Module 15: Observation and Charting
Statement of Purpose: The purpose of this unit is to prepare students to know how, when, and why to use objective and subjective observation skills. They will report and record observations on appropriate documents using medical terms and abbreviations.
Module 15 Vocabulary Study Tool: https://claude.ai/public/artifacts/4d01210f-49b5-4a71-8cf4-1e7e675ae16f
Performance Standards (Objectives): Define key terminology:
1. Abbreviation
2. Activities of Daily Living (ADL)
3. Assessment
4. Assessment Reference Day (ARD)
5. Incident report
6. Kardex
7. Minimum Data Set (MDS)
8. Objective
9. Observation
10. Paraprofessional Healthcare Institute (PHI) http://phinational.org/about/
11. Prefix
12. Range of Motion (ROM)
13. Resident Assessment Instrument (RAI)
14. Resident Assessment Protocol (RAP)
15. Patient/resident care plan
16. Root word
17. Subjective
18. Suffix
Patient, resident, and client are synonymous terms referring to the person receiving care
Module 15 Vocabulary Sentences for CNA California Exam
Observation and Charting Vocabulary Practice
- The nurse wrote “BP” on the chart as an abbreviation for blood pressure, which is a shortened version of the complete medical term.
- The nursing assistant helps residents with Activities of Daily Living (ADL), including basic personal care tasks like bathing, dressing, feeding, and using the bathroom.
- The licensed nurse completed an assessment by observing and interpreting the resident’s vital signs and overall condition.
- The Assessment Reference Day (ARD) is the specific date used as a reference point for completing resident evaluations and care planning.
- After Mrs. Johnson fell in her room, the nursing assistant completed an incident report to document this unusual and unplanned occurrence.
- The Kardex is a card file system that summarizes and keeps current information about each resident’s care needs and medical status.
- The nursing team uses the Minimum Data Set (MDS) form to identify and record each resident’s physical, mental, spiritual, and social needs for proper care planning.
- When documenting care, record objective information that can be seen, heard, felt, or smelled by another person, such as “resident’s skin is red and warm.”
- Good observation skills require using all your senses to collect accurate information about the resident’s condition and behavior.
- The Paraprofessional Healthcare Institute (PHI) provides resources and support for direct care workers in long-term care settings.
- The prefix “hyper-” is a word element placed at the beginning of medical terms that means “above normal” or “excessive.”
- The physical therapist taught the nursing assistant how to perform Range of Motion (ROM) exercises to move each of the resident’s joints through their normal movements.
- The Resident Assessment Instrument (RAI) is a comprehensive tool used to evaluate residents in long-term care facilities.
- The Resident Assessment Protocol (RAP) serves as the foundation for developing each resident’s individual care plan based on their specific needs.
- The patient/resident care plan is a recorded plan that provides specific instructions for giving care based on the resident’s special needs, problems, or medical conditions.
- The root word “cardi” contains the basic meaning “heart” and serves as the foundation for medical terms like cardiology and cardiac.
- Subjective information includes what the resident reports about their feelings or symptoms, such as “I feel dizzy” or “My back hurts.”
- The suffix “-itis” is a word element placed at the end of medical terms that means “inflammation,” as seen in words like arthritis and bronchitis.
Module 15: 5 CNA Dialogues for English Learners
Module 15: Observation and Charting Vocabulary
Dialogue 1: Shift Report and Care Planning
Setting: Two CNAs discussing a resident during shift change
Maria (Day Shift CNA): Good evening, Sarah. Let me give you the report on Mrs. Johnson in room 205.
Sarah (Night Shift CNA): Sure, I’m ready to take notes on her care plan.
Maria: Her ADL status has changed since yesterday. She needed more assistance with bathing and dressing today.
Sarah: Should I document that as an objective observation or subjective?
Maria: Objective – you can see that she couldn’t button her shirt independently. Also, her ROM exercises went well this morning. No complaints of pain.
Sarah: Got it. Any incidents to report?
Maria: No incident reports needed today. Her assessment shows she’s stable. Check the Kardex for her medication times.
Sarah: Perfect. I’ll continue monitoring and make observations throughout my shift.
