8.1 Medical Terminology, Charting Principles, and Objective vs. Subjective Documentation

Charting Principles for the Indiana CNA

Quick Answer: The medical record is a legal document. Chart what you see, hear, touch, and smell — not what you think. Objective documentation is measurable and observable (a blood pressure of 124/78, a 2 cm red area on the sacrum, a resident who coughs during feeding). Subjective documentation is the resident's own report ("I feel dizzy") or — used sparingly — your opinion clearly labeled as such ("appears in pain"). Correct errors with a single line, your initials, the date, and the time; never obliterate. Backdated or altered entries are treated as falsification under Indiana survey rules.

Why Documentation Matters in Indiana LTC

Under 410 IAC 16.2, Indiana long-term care facilities must maintain a clinical record for every resident that is accurate, complete, and contemporaneous. The CNA's charting is a required component of that record. IDOH surveyors review CNA documentation during annual surveys and complaint investigations; the record is also discoverable in civil litigation. The principle taught in Indiana CNA programs is blunt: if it isn't charted, it wasn't done. A care task that a CNA performed but did not document is, for legal and survey purposes, care that was not provided.

Medical Terminology and Abbreviations

Indiana CNA programs teach a working vocabulary of medical terms and abbreviations used in charting. The CNA must use only facility-approved abbreviations — non-standard or made-up shortcuts create ambiguous records and are a common survey citation.

Always verify against the facility's approved-abbreviation list. Some Indiana facilities have banned "U" and "IU" (mistaken as zero or the number four) and "QD, QOD" (confused with each other); use "daily" and "every other day" in those facilities.

Objective vs. Subjective: The Core Distinction

Objective documentation is what the CNA can measure, observe, or detect through the senses. It is repeatable — a second observer would record the same thing. Objective entries are the backbone of CNA charting.

Subjective documentation is what the resident says or what the CNA infers. Subjective data belong in the chart only when they are clearly attributed to the resident (in quotes) or clearly labeled as an observation of behavior — not as a diagnosis.

The trap is charting a diagnosis or opinion as if it were a fact. A CNA cannot chart "resident had a stroke" or "resident is depressed." A CNA charts the observations that would lead the nurse to consider those diagnoses: "right-sided facial droop, slurred speech, weakness in right arm; reported to charge nurse at 09:10" or "resident tearful, declined breakfast, stayed in bed all morning; reported to LPN."

The Rule: Chart What You See, Hear, Touch, Smell — Not What You Think

Indiana CNA training repeats this rule because it is the single most-tested documentation principle. The four senses named — see, hear, touch, smell — map to specific charting examples:

• See: skin color, rash, bruising, drainage, wound size, posture, facial expression, fall to the floor
• Hear: cough, wheeze, cry, groan, slurred speech, resident's stated complaint (quoted)
• Touch: skin temperature (warm, cool, clammy), pulse, firmness of abdomen, strength of grip
• Smell: foul odor from a wound, fruity breath, foul urine, fecal odor

"Not what you think" excludes the CNA's conclusions: "I think she had a stroke," "I think he's in kidney failure," "I think she's faking." Those are inferences outside CNA scope. The CNA reports observations; the nurse and physician determine the diagnosis.

Correcting Charting Errors

Errors in charting are common and correctable — but only by an approved method. The Indiana rule:

1. Draw a single line through the incorrect entry so the original writing is still readable
2. Write the correct entry next to or above the line
3. Initial the correction
4. Write the date and time of the correction
5. Continue charting

The original entry must never be erased, white-outed, scribbled over, or obliterated. The reason is legal: a readable original shows what was wrong and that it was corrected transparently; an obliterated entry looks like falsification. IDOH surveyors are trained to look for white-out, heavy scribbling, and torn-out pages; each is a documentation-deficiency citation.

Example of a corrected entry:

BP 124/78 left arm — single line — Initials JK — 07/12/26 14:30 — corrected to: BP 124/78 RIGHT arm, resident seated — Initials JK — 07/12/26 14:30

Late Entries

A late entry is documentation written after the care was provided. Indiana allows late entries, but they must be labeled. The format:

Late entry for 07/11/26, 09:30 — "Resident ambulated 50 ft with rolling walker, no complaints of pain; steady gait. — JK, CNA, written 07/12/26 06:15."

This tells the reader exactly when the care happened and when the note was written. A late entry without this label looks like care that was not documented in real time — and Indiana surveyors treat undocumented care as care not provided.

Never backdate a late entry. Writing today's care with yesterday's date is falsification of the medical record, a registry-sanctionable act under INAR rules, and potentially a criminal matter.

Legal Responsibility of Accurate Charting

The medical record is a legal document. A CNA's chart entries:

• Can be subpoenaed in civil litigation (personal injury, malpractice, estate)
• Are reviewed by IDOH during annual surveys and complaint investigations
• Are reviewed by the facility's Quality Assurance committee
• Form the basis for the resident's care plan updates

A CNA who charts care that was not provided ("dry bedding" when the bed was wet, "refused lunch" when the resident ate) is committing falsification, which is grounds for a substantiated INAR finding and termination. A CNA who charts care another aide provided (or vice versa) is also falsifying the record — chart only the care you personally provided or directly observed.

Indiana facilities use electronic health records (EHR) in most settings; each chart entry is time-stamped and user-attributed. Sharing login credentials to chart another aide's care is falsification and a security violation; do not share logins, and log out after each entry.

Common Charting Traps

• Charting an opinion as fact: "resident seems depressed" — chart the behavior instead
• Charting ahead of time: documenting a turning schedule at the start of shift before turns are done — chart after the care is provided
• Using unapproved abbreviations: "QD" or "U" if the facility has banned them
• Copying forward: pasting yesterday's note without verifying today's findings
• Charting for someone else: signing another aide's initials or logging in as another user
• Failing to report a change verbally first: acute changes must be reported to the nurse by voice or in person before they are charted — charting alone is not a substitute for reporting