In this article we will cover some of the more important factors involved in the documentation and observation that you will learn about in CNA training. CNA training is designed to equip you with all of the necessary skills you will need to carry out your Observation and documentation duties as a certified nursing assistant or aide.
Learning How to Document in CNA Training
How do I know I’m completing my documentation properly?
You should follow your medical facilities guidelines as well as state and federal guidelines and legal requirements. If you ensure that you are following all stated guidelines then you are fulfilling your requirements as a CNA. The cornerstones of medical record documentation include:
- Complete Records
- Correct Records
- Timely documentation
- Legally appropriate documentation
- Professionally appropriate documentation
The importance of complete records has been emphasized in another article on our CNA training blog covering documentation. You can find it on the main page of CNAtrainingclass.com.
What is involved in correct documentation?
CNA training manuals and text books out line correct documentation as including:
- Accurate times of tasks, beginning and completion
- Accurate measurements for vitals and observations
- Accurate records of communication and interaction with patients, residents or their families
- Clear writing and annotation
- Only facts, not assumptions
Correct documentation helps doctors and nurses to create appropriate care and treatment plans for patients and residents. Inaccurate records could lead to misdiagnosis and inappropriate or dangerous treatments and care regimes. Correct documentation could be the difference between poor and high quality of care?
What constitutes timely documentation?
Timely documentation involves documenting any activities as soon as is possible. Do not wait until the end of your shift or your break as the longer you wait the more likely your documentation is to contain inaccuracies. Ensure you take the time to document and accurately observe patients or residents to ensure accurate and complete documentation. CNA training can help you to prioritize your care and documentation duties.
What are the legalities of CNA documentation?
There are very strict guidelines for what you can and cannot include in medical records as legal documents including which you will learn during your CNA training:
- Using blue or black ink; some hospitals may use computers for records or alternate between different colors of ink for different shifts.
- Not using erasable or alterable pencils or recording implements
- Write clearly and concisely so that your notes are legible
- Include dates and times on all your notes
- Annotate all notes with your name and title (CNA, LPN etc)
- Don’t scribble or use white out to cover up mistakes
- Write facts not assumptions
- Do not make a note of tasks that you have not yet completed
- Only use hospital sanctioned abbreviations
- Do not allow access to a patient’s records to anyone who is not a healthcare professional directly linked to the care of the patient or resident
- Medical records must be kept secure
- Medical records must be kept confidential
These guidelines will be cover extensively during the course of your CNA training.
What constitutes professional CNA documentation?
Presentation of medical documents should be neat and legible, with correct spelling and without emotion. Professional documentation in CNA training and employment is about unemotional, accurate and concise records of the interactions with and observations of a patient or resident.