Chapter 14

Client Care:
Planning, Processes,
Reporting, and Recording

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 The Care Planning Process
 The care planning process (also known as
nursing process) is the method nurses use to
plan and deliver nursing care.
 The care planning process has five steps:
Assessment
Nursing diagnosis
Planning
Implementation
Evaluation

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 Care Planning Process
 Assessment
 Assessment involves collecting information about
the client
• Assessment occurs through the evaluation of information
collected about the client through observation, reflection,
and communication
• Assessment of the client’s emotional, social, intellectual,
and spiritual health
• The team leader—a nurse, social worker, or caseworker
—gathers as much information as possible from various
sources
• Once assessment completed, the team members gather
to set goals
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Care Planning Process (Cont.)
 Support workers play a key role in assessment
• You make many observations as you give care and talk
to the client
• Objective data (signs) are seen, heard, felt, or smelled
• Subjective data (symptoms) are things a client tells you
about that you cannot observe through your senses

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 Care Planning Process (Cont.)
 Nursing diagnosis
 The RN uses assessment information to make a
nursing diagnosis
 Support workers’ observations are very important
• You make many observations as you give care and talk
to the clien.
 A nursing diagnosis describes a health problem
that can be treated by nursing measures
 A client can have many nursing diagnoses
• NANDA examples, Box 14-1 (p. 203)

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 Care Planning Process (cont.)
 Planning
 Planning involves setting priorities and goals
 The needs are arranged in order of importance
 Goals are then set
• Goals are aimed at the client’s highest level of well-being
and function.
 Nursing interventions are chosen after goals are
set
• A nursing intervention is an action or measure taken by
the nursing team to help the client meet a goal

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Care Planning Process (Cont.)
 The nursing care plan (care plan):
• Is a written guide about the client’s care
• Has the client’s nursing diagnoses and goals
• Has the measures or actions for each goal
• Is a communication tool
• Is used by nursing staff to see what care to give
• Helps ensure that the nursing team members give the
same care
• The care plan is not a finished document—it is
continually reviewed and revised, depending on the
client’s needs, condition, and progress

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 Care Planning Process (Cont.)
 The implementation step is performing or
carrying out nursing measures in the care
plan
 Four main functions:
• Providing the care
• Observing the client during the care
• Reporting and recording the care
• Reporting and recording observations during the care
 Nursing care ranges from simple to complex
• The nurse delegates nursing tasks that are within your
legal limits and job description

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Care Planning Process (Cont.)
 Support workers report the care given to the nurse
• In some agencies, you record the care given
 Reporting and recording are done after giving
care, not before
 Report and record your observations
• Observing is part of assessment
• New observations may change the nursing diagnoses
• Changes in nursing diagnoses result in changes in the
care plan

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 Care Planning Process (cont.)
 Evaluation
 The evaluation step involves measuring whether
the goals in the planning step were met.
• Progress is evaluated
 Assessment information is used for this step
 Changes in nursing diagnoses, goals, and the
care plan may result
 Support workers provide valuable information
toward this evaluation, which may result in
changes being made to the care plan

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 The Care Plan in a Community
Setting
 Case managers coordinate and manage
client care
 Meetings take place in the client’s home
 Family members are very important to the
assessment process because serious illness
greatly affects the family roles

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 Community Planning
 Case manager establishes priorities, sets
goals, and determines available resources
 Plan includes services provided by family
members, outside professionals, and
agencies
 Some clients choose to coordinate and
manage their own care

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 Community Care Planning
 The nurse uses an assignment sheet or the
telephone to communicate delegated measures
and tasks to the support worker
• The assignment sheet tells you about:
 Each client’s care
 What measures and tasks need to be done
 Which nursing tasks to do
 If an assignment is unclear:
• Talk to the nurse
• You must ensure you know exactly what you are allowed to do
according to your employer’s policies

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 Community Implementation
and Evaluation
 Unforeseen needs arise—support workers
must be able to adapt to requests and adjust
the care to best meet the client’s needs
 Evaluation is ongoing—case manager
reviews care and services

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 Support Worker Role
 The nurse uses support worker observations
and feedback in the care planning process
 Your observations are used for the evaluation step

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 Developing Observation Skills
 Observations—support workers generally
spend more time with clients than other
health care providers do
 Use senses for objective data gathering:
 Sight, hearing, touch, smell
• Listening to the client breathe; noticing flushed or pale
skin or red swollen ankles; or smelling unusual odours
from urine or bowel movement

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 Data (Signs)
 Objective data—information observed about the
client
 Red swollen ankles
 Coughing
 Crying
 Box 14-2: Basic Observations (p. 207)
 Subjective data—information reported by a client
that is not directly observed
 I feel faint
 The pain is worse
 I have a headache
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 Describing Observations
 Communication
 Communication is the exchange of information
 For good communication:
• Be precise and accurate
• With subjective data, use the clients’ exact words
• Give information in a logical and orderly manner.
• Give facts and be specific; do not interpret or make
assumptions

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 Verbal Reporting
 When reporting, follow these rules:
 Be prompt, thorough, and accurate
 Give the client’s name and room or bed number
 Give the time when your observations were made
or the care was given
 Report only what you observed or did yourself
 Prioritize your report with the most important
points first
 Report care measures that you expect the person
to need

