Caring throughout

the Lifespan
Abraham Maslow

Pyramid of Hierarchy of Needs

Is a theory of motivation which states that five categories of
human needs dictate an individual’s behavior. Those needs
are physiological needs, safety needs, love and belonging
needs, esteem needs, and self-actualization needs.
People have a variety of needs
that motivate them.

We are motivated to meet our

basic or lower- level needs
before we pursue higher order
needs.
Sigmund Freud
Psychosexual Theory
A person goes through the sequence of 5 stages. Along the
way there are needs to be met. Whether this needs are met
or not determines whether the person will develop a
healthy personality or not.
Sigmund Freud
Sigmund Freud
Psychosexual Theory
Sigmund Freud
Psychosexual Theory
Sigmund Freud
Psychosexual Theory
Sigmund Freud
Psychosexual Theory
Sigmund Freud
Psychosexual Theory
Erik Erikson
Psychosocial Theory
Unlike Freud’s theory of psychosexual stages, however,
Erikson’s theory described the impact of social experience
across the whole life span. Erikson is interested in how social
interaction and relationships played a role in the
development and growth of human beings.
Erik Erikson
Psychosocial Theory
Erik Erikson

Psychosocial Theory
Trust vs Mistrust (Birth to 18 months)
Task: To develop a basic trust in the mothering figure and to
generalize it to others.
Trust Mistrust
Believing in caregivers Distrusting caregivers
Trusting that the world is safe Fearing the world
Knowing that needs will be met Unsure that the needs will
be met
Erik Erikson

Psychosocial Theory
Autonomy vs Shame and Doubt (18 months to 3 years)
Task: To gain some self control and independence within the
environment.
Autonomy Shame and doubt
Self control, Realistic self concept Self doubt, dependence
and self esteem on others, O/C behaviors
Erik Erikson

Psychosocial Theory
Initiative vs Guilt (3 years to 5 years old)
Task: To develop a sense of purpose and the ability to
initiate and direct one’s own activity.
Initiative Guilt
Sense of direction. Avoidance of
Healthy Competitiveness. activities.
Curiosity and exploration. Reluctance to
show emotion.
Erik Erikson

Psychosocial Theory
Industry vs Inferiority (5 years to 13 years old)
Task: To achieve a sense of self confidence.
Industry Inferiority
Sense of competence. Inadequate problem-solving
Completion of projects. Skills.
Cooperate and compromise. Lack of friends of the same sex.
Erik Erikson

Psychosocial Theory
Identity vs Role Confusion (13 years to 21 years old)
Task: To integrate the tasks mastered in the previous stages
into a secure sense of self.
Identity Role Confusion
Devotion, Fidelity. Feelings of confusion
Confident sense of self. Indecision and alienation
Testing out adult roles. Dramatic over confidence
Establishing relationship Sort term relationship with the
opposite sex. opposite sex.
Erik Erikson

Psychosocial Theory
Intimacy vs Isolation (21 years to 39 years old)
Task: To form an intense lasting relationship or a commitment
to another person, a cause, an institution, or a creative effort.
Intimacy Isolation
Affiliation. Isolation.
Ability to give and receive love. Emotional distance
Commitment and mutuality with others. in all relationships.
Responsible sexual behaviors. Seeking intimacy
through sexual
encounters.
Erik Erikson

Psychosocial Theory
Generativity vs Stagnation (40 years to 65 years old)
Task: To achieve the life goals established for oneself while
considering the welfare of future generations.
Generativity Stagnation
Productive, Constructive Self centeredness
Personal and professional growth. Lack of interest in
Parental and societal responsibilities. the welfare of others
Loss of interest in
marriage.
Erik Erikson

Psychosocial Theory
Ego Integrity vs Despair (65 years to death)
Task: To review one life and derive meaning from both positive
and negative events, while achieving positive sense of self.
Ego integrity Despair
Sense of dignity, worth and importance. Sense of helplessness,
Feeling of acceptance. hopelessness,
worthlessness.
Regression, Focusing on
past mistakes.
Jean Piaget

