When dealing with Oral reports, it is always a good idea to ask for more. As clients explain their events, feelings or symptoms make sure that they repeat these descriptions and always ask for more information where possible. Also, make sure to avoid asking simple questions that can be answered with just a “yes” or “no” answer. A better approach is to ask questions that encourage the client to provide better descriptions of what they are feeling. Here is an example: if you ask a client “did you sleep ok last night”, they could easily answer this with a “yes” or “no”. On the other hand, if you asked the client to “describe to me how you slept last night”, this question will be much more likely to receive facts, details and a better description than “yes” or “no” or “ok”.
As a home health aide, you will need to develop your skill in making brief and accurate oral and written statements or presentations to both clients as well as the client care team. When a HHA gives a report on their client’s status, the report is used in 2 different ways. The first is a report which is used to bring critical information to your supervisor’s attention immediately. The signs and symptoms that need to be reported will be discussed throughout this training series. Additionally, there are quite a few dangerous symptoms that should be immediately reported.
Some examples of these symptoms are:
- Falls
- Chest pain
- Severe headache
- Difficulty in breathing
- Abnormal pulse, respiration or blood pressure
- A change in the client’s mental capacity
- A sudden weakness or loss of mobility
- High fever
- Loss of consciousness
- Bleeding
- Change in client’s conditioin
- Bruises, abrasions, or other signs of potential abuse
Another common way to use oral reports are to use them to convey your experiences regarding a client’s condition or care with a client, a family member or the care team. A good report giver will take notes – even for an oral report – so they do not forget any important details. Often times written reports will need to be prepared in follow up to oral reports so this is a good reason to take good notes. After giving an oral report, we recommend documenting the 5 W’s (who, what, where, when and why) of the situation.
On the flip side, there will be times when your supervisor or another member of the care team gives a brief oral report to you on one of your clients. Make sure to listen carefully and take notes where appropriate. Do not be afraid to ask for clarification or about things you do not understand. At the end of the conversation, you should restate all of the facts that you have been told to make sure you understand them properly. Furthermore, when team members see you taking notes and asking diligent questions, they will understand that you are doing a good job and a HHA to be trusted.
In order to provide accurate reports, the HHA must observe their clients, client families and client homes. When observing, try to use as many senses as possible in the information gathering process. Here are some examples of how to use your senses:
Sight: Look for changes in a client’s dress or appearance. these might include rashes, redness, paleness, swelling, discharge, weakness, sunken eyes and posture or gait (walking) changes. Also look for changes in the home setting. Ask yourself, does the home appear dirty or unorganized? Is food available or is it needed. Are there safety hazards?
Hearing: Always listen to what the client tells you about their condition, family setting and needs. Can the client speak clearly and do they make sense? Is the client displaying emotions such as anger, sadness or frustration? Is their breathing normal? Does the client wheeze, cough or gasp? Also, listen to the observations of family members regarding the clients needs or care. Is the area calm enough for the client to get their required rest?
Touch: Does the client’s skin feel cold or hot, dry or moist? Is their pulse rate normal or within acceptable limits? Use your sense of touch to check environmental factors like bathwater or the homes heating and cooling systems.
Smell: Do you notice any odors from the clients body? Odors can suggest many things such as inadequate bathing practices, infections or incontinence. Breath odor sometimes may suggest the use of alcohol or tobacco, poor oral care, indigestion or even diseases such as diabetes. Odors the general home area may suggest deficiencies in house cleaning, or that repairs or needed. In some cases, odors will be the result of food spoilage or improper trash removal.
Using all of your senses will allow you to make the best and most complete reports when you need to communicate your client’s situation to family or care team members.
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