3.4 Communication & Documentation
Key Takeaways
- Objective information is what the CNA observes or measures; subjective information is what the resident says or feels.
- Reporting is timely verbal communication to the nurse; recording is the written legal record of care and observations.
- Urgent changes are reported verbally first, then documented; charting never replaces telling the nurse.
- A hand-off should be organized, factual, and complete: who, what was observed, when, and any change from baseline.
- Errors and incidents such as falls are documented factually and reported promptly; never chart care before it is performed.
Communicating As The Eyes And Ears
The Florida CNA usually notices a change first because you know each resident's normal pattern. Clear communication turns that observation into safe care.
Objective Versus Subjective
- Objective information is what you see, hear, measure, or do, such as "blood pressure 150/92" or "reddened area over the sacrum."
- Subjective information is what the resident reports, such as "my chest feels tight." Put important resident statements in quotation marks.
Both are documented, but they must be labeled correctly and never mixed with opinion or blame.
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. Examples that require an immediate verbal report: a fall, chest pain, new shortness of breath, sudden confusion, or output far below normal.
Organized Hand-Off
When you give a change-of-shift hand-off or report to the nurse, keep it structured so nothing critical is lost. A useful order is the situation, the relevant background, what you observed, and what you recommend or are asking the nurse to check.
Example: "Room 14, Mr. Diaz. He has a history of falls. At 0900 he was newly confused and unsteady, which is different from his baseline. I placed the call light in reach and want the nurse to assess him."
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 output, percentage for meal intake, mmHg for blood pressure, beats per minute for pulse.
Error And Incident Reporting
For a documentation error on paper, follow facility policy: draw a single line through the entry, write the correction, then date and initial. Do not erase, white out, or delete. Never chart care before it is done and never chart for another person.
For an incident such as a fall, keep the resident safe, notify the nurse immediately, and complete the incident report with objective facts only. An incident report records what happened; it is not a place to assign blame or guess at causes.
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?