Observation, Reporting, and Recording

Observation, Reporting, and Recording 

The purpose of this course is to instruct caregivers in skills for effective observation and reporting of findings related to client care. Types of documentation for recording tasks and observations are reviewed, as well as situations involving neglect and abuse in which caregivers have a legal duty to report their findings.


Hours: 1.00


Certificates provided by accrediting body (1 Match)

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: CO1933286

Course Details

Course Code: REL-PAC-0-ORR
Hours: 1
Type: Online Course
Content Expiration Date: 6/30/2025
Learning Objectives:
Implement skills for good observation - what to watch for and how to observe.
Report your observations effectively using sound communication techniques.
Record your tasks and observations according to best practices.
Describe common types of documentation used for reporting your observations
Identify situations that caregivers have a legal obligation to report


I.                     Observation, Reporting and Recording

II.                   Course Description

III.                 Course Objectives

IV.                Checkpoints

V.                  Glossary

VI.                The Care Team

VII.               Important information

·         Obtaining Baseline information

·         Examples of baseline information

VIII.             Communication

·         Communication skills

·         Making Observations and using the information

IX.                 Client Care Process

·         Reporting your Observations

·         Give Clear Descriptions

·         Use Plain Language

·         Be Descriptive

X.                   Directing Your information

·         When to Report

XI.     &

Instructor: Laura L. Morgan, MSN, RN, NEA-BC
Laura L. Morgan, MSN, RN, CCRP, NEA-BC, currently serves as the Clinical Education Specialist at Lincoln County Medical Center in Ruidoso, New Mexico.  She plans, develops, implements, and evaluates educational programs for clinicians, using the most current research and clinical data, while fostering the implementation of evidence-based practice. Ms Morgan is an endorsed member of the Society of Clinical Research Associates, member of Sigma Theta Tau international honors Society of nursing, an instructor for Basic Life Support, Advance Cardiovascular Life support and a Board Certified Nurse Executive-Advanced from the American Nurses Credentialing Center. Disclosure: Laura L. Morgan, MSN, RN, NEA-BC has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
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.