Sample Observational Report

The Observational Report summarizes, in outline form, the notes you took while
Shadowing a patient and family throughout their Care Experience. It is helpful to
write your Observational Report as soon after Shadowing as possible. Refer to
this Observational Report when drafting your Final Shadowing Report.

In your Observational Report, remember to identify opportunities for

improvement, and propose possible solutions expressed by the patient, family,
and Care Givers. And don’t forget to share your own improvement ideas, too!

A sample Observational Report follows.

Same Day Surgery Care Experience

June 9, 2011

• 5:00 AM Hospital and Same Say Surgery entrances

o Patient and wife arrive at hospital

o Trouble finding the unit

o Discrepancy in signage (Outpatient Surgery vs. Ambulatory Surgery)

o Observed multiple patients arriving at Entrance A - no staff sitting at

registration desk at Entrance A – patients and families not sure where to
go; No sign at desk directing patients to Surgical Waiting Room

o Upon arrival at Waiting Room, patients are told to “Sign In, Take a Seat”--
no “Hello, Good Morning,” etc. After 5 minutes the patient was called back
to the desk where patient demographics/ID were reviewed and ID band
was placed on patient, VERY quick review of Case Tracking, Parking
Ticket validated at this time. Family members are told not to leave area
without letting the desk know

o Introduce self to patient and wife

• 5:17 AM Pre-Op Area

o Patient is taken back to “get dressed”

o Wife mentions husband’s comment of “funeral music” over the speaker

when entered the hospital
 o Patient is unsure how long the procedure would last (20 minutes or a 4-
hour surgery?)

o Patient had been informed of the tracking numbers

o Room had two televisions

 Half of each screen displayed the news & tracking monitor on other
half

 TVs on opposite sides (could see from any seat)

o Wife mentions parking is more expensive than it used to be ($4)

 Her ticket was validated

o Wife is not sure about home care after the procedure

o Comments made by Wife:

 Sheets in rooms should be changed every day

 Phone and TV charges need to be explained better

• 5:45 AM

o Patient and wife introduced to Pre-Op Nurse

• 6:00 AM

o Nurses introduced themselves again and took patient’s vital signs,

reviewed H&P, nursing assessment, confirmed procedure (time with
patient 10 min).

• 6:10 AM - 6:15 AM

o Anesthesiologist in to perform anesthesia assessment; RN’s left the room

o I observed the lack of privacy – conversation of patient’s medical history

can be heard by others outside of cubicle

• 6:15 AM – 6:25 AM

o Nurses with patient to do Sage wipe and hair removal

• 6:24 AM

o Wife is told she can go back to pre-op to see her husband

o Woman at front desk asks wife for a cell phone number so that during her
wait, she can be contacted if she would like to leave the hospital

o Wife does not know her own cell number

o Pre-op area is much cooler than waiting room (noted by wife)

o Curtains are open; patients are able to view each other

• 6:39 AM

o PA and 2 nurses enter patient area

o PA takes history and performs physical exam

o Nurses speak to wife about her husband’s mediations (confirmation)

• 6:43 AM

o Anesthesia team member enters (SRNA) (others caregivers leave the

area)

 Asks pre-op questions and then asks if patient has any questions

• Wife is NOT addressed

 Inserts IV drip

• 6:48 AM

o OR RN enters, introduces herself and her role on the care team

 Asks patient about medical history (confirmation)

• 6:49 AM

o Surgeon enters the area & explains process (patient is happy to see him)

• 6:51 AM

o Surgeon exits

• 6:52 AM
 o OR RN exits

• 6:58 AM – 6:59 AM

o OR RN comes back to see wife to let her know that she will be contacting
her with updates throughout the surgery.

• 7:04 AM

o CRNA’s and another nurse enter the area  close curtain

o Give heparin shot

o Tell patient that they are “ready for him”

o Wife is able to stay in the area

• 7:06 AM

o Curtain opens

o Nurse explains to patient what he should expect

o Wheels patient to OR

 Nurse at nurse station wishes patient good luck and addresses him
by name

 Another nurse wishes luck to Wife

 Wife became tearful – Nurse offered support

 Wife kisses husband goodbye, but is NOT escorted back to the

waiting room; verbal instructions only to “go to waiting room”.

 Wife confused on where to go

• 7:09 AM—Waiting Area

o Arrive in waiting room

• 7:18 AM

o Someone walked around offering copies of the local paper to patients

(nice gesture!)

• 8:40 AM

o Becoming louder and more crowded in waiting room

 o One family enters with six children who must wait by themselves while
their mother went to pre-op to see the patient

o Wife jokes “where is the Krispy Kreme?”

 (It would go well with the coffee!)

o Wife likes the volunteers and thinks they are very helpful

o We joke about how nice a “barista cart” would be

o Wife talks on the phone to family at times during her wait

• 10:08 AM

o Wife is informed that there is a call from the OR nurse with an update

 Told about surgery progress and informed she would be given

another update

• 10:27 AM

o The mother-in-law of the patient’s daughter comes to the waiting room to

keep Wife company

 She is immediately approached by staff member and asked if she

needs her parking validated

Copyright  ©  2013.    Anthony  M.  DiGioia  III,  MD,  AMD3  Consulting,  Inc.    and  The  PFCC  Innovation  Center  of  UPMC.  
All  rights  reserved.