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.

Document What You Do Checklist

The entries you make in the medical record should show you took appropriate actions in response to the patient’s condition. Record as close to the timing of the events as possible otherwise you may not remember key points, times, or persons that are important to record.  Record “real-time” when documenting interventions.  Real-time entries may avoid the appearance that a delay occurred in your response to significant findings.  Always follow interventions with entries that show how the patient responded indicating the effectiveness of the intervention because not all interventions are effective as you know. 

Referrals are often necessary for ongoing care and treatment.  When referrals involve other providers, such as home care or social services, include interdisciplinary meetings discussions and patient current plan of care and discharge planning.

Documentation Checklist 

Essential Documentation Goals

- Accurately describe the patient’s condition and progress.
- Communicate clearly.
- Satisfy legal requirements.

Accurately describe the patient’s condition and progress 

• List initial assessment data. 
• Identify potential and actual problems on the plan of care. 
• Describe specifically procedures, treatments, and medications administered. 
• Describe the patient’s responses to procedures, treatments, and medications. 
• Outline patient teaching by including topics covered and evaluation of the patients understanding using teach-back method or teach-to-goal. 
• List nursing actions; interventions. 
• Name individuals you consulted with regarding the patient’s condition. 

Communicate clearly

• Record dates and exact times for assessments, interventions, and other events. 
• State the facts in a concise manner. 
• Use quotation when describing symptoms a patient tells you; avoid interpreting what they say. 
• Describe only what you have seen, heard, touched, or smelled. “First-hand knowledge”. A
• Avoid recording assumptions and personal opinions. 
• Use only standardized abbreviations. 
• Spell correctly. Check the spell check! 
• All handwritten entries must be legible. 

Satisfy legal requirements

• Make corrections according to your facility policy for documentation. 
• Be accurate and truthful. 
• Avoid omissions, blank spaces, or unused spaces. 
• Follow your facility policy for documentation on forms.
• Record ALL communications with those who have the authority to give you orders. 
• List all nursing assessment findings and actions taken. 
• Never refer to an incident report or other documents that are not a part of the medical record. 
• Sign your entries: handwritten or electronic as appropriate. 

What difficulties do you have with the EMR?

Document What You Assess and What You Are Told

Document What You Assess

The first encounter with a patient usually includes obtaining a health history interview when you gather information about the patient’s current symptoms and past health status, previous medical treatments, and responses to treatments or procedures.  This information is the basis for the formulation of the plan of care and the devising a teaching plan appropriate to the patient’s health literacy level.  The primary source for this information is the patient, however when the patient is not able to provide reliable information or is incapacitated, the next best source may be immediate family members and the previous medical chart if the patient if available.  If you are able to speak with the patient, use quotations to describe the patient’s symptoms, avoid interpreting what they say.  This helps to clearly differentiate yours words from the patient’s words. 

The first encounter with a patient usually includes obtaining a health history interview when you gather information about the patient’s current symptoms and past health status, previous medical treatments, and responses to treatments or procedures.  This information is the basis for the formulation of the plan of care and the devising a teaching plan appropriate to the patient’s health literacy level.  The primary source for this information is the patient, however when the patient is not able to provide reliable information or is incapacitated, the next best source may be immediate family members and the previous medical chart if the patient if available.  If you are able to speak with the patient, use quotations to describe the patient’s symptoms, avoid interpreting what they say.  This helps to clearly differentiate yours words from the patient’s words.  

The information you collect from performing your physical assessment includes vital sign measurements, inspection, palpation, percussion and auscultation.  Abnormal findings should be described in detail as they relate to the patient’s current condition.  It is also important to record the patient’s denial of symptoms that would be of concern as related to the patient’s current diagnosis or condition, for example, a diagnosis of myocardial infarction and denial of symptoms of chest pain.  These are what could be called pertinent negatives. 

Use objective terms and be specific to avoid making judgments of assessment data.  For example, “The patient’s urine output was only 90 ml,” this may suggest you think the urine output was too low.  Quantify your findings whenever you can by specifying numbers, ranges, degrees of elevation, temperature of heating or cooling blanket, or aqua K pads etc.  Phrases like “a little”, “a lot”, "appears", "fairly well", etc. leave ample room for wide interpretation, so avoid using them. 

Describe first-hand knowledge which means what you see, feel, smell, and hear during your assessment.  Avoid documenting your interpretation of patient behavior.  For example, document “Sarah was crying during the assessment” instead of “Sarah was crying during the assessment because she is depressed.”

Document What the Patient Tells You

The first encounter with a patient usually includes obtaining a health history interview when you gather information about the patient’s current symptoms and past health status, previous medical treatments, and responses to treatments or procedures. The information should be verified as understood so misunderstandings are less likely to occur.  This information is the basis for the formulation of the plan of care and the devising a teaching plan appropriate to the patient’s health literacy level. The primary source for this information is the patient, however when the patient is not able to provide reliable information or is incapacitated, the next best source may be immediate family members and the previous medical chart if the patient if available. If you are able to speak with the patient, use quotations to describe the patient’s symptoms, avoid interpreting what they say. This helps to clearly differentiate yours words from the patient’s words. 

Organize Your Entries

It is not always easy to make documentation a priority.  Time constraints may lead you to think that other patient care activities are more important, particularly in a crisis situation.  Often documentation is pushed to the bottom of the list of priorities.  To help prevent documentation from becoming a burden, organize patient care information into categories. 

If  you have other areas that work for you, please share them!

What the patient tells you.	This is information you obtain directly from the patient or from the patient’s representative if the patient is incapacitated in some way.
What you assess.	This is the information you collect from performing your physical assessment.  It includes vital sign measurements and inspection, palpation, percussion and auscultation.
What actions you take in response to your assessment.	The interventions you perform. Interventions may be dependent, interdependent, or independent.
The patient’s response to your interventions.	The patient’s response may be favorable or may be an abnormal or deterioration in response to treatment or therapy, which would then require a modification in the plan of care.
What you teach your patient / family.	The health information or instructions you give a patient or their family.  Health information is expected to be provided in a manner that is meaningful and useful to patients i.e. health literacy factors.