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Developing good observation skills means:
It is always better to report an observation, even if it seems unimportant or you are unsure about it, rather than risk the client’s well-being by not reporting it.
Be aware of physical changes in your client, such as:
Never document before you have completed a task.
Observe emotional and mental changes in your client, including:
If you make a mistake when documenting, mark a single line through the word or sentence and write your initials next to that. Never erase or use correction fluid.
There are two kinds of reporting:
Use proper spelling and language when documenting. Use a medical dictionary if you are not sure of spelling.
Things you must report include:
The care plan describes:
For legal and medical reasons, documentation should be:
Important points when documenting include:
It’s important to document correctly because:
Observing and reporting changes provides vital information that the nurse and doctor rely upon to make decisions about the client’s care.
Pain can make your client feel frustrated, irritable, angry or depressed.
Subjective observation is factual and measurable.
Reporting is always done in written form.
Events that put the client in danger, such as falls, deep wounds or chest pain must be reported immediately.
Your documentation is proof that you have followed the procedures and methods defined in the care plan.