The Importance of Observation and Documentation

Hartman's

In-Service Education SourceBook Series

Helping in-service educators since 1994!

The Importance of

Observation and Documentation

The Importance of

OBSERVATION and DOCUMENTATION

Contributor Jetta Fuzy, RN, MS Director of Education & Training Health Education, Inc. Fort Lauderdale, Florida

The publisher gratefully acknowledges the contributions of the following individuals who reviewed this material: Sharon Edwards, RN, MSN, CS Clinical Nurse Specialist Superior Home Health Care Kingsport, Tennessee Catherine A. Whaley, RN, CRNI Director of Education Woodbine Rehabilitation & Healthcare Center Alexandria, Virginia

Albuquerque, NM

NOTICE TO THE READER

Though the guidelines contained in this text are based on consultations with health care professionals, they should not be considered absolute recommendations. The instructor and readers should follow employer, local, state, and federal guidelines concerning health care practices. These guidelines change, and it is the reader's responsibility to be aware of these changes and of the policies and procedures of her or his health care facility/agency.

The publisher, author, editors, and reviewers cannot accept any responsibility for errors or omissions or for any consequences from application of the information in this book and make no warranty, express or implied, with respect to the contents of this book.

Publisher does not warrant or guarantee any of the products described herein or perform any analysis in connection with any of the product information contained herein.

CREDITS

Contributor: Jetta Fuzy, RN, MS Development Editor: Celia McIntire Composition: Tech Reps, inc. Design: John W. Davis Illustration: Celia McIntire

ISBN 1-888343-13-3

?1998 Hartman Publishing, Inc. All rights reserved. Limited permission to photocopy the labeled handouts in this text is granted to direct purchasers of this book from the publisher. Copies can only be made for employees or students at ONE LOCATION of a multi-site employer or school. No other part of this book may be reproduced, in any form or by any means, without permission in writing from the publisher.

Table of Contents

FYI

5

Introduction and Assessment

7

Handout Intro-1 Assessment A (pg.8)

Handout Intro-2 Assessment A Answer Key (pg. 10)

Handout Intro-3 Note-Taking Worksheet (pg. 12)

Handout Intro-4 Key Terms (pg. 16)

Learning Objective 1: Define documentation and identify its importance

17

Handout 1-1 What is Documentation? (pg. 19)

Transparency 1-1 What is Documentation? (pg. 20)

Transparency 1-2 Sources of Documentation (pg. 21)

Learning Objective 2: Describe four forms commonly used in documentation 22 Handout 2-1 Commonly Used Documentation Forms (pg. 24) Transparency 2-1 Four Forms (pg. 29)

Learning Objective 3: Describe legal aspects of documentation

30

Handout 3-1 Legal Aspects (pg. 31)

Transparency 3-1 Legal Aspects (pg. 33)

Learning Objective 4: List eight reasons for careful documentation

34

Handout 4-1 Eight Reasons for Careful Documentation (pg. 35)

Transparency 4-1 Eight Reasons for Careful Documentation (pg. 36)

Transparency 4-2 Continuity of Care (pg. 37)

Transparency 4-3 Documentation is Communication (pg. 38)

Learning Objective 5: Define objective and subjective information and

observation

39

Handout 5-1 Objective vs. Subjective (pg. 41)

Transparency 5-1 Objective Observations (pg. 42)

Transparency 5-2 Subjective Information (pg. 43)

Handout 5-2 Signs or Symptoms (pg. 44)

Handout 5-3 Signs or Symptoms Answer Key (pg. 45)

Learning Objective 6: Describe basic observations essential to daily

documentation

46

Transparency 6-1 Basic Observations for Documentation (pg. 47)

Handout 6-1 Basic Observations for Documentation (pg. 48)

Learning Objective 7: List nine guidelines for documentation

51

Handout 7-1 Nine Guidelines for Documentation (pg. 53)

Transparency 7-1 Nine Guidelines for Documentation (pg. 54)

Learning Objective 8: Identify commonly misspelled words and guidelines to

avoid spelling and grammar errors

55

Handout 8-1 Spelling Test (pg. 56)

Transparency 8-1 Spelling Test Answer Key (pg. 57)

Handout 8-2 Four Guidelines to Avoid Errors (pg. 58)

Transparency 8-2 Four Guidelines to Avoid Errors (pg. 59)

Learning Objective 9: List the most common abbreviations used in healthcare 60 Handout 9-1 Abbreviations Test (pg. 61) Transparency 9-1 Abbreviations Test Answer Key (pg. 62)

Learning Objective 10: Describe incident reporting and recording

63

Handout 10-1 Incidents (pg. 65)

Transparency 10-1 Sample Incident Form (pg. 66)

Closing and Assessment

67

Handout Closing-1 Assessment B (pg. 68)

Handout Closing-2 Assessment B Answer Key (pg. 70)

In-Service Evaluation Form

71

Certificate of Completion

72

Record Keeping Form

73

For More Information

74

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