2.2.6: Documentation
- Page ID
- 67561
Observing, Recording, Reporting
Recording and reporting information about a patient is an important part of the job of a Home Health Aide/Personal Care Aide. It is important that they understand the types of information that should be included in reports. Information included in reports should always be based on facts.
Objective information is based on information that a person can actually see, hear, touch, or smell (Leahy, Fuzy & Grafe, 2013). It includes actions performed, care provided, and measurements such as how much food or fluid a patient took in or how much urine the patient voided. These types of information are based on fact. Subjective information is information which a person did not see, hear, touch, or smell. It includes statements that a patient has made to a HHA/PCA about how they feel or what they think (Leahy, Fuzy & Grafe).. When recording subjective statements, the HHA/PCA should try to include what the patient stated to them using direct quotes.
1. The patient states, “My pain is worse than it was this morning.” ____________
2. A HHA/PCA notices that their patient’s right leg is more swollen today than yesterday. ______________
- Answer
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1. Subjective
2. Objective
Feedback:
1. A patient’s report of symptoms is subjective information as it is something the health care worker did not or cannot observe.
2. Directly observing an increase in swelling of a patient’s leg is objective information as it can be measured.
Use of Your Senses
Home Health Aides/Personal Care Aides use all their senses to make observations about their patients and their conditions. Their report includes observations they made by using their senses: sight, hearing, touch, and smell (Leahy, Fuzy & Grafe, 2013).
Sight
The use of sight includes observations Home Health Aides/Personal Care Aides made using their vision. They will note their patient’s condition as they work with them. Changes in appearance, skin, swelling of the legs, weakness while ambulating, new bruises or rashes, trembling of the hands while using a fork and facial expressions are observations they make about their patient using their vision. They may also notice things in the home such as a lack of food or clean clothing for the patient. These are all observations they make through using their sense of sight.
Hearing
The use of hearing is an important sense in a Home Health Aide/Personal Care Assistant’s work with their patient. They will be listening to their patient as they converse. They may notice changes in their patient’s tone of voice, ability to use speech, rate of respiration (breathing), coughing, or gasping for breath.They may hear a patient sighing often to indicate they are tired or sad. These are all observations made through use of their hearing.
Touch
The use of touch is one Home Health Aides/Personal Care Aides will use all the time as they provide hands on care for their patient. They may notice the temperature of their patient’s skin (hot or cold), or feel for moisture if their patient has spilled a cup of water or is sweating. They will use their sense of touch when testing bath water or a bottle for feeding a baby. Their sense of touch will tell them if there are rough edges on their patient’s nails indicating they need to be filed, or wrinkles or moisture on their patient’s linen, indicating they need to be changed. The use of touch allows them to make observations about their patient’s health and helps them to properly care for their patient.
Smell
The use of smell can give Home Health Aides/Personal Care Aides an indicator of the patient’s health and how well they are being cared for. They may notice odors in the home coming from trash that has not been removed, soiled incontinence briefs or urine on bed linens. They may notice an odor from the patient’s body or mouth, indicating they are in need of bathing or mouth care. They may smell alcohol or tobacco coming from their patient or those around their patient. When preparing food, they may notice foul food odors which could indicate that the food has spoiled. Using their nose and sense of smell gives them good information to include in their reports to their supervisor.
What Information to Include in Documentation
The information that Home Health Aides/Personal Care Aides include in their verbal or written report should be of importance and pertinent to the situation. They should avoid including things such as their own personal thoughts about the patient. They should avoid including personal opinions about the patient or their health. For example, they should not write, “I think the patient’s heart failure is worse because she is more short of breath than usual.” They would only record, “Patient reports an increase in shortness of breath. The patient was observed to be short of breath while eating her dinner.” they also want to be careful to not use judgmental statements such as, “Mrs. Smith was very rude to me today.” They do not need to include every detail about the patient or about their visit. For example, it is not necessary to state that they spoke about a favorite television show or that their patient ate soup for lunch (unless the care plan directs them to include specifically what the patient ate). In most instances, they only need to state a percentage of what the patient ate.
