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Documenting and Reporting Data

Unit 7 Lesson 1

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Describe why timely and accurate documentation is important
Identify the nurse’s aide’s responsibilities for documentation

Student Learning Outcomes

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Importance of Documentation

Legal Requirement

Mandatory for recording client observations and care provided
Forms part of the official medical record

Ensures Continuity of Care

Facilitates seamless information transfer across shifts
Supports coordinated care among healthcare team members

Sandquist-Reuter, 2023

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Importance of Documentation continued…

Quality Assurance

Monitors adherence to standards of care
Supports quality improvement initiatives

Reimbursement

Essential for insurance claims and government programs

Example: Medicare/Medicaid

Documentation must be accurate for financial purposes

Sandquist-Reuter, 2023

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Importance of Documentation continued…

Legal and Research Use

Can be used in legal proceedings
Provides data for healthcare research

Sandquist-Reuter, 2023

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Types of Documentation

Charting by Exception (CBE)

Records only deviations from the norm, making it concise
Uses checklists and flowsheets for routine care
Example

ADL (Activities of Daily Living) flowsheets for documenting daily routines and vital signs

Reduces time spent on documentation, allowing more time for direct client care

Sandquist-Reuter, 2023

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Critical Thinking Question

A nurse aide working the morning shift notices that a resident has a slight fever and is more lethargic than usual. The nurse’s aide has been using Charting by Exception (CBE) for documentation.

What actions should be taken in documenting and reporting the resident’s condition?

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Nurse Aide’s Responsibilities

Document Care Provided

Always record own actions and observations
Never document for someone else
Ensure documentation reflects accurate and honest records of care

Training and Facility Guidelines

Follow employer-specific guidelines on documentation procedures
Participate in training sessions to understand documentation expectations

Sandquist-Reuter, 2023

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Nurse Aide’s Responsibilities continued…

Timely Reporting

Routine observations are reported during shift changes
Immediate reporting is required for any abnormalities or urgent changes in client condition

Sandquist-Reuter, 2023

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Reporting Observations

Normal vs. Abnormal

Normal findings

Routine reporting during standard reporting times

Abnormal findings

Immediate reporting required for changes in

Breathing
Circulation
Cognition
Pain levels
Falls or accidents

Sandquist-Reuter, 2023

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Reporting Observations continued…

Critical Thinking

Utilize critical thinking to evaluate the significance of observations
When unsure, always report to the nurse for further assessment

Sandquist-Reuter, 2023

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Critical Thinking Question

During the nurse’s aide shift, they observe that a resident has a sudden change in their breathing pattern. Which of the following actions should be taken?

A. Wait until the end of the shift to report the change.

B. Immediately document the change and inform the nurse.

C. Ask another nurse aide if they noticed the same change.

D. Record the change only if the resident requests medical attention.

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Tips for Effective Documentation

Accuracy

Double-check all entries for correctness
Ensure dates, times, and specifics are correct

Conciseness

Be brief but cover all necessary details
Use standard abbreviations and terminology

Clarity

Write legibly and clearly
Avoid ambiguous language to ensure clear communication

Sandquist-Reuter, 2023

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Critical Thinking Question

The nurse’s aide notices that the resident has a bruise on their arm that was not present during their previous shift. What should the nurse’s aide do first?

A. Assume it was documented by another aide.

B. Immediately report the bruise to the nurse and document findings.

C. Wait to see if the bruise changes before reporting.

D. Document the bruise at the end of the shift.

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References

Sandquist-Reuter, M. (2023). Nursing Assistant. WisTech Open. https://wtcs.pressbooks.pub/nurseassist/

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