Documenting Communication and Cognitive Function

General observations made during the initial assessment of a patient include their appearance, mobility, ability to communicate, and cognitive function.  Use this table to evaluate your general assessment skills and how you record your findings. If you identify areas you are shallow in, and then make the appropriate adjustments the next time you record patient care. 

Guidelines for General Observations
Communication
Speech	Speaks clearly in English (or other spoken language)
	Speaks with only one word responses; does not respond to verbal stimuli
	Speech is slurred, hearse, loud, soft, incoherent, hesitant, slow, fast, or nonsensical
	Has difficulty completing sentences due to shortness of breath or pain.
Hearing	Hears well enough to respond to questions
	Hard of hearing; wears hearing aid; must speak loudly into left or right ear.
	Deaf; reads lips or uses sign language
Vision	Sees well enough to read instructions in English or other language
	Wears corrective lenses to see or to read
	Cannot read.
	Blind (one eye or both)
Cognitive functions
Awareness	Oriented x 3 and aware of surroundings and situation
	Disoriented; unaware of time, place, person, or situation
Mood	Responds appropriately; talkative
	Answers in one-word responses; offers information only when asked direct questions
	Hesitates in answering questions; looks to family or support person before answering
	Angry; states “Leave me alone” (use quotations to record what they say); speaks loudly and abruptly to family or support person(s).
	Maintains or avoids eye contact
Thought processes	Maintains a conversation; makes relevant statements; follows commands appropriately
	Mind wanders; makes irrelevant statements; follows commands inappropriately.

Top 5 Malpractice Claims Made Against Nursing Professionals

Chances are at some point in your career, you will either:

• Have a claim made against your professional services.
• You will be named in a group lawsuit - whether as part of a larger group of health care professionals and/or included with your health care facility.
• Witness a negligent act by another health care professional during the course of a normal work day.
• Be deposed to testify on behalf of yourself, your employer or colleague. 

No matter what the situation, being involved in any allegation of malpractice can be emotionally and financially devastating for all parties.   However, if you are specifically named in the malpractice suit, your asset, reputation and career could all be in jeopardy.  It is important to understand the most common allegations and how they happen in order to minimize your risk.  Most malpractice calms involve at least one of the following allegations:

1. Failure to follow standards of care
2. Failure to use equipment responsibly
3. Failure to document
4. Failure to assess and monitor the patient
5. Failure to communicate.

I will discuss these five common allegations in the coming blog posts, so stay in touch!

Documenting Appearance and Mobility

General observations made during the initial assessment of a patient include their appearance, mobility, ability to communicate, and cognitive function.  Use this table to evaluate your general assessment skills and how you record your findings. If you identify areas you are shallow in, and then make the appropriate adjustments the next time you record patient care. 

Guidelines for General Observations
Appearance
Age	Appears to be stated age
	Appears older or younger than stated age
Physical condition	Physically fit, strong, appropriate weight for height
	Deconditioned, weak, underweight or overweight for height
	Limitation due to amputation or paralysis
Dress	Dressed appropriately or inappropriately for the weather
	Clean and well-kept clothing
	Soiled or torn clothing; smell of alcohol, urine, or feces
Hygiene	Clean and well-groomed
	Unkempt; unshaven, dirty skin, dirty hair, dirty nails
	Body odor or unusual breath odor
Skin color	Appropriate for race.
	Pale, ruddy, cyanotic, jaundiced, or tanned
Mobility
Ambulation	Walks independently; steady gait
	Uses a cane, crutches, wheel chair, or walker
	Unsteady, slow, hesitant, or shuffling gait; leans to  one side; unable to support own weight
	Transfers from chair to bed independently
	Needs (from one, two, or three person) assistance to transfer from chair to bed.
Movement	Moves all extremities
	Has right or left sided weakness; paralysis
	Cannot turn in bed independently; cannot shift weight in bed independently
	Has jerky or spastic movements of (specific) body parts.

Top 5 Malpractice Claims Made Against Nursing Professionals

Chances are at some point in your career, you will either:

• Have a claim made against your professional services.
• You will be named in a group lawsuit - whether as part of a larger group of health care professionals and/or included with your health care facility.
• Witness a negligent act by another health care professional during the course of a normal work day.
• Be deposed to testify on behalf of yourself, your employer or colleague. 

