Observation, Documentation, and Reporting
What the exam expects
Documentation must be factual, objective, accurate, complete, timely, and legible. Objective data is what you observe or measure - "temperature 101.2°F, skin warm and flushed, resident reports chills." Subjective data is what the resident tells you, and it is best recorded in their own words inside quotation marks. Chart what you did, what you saw, and the outcome; never chart care you did not give or for someone else. Correct an error with a single line through it, your initials, and the date - never obliterate, erase, or use correction fluid. Incident reports are completed factually and routed per policy; the nurse's notes describe the event and the resident's condition, not the existence of the report.
Reporting changes
Know normal adult ranges so you can recognize abnormal: pulse 60–100, respirations 12–20, oral temperature roughly 97–99°F, oxygen saturation about 95% or higher, and blood pressure under 120/80 as normal. Report immediately: chest pain, difficulty breathing, sudden weakness or facial droop, new confusion, a fall or injury, a fever, a change in urine output or color, skin breakdown, vomiting, refusal of medications, or a resident who seems suddenly withdrawn. Use SBAR - Situation, Background, Assessment, Recommendation - to give a concise, organized report to the nurse.
Traps
Answers that chart opinions ("resident was being difficult"), that chart before the fact, that omit the time, or that say the incident report belongs in the medical record are wrong. "Resident seems sad" is not measurable; "resident crying, states, 'I miss my family'" is.
Rule of thumb
Chart what you see, what you did, what you said, and what happened next - not what you think or assume. If it is not written down and signed, it did not happen.