Reporting Patient/Client Observations If the aide observes any changes in patient/client condition or if the patient/client and/or caregiver reports any problems, the aide must report immediately to the RN. Guidelines for Charting • All entries must be written in ink. • Entries must be neat and legible. • Document the following information for all comments: o Date and time. o What you reported. o Whom you reported it to. o Any instructions you were given. o Your signature and title at the conclusion of your entry. Example Comments: 03/19/15 10:15 A.M. Reported elevated B/P of 205/115 to Mary Smith, RN. Instructed to retake B/P in 20 minutes. Jane Jones, HHA 10:35 A.M. B/P 190/110. Reported this to Mary Smith, RN. Jane Jones, HHA. • Record the patient’s/client’s own words when possible; use quotation marks. • Avoid such words such as “normal”, “good”, or “adequate.” • Document only what you observed or performed. • Never document a procedure or task until it has been completed. • Never white-out or erase an entry. • If you make an error, draw a single line through it, then date and sign it. Approved Medical Abbreviations Approved medical abbreviations are listed in policy. Home health aides will follow policy. Online Bookmark Title of Policy Management of Information (IM) Interfacing Standardized Information
