PSW 1023: Planning, Reporting, and Recording

• Planning, reporting, and recording client care is essential in PSW 1023.
• Client care involves planning, processes, reporting, and recording information.
• Documentation methods and their principles need to be identified and understood respectively.
• The goal is to utilize a systematic documentation system.

Care Planning

• Care planning, also known as the Nursing Process, organizes client care.
• It outlines a client's plan or goal, and how to achieve it.
• The focus should always be on the client and is a dynamic process.
• The care planning process, or nursing process, has five steps.
• Assessment is the first step.
• Nursing diagnosis is the second step.
• Planning is the third step.
• Implementation is the fourth step.
• Evaluation is the fifth, and final step.

Care Planning Process - Assessment

• Assessment involves collecting information about the client.
• Assessment occurs through evaluating information collected about the client through observation, reflection, and communication.
• Assessment focuses on the client's emotional, social, intellectual, and spiritual health.
• The team leader gathers as much information as possible from various sources.
• Once the assessment is complete, the team members gather to set goals.
• PSWs play a key role in the assessment because of the many observations made while giving care and talking to the client.
• Objective data, or signs, are seen, heard, felt, or smelled.
• Subjective data, or symptoms, are things a client communicates that cannot be personally observed.

Care Planning Process - Nursing Diagnosis

• A nursing diagnosis can be made based on the assessment findings.
• It describes a health problem treated by nursing measures.
• Nursing diagnoses are made by nurses, and most Canadian nurses use diagnoses from the NANDA list.
• PSW's observations are important when making a nursing diagnosis.

Care Planning Process - Planning

• Planning involves setting priorities and goals.
• Client needs are arranged by order of importance.
• Establish client priority and goals by using a SMART goal.
• Measures or actions are developed to help the client meet their goals through interventions.

SMART Goals

• Specific - simple enough to be understood and client centered (client will be able to grasp a tennis ball with their affected hand).
• Measurable - how will the goal be evaluated to determine if it is met or not (the client walks 10 steps two times a day).
• Achievable - client needs to be able to reach the goal to make it relevant (client will pick up a fork with their affected hand).
• Realistic - reasonable for the client to attain (the client will be able to reach the end of the corridor using a walker).
• Time-Framed - goals need time limits to determine progress (the client will walk 10 steps two times a day after 3 days).

Client Planning Process - Planning - Interventions

• Interventions are actions or measures taken by a health care team to help the client meet a goal.
• A care plan is the nursing process written to provide information to care for clients.
• Care plans guide the provision of care.
• Care plans can be paper or electronic.
• Care plans promote consistent and detailed care.

Client Planning Process - Implementation

• Implementation involves carrying out or performing an action with the actions outlined within the care plan.
• Nurses assign or delegate tasks within the description of your role and job.
• The four main functions of implementation are providing care, observing the client during care, reporting and recording the care that was completed, and reporting and recording the observations made during the care.
• PSWs report the care given to the nurse.
• In some agencies, care providers record the care given.
• Reporting and recording are done after giving care, not before.
• Observations must be reported and recorded.
• Observing is part of assessment.
• New observations may change the nursing diagnosis.
• Changes in nursing diagnoses result in changes to the care plan.

Client Planning Process - Evaluation

• Evaluation involves assessing and measuring the progress of the client toward meeting the agreed upon goal.
• Goals may be totally met, partially met, or not met at all.
• Progress is evaluated during this process.
• Assessment information is used during evaluation.
• Changes in nursing diagnoses, goals, and the care plan may result from evaluation.
• PSWs provide valuable information that impacts the evaluation, which may result in changes being made to the care plan.

Care Plan (also known as Kardex)

• Care plans help ensure healthcare team members give the same care.
• The care plan is continually reviewed and revised, depending on the client's needs, condition, and progress
• It is a written guide about the client's care.
• Contains the client's nursing diagnoses and goals.
• Contains the actions for each goal.
• The care plan serves as a communication tool.
• Used by nursing staff to see what care to give.

