3.4 Communication & Documentation
Key Takeaways
- Objective information is what the CNA observes or measures; subjective information is what the resident says or feels (recorded in quotation marks).
- Reporting is timely verbal communication to the nurse; recording is the written legal record of care and observations — charting never replaces telling the nurse.
- Urgent changes (fall, chest pain, new shortness of breath, sudden confusion) are reported verbally first using a structured SBAR-style hand-off, then documented.
- Errors and incidents such as falls are documented with objective facts only; correct a paper error with a single line, the correction, and your date and initials.
- Prioritize the workload using ABCs and Maslow's hierarchy: airway/breathing/circulation and life-safety needs come before comfort or routine tasks.
Communicating As The Eyes And Ears
The Florida CNA usually notices a change first, because you know each resident's normal pattern better than anyone. Clear communication turns that observation into safe nursing action. The exam tests whether you can separate fact from opinion, report at the right time, and document in a way that stands up as a legal record.
Objective Versus Subjective
- Objective information is what you see, hear, measure, or do — for example, "blood pressure 150/92 mmHg" or "reddened area over the sacrum." It is verifiable.
- Subjective information is what the resident reports — for example, "my chest feels tight" or "I feel dizzy." Put important resident statements in quotation marks so it is clear they are the resident's words.
Both are documented, but they must be labeled correctly and never mixed with opinion, diagnosis, or blame. Writing "resident is faking pain" is an interpretation a CNA is not licensed to make; writing the resident's exact words and the measurable findings is correct.
| Statement | Objective or Subjective? |
|---|---|
| "Pulse 96 and irregular" | Objective |
| "My stomach hurts" | Subjective |
| "Ate 50% of breakfast" | Objective |
| "I feel nauseated" | Subjective |
| "Skin warm and reddened over heel" | Objective |
Reporting Versus Recording
| Reporting | Recording | |
|---|---|---|
| Form | Verbal to the nurse | Written or electronic chart |
| Timing | Immediately for urgent findings | As soon as care is complete |
| Purpose | Trigger nursing action | Legal record and continuity of care |
For an urgent change, report first, then document. Documentation does not replace telling the nurse — by the time someone reads a chart entry, the moment to act may have passed. Findings that require an immediate verbal report include a fall, chest pain, new shortness of breath, sudden confusion, a seizure, choking, or output far below normal.
Organized Hand-Off (SBAR)
When you give a change-of-shift hand-off or report a change to the nurse, keep it structured so nothing critical is lost. Healthcare uses SBAR:
| Letter | What You Say |
|---|---|
| Situation | Who and what is happening right now |
| Background | Relevant history or baseline |
| Assessment/observation | What you observed or measured |
| Recommendation/request | What you want the nurse to check or do |
Example: "Room 14, Mr. Diaz (Situation). He has a history of falls (Background). At 0900 he was newly confused and unsteady, which is different from his baseline (observation). I placed the call light in reach and I'd like the nurse to assess him (Request)." As a CNA you supply observations, not a clinical "assessment" — but the SBAR order keeps your report short and complete.
Documentation Quality
| Weak Entry | Stronger Entry |
|---|---|
| Resident was difficult | Resident declined the bath at 0830 and stated, "I am too tired." Nurse notified. |
| Ate poorly | Ate 25% of lunch and drank 120 mL water. |
| Skin looked bad | Reddened area noted over the sacrum during turning; skin intact. Nurse notified. |
Record measurements in the required units: mL for fluids, percentage for meal intake, mmHg for blood pressure, and beats per minute for pulse. Chart promptly and only what you personally did or observed.
Error And Incident Reporting
For a paper charting error: draw a single line through the entry so it stays readable, write the correction, then date and initial. Do not erase, white out, or delete — those look like falsification. Never chart care before it is done, and never chart for another person.
For an incident such as a fall: keep the resident safe, do not move the resident if injury is possible, notify the nurse immediately, then complete the incident report using objective facts only (where the resident was found, position, what the resident said, who was notified, the time). An incident report records what happened — it is not a place to assign blame or guess at causes.
Time Management And Organizing The Shift
A CNA cares for many residents at once, so the exam expects you to prioritize rather than work in random order. Two tools drive prioritization:
- ABCs — Airway, Breathing, Circulation. A resident who is choking or struggling to breathe always comes before a routine bath.
- Maslow's hierarchy of needs — physiological needs (oxygen, food, fluids, elimination, safety) outrank psychosocial needs (companionship, self-esteem). A resident in pain or unable to breathe is served before a lonely resident who wants to chat.
Practical organization habits: review your assignment at the start of the shift, group tasks by room to save steps, gather supplies before entering, place call lights and water within reach every time you leave, and answer call lights promptly because an unanswered light is both a safety risk and a rights issue. Never skip required care to "catch up" — if you genuinely cannot finish an assignment, tell the nurse so the work can be reassigned, and document what was and was not completed.
| Two residents need you at once… | Serve first because… |
|---|---|
| One short of breath, one wants the TV channel changed | Breathing is an ABC/physiological need |
| One on the floor after a fall, one needs a bath | Fall is a safety/injury emergency |
| One needs the bathroom now, one wants to talk | Elimination is a physiological need |
Good time management is not about rushing residents; it is about doing the most important care first so everyone stays safe.
Which of these is an example of objective information a Florida CNA should document?
A Florida CNA finds a resident on the floor next to the bed. After ensuring safety, what is the correct order of action?
How should a Florida CNA correct a handwritten charting error?
A CNA must respond to two residents at once: one is short of breath and one wants the television channel changed. Using prioritization, who is served first and why?