2.4 Documentation and Reporting

Why Documentation Matters

Documentation is the written (or electronic) record of care; reporting is the spoken communication of the same information. The exam stresses the legal saying "If it wasn't documented, it wasn't done." A chart that omits care you gave is treated, legally, as if the care never happened.

Accurate records:

• Provide legal proof of the care delivered
• Ensure continuity of care across shifts and staff
• Track resident progress and trends over time
• Support billing, reimbursement, and survey compliance
• Communicate vital information to the whole team

CNAs document objective, measurable facts. Whatever you chart can be read aloud in court years later — so it must be clear, neutral, and true.

Where CNAs document

The Six Principles of Good Documentation

Every entry you make should meet all six standards. A frequent test format gives a sample entry and asks if it is objective.

What NOT to document

• ❌ Opinions/judgments — "Resident is lazy" or "is faking"
• ❌ Diagnoses — "Resident has a UTI" (the nurse/provider diagnoses)
• ❌ Assumptions — "Must have fallen at home"
• ❌ Blank lines — draw a line through unused space so nothing can be added later
• ❌ Pre-charting — never chart care before you actually give it

Correcting an error

1. Draw a single line through the mistake (the original must stay readable).
2. Write "error" and your initials beside it.
3. Add the date and time of the correction.
4. Enter the correct information next to it.
5. Never use white-out, erase, or scribble out an entry — that looks like tampering.

Verbal Reporting and SBAR

Reporting is how time-sensitive information reaches the nurse. Report immediately for: a change in condition, abnormal vital signs, a fall or injury, refusal of care, or anything you are unsure about. Routine information is shared at the shift handoff.

SBAR — the standard report framework

SBAR organizes a report so the nurse gets the full picture fast.

For the CNA, the "A" is observed facts, not a clinical diagnosis — that stays within scope.

End-of-shift handoff

Give the next caregiver: the resident's current condition, any changes this shift, care provided and the response, outstanding tasks, and upcoming needs (appointments, scheduled turns).

Confidentiality (HIPAA)

The Health Insurance Portability and Accountability Act (HIPAA) protects resident information. Document only relevant facts, keep charts and screens out of public view, log off shared computers, and never discuss residents in elevators, hallways, or on social media. A casual hallway comment about a resident is a reportable privacy breach.

Measuring, Abbreviations, and What Must Be Reported Now

Much CNA documentation is numeric, and the exam expects you to record in the right units. Intake and output (I&O) is charted in milliliters (mL), not ounces — you must know common conversions and that 1 ounce = 30 mL. A standard styrofoam water cup is often 240 mL; a juice carton about 120 mL; an ice-cream cup about 120 mL. If a resident drinks half a 240 mL cup, you chart 120 mL, not "about half."

Common documentation abbreviations

Use only your facility's approved abbreviation list — many facilities have banned error-prone abbreviations to prevent mistakes.

Changes you report to the nurse immediately

Some observations cannot wait for the routine handoff. Report at once if you notice:

• A fall, injury, or skin tear/new bruise
• Chest pain, trouble breathing, or a change in skin color (pale, bluish)
• A sudden change in mental status — new confusion or unresponsiveness
• Abnormal vital signs outside the resident's baseline
• Bleeding, vomiting, or signs of choking
• Refusal of food, fluids, or medication
• A complaint of pain that is new or worsening

When you report, document that you reported it, to whom, and the time — closing the loop between reporting and documentation. This double habit is the heart of safe CNA practice and a recurring exam theme: you both tell the nurse and write it down.