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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.
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.