As a Certified Nursing Assistant (or certified nursing aide) you form a pivotal part of a resident or patient’s medical support and care network. In this network there are also other CNAs, Licensed Nurses, Registered Nurses and Doctors. Because of the complexity and changeability of this network observing and documenting forms a crucial part of CNA training and employment.
Observation and Documentation Info For CNA Training
What are medical records?
Medical records are legal documents and must be completed in a particular way in accordance with guidelines. All patients and residents of a facility will have a medical record on admission.
Medical records are required because:
- A patient’s medical record communicates the details of a patients care to other members of staff. This includes treatments and care.
- Medical records state facts about the patient or resident
- Medical records help Doctors and supervising nursing stuff to develop appropriate care plans
- These records also serve as a means to monitor the quality and consistency of patient care.
- These records need to be accurate, complete and filled out in a timely fashion so as to keep the details current and relevant. They also need to use appropriate professional and legal language.
What should documentation include?
Whether this information is expressed via flow charts, progress notes or via digital record keeping the following information must be included:
- Any care tasks you undertake for a patient or resident
- Any observations such as mood, lucidity and general well-being
- Any necessary vitals noted
- Fluid and food consumption by patient or resident
- Any concerns or issue that need to be followed up
- Any treatments you undertake for a patient or resident
- Any other interactions you have with the patient or resident in your duties as a CNA
Your CNA training course will cover all the requirements for residential and clinical care observation and documentation. Remember if in doubt document it.
Why is it important to keep complete medical records?
Treat your patient or resident’s medical records as evidence of care; if it is not recorded then it was not done. This means that anything you neglect to write down you cannot prove that you completed and fulfilled your duty of care for your patient. Accurate and complete medical records avoid doubling up on care duties and allow for staff accountability. It is also essential to record observations of patient health and welfare to ensure that no alarm bells or warning symptoms go unchecked. It is also possible for a nurse or doctor to accurately chart a patient’s progress or relapse via detailed and accurate charts and medical records.
What care needs to be documented?
Every care task that you undertake for or with a patient has to be documented. This may include:
- Baths and showers
- Oral care including denture care
- Hand and foot care
- Nail clipping and hair trimming
- Catheter maintenance and care
- Back care
- Ambulating, movement and positioning
- Fluid and food intake
- Physical activities
- Warm soaks and cold applications
- Discussions with patients, residents or family
What do you need to observe and document about a patient’s condition?
Things that you need to take note of when observing a patient:
- Level of consciousness
- Is the patient disorientated?
- Height and weight measurements
- Urinary fluid passed
- Temperature, pulse and respiration rate
- Blood pressure and glucose readings
- Characteristics of skin,
- Patient comments and communication
- Patient or resident’s emotional responses and behavior