Observation, Reporting, and Documentation

Observation, Reporting, and Documentation 

As a caregiver you are the eyes and ears of the care team. You are often the person who sees individuals most often; the one who gives daily care and follows the care plan. In this course you will be given information on how to observe, what to observe, and what to report. This will include routine reporting, issues to report immediately, and documentation of what you observe.


Hours: 1.00


Certificates provided by accrediting body (6 Match)

Florida Board of Nursing - Certified Nursing Assistants


This is not an accredited course for professional license renewal. Florida CNAs may use this inservice toward meeting their annual inservice requirement.This activity is approved for 1.00 contact hours.

Non-Licensed Direct Care (DSP, HHA, CNA, DCW, PCA, IHA, NA)


Washington State Department of Social and Health Services (ALL Direct Care Workers)


Relias Learning, LLC is approved as a Curriculum Developer by the Washington State Department of Social and Health Services. This activity is approved for 1.00 contact hours for all WA State Direct Care Workers. Training Provider Code: WA0624. CE Approval Code: CO1729959

California Department of Public Health (CNA)


Relias, LLC is an approved provider of continuing education by the California Department of Public Health, Provider # NAC7001.

The certificate must be retained by the licensee for a period of four (4) years after the course is completed.

This learning activity meets the definition of *** ONLINE *** CEUs. This activity is approved for 1.00 contact hours.

Pennsylvania Personal Care Home Administrators


This activity is approved for 1.00 contact hours.

National Certification Council for Activity Professionals


This course is NCCAP approved NCCAP500267-21NT. All NCCAP approved courses count 100% towards certification.

Course Details

Course Code: REL-SRC-0-ORD
Hours: 1
Type: Online Course
Content Expiration Date: 11/30/2022
Learning Objectives:
Give examples of observations made using your senses.
Distinguish between signs and symptoms.
Distinguish between objective and subjective observations.
Identify signs and symptoms that indicate a change in condition.
Illustrate effective methods to report and document condition changes.

Section 1: Introduction
A. About This Course
B. Breaking News Reporter
C. Learning Objectives
Section 2: Observation
A. Using Your Senses
B. Signs Versus Symptoms
C. Objective Versus Subjective
D. Review
E. Summary
Section 3: What to Report and When
A. Report Immediately
B. Abnormal Signs to Report
C. Signs of Pain
D. Pressure Injury
E. Observing the Dying Process
F. Changes in Condition
G. Functional Decline
H. Review
I. Summary
Section 4: Reporting and Documentation
A. Verbal Reports
C. Feedback During Report
D. Closed Loop Communication
E. Documentation
F. Electronic Medical Record
G. Incident Reports
H. Review
I. Summary
Section 5: Conclusion
D. Summary
E. Course Contributors
F. References
G. Congratulations

Instructor: Elizabeth Kellerman, MSN, RN
Elizabeth Kellerman MSN, RN started in nursing in 2007 after graduating from Samuel Merritt University in Oakland, California. While working in a critical care unit at Sutter Mills-Peninsula Hospital she earned her CCRN and TNCC. Her experience and knowledge led her to nursing education where she taught at a community college while working to receive her Master's in Nurse Education at Western Carolina University. As a nursing instructor, she spent time in many types of care settings including medical-surgical inpatient and community living centers. Her passion for education and training has most recently led her to a position as subject matter expert and content writer for Relias. Disclosure: Elizabeth Kellerman, MSN, RN has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Target Audience:
The target audience for this course is: Entry level Direct Care Workers; in the following settings: Post-Acute Care.
Relias will be transparent in disclosing if any commercial support, sponsorship or co-providership is present prior to the learner completing the course.
Course Delivery Method and Format
Asynchronous/Online Distance Learning; please see certificate details for specifics on delivery format.
Relias has a grievance policy in place to facilitate reports of dissatisfaction. Relias will make every effort to resolve each grievance in a mutually satisfactory manner. In order to report a complaint or grievance please contact Relias.
If you require special accommodations to complete this module, please contact Relias Support by completing the web form (https://www.relias.com/help) or by using the chat functionality.
All courses offered by Relias, LLC are developed from a foundation of diversity, inclusiveness, and a multicultural perspective. Knowledge, values and awareness related to cultural competency are infused throughout the course content.
Reference herein to any specific commercial product, process, or service by trade name, trademark, service mark, manufacturer or otherwise does not constitute or imply any endorsement, recommendation, or favoring of, or affiliation with, Relias, LLC.
All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental.
To earn continuing education credit for this course you must achieve a passing score of 80% on the post-test and complete the course evaluation.
If you require special accommodations to complete this module, please contact Relias Customer Support here.