4.2 Documentation, Charting, and Reporting

Documentation Is a Legal Record

Documentation (charting) is the permanent legal record of the care a resident received. In Illinois, the medical record is evidence in court, the basis for Medicare and Medicaid reimbursement, and the first thing an Illinois Department of Public Health (IDPH) surveyor reviews during an inspection. The governing principle is blunt: "if it wasn't documented, it wasn't done." A turn you performed but never charted cannot be proven, and a vital sign you took but never recorded cannot protect you.

What CNAs Chart

Objective vs. Subjective — and Why It Matters

The INACE tests the difference repeatedly. Objective data is what you can see, hear, measure, or count. Subjective data is what the resident reports — chart it in quotation marks. What you must avoid is your interpretation.

Instead of "resident seems depressed," chart the facts that led you there: "Resident crying, refused breakfast, stated 'I just want to be left alone,' remained in bed." The nurse and surveyor can draw conclusions from facts; they cannot verify your guesses.

Documentation Rules Checklist

• Be factual and specific — "2-inch reddened area on left heel," not "skin problem on foot."
• Be timely — chart as soon as possible after care, never pre-chart something you have not yet done.
• Use only facility-approved abbreviations — when in doubt, write it out.
• Sign every entry with your name, the title CNA, the date, and the time.
• Correct paper errors properly — draw a single line through the mistake (it must stay legible), write "error," add your initials and the date, then write the correct entry. Never erase, scribble out, or use white-out; obliterating an entry looks like you are hiding something.
• Leave no blank lines between entries on a paper chart.

Reporting to the Nurse

CNAs observe residents more than any other team member, so you are the early-warning system. Some findings must go to the charge nurse immediately — do not wait for shift change.

Report immediately:

• Change in level of consciousness or new confusion
• Vital signs outside the resident's normal range (for example, blood pressure 190/110 or a temperature of 101.5°F)
• Chest pain, shortness of breath, or a change in breathing
• A fall — even with no visible injury
• New skin breakdown, redness over a bony area, or a fresh wound
• Bleeding, unusual drainage, or a change in urine color, amount, or odor
• Refusal of food, fluids, or treatment
• Any statement about wanting to harm self or others, or any sign of abuse or neglect

Report at shift change (handoff): a summary of care given, condition changes already reported, tasks left undone and why, scheduled care coming due, and family concerns.

SBAR: Structured Reporting

SBAR gives your verbal report a clear, complete structure that nurses expect:

Electronic Health Records (EHR)

Most Illinois facilities chart in an electronic health record, often at the bedside (point-of-care). Document care in real time, not in a batch at the end of shift. Never share your password or chart under another person's login — entries are tied to that identity. Avoid copy-and-paste, which can carry forward stale or wrong information, and always log out when you step away from the workstation to protect resident privacy.

In an EHR you cannot draw a line through an error; instead you create an addendum or late entry that the system time-stamps, leaving the original visible. The audit trail records who entered, changed, or viewed each item, which is why borrowing a coworker's login is both a documentation violation and a privacy breach under the Health Insurance Portability and Accountability Act (HIPAA).

Vital Signs: Normal Ranges and Reporting Triggers

Much of what a CNA charts is vital signs, and the INACE expects you to recognize values that must be reported. Memorize the normal adult ranges and the action thresholds.

Chart the actual number with units, the route, and the time — "T 99.2°F oral, 0800" — and compare against the resident's documented baseline, because a value normal for one resident may be a red flag for another. A sudden change from baseline is itself reportable even if the reading stays inside the textbook range.

Incident and Occurrence Reports

A fall, an injury, a medication error you witness, or any unusual event triggers an incident report. Complete it as soon as the resident is safe, document only the objective facts (what you saw, what you did, what you reported, and to whom), and never record an incident report as if it were a routine note or admit fault in the medical record. The incident report is a separate quality-and-risk document; in the resident's chart you record only the factual observations and the care provided. Always notify the nurse first — the nurse, not the CNA, assesses the resident after a fall.