Observation, Reporting, and
Documentation
Unit 8
Nursing Process
• Steps of Nursing Process:
• Assessment
• Planning
• Implementation
• Evaluation
Nursing Process
• Assessment: learning about the patient
• Nursing assistant actions include:
• Observing carefully during admission
process
• Listening carefully to what the patient and
family say
• Measuring vital signs
• Reporting findings to the nurse
Nursing Process
• Assessment: learning about the patient
• Nursing assistant actions include:
• Reporting changes in the patient’s
condition, response, and behavior
promptly
• If permitted, charting or documenting
• Charting: vital signs, intake/output
(objective)
• Documenting: observations
(subjective/objective)
Nursing Process
• Planning: preparing the nursing plan
• Nursing assistant actions include:
• Being informed of, and following the
nursing care plan
• Participating in the planning conference
• Contributing information and observations
that will help the team develop a plan
Nursing Process
• Implementation: seeing that the care plan is
followed
• Nursing assistant actions include:
• Carrying out assignments correctly
• Being willing to cooperate and help other
team members
Nursing Process
• Evaluation: determine how well care plan
goals have been met
• Nursing assistant actions include:
• Reporting your observations
• Inform the nurse if an approach cannot
be implemented
• Informing the nurse if the patient has
problems with a listed approach
Making Observations
• Observing is an important part of the nursing
assistant's job, which includes:
• Using all of your senses when making
observations
• Noting anything unusual or extraordinary
• Reporting your observations to your team
leader in an accurate, timely manner
Making Observations
• Observations of normal values:
• The nursing assistant must have basic
knowledge of the range of normal
observations
• Anything outside the range of normal
should be reported to the nurse
Making Observations
• Observations of specific body systems:
• Integumentary system:
• Color, temperature, flexibility (turgor),
dryness, moisture, redness, open areas,
bruises, swelling, scars, rashes
• Musculoskeletal system:
• Deformities, ability to walk, sit, or move,
pain, posture, or abnormal movements
• Circulatory system:
• Skin color, heart rate, pulse, blood
pressure, nails, lower extremities
Making Observations
• Observations of specific body systems:
• Respiratory system:
• Difficulty breathing, blueness of skin,
shortness of breath, rate of respirations,
noisy respiration, cough
• Nervous system:
• Level of consciousness, response to
questions, paralysis, orientation to time &
place, condition of eyes & ears
Making Observations
• Observations of specific body systems:
• Urinary system:
• Frequency, amount and character of
urine, inability to hold urine, drainage,
color of urine, blood in urine, pain during
urination
• Digestive system:
• Appetite, tolerance to certain foods,
diarrhea, constipation, gas, difficulty
chewing or swallowing, unusual color or
consistency of stool, nausea, vomiting
Making Observations
• Observations of specific body systems:
• Endocrine system:
• Signs and symptoms of
hypo/hyperglycemia
• Reproductive system:
• Abnormalities of the breasts, menstrual
cycle, and vaginal discharge, lumps in
testes, abnormal drainage from the penis
• Other observations:
• Pain, behavior, ability to function
Making Observations
• Observations of pain:
• Pain is never normal
• Body language and facial expressions may
provide clues to the presence of pain,
particularly in children and cognitively
impaired adults
• The patient’s self-report of pain is always
the most accurate; avoid making
assumptions about pain (subjective)
• Pain scales are used to help patients
communicate level/intensity of pain
Reporting
• A “report” is given by staff going off duty to the
oncoming shift
• Oral Reporting:
• Most accurate because it is “up to the
minute”
• Face to face
• Allows for questions
• Allows for review of medical records, lab
results, etc.
Reporting
• A “report” is given by staff going off duty to the
oncoming shift
• Written report:
• Less accurate
• Writing can be illegible
• Details can be omitted for sake of brevity
• Events that occur after report is written may
not be updated on report for oncoming shift
• Can be “misplaced”
• Can be HIPPA violation if not secured
Documentation
• General guidelines for charting:
• PRINT entries as neatly as possible, unless
cursive entries are allowed – must also be
neat and legible
• Use BLACK ink for all entries
• Use short, concise, factual phrases – no
opinions
• Always chart after the event – NEVER
before
• Always enter time of event in entry
Documentation
• General guidelines for charting:
• Leave no blank spaces when documenting
• Sign EACH entry with first initial, last name
and your title
• NEVER, ever (next slide please…..)
Documentation
• General guidelines for charting:
•NEVER
Documentation
• General guidelines for charting:
• Leave no blank spaces when documenting
• Sign EACH entry with first initial, last name
and your title
• NEVER, ever erase, use “white-out,” or
repeatedly cross through an error.
• Draw single line through error, print word
“error,” and initial. Single line
• Use medical terms appropriately and spell
them correctly
Documentation
• General guidelines for charting:
• Use international (military) time when you
document, or follow your facility’s policy
• 1:00 PM = 1300 Hours
• 12:00 AM (midnight) = 0000 Hours