Observing, Reporting, and Documenting

Presented by Rachel Madsen

Observing, Reporting, and Documenting

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Observation and reporting are vital skills for healthcare providers, especially home health aides, who often detect early changes in a client’s condition. This course reviews using our senses to observe a client’s condition and how to assess and report changes in a client’s appearance, behavior, and physical condition accurately. Designed for in-home aides and healthcare providers, it offers practical tools for clear documentation and effective communication to enhance client care.

Learning Objectives
  • Recognize the importance of observing, reporting, and recording, and identify what information aides should observe for, report, and record
  • Differentiate between subjective and objective information
  • List information that can be observed using each of the senses: smell, hear, see, and touch
  • Express the importance of accurate and timely documentation
  • Recognize five guidelines for documenting visits and incidents
  • Identify what information should be reported (not just recorded) and how to accurately report to a supervisor

Meet your instructor

Rachel Madsen

Rachel is a Registered Nurse with experience in home health care, long term care, and emergency medicine. She is also a certified educator and has taught certified nursing assistants and other health science classes for over 20 years. She has been a school administrator and works as a health coach to assist others in…

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Chapters & learning objectives

Introduction

1. Introduction

This chapter introduces the foundational concepts of observing, reporting, and documenting in home healthcare. It highlights the critical role home health aides (HHAs) play in identifying changes in a client’s condition and communicating these effectively. Learners will also become familiar with the key objectives of the course, which include recognizing the importance of accurate documentation and understanding the difference between subjective and objective information.

Observing

2. Observing

This chapter dives into the art of observation and teaches HHAs how to use their senses to gather vital information about their clients’ conditions. Through examples and scenarios, learners will understand how to use sight, hearing, touch, and smell to identify potential issues. The chapter also explains the importance of distinguishing between subjective reports from clients and objective observations to ensure accurate communication with the healthcare team.

Documenting

3. Documenting

In this chapter, participants will learn the principles of timely and accurate documentation. It covers essential topics such as how to create clear and factual records, the importance of following agency policies, and the process for documenting unusual incidents. By mastering these skills, HHAs will be able to ensure continuity of care and maintain a reliable legal record of the care provided.

Reporting

4. Reporting

The final chapter focuses on what information needs to be reported immediately and how to do so effectively. HHAs will learn how to recognize signs and symptoms that could indicate serious health issues and how to provide detailed, concise reports to a nurse or supervisor. This chapter emphasizes the importance of proactive communication and provides strategies for making informed decisions about what to report to ensure client safety and well-being.