Improving Observation and Documentation Skills

Contact Hours: 3 Hours

This program focuses on knowing how to make good objective observations, gather the client's subjective input, report and record these observations. The manager/caregiver and home health aide will learn how to pick up on subtle body language cues from the client and become more familiar with the Patient's Bill of Rights, all of which will make taking care of the client more rewarding.

At the completion of this class the caregiver will be able to:

1. List four different observations that can be made using the senses.
2. Describe the sequence of objective observations that can be made when first meeting a client.
3. Define subjective observation and give examples.
4. Identify three client observations that must be reported immediately.
5. List at least four basic rules for recording client information.
6. List three rights covered by the Patient's Bill of Rights.

Topics will include a discussion on patient assements, Problem Identification, Planning, Implementation, Evaluation and the role of the manager/caregiver