4.2 Documentation, Charting, and Reporting
Key Takeaways
- "If it wasn't documented, it wasn't done" — documentation is a legal record of care
- Use objective, factual language with specific measurements and observations
- Report changes in condition, abnormal vital signs, falls, and safety concerns to the nurse immediately
- Use SBAR (Situation, Background, Assessment, Recommendation) for structured communication
- For paper chart errors: single line through, initial, and correct — never erase or white-out
- Never share EHR passwords or use someone else's login credentials
Last updated: March 2026
Documentation, Charting, and Reporting
Documentation is a legal record of the care provided to residents. In Illinois, accurate documentation is not only essential for quality care but is also a legal requirement that protects both the resident and the CNA. The phrase "if it wasn't documented, it wasn't done" is the guiding principle.
Why Documentation Matters
| Reason | Explanation |
|---|---|
| Legal Protection | Documentation is evidence in court that care was provided |
| Communication | Ensures continuity of care between shifts |
| Reimbursement | Medicare/Medicaid payments depend on documented care |
| Quality Improvement | Identifies trends and areas for improvement |
| Regulatory Compliance | IDPH surveyors review documentation during inspections |
| Care Planning | Provides data for updating care plans |
What CNAs Document
| Document Type | Information Recorded |
|---|---|
| ADL (Activities of Daily Living) Flow Sheets | Bathing, dressing, grooming, eating, toileting, mobility |
| Vital Signs Records | Temperature, pulse, respirations, blood pressure, pain |
| Intake and Output (I&O) Records | Food eaten, fluids consumed, urine/stool output |
| Weight Records | Weekly or as-ordered weights |
| Repositioning/Turning Schedules | Position changes, skin checks |
| Behavioral Observations | Mood changes, agitation, unusual behaviors |
| Incident/Occurrence Reports | Falls, injuries, errors, unusual events |
Rules of Documentation
| Rule | Application |
|---|---|
| Be Factual | Record what you observed, not your interpretation |
| Be Objective | "Resident ate 50% of lunch" NOT "Resident didn't eat well" |
| Be Timely | Document as soon as possible after providing care |
| Use Approved Abbreviations | Only facility-approved abbreviations |
| Sign and Date | All entries must have your name, title (CNA), date, and time |
| Never Erase | For paper records: single line through errors, initial, and correct |
| Be Specific | "2-inch red area on left heel" NOT "skin problem on foot" |
| Use Quotes | Record resident statements in quotes: Resident stated, "My stomach hurts" |
Objective vs. Subjective Documentation
| Type | Description | Example |
|---|---|---|
| Objective | What you can see, hear, measure, count | "Blood pressure 142/88 mmHg" |
| Subjective | What the resident tells you (use quotes) | Resident states, "I feel dizzy" |
| What to Avoid | Your personal interpretation or opinion | "Resident seems depressed" (say instead: "Resident crying, refused breakfast, stayed in bed") |
Reporting to the Nurse
CNAs must immediately report certain observations to the charge nurse:
Report IMMEDIATELY:
- Change in level of consciousness or mental status
- Vital signs outside normal range
- New pain or sudden increase in pain
- Difficulty breathing or changes in respirations
- Skin breakdown, redness, or new wounds
- Falls (even without apparent injury)
- Bleeding or unusual discharge
- Change in urine color, amount, or odor
- Refusal of food, fluids, or medications
- Resident complaints of chest pain or numbness
- Signs of possible abuse or neglect
- Statements about wanting to harm themselves or others
Report at Shift Change (Handoff):
- Summary of care provided during the shift
- Any changes in condition (even if already reported)
- Tasks that were not completed and why
- Upcoming scheduled care (e.g., "blood pressure due at 2 PM")
- Family concerns or requests
- Behavioral changes or mood shifts
The SBAR Communication Tool
SBAR is a structured communication framework used in healthcare:
| Letter | Meaning | CNA Example |
|---|---|---|
| S | Situation | "I need to report on Mrs. Johnson in room 214" |
| B | Background | "She has a history of falls and hip replacement last month" |
| A | Assessment | "I noticed she is confused and unable to stand without help" |
| R | Recommendation | "I think the nurse should assess her before she gets up again" |
Electronic Health Records (EHR)
Most Illinois facilities use electronic documentation systems:
- Point-of-care documentation — Document at the bedside using tablets or computers
- Login security — Never share your password or use someone else's login
- Real-time entry — Document care as it is provided, not at the end of the shift
- Avoid copy-paste — Each entry should reflect actual care for that specific shift
- Log out — Always log out when leaving a workstation
Test Your Knowledge
Which of the following is the BEST example of objective documentation?
A
B
C
D
Test Your Knowledge
You discover that you documented the wrong blood pressure reading on a paper chart. What should you do?
A
B
C
D
Test Your Knowledge
What does the "A" in SBAR stand for?
A
B
C
D