The document discusses nurse aide observations, recording, and reporting. It provides examples of observations that can be made using sight, hearing, touch, and smell. It emphasizes the importance of objective and accurate reporting using notes. Nurse aides must report facts like the care provided, resident responses, and anything unusual. Proper documentation includes recording in care plans, medical records, and using guidelines for charting entries.

1. • Understand nurse aide
observations,
recording, and
reporting.
Nursing Fundamentals 7243 12.02
Unit A
Nurse Aide Workplace Fundamentals
Essential Standard NA2.00
Apply communication and interpersonal skills and physical care that promote mental health and meet the social and special needs of
residents in long-term care.
Indicator 2.02
Understand nurse aide observations, recording, and reporting.

2. Nursing Fundamentals 7243 2
Examples using sight:
• Rash
• Skin color
• Bruising
Methods of Observation
2.02

3. Nursing Fundamentals 7243 3
Examples using hearing:
• Wheezing
• Moans
• Words spoken by resident
Methods of Observation
(continued)
2.02

4. Nursing Fundamentals 7243 4
Methods of Observation
(continued)
Examples using touch:
• Lump
• Temperature of skin
• Change in pulse
2.02

5. Nursing Fundamentals 7243 5
Examples using smell:
• Odor of breath
• Odor of urine
• Odor of body
Methods of Observation
(continued)
2.02

6. Nursing Fundamentals 7243 6
Reporting
• Reports are made:
– immediately
– thoroughly
– accurately
• Use notepad and pencil to write down
information for reporting
2.02

7. Nursing Fundamentals 7243 7
Reporting
(continued)
• Report only facts, not opinions
–objective data - that observed using
senses
–subjective data - that told to nurse
aide by the resident
2.02

8. Nursing Fundamentals 7243 8
Reporting
(continued)
Observe resident’s
environment and
report safety
hazards
2.02

9. Nursing Fundamentals 7243 9
Reporting
(continued)
• When reporting, consider:
– care or treatment given
– time of treatment
– resident’s response to care
2.02

10. Nursing Fundamentals 7243 10
Reporting
(continued)
• When reporting, consider:
–observations helpful to other health
care workers
–information resident has given that
would affect his or her treatment
–anything unusual about resident
2.02

11. Nursing Fundamentals 7243 112.02
Communicating with
other Staff Members

12. Nursing Fundamentals 7243 12
Forms of Communicating
• Body language
• Reporting or
communicating orally
• Written communications
2.02

13. Nursing Fundamentals 7243 13
Written Communications:
Resident Care Plans
• Resident care plans prepared by
nurse
• One for each resident
• Kept at nurses’ station
2.02

14. Nursing Fundamentals 7243 14
Written Communications:
Resident Care Plans
(continued)
• Working record to provide
consistent, well-planned care
on a daily basis
• Changed and updated as
needed by licensed nurse
2.02

15. Nursing Fundamentals 7243 15
Written Communications:
Resident Care Plans
(continued)
• Information included:
–Resident’s level of
independence in ADL
–Treatments
–Statement of problems
2.02

16. Nursing Fundamentals 7243 16
Written Communications:
Resident Care Plans
(continued)
• Information included (continued):
–Short-term and long-term goals
–Plan to attain goals
–Date plan initiated and
reevaluated
2.02

17. Nursing Fundamentals 7243 17
Written Communications:
Resident Care Plans
(continued)
• Nurse aides contribute by:
–Helping to identify
problems
–Attending care
conferences
2.02

18. Nursing Fundamentals 7243 18
Written Communications:
Resident Care Plans
(continued)
• Nurse aides contribute by (continued):
–Directing questions about plan to
supervisor
–Reporting resident response to
treatment and activities
2.02

19. Nursing Fundamentals 7243 19
Written Communications:
Resident‘s Medical Record
• Includes information
from all disciplines
providing direct service
to residents
2.02

20. Nursing Fundamentals 7243 20
Written Communications:
Resident’s Medical Record
(continued)
• A record of:
–assessments, implementations,
evaluations
–management plans
–progress notes
• Permanent legal record
2.02

21. Nursing Fundamentals 7243 21
Written Communications:
Resident’s Medical Record
(continued)
• Purpose
–Organizes all information on care in
one document
–Accountability so care can be
evaluated
–Documentation so there is
knowledge of what each discipline is
doing
2.02

22. Nursing Fundamentals 7243 22
Written Communications:
Resident’s Medical Record
(continued)
• Confidential information
available only to health
care workers involved in
care of resident
2.02

23. Nursing Fundamentals 7243 23
Guidelines For Charting
If Allowed By Facility
• Make sure entries are
accurate and easy to read
• Always use ink
• Print, unless script is
accepted form
• Do not use the term
“resident”
2.02

24. Nursing Fundamentals 7243 24
Guidelines For Charting
If Allowed By Facility
(continued)
• Use short, concise
phrases
• Always chart after care
is performed
• Make sure writing
legible and neat
2.02

25. Nursing Fundamentals 7243 25
Guidelines For Charting
If Allowed By Facility
(continued)
• Use only abbreviations accepted
by facility
• Make sure spelling, grammar
and punctuation are correct
• Do not record judgments or
interpretations
2.02

26. Nursing Fundamentals 7243 26
Guidelines For Charting
If Allowed By Facility
(continued)
• Record in a logical and
chronological manner
• Be descriptive
• Make sure all forms added
to the chart contain
identifying information
2.02

27. Nursing Fundamentals 7243 27
Guidelines For Charting
If Allowed By Facility
(continued)
• Avoid using words that have
more than one meaning
• Use resident’s exact words in
quotation marks whenever
possible
• Always indicate the time of care
2.02

28. Nursing Fundamentals 7243 28
Guidelines For Charting
If Allowed By Facility
(continued)
• Leave no lines blank
• Sign each entry with first
initial, last name and title
• Correct errors using
facility procedure
2.02

29. Nursing Fundamentals 7243 292.02
Medical Terminology

30. Nursing Fundamentals 7243 30
Medical Terminology
• Medicine has a language of its own
–Historical development
–Composed mainly of Greek and
Latin word parts
–Consistent and uniform
2.02

31. Nursing Fundamentals 7243 31
Medical Terminology
(continued)
• Three components
–Prefixes
–Root words
–Suffixes
• Medical dictionary
–Used for reference
–Spelling is important
2.02

32. Nursing Fundamentals 7243 322.02
Abbreviations

33. Nursing Fundamentals 7243 33
Abbreviations
• Help health care workers
communicate quickly and effectively
• Are shortened forms of words
• Reduce time needed to chart
important information
2.02

34. Nursing Fundamentals 7243 34
Abbreviations
(continued)
• Conserve space on medical record
• Used primarily in written
communication
2.02

35. Understand nurse aide
observations, recording, and
reporting.
35
 END 
2.02
2.02 Nursing Fundamentals 7243