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Documentation and Reporting

Unit 1 Lesson 5

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COPYRIGHT

NI Privacy Policy and Terms of Use.

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Explain the difference between reporting and documentation
List the essentials of professional documentation
Explain the relationship between MDS and documentation
List the essentials of professional reporting including subjective and objective information
Explain military time and its use

Student Learning Outcomes

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Reporting vs. Documentation

Reporting

Talking to other healthcare workers about a patient
Happens at the start and end of the work shift
Use of voice - oral communication

Documentation

Writing down patient care in charts or computer systems
Also called "charting"
Creates a legal record of care given

Sandquist-Reuter, 2023

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Critical Thinking Question

The nurse’s aide is giving an end-of-shift report to the incoming nurse. Which of the following pieces of information is most appropriate to include in the report?

The Patient seemed unhappy today.
The Patient’s family mentioned they might visit soon.
The Patient probably needs more attention in the afternoon.
The Patient had a temperature of 101°F at 3:00 p.m.

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Importance of Documentation

Legal Protection

Proves proper care was given to patient
Can be used in court cases
Rule: "If it wasn't documented, it wasn't done"

Better Patient Care

Other healthcare workers read the notes
Helps the whole team take care of patients
Shows what care was already given

Sandquist-Reuter, 2023

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Privacy Rules - Do's and Don'ts

DO

Cover paper charts when not using them
Log out of computers after each use
Only share charts with people caring for the patient

DON'T

Talk about patients in hallways or elevators
Leave computer screens open where others can see
Share passwords or PIN numbers with anyone

Sandquist-Reuter, 2023

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Professional Documentation Rules

Write Things Down Right Away

Document directly after care is given
Always write the date, time, and sign name

Use Facts, Not Opinions

Wrong: “The patient doesn't like their food”
Right: “Patient refused meal and said “I am not hungry””

Sandquist-Reuter, 2023

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Professional Documentation Rules (don

Paper Chart Rules

Always use black pen
If a mistake is made

Draw one line through it
Write "mistaken entry"
Add initials

Sandquist-Reuter, 2023

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Critical Thinking Question

During documentation, the nursing assistant notices an error in a previous entry. What is the best way to correct this mistake?

Use correction fluid to cover the mistake and write the correct information.
Draw a line through the error, write "mistaken entry," add initials, and document the correct information.
Erase the incorrect entry and replace it with the correct information.
The mistake was minor and won't affect care.

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Minimum Data Set (MDS)

Required documentation for long-term care facilities
Completed by registered nurses using notes taken by the nurse’s aide
Used for Medicare and Medicaid reimbursement

Why Documentation Matters

Nurses use the nurse’s aide’s notes to complete MDS forms
Accurate documentation helps facility get proper payment
Poor documentation can cause payment problems

Sandquist-Reuter, 2023

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What MDS Nurses Look for in Documentation

Communication and Senses

How well patient can communicate, hear, and see
Communication tools like whiteboards or picture books
Hearing aids and glasses used

Daily Care Activities

How much help patient needs with dressing, bathing, eating
Help needed with moving in bed or walking
Skin observations during care

Sandquist-Reuter, 2023

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Critical Thinking Question

A patient uses a hearing aid and glasses. How should this be documented to ensure accurate MDS reporting?

Record the use of both the hearing aid and glasses as assistive devices.
Document the use of glasses if they are new.
Mention the glasses but not the hearing aid, as it is not relevant.
Suggest the patient may have poor eyesight.

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Professional Reporting Examples

Where to Give Reports

Closed rooms away from other people
Nurse's station away from patient rooms
Private patient rooms with door closed

What to Report Immediately

Strong bad smells from urine, mouth, or wounds
Red, warm, or open areas on skin
Trouble breathing or chest pain

*Generally, a nursing assistant should report any physical changes in a client that seem unusual or behavior that is out of the ordinary for that person.

Sandquist-Reuter, 2023

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Critical Thinking Question

A nurse’s aide at a long-term care facility notices that a patient has developed a red, warm area on their skin that was not there during your previous shift. How should they proceed with documentation and reporting?

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Objective vs. Subjective Information

Objective Information = SIGNS

Information that can be seen, heard, felt, or smelled
Can be measured with tools
Example: "Temperature is 98.6°F" or "Patient's skin is red and warm"

Subjective Information = SYMPTOMS

Information the patient or family provides
Always use exact words in quotation marks
Example: Client said "I have a headache"

Sandquist-Reuter, 2023

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Critical Thinking Question

The Nurse’s Aide is completing documentation for a patient who has refused dinner, stating, “I am not hungry.” What is the best way to document this information?

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Military Time

Avoids confusion between morning and afternoon
No need for a.m. or p.m.
Each hour has its own number from 1 to 24

Basic Rules

Morning hours: Add zero in front (7:00 a.m. = 0700)
Afternoon/evening hours: Add 12 to the hour (1:00 p.m. = 1300)
No colons are used

Sandquist-Reuter, 2023

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Military Time Examples

Morning Hours

7:00 a.m. = 0700

pronounced "zero seven hundred" or "oh seven hundred"

9:24 a.m. = 0924

pronounced "zero nine twenty-four"

Special Times

Noon (12:00 p.m.) = 1200
Midnight = 2400 or 0000

Afternoon/Evening Hours

1:00 p.m. = 1300

pronounced "thirteen hundred"

1:46 p.m. = 1346

pronounced "thirteen forty-six"

2:43 p.m. = 1443

pronounced "fourteen forty-three"

11:30 p.m. = 2330

pronounced "twenty-three thirty"

Sandquist-Reuter, 2023

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Critical Thinking Question

The nurse’s aide is using military time to document an incident that occurred at 7:30 p.m. How should the time be recorded?

0730
1530
1930
0730 p.m.

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References

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

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