Key Takeaways
- "If it wasn't documented, it wasn't done" - documentation is legal proof of care
- Documentation must be factual, objective, complete, timely, legible, and signed
- Never document opinions, diagnoses, or assumptions
- Correct errors with a single line, initials, and date - never use white-out
- Use SBAR (Situation, Background, Assessment, Recommendation) for verbal reports
Last updated: January 2026
Documentation and Reporting
Documentation is the written record of patient care, while reporting is the verbal communication of information. Both are essential CNA responsibilities that directly impact patient safety.
Why Documentation Matters
The healthcare saying "If it wasn't documented, it wasn't done" emphasizes that:
- Documentation provides legal proof of care provided
- It ensures continuity of care between shifts
- It tracks patient progress over time
- It supports billing and reimbursement
- It communicates important information to the team
Types of CNA Documentation
CNAs typically document in several areas:
| Document Type | What to Record |
|---|---|
| ADL Flow Sheets | Bathing, dressing, eating, mobility, continence |
| Vital Signs Log | Temperature, pulse, respirations, BP, pain level |
| Intake and Output (I&O) | Fluids consumed, urine output, other drainage |
| Daily Care Record | Personal care provided, patient responses |
| Incident Reports | Falls, injuries, unusual occurrences |
| Behavior Records | Mental status, mood, agitation levels |
Documentation Principles
Accurate documentation must be:
| Principle | Description | Example |
|---|---|---|
| Factual | Record what you observed, not opinions | "Skin red on coccyx" not "bedsore developing" |
| Objective | Use measurable terms | "Ate 50% of meal" not "didn't eat much" |
| Complete | Include all relevant information | Time, location, patient response |
| Timely | Document as soon as possible | Within shift, not days later |
| Legible | Readable by others | Clear handwriting or proper entries |
| Signed | Initial or sign appropriately | Per facility policy |
What NOT to Document
Avoid these documentation errors:
- ❌ Opinions or judgments - "Patient is lazy"
- ❌ Diagnoses - "Patient has a UTI" (that's the nurse's role)
- ❌ Assumptions - "Patient must have fallen at home"
- ❌ Late entries without notation - Must indicate "late entry"
- ❌ Blank spaces - Draw line through unused areas
- ❌ Correction fluid or erasures - Single line through errors
Correcting Documentation Errors
If you make a mistake in documentation:
- Draw a single line through the error
- Write "error" or your initials above it
- Date and time the correction
- Write the correct information
- Never use white-out or scratch out completely
Verbal Reporting
Reporting is verbal communication of patient information:
When to Report:
- Beginning and end of shift (handoff)
- When patient condition changes
- When abnormal findings occur
- When you need clarification
- When incidents happen
SBAR Reporting Method:
| Letter | Component | Example |
|---|---|---|
| S | Situation | "Mr. Jones in 205 fell in the bathroom" |
| B | Background | "He has a history of falls, uses a walker" |
| A | Assessment | "He has pain in his right hip, can't bear weight" |
| R | Recommendation | "I think he needs to be seen by the nurse now" |
End-of-Shift Reporting
When reporting to the next shift, include:
- Patient's current condition
- Changes during your shift
- Care provided and patient response
- Outstanding tasks or concerns
- Upcoming needs (appointments, procedures)
Confidentiality in Documentation
Remember HIPAA requirements:
- Only document relevant information
- Keep records secure
- Don't leave charts visible
- Don't discuss patients publicly
- Don't access records you don't need
Test Your Knowledge
Which statement demonstrates proper objective documentation?
A
B
C
D
Test Your Knowledge
How should you correct a documentation error?
A
B
C
D
Test Your Knowledge
What does the "S" in SBAR stand for?
A
B
C
D