Health, Environment and Safety: Introduction to Observation, Reporting and Recording

Vocabulary flashcards covering key definitions, principles of observation, reporting types, documentation standards, and timekeeping from Module 1.3.

Observation

The act of gathering information about a client by watching carefully, listening, talking with them, and using the senses of touch and smell to detect changes in condition or circumstances.

Assumption

A guess based on insufficient evidence that leads to jumping to conclusions rather than reporting only what is directly observed.

Objective Reporting

Information gathered directly through the senses—seeing, hearing, smelling, feeling, and rarely tasting; also referred to as signs.

Signs

Objective clinical observations and physical findings detected through the senses, such as swelling, bleeding, skin rashes, or a change in ambulation.

Subjective Reporting

Information reported directly by the client regarding how they feel or what they experience that cannot be directly observed by others; also referred to as symptoms.

Symptoms

Subjective statements or complaints made by the client describing their physical or emotional feelings, such as a statement of sharp pain or feeling better.

Verbal Report

A spoken account of care provided and observations made, communicated face-to-face, through voicemail, or relayed by a third party such as a unit clerk or answering service.

Written Reporting (Recording / Charting)

The formal act of documenting care provided and observations made within client records to maintain a permanent written record.

Client Chart

A permanent, legal record of care provided to a client from admission to discharge or death, which can be filed for reference and used in court as evidence.

Accountability (in Charting)

The charting principle that requires team members to sign and date entries so actions and words can be tracked and individuals held legally responsible.

Continuity of Care (in Charting)

The documentation of past health issues and treatments that enables health care providers to detect patterns and changes in a client's health over time.

Funding (in Charting)

The provincial administrative process where reviews of clients' charts determine the financial support and dollar amounts allocated to long-term care facilities.

"If it is not charted it did not happen"

The core documentation rule establishing that any care, procedure, or observation not recorded in the client's chart is legally and clinically considered unperformed.

Incident

An unexpected accident or occurrence involving a client that must be reported to a supervisor immediately, regardless of whether injury is suspected.

Incident Report

The official institutional form used to document an unexpected occurrence, accident, or injury involving a client.

24-Hour Clock

A universal time system designed to eliminate confusion between a.m. and p.m., where the first two digits indicate hours from midnight and the last two indicate minutes.