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• CNA Duties: Eleven Golden Rules of Documentation

1. If you lot didn't write information technology down, information technology didn't happen
2. Date, time, and sign every entry
3. Chart intendance as soon as possible after yous give information technology
4. Write legibly every time
5. Exist systematic
6. Be accurate
7. You absolutely must be objective
8. If you notify the nurse of something important, include information technology in your entry
9. Utilize only abbreviations canonical by your facility
10. Never modify what you have charted
11. Don't chart for someone else or let anyone else chart for you

One of the almost critical responsibilities of all health intendance professionals is producing proper documentation. Documentation, as well called charting, is a clear and authentic method of keeping runway of everything that happens to each patient. It is a part of the CNA job description, a way to communicate with other squad members almost the patient so the squad can programme for and provide the best care.

Documentation has other important functions, as well:

• It creates a permanent record of the patient's health intendance.
• Information technology serves as proof of care and services for billing the insurance company.
• It can be used as evidence in a court of law.

As a CNA, you lot probably spend more fourth dimension with patients than whatsoever other professionals do, and so your charting is crucial. Documentation is not difficult, just it must be done properly.

Documentation is not difficult, but it must be done properly.

What practise CNAs document? Plenty!

• Level of consciousness or alertness
• Measurements of vital signs
• Height and weight
• Intake and output
• Bowel emptying
• Ambition and food intake
• Pare: color, condition, integrity
• Activities and intendance: ambulation, turning and positioning, range of motion, catheter care, unsterile bandage changes, hot or cold compresses, bathing, etc.
• Patient'due south response to activities and care
• Significant statements from the patient
• Conversations y'all take with other members of the health care squad

In that location are Eleven Golden Rules of Documentation. They use to every professional who makes entries in a patient'due south medical tape. Let's review them:

Eleven Golden Rules of Documentation

1. 1

   If you didn't write it downwards, it didn't happen.

   You've probably already heard this: "If you didn't write information technology downwards, it didn't happen." This statement is ane of the nigh important in wellness care. Failing to chart care properly may have ii dangerous consequences. First, there will be no proof that a handling or medication was given. Second, every bit a consequence, the treatment or medication may be given twice. Either consequence may be considered malpractice. Therefore, if you do information technology, nautical chart it!

   If yous do it, chart it.

2. two

   Engagement, time, and sign every entry.

   If your facility uses electronic health records, this information will be automatically entered and unalterable. If your facility uses newspaper charts, you will write this information for each entry.

3. 3

   Chart care as shortly as possible afterwards you give it.

   (Ideally, you should chart it immediately, but in practice, that is usually difficult.) Why must you lot be so prompt? Considering once it's entered in the nautical chart, no one volition incertitude that the care has been given and give information technology again. Patients don't always tell someone that their dressing was just changed or that they just got back from a walk. Never chart care before you give it. Not only is this illegal, merely if yous forget to give the care or something else happens, information technology volition count as a simulated entry.

4. 4

   Write legibly every time.

   As electronic health records become more common, written documentation volition subtract. But it's likely that the patient's chart volition always include newspaper forms or other written items. If your annotation tin can't be read, it won't do whatsoever good.

   If your note can't exist read, information technology won't do any good.

5. five

   Exist systematic

   Ever nautical chart the same way. For example, you might cull to e'er use a head-to-toe method. You'll begin with the patient'southward level of consciousness and vital signs. Then you'll chart your observations, care given, and activities. Y'all'll be less likely to skip something if y'all always practise your charting the same way.

6. half-dozen

   Exist accurate.

   E'er review your entry before you sign it. Did yous include everything? Is the spelling right? Is the entry in the correct patient's nautical chart? To include a argument from a patient, use quotation marks and record it verbatim. Two examples:

   Patient stated, "This is the worst pain I've ever had."
   Patient stated, "I'1000 so depressed. I desire to go home."

7. 7

   You lot absolutely must be objective.

   Do not tape your opinions. Use precise terminology and accurately depict what you take observed. For example, you can document that the patient's wound is red and warm with white secretions. You lot cannot document that the wound is infected, considering that conclusion would be across the scope of CNA practice. As some other case, it'southward fine to nautical chart that a patient is complaining of severe hurting or proverb that his or her level of pain is 9 out of 10, just not that the patient has a low tolerance for hurting or that he or she is childish.

   Do not record your opinions.

8. 8

   If y'all notify the nurse of something of import, include information technology in your entry.

   For example, suppose yous observe that the skin over a patient's sacrum is red and warm to the bear upon. Of course, yous will tell the nurse immediately. Write it in the chart also. If you report something nearly the patient to other team members, note that as well. You might exist at the patient's bedside when the physician comes in. You tin let the physician know that the patient complained of pain all night.

9. ix

   Utilise just abbreviations approved by your facility.

   Every facility has a list of canonical abbreviations, which can ordinarily exist plant in the policy transmission. There may also be a list of "Practise Not Utilize" abbreviations. Yous must follow the policy even if you used dissimilar abbreviations at some other job. If necessary, copy the listing and go on it with you.

10. q

    Never change what you have charted.

    Never . Once an entry is fabricated, information technology must be permanent. Electronic health records do not permit changes, but paper charts must not be altered either. If y'all make a mistake, follow your facility's policy for correction. Many facilities volition accept a single line through the mistake with the date, the time, and your initials. Never erase, blackness out, or employ correction fluid.

11. west

    Don't chart for someone else or permit anyone else chart for y'all.

    When things are decorated or others are way behind, yous may be tempted to aid, especially if nothing new has happened to the patients. But it must not exist done. Information technology's illegal and unethical. Period.

The patient'southward medical record is the only place that legally holds the patient'south data. Documentation is not difficult, but it must be done properly. Your charting is simply as important every bit that of every other member of the wellness care team. In every shift, your observations provide a baseline of each patient'due south condition and tin can be the cardinal to noticing a change in the patient'due south condition. Remember that your patients are counting on y'all, so accept pride in your charting.

About the Author

Winona Suzanne Brawl

Nursing Adviser, RN | MHS, Governors Land University, IL
Full member of the American Nurses Association. Learn more

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Source: https://cna.plus/cna-duties-documentation/

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