Theory of Cognitive Development

Jean Piaget's theory of cognitive development suggests that
children move through four different stages of mental
development. His theory focuses not only on understanding
how children acquire knowledge, but also on understanding
the nature of intelligence.
Jean Piaget

Theory of Cognitive Development

Jean Piaget
Theory of Cognitive Development
Learning through 5 senses (sight, hear, smell, taste, touch)
Development of imitative behaviors (copying actions
performed by others)
Development of symbolic knowledge (become aware of the
things around us)
Develops object permanence (continue to exist even we can’t
see them)
The beginning of goal-directed actions (sit, crawl, stand, walk
and run)
Jean Piaget
Theory of Cognitive Development
Semiotic function (uses symbols to representation)
Curiosity grows
Pretend Play (which allow to experience something new)
Egocentrism (Self centered)
Jean Piaget
Theory of Cognitive Development
“Hands on” thinking
Identity (understand self better)
Reversibility (can reverse action by doing the opposite)
Seriation (to position in orderly sequence)
Jean Piaget
Theory of Cognitive Development
Hypothetico-deductive reasoning (can compare two
reasonings)
Abstract thinking (understand success and failure)
“Scientific” reasoning
Adolescent egocentrism (shows compassion)
Human Growth and Development
Growth mainly focuses on quantitative
improvement while Development is associated
with both qualitative and quantitative
improvement.

Growth takes place within a limited scope of time

while Development takes place within a vast scope
of time.

Growth is associated with the progressive physical

change from one stage to another. On the other
hand, Development is the gradual transformation
of behavioral and skill set changes.
Human Growth and Development
NEONATE /NEWBORN Birth to 1 month
➢ Have certain reflexes (involuntary movements). These reflexes decline and then
disappear as the central nervous system develops.
Reflexes
➢ A physical reaction to something that you cannot control.
Types of Reflexes
1. Moro Reflex (Startle Reflex) When a baby is startled by a loud noise, a sudden
movement, or the head falling back. The arms are thrown apart. The legs extend
and then flex. A brief cry is common.
2. Rooting Reflex When the cheek is touched near the mouth.
3. Sucking Reflex When the lips are touched.
4. Grasp (palmar) reflex When the palm is stroked. The fingers close firmly around
the object.
5. Step (dance) Reflex When the baby is held upright, and the feet touch a surface.
Human Growth and Development
Human Growth and Development
INFANT 1 Month to 1 Year
Physical Changes
❑ May triple in weight and increase greatly in length by 1 year.
❑ Begins to control body movement: lifts head; holds and throws objects and puts them
in mouth; rolls over, sits up, crawls, climbs, takes first steps with assistance; and stands.
❑ Begins cutting teeth and taking solid food.
2 months:
✓ Can hold their heads up when held upright.
3 - 4 months:
✓ Can hold their heads up.
✓ They babble, coo, gurgle, and laugh out loud.
4 - 5 months:
✓ Can roll from front to back.
Human Growth and Development
5 - 6 months:
✓ Roll from back to front.
✓ They also can sit by leaning forward on their hands.
✓ They can play “peak-a-boo.”
6 months:
✓ They can bear weight when pulled up into a standing position.
✓ They sit with support and move around by rolling.
✓ Some start to drink from a cup.
7 months:
✓ Start to crawl.
✓ They can stand while holding on for support.
Human Growth and Development
8 months:
✓ Can sit for long periods. They also can change from lying to sitting and from sitting to
lying positions.
✓ They can hold small objects with the thumb and index finger.
✓ They can pick up small finger foods. They learn to drink from a cup with handles.
✓ They can say “mama” and “dada.”
9 months:
✓ Can pull up into a standing position with support.
✓ They can hold a bottle.
✓ Play “pat-a-cake,” and drink from a cup or glass.
10 months.
✓ Infants can stand alone.
Human Growth and Development
11 months:
✓ They may walk alone and use push toys.
✓ 12 months.
✓ Can walk without support.
Social/Emotional Changes
❑ Cries to communicate.
❑ Begins to smile and laugh.
❑ Begins to trust caregivers and cry at the sight of strangers.
Cognitive changes
❑ Uses senses to explore the world.
❑ Begins to say a few short words.
Human Growth and Development
Infant ( 1 month to 1 year old)
Human Growth and Development
TODDLER 1 to 3 years
Physical Changes
❑ Does many things that require coordination of large muscles in arms and legs: walks, runs, jumps, and climbs.
❑ Plays with toys.
❑ Has 6 to 12 baby teeth and eats regular table food.
❑ Learns to use the toilet and eats, drinks, and dresses with little or no help.
❑ Needs to rest frequently during the day.
Cognitive Changes
❑ Able to follow simple instructions when given slowly and clearly.
❑ Responds well to adult language and can point to objects named by adults.
❑ Has a strong, self-oriented point of view and is unable to understand others’ points of view.
❑ Begins to put words together to make short sentences.
❑ Understands that objects taken out of sight still exist.
❑ Likes to choose own activities and toys.
Human Growth and Development

