needs have been established, goals and objectives are
developed. Objectives inform the learner of what kind
of (learned) behavior is expected. Objectives also
assist the healthcare provider in determining how
effective the teaching has been. These basic principles
of teaching/learning are applicable to all patient-
education activities, from the simple procedure of
teaching a patient how to measure and record fluid
intake/output to the more complex programs of
behavior modification in situations of substance abuse
(i.e., drug or alcohol) or weight control.
As a member of the healthcare team, you share a
responsibility with all other members of the team to be
alert to patient education needs, to undertake patient
teaching within the limitation of your own knowledge
and skills, and to communicate to other team members
the need for patient education in areas you are not
personally qualified to undertake.
REPORTING AND ASSESSMENT
PROCEDURES
LEARNING OBJECTIVE: Recall proper
patient care reporting and assessment
procedures.
Although physicians determine the overall
medical management of a person requiring healthcare
services, they depend upon the assistance of other
members of the healthcare team when implementing
and evaluating that patients ongoing treatment.
Nurses and Hospital Corpsmen spend more time with
hospitalized patients than all other providers. This
situation places them in a key position as data-
collecting and -reporting resource persons.
The systematic gathering of information is called
data collection and is an essential aspect in assessing
an individuals health status, identifying existing
problems, and developing a combined plan of action to
assist the patient in his health needs. The initial
assessment is usually accomplished by establishing a
health history. Included in this history are elements
such as previous and current health problems; patterns
of daily living activities, medication, and dietary
requirements; and other relevant occupational, social,
and psychological data. Additionally, both subjective
and objective observations are included in the initial
assessment gathering interview and throughout the
course of hospitalization.
REPORTING
Accurate and intelligent assessments are the basis
of good patient care and are essential elements for
providing a total healthcare service. You must know
what to watch for and what to expect. It is important to
be able to recognize even the slightest change in a
patients condition, since such changes indicate a
definite improvement or deterioration. You must be
able to recognize the desired effects of medication and
treatments, as well as any undesirable reactions to
them.
Both of these factors may influence the
physicians decision to continue, modify, or
discontinue parts or all of the treatment plan.
Oral and Written Reporting
Equally as important as assessments is the
reporting of data and observations to the appropriate
team members. Reporting consists of both oral and
written communications and, to be effective, must be
done accurately, completely, and in a timely manner.
Written reporting, commonly called recording, is
documented in a patients clinical record. Maintaining
an accurate, descriptive clinical record serves a dual
purpose: It provides a written report of the information
gathered about the patient, and it serves as a means of
communication to everyone involved in the patients
care. The clinical record also serves as a valuable
source of information for developing a variety of
care-planning activities. Additionally, the clinical
record is a legal document and is admissible as
evidence in a court of law in claims of negligence and
malpractice.
Finally, these records serve as an
important source of material that can be used for
educating and training healthcare personnel and for
conducting research and compiling statistical data.
Basic Guidelines for Written Entries
It is imperative that you follow some basic
guidelines when you make written entries in the
clinical record.
All entries must be recorded
accurately and truthfully.
Omitting an entry is as
harmful as making an incorrect recording. Each entry
should be concise and brief; therefore, avoid extra
words and vague notations.
Recordings must be
legible.
If an error is made, it must be deleted
following the standard Navy policy for correcting
erroneous written notations. Finally, your entries in
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