Documentation is an important part of their job as a Home Health Aide/Personal Care Aide. It is important to maintain current and timely documentation of tasks they completed and the patient’s condition. It is the way that all members of the healthcare team communicate and become aware of potential problems or changes in the patient’s condition. Documentation protects them and the agency for which they work against liability. A patient’s record is a legal document that can be used in a court of law (Leahy, Fuzy & Grafe, 2013). It is also a necessity to have accurate and timely documentation for insurance and billing purposes.
Document Immediately After the Visit
Home Health Aides/Personal Care Aides should document tasks completed and observations made about their patients immediately after their visit (Leahy, Fuzy & Grafe, 2013).. It is difficult to keep track of so many observations and tasks they completed the longer they wait to document. They may see more than one patient per day. If they document immediately after their visit, they will have better accuracy of information.
If It Is Not Documented, It Did Not Happen
Home Health Aides/Personal Care Aides should also know that if something was not documented, for legal purposes, it did not happen. If they cared for a patient for two hours but forgot to document that they did so, for purposes of the patient chart, they never cared for them that day. Never document care prior to actually providing it (Leahy, Fuzy & Grafe, 2013). This is known as falsifying documents.
Fixing Errors
Use black ink or a computer to type their visit record, depending on their employer’s requirements. If an error is made, never use white out to remove the error. Draw a single line through it and put initials and date next to the error. Then, write in the correct information.
Use Full Name/Title
When documentation is complete, Home Health Aides/Personal Care Aides should sign it with their full name and title.
Dating/Timing Documents
All documentation should be dated and timed. Depending on the agency, regular or military time may be used. If regular time is used, it should be indicated whether the time is AM or PM. For military time, the time is expressed as 0000 hours. From 12 midnight until 12 noon, the time is the same as it is when using regular time, except the 0000 format is used. For example, for 1:00 AM, the time is expressed as 0100 hours. After 1 pm until 11:59 pm, 12 is added to the regular time. For example, if it is 5:00 pm, add 5+12=17. The time would be expressed as 1700 hours. For 9:00 pm, add 9+12=21. The time is expressed as 2100 hours. To change from military time to standard time, you subtract 12. For example, if it was 2330, you would subtract 12. Standard time would be expressed as 11:30.
24-Hour Conversion Table
- Standard Clock (12-Hour Clock) 24-Hour Clock Conversion
- 12:00 midnight 0000
- 1:00 am 0100
- 2:00 am 0200
- 3:00 am 0300
- 4:00 am 0400
- 5:00 am 0500
- 6:00 am 0600
- 7:00 am 0700
- 8:00 am 0800
- 9:00 am 0900
- 10:00 am 1000
- 11:00 am 1100
- 12:00 noon 1200
- 1:00 pm 1300
- 2:00 pm 1400
- 3:00 pm 1500
- 4:00 pm 1600
- 5:00 pm 1700
- 6:00 pm 1800
- 7:00 pm 1900
- 8:00 pm 2000
- 9:00 pm 2100
- 10:00 pm 2200
- 11:00 pm 2300
Convert the 12-hour time to the 24-hour time
1. 1 pm= _______
2. 6 pm=_______
3. 11:30 pm=________
4. 3:30 am=_________
5. 12:00 am=________
Convert the 24-hour time to the 12-hour time.
6. 2200= _________
7. 1930= _________
8. 1815= _________
9. 2330= _________
10. 1300= ________
- Answer
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1. 1300
2. 1800
3. 2330
4. 0330
5. 1200
6. 10:00 pm
7. 7:30 pm
8. 6:15 pm
9. 11:30 pm
10. 1:00 pm
Feedback:
1. 1 pm= 1 +12=13.The time is 1300 hours on a 24-hour clock.
2. 6pm= 6 + 12= 18. The time is 1800 hours on a 24-hour clock.
3. 11:30 pm= 11.30 + 12= 12.30. The time is 2330 on a 24-hour clock.
4. 3:30 am= 0330 on a 24-hour clock.
5. 12:00 am = 1200 on a 24-hour clock.
6. 2200= 22-12= 10:00 pm
7. 1930= 19-12=7. Add the 30= 7:30 pm
8. 1815= 18-12=6. Add the 15= 6:15 pm
9. 11:30= 23-12= 11. Add the 30= 11:30 pm
10. 1300= 13-12=1. The time on a 12-hour clock is 1:00 pm