You already understand the need to assess your client’s status, the ways to assess their status and the importance of reporting their status. You have also learned how to add your reporting comments to a medical record and other key documentation. Now, you will learn how to present your assessed observations verbally to the supervisor or the care team to assist in providing the best care for the client.
First, observe for the unusual; then, report and document only what you observe or what the client tells you. Do not make judgments or try to diagnose. Always report your observations to the supervisor or responsible nurse as soon as possible.
When talking to your supervisor, or participating in meetings with the medical team, be prepared to give the following information:
- Name of the client
- Abnormal signs and symptoms about the client noted from assessment
- Any symptoms the client mentions in the client’s words
- How long the client has had the change in status
- How the client is now
Watch this video where a nurse speaks about the information she provides to colleagues and supervisors at the end of her shift, as well as the information she looks to receive from others. Which elements will you include in your own practice? Write some notes now to help you remember.
Click here for a video transcript in .docx format: Video Transcript