ClassNotes/LearningLog/TextbookNotes

Iftherewasnoclasslecturethis
Week,writeaparagraphabout
whatyoulearnedand/or
questionsaboutwhatyoudidn't
understand.

Name:AJ Zepeda
Class:IHC
Period/Block:5
Date:Feb 2013

Topic:CN9.4
1. What are your tools of
observation and how can
you use them to evaluate
patients in the hospital?

2. What is the difference

between objective and
subjective observations?
3. What is the difference
between medical reporting
and medicalrecords?

4. Why is reporting
important?

5. What is documentation
and what should be
included in documentation?
6. What have we learned
about communication so far
that can be applied to
documentation?
7. What are some important
things that nurses
assistants chart?

Sight: Look for all visible signs that may indicate a reason for the clients complaint
Hearing: Listen carefully. Dont put thoughts or words into the mouth of others. Be
sure that you understand fully what you are told
Touch: Feel for changes in the skin, body temp, abnormal structures and etc.
Smell: Smell unusual odors
Subjective: Observations that cannot be seen. Ideas, thoughts or opinions. You cannot
see, feel, hear, or smell it. ( Like pain)
Objective: Observations that can be seen. You can see, feel, hear, or smell it. (A cut)
Medical Reporting: The reports that a health care worker might have to document
observations. Medical billing reports, insurance reports code analysis reports and
other administrative reporting functions.
Medical Records: A systematic documentation of a person medical history. Can be
the physical folder for the patient as well as the body info that makes up each
patients health history. Personal documents. Many ethical and legal issues
surrounding them. Third party access and appropriate storage and disposal.
Reporting is important be it is the workers responsibility to report unusual events or
change in behavior/condition. You can prevent serious situations by reporting
observations in a timely manner.

Documentation is a record of the patients progress throughout treatment.

What should be included: Clients name, address, age, identification number,
diagnosis and Physicians orders.

Documentations should be legible and clear and concise.

What personal care was given

What activities the client participated in
The patients skin condition
General observations about the client
Any unusual occurrences
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2004AVIDCenter.Allrightsreserved.

Any complaints the client has

What treatments were given
Any information that is important to the patients well-being

Summary, Reflection, Analysis

Both subjective and objective observations should be recorded. The worker is
responsible to report anything unusual about the patient and keep an up to date
documentation of the client. Information about the client is always confidential.

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2004AVIDCenter.Allrightsreserved.

Questions/Main Ideas:

Notes:

Summary, Reflection, Analysis

www.avidonline.org
2004AVIDCenter.Allrightsreserved.