Preschool Age 3 to 5 years

Physical Changes

❑ Has improved large-motor skills.

❑ Has more control over small-motor skills such as drawing or writing.

❑ Does many things to take care of self-such as dressing, eating, and using the toilet.

Social/Emotional Changes

❑ Has a strong sense of identity.

❑ Makes own choices.

❑ Plays easily with other children and enjoys games involving sharing and taking turns (Associative play).

❑ Looks up to and imitates adults.

❑ Likes routine and may feel insecure if schedule is changed too often.

Cognitive Changes

❑ Learns new words quickly and may start to read some words; counts and enjoys learning things with numbers.

❑ Groups objects that are alike and can pick out objects that do not it with others Follows directions.

❑ Has strong curiosity and imagination and asks many questions.

❑ Has a strong, self-oriented point of view and sometimes is unable to understand others’ points of view.
Human Growth and Development
School Age 5 to 12 years
Physical Changes
❑ Grows steadily.
❑ Develops muscle tone, balance, strength and endurance and is physically well coordinated.
❑ Uses large muscles for games and sports, cycling and dance.
❑ Uses small muscles to write, draw and do crafts.
❑ Enters puberty at about age 10 to 12 for girls and age 12 for boys.
Social/Emotional Changes
❑ Begins to form lasting relationships with friends.
❑ Forms small, close-knit groups that exclude other children, especially those of the opposite sex.
❑ Spends more time away from parents or other caregivers.
❑ Begins to understand that other people also have feelings.
❑ Has many emotions and sometimes has difficulty expressing them; may have dramatic mood swings that
accompany hormonal changes when going through puberty.
Human Growth and Development
School Age 5 to 12 years
Cognitive Changes
❑ Pays attention longer, remembers longer and follows more complex directions.
❑ Ability to think logically and make decisions increases.
❑ Starts to organize new information in meaningful ways.
❑ Behaves more responsibly.
❑ May question and resist adult decisions.
Adolescence 12 to 18 years
Physical Changes
❑ Reaches reproductive maturity: in girls, breasts develop, hips widen, pubic and underarm hair appears, and menstruation begins; in boys, penis and
testes grow to adult size, ejaculations begin, pubic and facial hair develops, voice deepens, and neck and shoulders grow.
❑ Girls tend to be taller than boys of the same age at the beginning of this age range and tend to be shorter at the end.
Social/Emotional Changes
❑ May feel awkward or embarrassed around adults and strangers because of recent physical changes.
❑ Assumes more responsibility for own behaviors.
❑ Often rebels against adult authority.
Human Growth and Development
Young Adulthood 18- 40 years of age
Physical Changes
❑ Muscle strength, bone density and senses are at their peak.
❑ Gets sick infrequently and recovers quickly from illnesses and injuries.
❑ Women may experience physical changes of pregnancy.
Social/Emotional Changes
❑ Establishes lasting and intimate relationships with friends and partners.
❑ Makes commitments.
❑ May begin a family.
Cognitive Changes
❑ Functions at higher level than children and adolescents, although some young adults continue to think and
reason much like adolescents and children.
❑ Can imagine being in another person’s situation and recognize how another feels.
❑ Has better-developed moral reasoning.
Human Growth and Development
Middle Adulthood 40-65 years of age
Physical Changes
❑ May develop chronic illnesses, although some individual that existing health conditions disappear or become less problematic.
❑ May have slight decreases in senses, physical strength, and coordination.
❑ Women experience menopause.
Social/Emotional Changes
❑ Begins to feel anxious about aging.
❑ Feels more satisfied by work.
❑ May become depressed as children grow up and leave or may delight in the new freedom.
