PM
1200
6:00 PM
1800
1:00 PM
1300
7:00 PM
1900
2:00 PM
1400
8:00 PM
2000
3:00 PM
1500
9:00 PM
2100
4:00 PM
1600
10:00 PM
2200
5:00 PM
1700
11:00 PM
2300
24 hour clock
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Each value has one hour value & one
minute value
– 5:03 a.m. = 0503
– 5:03 PM = 1703
– 11:57 AM = 1157
– 11:57 PM = 2357
– 12:00 midnight = 2400 or 0000
– 12:05 AM = 0005