Sifting through the extremely large garbage bag of clothes packed away in the bedroom closet; I ran across a pair of jeans that I haven’t worn since I was pregnant with my son Trevon, and he will be two years old on Wednesday of this week.
I started thinking back to those days when I was pregnant and how it was 90% bad days to the other 10% good days through out my whole pregnancy. These feelings hit me like a brick all at once, and compiled with the let-down on the cleaning job I was supposed to do for my roomate today (with the lie he told behind it I would have to be a BIG DAMN FOOL to actually believe him); I became enraged and very pissed.
Al the bad feelings of things buried and and the collosal lie I was fed this morning; I’ave been in rage mode all day. I’ve snapped at my son for nothing and been hateful to everyone around me as well.
If I had just received the “big lie” of 2014 and hadn’t ran across those jeans; I believe I would have been in a better mood today. I guess the fact that I was looking forward to that money and I really needed it is why I’m so pissed.
I’m still upset now, because I had plans for that money in a lot of ways and now I’m screwed until I can get my child suppport this week. Thanks for nothing so called friend and roommate. Some things are better left buried and NEVER dug backup.
Here is the Certified Nursing Assistant notes you asked me for from yesterday’s class. Look back on page 29 in chapter 5 for any clarification or questions that you might have.
Recording, also called documenting, is the written exchange of information between members of the health care team. Recording takes place on various forms, which are contained in the person’s medical record (a legal document that details the person’s condition, the measures taken by the health care team to diagnose and manage the condition, and the person’s response to the care provided). Traditionally, medical records have been kept on paper, but electronic medical records (kept on a computer) are becoming increasingly more common (Figure 5-8). When working with a person’s medical record, it is very important to remember what you learned in Chapter 3 about maintaining the person’s conﬁdentiality. Always return paper records to their proper location in the nurse’s station when you are ﬁ nished using them. If electronic medical records are in use, always log off the computer when you are ﬁ nished using it. Remember that only the members of the health care team who are directly involved in
providing care to the person need to have access to the person’s medical record.
The medical record contains many different forms. There are three forms that are of particular interest to Figure 5-7 Subjective observations are observations that you make based on what the person tells you. Here, this person is describing pain that he is having to the nurse assistant. The nurse assistant cannot feel his pain herself, but she knows it exists because the person is telling her about it. Chapter 5 | Communicating with People | 53 the nurse assistant: the care plan, the ﬂ ow sheet and nursing notes.
■ Care plan. Each day, the ﬁ rst form you will refer to is the person’s care plan. The care plan details the care the person requires, and the methods, equipment and frequency for providing that care. Because the person’s condition may change, the care plan is updated frequently, so you must check it every day. The care plan may take the form of a computer print-out, or it may be kept on a card in a ﬁle.
■ Flow sheet. A ﬂ ow sheet is used to track changes in measurements (such as vital signs, intake and output, and weight) over a period of time.
■ Nursing notes. This form is used by the nursing staff to document the person’s condition, the nursing care provided to the person, and any signiﬁcant events that took place during the shift or visit. Some employers allow nurse assistants to record certain
types of information in the nursing notes. Others will require you to report your observations to the nurse so that he or she can update the nursing notes. Guidelines for recording. Depending on your employer’s policy, you may be responsible for recording. For example, some employers allow nurse assistants to record information on the ﬂow sheet, but not the nursing notes. Others allow nurse assistants to document the care they provide and the observations they make in the nursing notes as well. If you are expected to record, it is important to do it correctly and accurately. The medical record is a legal document. As such, it is a formal accounting of the care a person receives while in the facility, and can be used as evidence should a legal problem or dispute arise. In addition, other members of the health care team rely on what is documented to evaluate the person’s condition (for example, how well the person is responding to treatment) and to make decisions about future care measures. Also, it is important to understand that in facilities and agencies that receive federal funding (for example, Medicare or Medicaid payments), accurate documentation is essential to ensure that the facility receives the proper payment for services that were provided, and that the person continues to receive services he is eligible for. Whenever you record information in the person’s medical record, include the date, the time and your initials or signature. When documenting, usually a 24-hour clock (also called military time) is used to express the time (Figure 5-9).
There that should help you out for now. Love you much brilliant child of mine. Oh yeah, why don’t you call home sometime other than when it class notes you need? LOL.