❑ Often takes on more responsibility for caring for aging parents.
❑ May have to cope with the loss of one or both parents.
❑ May become a grandparent.
Cognitive Changes
❑ Increases in mental growth and has high levels of intellectual performance.
❑ Finds this is often the most creative time of life.
Human Growth and Development
Late Adulthood 65 and Older
Physical Changes
❑ Is likely to experience the onset of more chronic illnesses but is generally healthy enough to continue normal physical activities.
❑ May have decreased vision, with loss of night vision and less depth and color perception.
❑ May experience some hearing loss and a decreased sense of smell and taste.
❑ May have less strength and balance and may be prone to accidents and falling.
❑ May be noticeably shorter because of spinal column shrinkage.
❑ May adjust less quickly to cold.
❑ Physical abilities may continue to decrease, both as a result of normal changes of aging and illness or injury.
Social/Emotional Changes
❑ May retire from a job, which can lead to increased energy, productivity and creativity; feelings of loss; or both.
❑ May have to cope with death of a spouse, friends or other family members (such as siblings).
❑ May have to cope with losses of independence, such as those caused by giving up a driver’s license, moving out of one’s own home
or accepting the need for someone else to enter the home to provide care.
Human Growth and Development
❑ May be less confident and have lower self-esteem because of loss of loved ones and
diminished physical and sensory capabilities.
❑ Often has to cope with major life changes, such as the death of a spouse or the need to
sell a house and move.
❑ May struggle with accepting failing health or increased dependency on others for
assistance and care.
❑ May begin to think about and plan for own death.
❑ May look back and reflect on own life.
Cognitive Changes
❑ Generally, maintains intellectual abilities and may pursue new interests and hobbies.
❑ Generally, maintains intellectual abilities but may not process information as quickly and
may make decisions with less speed.
❑ Can learn new information and skills but needs more time to learn Basic Human needs.
CHAPTER 4: CHAIN OF
COMMUNICATION

Refers to the way of sharing

information verbally or nonverbally
between the sender and the receiver.
CHAIN OF COMMUNICATION

Communication
Communication is the process of exchanging thoughts, ideas, feelings, and information between
and among others whether verbal or non-verbal to achieve goal or purpose.
Methods of Communication
Verbal Communication – Is the use sounds and words to express yourself.
Non-Verbal Communication – Does not use words. We can communicate non-verbally by visual
cues such as body language, eye contact, physical posture, facial expression.
CHAIN OF COMMUNICATION
Elements of Communication
Sender – Initiates the process of communication.
Encoding - Occurs when the message sender converts a thought, idea, or fact into a message
composed of symbols, picture, or words.
Message – Is the information, thoughts or ideas convey by the speaker into words or action.
Channel – Is used as a medium in transmitting ideas or thoughts. (face to face, video conference,
telephone conversation, written communication, mass media)
Receiver – Decodes the message.
Decoding – Means understanding and interpreting the encoded message sent by the sender.
Feedback – Responses, reactions.
Barrier/Noise – Misunderstanding. Affects the communication. (external and internal)
CHAIN OF COMMUNICATION

Strategies of Effective Communication

1. When you are the receiver, be a good listener.
2. When you are the sender, make sure your message is clear.
3. Learn techniques for encouraging people to talk.
4. Provide and seek feedback.
5. Be mindful of your body language and tone of voice.
6. Remember the value of silence and a comforting touch.

