needs have been established, goals and objectives aredeveloped. Objectives inform the learner of what kindof (learned) behavior is expected. Objectives alsoassist the healthcare provider in determining howeffective the teaching has been. These basic principlesof teaching/learning are applicable to all patient-education activities, from the simple procedure ofteaching a patient how to measure and record fluidintake/output to the more complex programs ofbehavior modification in situations of substance abuse(i.e., drug or alcohol) or weight control.As a member of the healthcare team, you share aresponsibility with all other members of the team to bealert to patient education needs, to undertake patientteaching within the limitation of your own knowledgeand skills, and to communicate to other team membersthe need for patient education in areas you are notpersonally qualified to undertake.REPORTING AND ASSESSMENTPROCEDURESLEARNING OBJECTIVE: Recall properpatient care reporting and assessmentprocedures.Although physicians determine the overallmedical management of a person requiring healthcareservices, they depend upon the assistance of othermembers of the healthcare team when implementingand evaluating that patient’s ongoing treatment.Nurses and Hospital Corpsmen spend more time withhospitalized patients than all other providers. Thissituation places them in a key position as data-collecting and -reporting resource persons.The systematic gathering of information is calleddata collection and is an essential aspect in assessingan individual’s health status, identifying existingproblems, and developing a combined plan of action toassist the patient in his health needs. The initialassessment is usually accomplished by establishing ahealth history. Included in this history are elementssuch as previous and current health problems; patternsof daily living activities, medication, and dietaryrequirements; and other relevant occupational, social,and psychological data. Additionally, both subjectiveand objective observations are included in the initialassessment gathering interview and throughout thecourse of hospitalization.REPORTINGAccurate and intelligent assessments are the basisof good patient care and are essential elements forproviding a total healthcare service. You must knowwhat to watch for and what to expect. It is important tobe able to recognize even the slightest change in apatient’s condition, since such changes indicate adefinite improvement or deterioration. You must beable to recognize the desired effects of medication andtreatments, as well as any undesirable reactions tothem. Both of these factors may influence thephysician’s decision to continue, modify, ordiscontinue parts or all of the treatment plan.Oral and Written ReportingEqually as important as assessments is thereporting of data and observations to the appropriateteam members. Reporting consists of both oral andwritten communications and, to be effective, must bedone accurately, completely, and in a timely manner.Written reporting, commonly called recording, isdocumented in a patient’s clinical record. Maintainingan accurate, descriptive clinical record serves a dualpurpose: It provides a written report of the informationgathered about the patient, and it serves as a means ofcommunication to everyone involved in the patient’scare. The clinical record also serves as a valuablesource of information for developing a variety ofcare-planning activities. Additionally, the clinicalrecord is a legal document and is admissible asevidence in a court of law in claims of negligence andmalpractice. Finally, these records serve as animportant source of material that can be used foreducating and training healthcare personnel and forconducting research and compiling statistical data.Basic Guidelines for Written EntriesIt is imperative that you follow some basicguidelines when you make written entries in theclinical record. All entries must be recordedaccurately and truthfully. Omitting an entry is asharmful as making an incorrect recording. Each entryshould be concise and brief; therefore, avoid extrawords and vague notations. Recordings must belegible. If an error is made, it must be deletedfollowing the standard Navy policy for correctingerroneous written notations. Finally, your entries in2-10
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