Observing and Reporting

Question 1

What is observation?

Answer 1

Paying attention to the people you support and recognizing a change has occurred

Question 2

What are the two types of observations?

Answer 2

Objective and subjective

Question 3

What is objective observation?

Answer 3

Factual information you will see, hear, feel, smell or measure

Question 4

What is a subjective observation?

Answer 4

When you work with a person who speaks or signs and they tell you how they are feeling

Question 5

What is reporting?

Answer 5

To give spoken or written information of something observed or told

Question 6

What are you responsible for reporting?

Answer 6

any physical or behavioral changes you notice

Question 7

What are the two types of reporting?

Answer 7

Everyday reporting
Immediate reporting

Question 8

What is everyday reporting?

Answer 8

Occurs between staff present at shift change

Question 9

What is immediate reporting?

Answer 9

Reporting without delay as soon as possible after a change is observed

Question 10

When should you call and report to 911?

Answer 10

•you are unsure a person is okay
•a person falls and cannot get up
•a person complains of chest pain, has difficulty breathing or is choking
•a person is unresponsive
•a MAP Consultant recommends you hang up and call 911
•directed by a current HCP order or Protocol

Question 11

When to call and report to poison control?

Answer 11

•person ingests a foreign substance such as laundry detergent
•MAP Consultant recommends you call poison control

Question 12

When should you report to a MAP consultant?

Answer 12

• An occurrence (error) is made when administering medication
• The medication received from the pharmacy seems different from the HCP order
•You notice the medication is different in color, size, shape and/or markings from the last time it was obtained
•You are not able to administer the medication based on the strength of medication received from the pharmacy

Question 13

When should you report to the HCP who prescribed the medication?

Answer 13

•medication is refused
•medication is not available from the pharmacy
•there are no refills left
•a medication parameter (guideline) for a HCP notification has been met
-For example: A HCP order states, ‘If pulse is below 56, do not give the medication and contact the HCP.’
•a MAP Consultant recommends you hang up and call the HCP
•an order is missing the person’s name, medication, dose, frequency, route or the date and the HCP signature

Question 14

When should you report to your supervisor?

Answer 14

•there is a math error in the Countable Controlled Substance Book
typically known as a Count Book
•the count signature pages in a Count Book are almost full
•the Count Book binding is loose
•a medication seems to be tampered with
•the medication supply is low and you are unsure if a refill has been ordered
you cannot locate a medication to administer

Question 15

What is documentation?

Answer 15

Documentation should tell a story from beginning to end whether an issue takes a day, many days or weeks to resolve.

Question 16

What should your documentation include?

Answer 16

Your question or concern

The response given to you

The name of who you contacted

Question 17

Where is additional medication relateddocumentation written?

Answer 17

On a medication progress note form; usually on the backside of a medication administration sheet or narrative notes

Question 18

What should you do if you write an error or to correct documentation?

Answer 18

•Draw a single line through the error
•Write ‘error’
•Write your initials
•Then document what you meant to write the first time

Question 19

What is a late entry?

Answer 19

A progress note written well after a task was
completed and tells a story of what happened earlier. Includes date, time, explanation and signature.

Question 20

When should real time documentation occur?

Answer 20

Should occur when documenting a medication progress note, narrative note or count signature page after conducting a two person ‘shoulder to shoulder’ count, etc.