Observation and Assessment for the PSW

• Observation and assessment are important components of the care planning process.
• When describing anything, be precise and accurate.
• Do not interpret or make assumptions, just provide the facts.
• The nurse uses support worker observations and feedback in the care planning process.
• Observations are used for the evaluation step.

Developing Observation Skills

• Support workers generally spend more time with clients than other health care providers do.
• Use objective senses, such as sight, hearing, touch, and smell for objective data gathering.
• Listen to the client breathe to gather information.
• Notice flushed or pale skin or red swollen ankles.
• Smell unusual odors from urine or bowel movements.

Objective vs Subjective Data

• Objective data is information that is observed about the client (red swollen ankles, coughing, and crying).
• Subjective data is information reported by a client that is not directly observed (I feel faint, the pain is worse, and I have a headache).

Describing Observations

• Give information in a logical and orderly manner, such as head to toe, anterior to posterior, or right to left.
• Give facts and be specific and avoid interpretations or assumptions.

Documentation

• Documentation is a valuable source of data used to ensure that health care providers have access to client information to provide safe and effective care and treatment.
• It is used to monitor a client's progress and communicate with other care providers.
• Good documentation is clear, concise, comprehensive, consistent, and complete with the date, time, signature, and designation, and incorporates correct grammar and spelling.
• Following guidelines, such as Do's and Don'ts for documentation ensures they are documented appropriately.

Documenting - Do's

• Follow agency policies and procedures.
• Check the full name on the chart before making an entry.
• Ensure the client's name ad identifying number is on each form/page.
• Read previous entries prior to documenting care that was given.
• Document the complete date/time of each entry.
• Use 24-hour clock to avoid error.
• Chart in the past tense ("what you did do” or what the patient stated or said).
• Use authorized abbreviations and medical terms appropriately.
• Sign every entry with printed name, signature, and professional designation.
• Use objective and measurable terms.
• Document exact quotes
• Report the failure of the client to follow treatment regimens, take medications, or receive treatments, and document the client provided rationale.
• Chart after delivery of care, never beforehand.
• Chart only the care given.
• Chart through ownership.
• Be precise when documenting information.
• Chart any changes in the client's condition, to whom it was reported (or attempts to report to) i.e., time of contact (and attempts).
• Substantiate with facts.
• Conclusions should be supported with data. Avoid documenting value judgments about a client or the client's behavior.

Chart Bloopers

• Patient was alert and unresponsive.
• The pelvic exam will be done later on the floor.
• Skin: Somewhat pale but present.
• Be accurate and concise: “Wound Appears to be red."
• It is either red or it is not red, don't sit on the fence.
• Chart specific data, "2 cm X 3 cm blue purple discolouration of skin on right forearm", not "large bruise on arm”.

Documenting - Don'ts

• Avoid general and vague terms, such as good, okay, apparently, poor, etc.
• Do not skip lines between entries or leave spaces.
• Do not tamper with records and avoid erasures.
• Additions to previous entries should be in an addendum (note added at the end and signed).
• Do not access client information without a purpose.
• Do not make entries suggesting an error or unsafe practice.
• Do not delete, alter, or modify the documentation of anyone else.
• Do not discard notes that have errors on them.
• Follow procedure for correcting an error in documentation.
• Do not add additional comments in a separate entry that is dated and signed.
• Do not backdate, tamper with or add to notes that were previously written.
• Do not use unfounded conclusions by writing opinions or biased statements, labeling a client will alter client care.

Documentation - Clarity and Accuracy

• Accurate notations consist of facts or observations rather than opinions or interpretations.
• It is more accurate to write that the client “refused medication” (fact) than to write that the client “was uncooperative” (opinion).
• It is more accurate to write that a client “was crying” (observation) versus the client “was depressed" (interpretation).
• Document conclusions that can be supported with data
• Avoid statements such as “client uncooperative,” or “client depressed.”
• Document the observed behavior, such as “client refuses bath, shouts and shakes fists".
• Remember to record what you observed (objective/measurable), signs and symptoms the client reports to you (subjective data) during documentation.
• Include what you did, when you did it, and the client's response during documentation.