Goal of Communication The receiver understands the meaning of a message and perceives it the same as
the sender.
Effective Communication Is defined as the ability to convey information to another effectively and
efficient.
CHAIN OF COMMUNICATION

5 Keys to Effective Communication

Be positive.
Be a listener.
Be an echo.
Be a mirror.
Be real.
3 C's of Assertive Communication
Confidence – you believe in your ability to handle a situation.
Clear – the message you have is clear and easy to understand.
Controlled – you deliver information in a calm and controlled manner.
Barriers To Communication
Poor Listening Skills
Contribute to ineffective communication. Listening involves not just hearing the message, but the
ability to understand, remember, evaluate, and respond. Be an active listener.
Steps to Improve Your Listening Skills:
1. Be quiet. Pay attention to what the other person is saying.
2. Stop all other activities. Focus on the speaker.
3. Look and sound interested.
4. Do not interrupt the speaker. Let the speaker finish, even if it takes a long time.
5. Do not try to think of a response while the person is speaking.
6. Do not finish sentences that the speaker begins.
Barriers To Communication
Poor Listening Skills
Contribute to ineffective communication. Listening involves not just hearing the message, but the
ability to understand, remember, evaluate, and respond. Be an active listener.
Steps to Improve Your Listening Skills:
1. Be quiet. Pay attention to what the other person is saying.
2. Stop all other activities. Focus on the speaker.
3. Look and sound interested.
4. Do not interrupt the speaker. Let the speaker finish, even if it takes a long time.
5. Do not try to think of a response while the person is speaking.
6. Do not finish sentences that the speaker begins.
Communicating with those in Care Visual
Impairment:
1. Knock on the person’s door or tell him right away that you are there so that you don’t startle
him and call him by name.
2. Describe the person’s surroundings and tell him what is going on. Describe the people or events
in a way that helps to create a mental picture.
3. As you move through a skill, describe each step as you are doing it. When using a piece of
equipment, describe it to the person. If it doesn’t cause an infection control risk and if he is
interested, let him touch what you are holding.
4. When helping the person move around, encourage him to hold your arm just above your elbow
for support, describe where you are going and mention things that are in your path.
Hearing Impairment
• Always approach the person from the front, and gently touch the person on the hand or arm to
gain the person’s attention before speaking. If someone hears more clearly in one ear than the
other, in and out which ear is better, and position yourself near that ear when you talk.
• Be aware that hearing-impaired people often learn to read lips and rely on watching your mouth
move. When speaking with the person, position yourself so that she can see your mouth and
facial expressions. Pronounce your words slowly and clearly and speak in short sentences.
• If the person does not seem to understand what you say, change your words, not the volume of
your voice, unless you spoke too softly. Shouting sometimes creates more distress for the person,
and she still may not understand what you are saying. Reduce background noise as much as
possible because television or radio sounds can be very distracting to the person with a hearing
impairment during conversation.
• Use gestures to help explain what you are saying. Or, if the person can read, write messages on
paper. When you have important information to get across, make sure that the person
understands you by asking her for confirmation.
Types Of Hearing Loss
A. Sensorineural hearing loss is the most common type of hearing loss.
B. Conductive hearing loss.
C. Mixed hearing loss.

