By Winona Suzanne Ball, RN, MHS
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- CNA Duties: Eleven Golden Rules of Documentation
- If you didn’t write it down, it didn’t happen
- Date, time, and sign every entry
- Chart care as soon as possible after you give it
- Write legibly every time
- Be systematic
- Be accurate
- You absolutely must be objective
- If you notify the nurse of something important, include it in your entry
- Use only abbreviations approved by your facility
- Never change what you have charted
- Don’t chart for someone else or let anyone else chart for you
One of the most critical responsibilities of all health care professionals is producing proper documentation, also called CNA charting. This is a clear and accurate method of keeping track of everything that happens to each patient. It is a part of the CNA job description and a way to communicate with other team members about the patient so the team can plan for and provide the best care.
Documentation has other important functions, as well:
- It creates a permanent record of the patient’s health care.
- It 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 probably spend more time with patients than any other professionals do, so your charting is crucial. Documentation is not difficult, but it must be done properly.
Documentation is not difficult, but it must be done properly.
What do CNAs document? Plenty!
- Level of consciousness or alertness
- Measurements of vital signs
- Height and weight
- Intake and output
- Bowel elimination
- Appetite and food intake
- Skin: color, condition, integrity
- Activities and care: ambulation, turning and positioning, range of motion, catheter care, unsterile bandage changes, hot or cold compresses, bathing, etc.
- Patient’s response to activities and care
- Significant statements from the patient
- Conversations you have with other members of the health care team
There are Eleven Golden Rules of Documentation. They apply to every professional who makes entries in a patient’s medical record. Let’s review them:
