Recognizing & Reporting Abnormal Observations

UNDERSTANDING PRIORITY LEVELS

One of the primary roles of the nursing assistant is to collect and communicate information. That information is collected by observing clients and communicated by reporting to the nurse and/or documenting in the client's chart.

URGENT!

When you observe something abnormal that falls under this category, you must STOP what you are doing and REPORT to a nurse or your supervisor right away. Urgent abnormal observations are those that are immediately life-threatening. They include the ABC’s (airway, breathing and circulation problems) and abnormal vital signs.

IMPORTANT

This category contains abnormal signs and symptoms that require you to REPORT to the nurse or your supervisor and RECORD your observations in the chart as soon as you complete your task with the client. This category includes signs and symptoms that require intervention but are not immediately life-threatening.

SIGNIFICANT

This third category are those signs and symptoms that should be RECORDED in detail in the chart. There is no urgency but these abnormal observations should not be ignored.

TIPS FOR REPORTING ABNORMAL OBSERVATIONS

It’s not enough to just know what is normal or abnormal. You also have to know what’s normal for YOUR client.
Always carry a pen and paper in your pocket to write down important pieces of information. This will make reporting easier.
When giving a verbal report to the nurse or your supervisor, be sure to use the client's full name, room number and even bed number (if applicable) to correctly identify the client.
Be factual in your reporting. Use objective information as much as possible. Remember, objective information is measurable and can be confirmed. It is not an opinion or a judgment.
If documentation is required for caregivers at your workplace, document your observations in the client’s chart, even if you’ve given a verbal report to the nurse. Be sure to document the date and time of the observation in addition to the name and title of the person to whom you reported.