LEARNING OBJECTIVE: Recall proper patient care reporting and assessment procedures.
Although physicians determine the overall medical management of a person requiring healthcare services, they depend upon the assistance of other members of the healthcare team when implementing and evaluating that patientís ongoing treatment. Nurses and medical technicians spend more time with hospitalized patients than all other providers. This situation places them in a key position as data-collecting and -reporting resource persons.
The systematic gathering of information is called data collection and is an essential aspect in assessing an individualís health status, identifying existing problems, and developing a combined plan of action to assist the patient in his health needs. The initial assessment is usually accomplished by establishing a health history. Included in this history are elements such as previous and current health problems; patterns of daily living activities, medication, and dietary requirements; and other relevant occupational, social, and psychological data. Additionally, both subjective and objective observations are included in the initial assessment gathering interview and throughout the course of hospitalization.
Accurate and intelligent assessments are the basis of good patient care and are essential elements for providing a total healthcare service. You must know what to watch for and what to expect. It is important to be able to recognize even the slightest change in a patientís condition, since such changes indicate a definite improvement or deterioration. You must be able to recognize the desired effects of medication and treatments, as well as any undesirable reactions to them. Both of these factors may influence the physicianís decision to continue, modify, or discontinue parts or all of the treatment plan.
Oral and Written Reporting
Equally as important as assessments is the reporting of data and observations to the appropriate team members. Reporting consists of both oral and written communications and, to be effective, must be done accurately, completely, and in a timely manner. Written reporting, commonly called recording, is documented in a patientís clinical record. Maintaining an accurate, descriptive clinical record serves a dual purpose: It provides a written report of the information gathered about the patient, and it serves as a means of communication to everyone involved in the patientís care. The clinical record also serves as a valuable source of information for developing a variety of care-planning activities. Additionally, the clinical record is a legal document and is admissible as evidence in a court of law in claims of negligence and malpractice. Finally, these records serve as an important source of material that can be used for educating and training healthcare personnel and for conducting research and compiling statistical data.
Basic Guidelines for Written Entries
It is imperative that you follow some basic guidelines when you make written entries in the clinical record. All entries must be recorded accurately and truthfully. Omitting an entry is as harmful as making an incorrect recording. Each entry should be concise and brief; therefore, avoid extra words and vague notations. Recordings must be legible. If an error is made, it must be deleted following the standard policy for correcting erroneous written notations. Finally, your entries in the clinical record must include the time and date, your signature, and your rate or rank.
SOAP Note Format
SOAP stands for SUBJECTIVE, OBJECTIVE, ASSESSMENT, and PLAN. Medical documentation of patient complaint(s) and treatment must be consistent, concise, and comprehensive.
SUBJECTIVE.óThe initial portion of the SOAP note format consists of subjective observations. These are symptoms verbally given to you by the patient orby a significant other (family or friend). These subjective observations include the patientís descriptions of pain or discomfort, the presence of nausea or dizziness, and a multitude of other descriptions of dysfunction, discomfort, or illness.
OBJECTIVE.óThe next part of the format is the objective observation. These objective observations include symptoms that you can actually see, hear, touch, feel, or smell. Included in objective observations are measurements such as temperature, pulse, respiration, skin color, swelling, and the results of tests.
ASSESSMENT.óAssessment follows the objective observations. Assessment is the diagnosis of the patientís condition. In some cases the diagnosis may be clear, such as a contusion. However, an assessment may not be clear and could include several diagnosis possibilities.
PLAN.óThe last part of the SOAP note is the plan. The plan may include laboratory and/or radiologic tests ordered for the patient, medications ordered, treatments performed (e.g., minor surgery procedure), patient referrals (sending patient to a specialist), patient disposition (e.g., binnacle list, Sick-in-Quarters (SIQ), admission to hospital), patient directions, and follow-up directions for the patient.
SELF-QUESTIONING TECHNIQUES FOR PATIENT ASSESSMENT AND REPORTING
Table 2-1 outlines the self-questioning techniques for patient assessment and reporting is a good guide toassist you in developing proficiency in assessing and reporting patient conditions.
Table 21.óSelf-Questioning Techniques for Patient Assessment and ReportingĺContinued
|Area of Concern||Assessment Criteria|
|General Appearance||Is the patient
|Behavior||Does the patient
|Position||Does the patient
|Skin||Is the patientís skin
|Eyes||Are the patientís
|Ears||Does the patient
|Nose||Is the patientís
Are the patient's nares (nasal openings) equal in size?
Is the patient sniffling excessively?
|Mouth||Does the patientís
Does the patient
|Chest||Does the patient
|Abdomen||Does the patient
|Bladder & Bowel||Does the patient have
|Vagina or Penis||Does the patient have
|Food & Fluid Intake||Does the patient
|Medications||Does the patient
A patient will often require inpatient care, whether due to injury or illness. Frequently, the inpatient will need specialized treatments, perhaps even surgery. In this part of the chapter, we will discuss the procedures for assisting both the medical inpatient and the surgical inpatient.