Observation and Reporting
Observation is systematic
Observation is not casual looking. Observe general condition, consciousness, skin colour, breathing, pain, mobility, appetite, urine and stool, IV site, drains and dressings, and the patient's mood and safety. Record objective findings (what you see, hear, count, smell) separately from subjective ones (what the patient says).
Frequency and escalation
Frequency is set by the care plan – routinely four-hourly, more often if unstable. Compare each reading with the previous one and with normal ranges. A single abnormal value, a trend (rising pulse with falling BP), or a change in behaviour is reportable. When in doubt, report. Never wait for the next round.
SBAR – the standard handover call
- Situation: who you are, patient, ward, bed, what is wrong now.
- Background: diagnosis, admission date, relevant history, allergies.
- Assessment: your observations and readings.
- Recommendation: what you think is needed and by when.
Documentation rules
Record contemporaneously, in blue or black pen, legibly, with date, time, name and signature. Quote measurements. Do not record opinions as facts, do not leave gaps, and never alter a colleague's entry. Report incidents through the incident form even if no harm occurred.
Worked example
The patient in bed 12 is breathless with respiration 28/min and SpO₂ 90 %. Reasoning: these are abnormal and worsening together. Call the nurse and use SBAR: “Situation: Mr A, bed 12, breathless; Background: admitted yesterday with pneumonia; Assessment: respiration 28, SpO₂ 90 % on room air, using accessory muscles; Recommendation: please review now; I have sat him up and started oxygen as per protocol only if authorised.” Then document time and who was informed.
Traps
- Reporting only at the end of the shift.
- Writing “patient fine” instead of measurements.
- Recording a value you were told rather than measured, without noting the source.