PSW 1023: Planning, Reporting, and Recording

• Planning, reporting, and recording client care is part of PSW 1023.
• The learning objectives involve understanding client information related to care which includes planning, processes, reporting, and recording.
• Also included are identifying ways of documentation, understanding the principles of documentation, and utilization of systematic documentation.

Care planning

• Care planning is a nursing process.
• It organizes care for clients and outlines a client's plan or goal and how to achieve it.
• This process focuses always on the client and is dynamic.

Care Planning Process

• This process is also known as the Nursing Process, which nurses leverage it to plan and deliver nursing care.
• Assessment is the first of 5 steps:
  • This involves collecting information about the client through evaluation by observation, reflection, and communication.
  • Assessments should include emotion, social, intellectual, and spiritual health
  • Team leaders comprised of nurses, social workers, or caseworkers gather as much information from various sources.
  • After this assessment, team members gather to set goals

PSW Role in Assessment

• PSWs play a key role because they make many observations while giving care and talking to the client.
  • Objective data(signs) are seen, heard, felt, or smelled
  • Subjective data(symptoms) are things from the client that can't be observed by PSWs

Nursing Diagnosis

• Based on the assessment findings, a nursing diagnosis can be made.
• The diagnosis is a statement describing a health problem that is treated through nursing measures.
• Diagnoses are made by nurses using NANDA – most Canadian nurses use diagnoses from the established list.
• PSW's observations are very important in making the nursing diagnosis and in the client's care.

Planning

• This involves setting priorities and goals arranged in order of importance.
• Establishment of client priority and goals should follow the SMART goal methodology.
• Measures are developed to help clients meet goals via interventions.

SMART Goal

• The following are important aspects:
  • Specific - simple enough to be understood and client centered
  • Measurable - how will the goal be evaluated to determine if met
  • Achievable - client needs to be able to reach the goal to make it relevant
  • Realistic - reasonable for the client to attain
  • Time-Framed - goals need time limits to determine progress

Interventions

• These include 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.
• These care plans provide a guide for providing care, and can be on paper or electronic.
• They are defined as methods to provide consistent, detailed care.

Implementation

• Implementation includes carrying out or performing an action and actions listed in the care plan.
• Nurses assign or delegate tasks that are within the job description.
• The four main functions are:
  • Providing care
  • Observing the client during care
  • Reporting and recording the care that has been completed
  • Reporting and recording observations made during the care
• PSW's report the care given to the nurse and in some agencies, record the care given.
• Reporting and recording occurs after giving care.
• Observations are part of the assessment and new observations may change the diagnosis in changes to the care plan.

Evaluation

• Evaluation includes 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 using assessment data which can result in changes to diagnoses, goals and the plan.
• PSW's provide valuable information towards this evaluation, which may result in changes being made when planning the care.

Care Plans (aka Kardex)

• These plans help ensure that the healthcare team members give the same care.
• The care plan is not a finished document as it is continually reviewed and revised, and depends on client needs, condition, and progress.
• These plans are written guides about the client’s care.
• Plans include client's diagnoses and goals with accompanying measures or actions for each.
• Care Plans are a communication tool used by nursing staff to see what care to give.

Observation and Assessment

• Observations are important for the care planning process, which should be precise and accurate, and do not interpret or make assumptions.
• Basic observations and assessments include support workers providing observations and feedback in the care process.
• Nurses use these observations, which are then used for the evaluation step.

Developing Observation Skill

• Support workers generally spend more time with clients than other health care providers do.
• Senses are used for objective data gathering like sight, hearing, touch, or smell.

Objective vs Subjective data

• Objective data is information observed about the client whereas subjective data is information reported which cannot be observed directly.
• Objective examples: red swollen ankles, coughing, or crying
• Subjective data: stating that "I feel faint", "the pain is worse", or "I have a headache"

Describing Observations

• Observations should be given information in a logical and orderly manner such as head to toe, anterior to posterior, and right to left.
• Descriptors should be specific using facts and avoid assumptions.

Documentation

• Documentation is a valuable source of data that ensures health care providers ongoing access to client information to provide and effective care.
• It is used to monitor progress and communicate with others on the care team.
• Good documentation should be clear, concise, comprehensive, and consistent.
• Documenting should be complete with a date/time signature, appropriate designations, and correct grammar and spelling.
• Guiding principles for the documentation process should be adhered to.

Documenting "Do's"

• Follow agency policies, check the full name on the chart, ensure name and number are included on each form and page, read previous entries prior to documenting.
• Include the complete date/time in each entry and use 24-hour time.
• Chart in the past tense related to what you did or what the client stated.
• Use authorized abbreviations and medical terms and sign every entry with a printed name, signature, and professional designation.
• Use objective, measurable terms.
• Document exact quotes in quotations.
• Report any failure of client to follow regimens
• Chart promptly after care and through client ownership.
• Note any changes in the client's condition plus time of contact and substantiate with facts.

Documenting "Don'ts"

• Avoid general, vague terms, assumptions, skipping lines between entries, leaving spaces, tampering with records, and accessing client information without purpose.
• Do not make entries suggesting an error, deleting, altering, discard notes or adding additional comments.
• Do not backdate, tamper or note unfound conclusions when writing opinions in statements.
• Documentations hould be facts.
• Document only observed behavior.
• Documentation should include what was observed, what was done, when it was done, and the client's response.