Observing, Reporting and Charting.
Carefully observe each client throughout your daily contacts.
Personal Care Worker need to be alert to problems or changes in each client’s physical or emotional condition. Follow agency procedures for what to report immediately and what to report in writing. Accurate, thorough, and timely records of care and observations of each client are critical.
All information is confidential, and records must be safely stored when not in use. Some facilities keep handwritten records, and other facilities use computerized systems.
The HIPA A* Privacy Rule provides federal protection for personal health information. All records (written or electronic) are confidential. As a health team member, it is critical that you understand the facility policies regarding the safekeeping and privacy of all records.
- Health Insurance Portability and Accountability Act
Everything in the chart is confidential.
Keeping the information confidential is
your responsibility legally, ethically, and morally.
Observe each client throughout your daily contacts. Being a skilled observer helps prevent serious problems and earns the respect of the team staff. Being alert to the client and the environment reduces safety hazards and health problems. Careful observation increases your awareness of each client’s physical, emotional, and social needs.
Learn to recognize signs and symptoms of common diseases and conditions. Detecting problems in their early stages is critical. Trust your instincts. If something seems wrong, report it.
Be alert to emotional changes:
- Mood swings, loss of control
- Depressed, hopeless, crying, tearful
- Angry, difficult, irrational, agitated
- Disoriented, confused
- Anxious, frightened, pacing, restless
- Decreased or increased functioning (e.g., pulse, breathing, elimination)
- unconscious, weak, dizzy, drowsy
- Shaking, trembling, spasms.
- Chest pains.
- Cold, pale, clammy, chills.
- Hot, burning, sweating, feverish.
- Nausea, vomiting odor.
- Diarrhea, constipation.
- Excessive thirst, change in appetite.
- Change in skin color.
- Ringing in the ears.
- Blurred vision.
Be alert to physical changes:
- Swelling, edema rash, hives, blisters;
- Choking, coughing, wheezing, sneezing shortness of breath;
- Red or irritated areas, pus, drainage.
- Change in activity level weakness on one side.
Thorough and accurate reports are made to the nursing staff as often as the resident’s condition requires. End-of-shift reports to the oncoming staff provide the information necessary for continued good care. Follow facility procedures.