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 Verbal Reporting (Cont.)
 Give reports as often as the client’s condition
requires
 Give reports when the nurse asks you to
 Report any changes from normal or changes in
the client’s condition
• Report these changes at once
 Use your written notes to give a specific, concise,
and clear report
 Box 14-4: When to Contact Your Supervisor (p.
211)

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 Documentation “Charts”
 Charts are legal documents, also known as a
record
 A written account of a client’s condition,
illness, and responses to care
 It is a permanent, legal record that provides
communication for health care teams

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 Documentation
 Allows for communication and planning of
client care
 Provides currency as the care plans change
and as clients’ needs change
 Provides accountability—signed and dated

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 Documentation (Cont.)
 Provides continuity of care because it
provides information about past health
problems and may help to detect patterns
and changes in the client's health
 Quality assurance
 Education and research

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 Documentation (Cont.)
 Funding
 Based on client records, the acuity or severity of
an illness can influence staffing and equipment
needs for the agency

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 Documents Used in Charts
 Data forms
 Details about physical, emotional, social, and
cognitive health, plus activities, interests,
medications, treatments, and therapies
 Assessment forms
 Assist with identifying a problem area
 Home assessment forms
 Document changes that need to be made to a client’s
home
 Care plans
 Contain goals and interventions
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 Types of Charts
 Progress notes
 Vary; describe progress of the client
 Graphic sheets
 Record measurements and observations made on
every shift, e.g., BP, temperature, pulse
 ADL checklists and flow sheets
 Sometimes called tick sheets
 Task sheets
 Used by agencies in community setting to record
provided care and services
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 Types of Charts (Cont.)
 Other flow sheets
 Record frequent measurements and observations,
e.g., BP every 15 minutes
 Summary reports
 Monthly or every second or third month summary
 Incident reports
 Written accounts made after an accident, error, or
unexpected event
 Kardex
 A card file that summarizes information

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 Documentation (Charting)
 The record (chart) has many forms
 These are organized into sections for easy use
 Each page is stamped with the client’s name, room number,
and bed number, and other identifying information
 Health team members record information on the forms for
their departments
 Agency policies about medical records address:
 Who records, when to record
 Terminology, abbreviations, correcting errors
 Ink colour, signing entries; never erase an entry
 Box 14-7: Documentation Guidelines (p. 218)

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 Consistency and Accuracy
 Record clearly and thoroughly
 Make sure measurements and numbers are
accurate
 Avoid use of the third person (he, she, they)
 Record time with a 24-hour clock to document
care
 Use terminology and abbreviations that are
acceptable by your employer

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 Narrative Charting
 Telling a story
 All details to be included
 Begin with date, time
 Record in chronological order
 Represents a log of the client’s day

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 Methods of Charting
 SOAP:  ADPIE:
 Subjective data  Adds two
components to PIE:
 Objective data
 A: analysis
 Assessment  D: diagnosis
 Plan
 DAR charting:
 PIE:  D: data
 Problem  A: analysis and
 Intervention action
 Evaluation  R: response

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 Examples of Progress Notes
 Box 14-9: Examples of Progress Notes
Written in Different Formats (p. 219)

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Slide 32
 SOAP: Subjective or Objective?

Place an “S” or “O” in the  Rapid breathing ___

blank:  Difficult___
Sleepy ___
Shivering___
 Crying ___
Pain when urinating ___
 Toothache___
Chest pain ___  Sore toe ___
Skin cool ___  Drooling ___
Productive cough ___
 Coughing ___
Bruises ___

Rapid breathing ___

 Headache___
Nauseated ___
 Itchy ___
Vomiting ___  Aching joints ___
Sore throat ___  Blurred vision ___
Difficulty swallowing ___

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 Questions
 What are the four senses you use to obtain
information about a client?
1.
2.
3.
4.

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 24-Hour Clock
 Uses four-digit number for time
 First two digits are for the hour
 Last two digits are the minutes
 a.m.: begins at 0100 for 1 a.m.
 noon: 1200
 p.m.: ends at 2400 or 0000 for 12:00 midnight

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 24-Hour Clock (Cont.)
 Recording time
 Figure 14-8: The 24-hour clock

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 Next to each of the following, write the
times using the 24-hour clock
 11:00 AM _____  3:00 AM _____
 8:00 AM _____  4:50 AM _____
 4.00 PM _____  5:30 PM _____
 7:30 AM _____  10:45 PM _____
 6:45 PM _____  11:55 PM _____
 12 NOON _____  9:15 PM _____

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 Access to Client Charts
 A client chart is confidential, and you are
ethically and legally bound to keep client
information confidential
 Only health care team members involved in
the client’s care have access to confidential
information
 Your supervisor will tell you who is allowed to
look at the record, e.g., family members

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 Impact of Electronic
Communication
 Internet search engines do not screen information for
accuracy and reliability
 There are websites and telephone services that are
reliable
 In rural and remote areas, health care workers may
send health data about the client electronically to a
nurse practitioner, doctor, or health team member
many kilometres away
 Electronic health records are easy to read and
respond to and are helping to bridge the distance gap
for access to care

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