Observation, Reporting, and Documentation
What this domain covers
Observation is noticing; reporting is telling the right person promptly; documentation is the written record. Gather objective data (what you see, hear, smell, or measure - a temperature of 101 F, a bruise on the left hip, 200 mL of urine) and subjective data (what the client says - 'I feel dizzy').
Know the client's baseline so you can recognize change: mental status, appetite, skin, bowel and bladder patterns, pain, breathing, and mobility. Report changes immediately to your supervisor or the nurse according to agency policy; do not save them for the next shift. Know your chain of command and when to call emergency services.
Document only care you personally gave or observed, at the time it was given, in factual terms. Sign and date each entry, and correct errors with a single line, your initials, and the date - never erase, use correction fluid, or rewrite a page. An incident report describes what happened factually, not who was to blame.
Traps
Charting 'client seems depressed' (an opinion), charting before care is finished, charting for a coworker, delaying a report, offering a diagnosis, or discussing a client with another client's family.
Rule of thumb
If it changed, report it now; if you did it, document it now - factually, briefly, and on time.