No matter what the situation, being involved in any allegation of malpractice can be emotionally and financially devastating for all parties.   However, if you are specifically named in the malpractice suit, your asset, reputation and career could all be in jeopardy.  It is important to understand the most common allegations and how they happen in order to minimize your risk.  Most malpractice calms involve at least one of the following allegations:

1. Failure to follow standards of care
2. Failure to use equipment responsibly
3. Failure to document
4. Failure to assess and monitor the patient
5. Failure to communicate.

I will discuss these five common allegations in the coming blog posts, so stay in touch!

Subjective Data and Patient Assessment

Objective data includes measurable and observable criteria that are specific to a clinical problem.  Objective indicators are factual that can be observed.  These types of data are obtained through the assessment process using the techniques inspection, palpation, percussion, and auscultation when examining the patient.  Objective data is also referred to as “signs”. In medicine a symptom is generally subjective while a sign is objective.  

Subjective data is information provided by the patient or significant knowledgeable other.  Objective data is information a healthcare provider obtains directly through observation or measurement, from patient records, or from diagnostic studies.

I will address What are Symptoms? What are Signs? is subsequent posts.  Stay tuned.

Examples of Subjective Data

Obtaining subjective data requires good listening skills, as well as respect and empathy.  This data is often the assessment of what the patient, family, or care provider perceives to be the problem. Subjective data is collected through the process of interviewing the patient during the nursing history and during each patient encounter.  This information can only be described or verified by the patient.  Subjective data is also referred to as “symptoms”.  The best method to represent subjective data entries in a medical record is to use quotations.

Does your electronic medical record have a place where you can enter the "details" of your objective data? Or is it in general terms like, within normal limits, within expected range?  The extent of your vulnerability may come down to the "details".  Take time to record completely your patient care.

If you enter responses to subjective inquiry in an electronic medical record for the nursing admission data base, then; the answers in response to many of these questions are considered to be from the patient unless otherwise stated.  Quotations would not be necessary under this circumstance.  If the responses are obtained from a family member, it is necessary to record the historian to make the record clear where, or from whom the information was obtained.  Quotations are necessary when subjective entries are made that are not a part of the initial nursing data base questionnaire.  The following table demonstrates a comparison between subjective and objective entries.

Subjective Entries	Objective Entries
Patient is drinking well.	Drank 1,200 ml clear liquids between noon and 6 p.m.
Patient reported good relief from Demerol.	Pain in right hip decreased from 9/10 to 3/10.
Dorsalis pedis pulse present. Or Good pedal pulses.	Bilateral peripheral pulses in legs 2+/4+.
Voiding qs.	Voided 400 cc clear yellow urine in bedpan.
Patient is nervous.	Repeatedly asks about length of hospitalization, pain and discomfort, and time off from work.
Breath sounds normal.	Breath sounds clear to auscultation in all lobes, nail beds pink, equal chest expansion, no cough.
Bowel sounds normal.	Bowel sound present in all quadrants, abdomen flat, non-tender.  NPO since 11 a.m.

Objective Data and Patient Assessment

Objective data includes measurable and observable criteria that are specific to a clinical problem.  Objective indicators are factual that can be observed.  These types of data are obtained through the assessment process using the techniques inspection, palpation, percussion, and auscultation when examining the patient.  Objective data is also referred to as “signs”. In medicine a symptom is generally subjective while a sign is objective.  

Subjective data is information provided by the patient or significant knowledgeable other.  Objective data is information a healthcare provider obtains directly through observation or measurement, from patient records, or from diagnostic studies.

I will address What are Symptoms? What are Signs? is subsequent posts.  Stay tuned.

Examples of Objective Data

Height, weight

General appearance: Well-nourished, well-hydrated, well-developed white woman or man in no acute distress.  Appears stated age, looks pleasant, smiles readily, speech clear and evenly paced; alert and oriented x 4; calm and cooperative.

Caloric intake

Vital signs: Blood pressure, respiration, temperature, heart rate, hemodynamic measures

Level of consciousness

Tears, crying

IV solution, rate infusing, site description

Lab values (hemoglobin, hematocrit)

Presence of indwelling catheter

Functional mobility

Diaphoresis

Dyspnea

History of illness (include dates)

Lung sounds

Sputum production, frequency, amount, character

Oxygen use

Bed position (e.g., low position, semi-Fowler’s)

Restlessness

Visitors present (be as specific as possible)

Skin integrity: color, lesions, scars, bruises, edema, moisture, texture, temperature, turgor, vascularity

Loose or liquid stools 

Does your electronic medical record have a place where you can enter the "details" of your objective data? Or is it in general terms like, within normal limits, within expected range?  The extent of your vulnerability may come down to the "details".  Take time to record completely your patient care.