ppt课件-observationcharting.pptVIP

Observation Charting Module 15 Observation Use of senses to collect information Senses Sight Touch Hearing Smell Observations that should be made 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 contacts- note any changes or needs REPORT ABCs of observation Appearance Behavior Communication Observation Objective – Signs that you can see, hear, feel, smell Factual, measurable, observable Subjective – what the resident or family tells you Not directly seen or observed by CNA Symptoms reported by resident Types of Charting Documents Resident Record Chart Communicates records health history, status, treatment Legal record Kardex Summarizes dr’s orders Identifies critical data – allergies, code status, diet, activity, etc. Gives medication treatment info Types of Charting Documents Nursing Care Plan Lists resident’s need provides specific nursing activities that address needs Guide for the CNA providing care Graphic sheet VS, I O, Weight ADLS sheet Documents care at each shift for ADLs Record on which most facilities have the care work chart Charting Procedures Correct chart or ADL sheet Write legibly neatly Write notes on paper first Check for spelling accuracy 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) Errors – cross out, one line DO NOT ERASE OR USE WHITE OUT Write “error” above the line Initial the entry Include resident’s complete info on each page Some facilities have imprint stampers If no stamper, write in name info 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