Communicating Family
❖You can help family members feel more comfortable by explaining your role in providing care and
explaining why you do things in a certain way. Build a relationship with the family by getting to
know the family members, learning about their family history, talking with them and listening to
them.
Communicating with other Members of Health Care Team

Communication and teamwork skills

are essential for providing quality
health care. When all clinical and
nonclinical staff collaborate
effectively, health care teams can
improve patient outcomes, prevent
medical errors, improve efficiency
and increase patient satisfaction.
I. Medical Terms:
➢ Root. The root is the foundation of the word. All medical words have at least one root, and some may
have two.
➢ Prefix. A prefix may be added before the root to make the root more specific.
➢ Suffix. A suffix may be added after the root to make the root more specific.
➢ A combining vowel. A combining vowel, which may be an “o,” an “a” or an “i,” is added between the
root and the suffix to join them together and make the word easier to say.
Example:
1. Cholecystectomy- means “removal of the gallbladder
Root - cholecyst, which means “gallbladder.” Suffix - ectomy, which means “removal of.”
2. Hypoglycemia- means “low blood sugar.”
Root - glyc means “sugar.” Prefix - hypo -, which means “under.’’ Suffix - emia, which means
“blood disorder.”
Medical Terms
MEDICAL ABBREVIATIONS
9 Abdominal Regions and 4 Quadrants
Anterior (Ventral)
At or toward the front of the body or body part.
Posterior (Dorsal)
At or toward the back of the body or body part.
Proximal
The part nearest to the centre or to the point of
origin.
Distal
The part farthest from the centre or from the point
of attachment.
Lateral
Away from the midline; at the side of the body or
body part.
Medial
At or near the middle or midline of the body or body
part.
Reporting
Is the verbal exchange of information between members of the health care team.
Observation
Is something that you notice about the patient or resident, typically related to a change in the person’s
physical or mental condition.
1. Objective Observations
❑ Relate to information that you obtain directly, using one of your five senses.
EXAMPLE: You may feel that a person’s skin is hot and dry, or you may measure a person’s blood pressure
using a blood pressure cuff.
2. Subjective Observations
❑ Relate to information that you cannot detect with one of your five senses or cannot measure using
equipment. EXAMPLE: a person may tell you that she has a headache or that she did not sleep well the
night before.
Recording
Recording, sometimes referred to as “charting,” Is communicating information about a patient or
resident to other health care team members in written form.
Medical Record (Chart)
❖ Is a legal document where information about the person’s current condition, the measures that
have been taken by the medical and nursing staff to diagnose and treat the condition, and the
person’s response to the treatment and care provided is recorded.
❖ Most medical facilities and agencies use the 24-hour time clock, also referred to as “military
time,” for recording the time in a patient’s medical record. The 24-hour time clock eliminates the
need to differentiate between morning (A.M.) and night (P.M.), thus reducing errors in recording.
On the 24-hour time clock, the morning hours are the same as on the conventional clock.
Medical Record Contains the Following Forms:
Admission Sheet
➢ The admission sheet provides standard information about the person, including the person’s
name, address, date of birth and age, Social Security number, gender, insurance and employment
information, emergency notification information, and advance directive information.
Medical History
➢ Usually, the medical record contains a dictated and typed medical history from the person’s
doctor. The medical history contains information about the person’s previous surgeries and medical
conditions, current medications, allergies, and current medical diagnosis.
Nursing History
➢ The nursing history is completed by the nurse at the time of the person’s admission to the
facility. The nursing history provides information related to the person’s care needs, such as
information about physical disabilities or limitations, bowel and bladder habits, dietary preferences,
and use of ambulation aids.
Physician’s Order Sheet
➢ The physician’s order sheet is used by the doctor to communicate to the other members of the health
care team what should be done for the patient or resident. For example, the doctor may use the
physician’s order sheet to order treatments (such as medications), specify dietary orders or activity