Dialogue 2: Documentation Training
Setting: Experienced CNA training a new employee
Supervisor: Welcome to your first day, Tom. Let me explain our documentation system.
Tom (New CNA): Thank you. I’m excited to learn about the charting process.
Supervisor: First, understand that we use many abbreviations to save time. For example, “ADL” means Activities of Daily Living.
Tom: I see. What’s the difference between objective and subjective observations?
Supervisor: Objective observations are facts you can see or measure, like “blood pressure 120/80.” Subjective observations are what the resident tells you, like “I feel dizzy.”
Tom: That makes sense. What about those longer forms I heard about?
Supervisor: You mean the MDS – Minimum Data Set. It’s a comprehensive assessment we complete regularly. The RAI (Resident Assessment Instrument) includes the MDS and helps us create RAPs – Resident Assessment Protocols.
Tom: When do we complete these assessments?
Supervisor: The ARD – Assessment Reference Day – determines our timeline. Each resident has scheduled assessment dates.
Dialogue 3: Medical Terminology Lesson
Setting: ESL classroom focusing on healthcare vocabulary
Teacher: Today we’ll break down medical terms using root words, prefixes, and suffixes.
Student 1: Can you give us an example?
Teacher: Sure! Take the word “assessment.” The root word is “assess,” meaning to evaluate. What about abbreviations?
Student 2: We use ROM for Range of Motion, right?
Teacher: Exactly! In healthcare, abbreviations save time. ADL stands for Activities of Daily Living – basic self-care tasks.
Student 1: What’s the difference between assessment and observation?
Teacher: Good question! Observation is watching and noting what you see. Assessment is evaluating that information to understand the patient’s condition.
Student 2: Are patient, resident, and client the same?
Teacher: Yes, they’re synonymous terms for the person receiving care. In long-term care, we typically say “resident.”
Dialogue 4: Incident Reporting
Setting: CNA speaking with charge nurse about an incident
CNA: I need to complete an incident report for Mr. Davis.
Charge Nurse: What happened? Give me your objective observations first.
CNA: At 2:30 PM, I found Mr. Davis on the floor beside his bed. He was alert and responsive.
Charge Nurse: Any subjective information from the resident?
CNA: He said he felt dizzy when he stood up and lost his balance. He denied pain.
Charge Nurse: Good observation skills. Did you check his vital signs?
CNA: Yes, blood pressure was low at 90/60. I documented everything in the Kardex and notified you immediately.
Charge Nurse: Perfect. This information will be important for his care plan revision and next assessment. The PHI (Paraprofessional Healthcare Institute) guidelines emphasize thorough incident documentation.
CNA: Should I monitor his ADL abilities more closely now?
Charge Nurse: Absolutely. Include ROM checks and mobility assessment in your observations.
Dialogue 5: Care Plan Meeting
Setting: Healthcare team discussing resident care
RN: Let’s review Mrs. Thompson’s updated care plan based on her recent MDS completion.
CNA: I’ve been doing daily observations. Her ADL independence has improved significantly.
Physical Therapist: Her ROM exercises are showing results. She can dress herself now with minimal assistance.
RN: Excellent objective data. Any subjective complaints from the resident?
CNA: She mentioned feeling more confident during transfers. That’s important for her assessment.
Social Worker: The RAP recommendations suggest continued independence training.
RN: Good. Tom, update the Kardex with these changes. Use proper abbreviations and medical terminology.
CNA: I’ll include both objective measurements and subjective feedback in my charting.
RN: Remember, accurate documentation protects both the resident and our facility. If anything unusual happens, complete an incident report immediately.
Physical Therapist: The ARD for her next full assessment is coming up next month.
RN: Perfect. Continue monitoring and make detailed observations. This resident’s progress shows the importance of our comprehensive RAI system.
Key Learning Points:
- Objective vs. Subjective observations
- Proper use of medical abbreviations
- Understanding assessment tools (MDS, RAI, RAP)
- Documentation in Kardex and care plans
- Incident report procedures
- Medical terminology structure (root words, prefixes, suffixes)
- Synonymous terms: patient/resident/client
