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If Its Not Documented, It Was Not Done

As a certified nursing assistant, we must understand the importance of documenting accurately and regularly.  A resident/patients medical record is a legal document that consists of all documentation regarding the care and services that were provided.  Accurate information that has been gathered by the nursing assistant is vital to the report.  A CNA must understand the consequences of not documenting patient care properly.

There are several Key Purposes of Documenting

  • It reflects the quality of care that you give
  • What care was given and by whom
  • How the patient/ resident responded to the care
  • Gives the healthcare team a way to communicate with each other
  • Provides a system that enables the healthcare team to identify patient/residents problems as they arise
  • Builds a foundation for an effective care plan

All patient care documents need to be done accurately, complete and in a timely matter.  Documentation that is complete and accurate is a key to demonstrating the care provided to residents/patients. Done on a timely manner this tool is used as an important communication tool for care providers.

Certified nursing assistants must

  • Document the care that they provide
  • If you did not witness an event such as seeing it, hearing it, or feel it, you can not document it
  • Do Not document judgments.  If a patient is acting crazy, you do not put that the patient was acting crazy.  Instead you need to document the behavior of the patient/ resident. 
  • Document patient/resident refusals
  • Never document ahead of time
  • A change in a resident/ patient condition needs to be reported first and then documents what the condition was and whom it was reported to. 
  • Always sign and date

It is illegal and unacceptable to document care that you intend to do in the future.  Things are always changing on a daily basis, and documenting something that you may generally do on that day may or may not happen. 

Documentation tips for CNAs

1. Make sure you have the right patient/resident chart
2. Write legibly with blue or black ink
3. Chart all patient/resident changes in condition, to whom and when changes were reported
4. Sign and Date

Sometimes it may be necessary for a resident/ patient medical record to be evaluated by external personnel.  This may the case where state surveyors or attorneys need to have access to it . It is critical that the certified nursing assistant documentation in the medical record portray a clear and precise  picture of the care that is being provided to the resident.  If not you could be held liable to neglect.