status, or order diagnostic tests.
Medication Administration Record (MAR)
➢ The medications ordered for the patient or resident are listed here, along with the dosage and the
time at which they are to be administered. This form is also used to record when medications are given,
and by whom. Some long-term care and assisted-living facilities provide additional training to allow
nursing assistants to give medications. If giving medications is within your scope of practice, then you will
record your activities on the MAR.
Physician’s Progress Notes
➢ The doctor uses this form to record his notes and observations about the person’s progress and
response to treatment.
Narrative Nurses’ Notes
➢ The nurse uses this form to document the person’s complaints (symptoms) and the actions taken by the nursing staff in response
to them
➢ Some facilities allow nursing assistants to make notations in the narrative nurse’s notes, and some do not.
Graphic Sheet
➢ This is where information that is gathered routinely—such as vital signs, the frequency of urination and bowel movements, and
food and fluid intake—is documented
➢ Some long-term care facilities use a type of graphic sheet to record a resident’s activities of daily living (ADLs) and exercise therapy.
The graphic sheet is the form used by nursing assistants most often to document the care that they provide.
Miscellaneous Documents
➢ Laboratory reports, radiology reports, and reports related to other diagnostic tests or therapeutic treatments are usually included
in specific sections of the person’s medical record.
Kardex
➢ Is a card file, containing condensed versions of each patient’s or resident’s medical record, summarizes information in the medical
record—drugs, treatments, diagnoses, routine care measures, equipment, and special needs. is a quick, easy source of information
about the person.
Rules in Reporting and Recording
Reporting
❖ Be prompt, thorough, and accurate.
❖ Give the person’s name and room and bed number. Give the time your observations were made,
or the care was given. Use conventional time (AM or PM) or 24-hour clock time according to agency
policy.
❖ Report only what you observed or did yourself.
❖ Report expected changes in the person’s condition. For example, the person may be tired after
physical therapy.
❖ Give reports as often as the person’s condition requires. Or give them when the nurse asks you
to.
❖ Use your written notes to give a specific, concise, and clear report Recording
❖ Follow agency policies and procedures for recording. Ask for needed training.
❖ Use only agency-approved abbreviations.
❖ Use correct spelling, grammar.
❖ Do not use ditto marks.
❖ Sign all entries with your name and title as required by agency policy.
❖ Make sure each form has the person’s name and other identifying information.
❖ Never chart a procedure, treatment, or care measure until after it is completed.
❖ Be accurate, concise, and factual. Do not record judgments or interpretations.
❖ Record in a logical and sequential manner.
❖ Be descriptive. Avoid terms with more than one meaning.
❖ Use the person’s exact words whenever possible. Use quotation marks (“...”) to show that the
statement is a direct quote. Chart any changes from normal or changes in the person’s condition. Also
chart that you told the nurse (include the nurse’s name), what you said, and the time you made the
report.
❖ Do not omit information.
❖ Record safety measures. Examples include placing the signal light within reach, assisting a person
when up, or reminding a person not to get out of bed.
Paper Charting
❖ Always use ink. Use the ink colour required by the agency.
❖ Make sure writing is readable and neat.
❖ Never erase or use correction fluid. Draw a line through the incorrect part. Date and initial the line.
Write “mistaken entry” over it if this is agency policy. Then re-write the part. Follow agency policy for
correcting errors.
❖ Do not skip lines. Draw a line through the blank space of a partially completed line or to the end of the
page. This prevents others from recording in a space with your signature.
Electronic Charting
❖ Log in using your username and password. Do not chart use another person’s username.
❖ Check the time your entry is made. Make sure it is the right time.
❖ Check for accuracy. Review your entry before saving.
❖ Save your entries. Unsaved data will be lost.
❖ Follow the manufacturer’s instructions for changing or uncharting a mistaken entry. Most
electronic systems keep a record of an entry before a change was made. This works the same way as
drawing a line through a mistaken entry in paper charting. The first entry is still visible.
❖ Log off when done charting. This prevents others from charting under your username.