3.3 Documentation and Reporting
Key Takeaways
- Documentation is the legal record of care provided and observations made.
- Chart facts, not blame, guesses, or opinions.
- Use approved abbreviations only and record measurements in the required units.
- Report urgent changes verbally first, then document according to policy.
- Do not chart care before it is performed or chart for another person.
Documentation Principles
Documentation communicates care to the team and creates a legal record. A good CNA note is factual, accurate, complete, and timely.
| Poor Documentation | Better Documentation |
|---|---|
| Resident was lazy today | Resident refused to ambulate at 0900 and stated, "My left hip hurts." Nurse notified. |
| Ate well | Ate 75% of breakfast and drank 240 mL orange juice. |
| Skin looked bad | Reddened area observed over sacrum during turning. Skin intact. Nurse notified. |
| Acting weird | Resident was newly confused and asked for deceased spouse twice. Nurse notified at 0715. |
Objective vs Subjective
Objective information is what you see, measure, hear, or do. Subjective information is what the resident says or feels.
Both can be documented, but label them correctly. Use quotation marks for important resident statements.
Reporting Before Charting
If a finding is urgent, report first. Documentation does not replace notifying the nurse.
Urgent report examples:
- "Respirations 30 and labored."
- "Resident slid to floor beside bed."
- "Urine output 60 mL in 8 hours."
- "Resident coughed repeatedly while drinking water."
- "New open area on heel."
Measurement Accuracy
California skills and knowledge questions often test measurement. Record units exactly: mL for fluid output, percentage for meal intake, mmHg for blood pressure, beats per minute for pulse, and breaths per minute for respirations.
Correcting Errors
Follow facility policy. On paper, the classic method is a single line through the error, write correction, date, and initial. Do not erase, cover, delete, or falsify.
Never chart before care is done. "I planned to do it" is not documentation of care.
Which documentation entry is best?
A resident has new shortness of breath. What should the CNA do before routine charting?