6.1 Communication, Observation, Documentation & Reporting

Communication: The SRNA's Most-Used Skill

Communication is the foundation of every task a State Registered Nurse Aide (SRNA) performs. Because SRNAs spend more direct time with residents than any other member of the care team, they are usually the first to notice a change and the person a resident trusts with a worry. On the KCTCS written exam, the Communication area is about 6 of the 75 questions, and it threads through the Client Rights, Role, and Care-of-Impaired domains as well.

Verbal, Nonverbal & Therapeutic Communication

Verbal communication is the spoken or written message. Nonverbal communication — facial expression, posture, gestures, eye contact, tone, and touch — often carries more meaning than the words, and it is what a confused or aphasic resident reads most reliably. Face the resident at eye level, keep an open and unhurried posture, and let your tone match a calm message.

Therapeutic communication is a set of techniques that build trust and invite the resident to share:

• Use open-ended questions ('How are you feeling this morning?') instead of yes/no questions that shut conversation down.
• Practice active listening — nod, restate ('You're saying the pain is worse when you move'), and allow silence so the resident can gather their thoughts.
• Show empathy, not false reassurance. 'It's normal to feel anxious before surgery' validates the feeling; 'Don't worry, everything will be fine' dismisses it and may not be true.
• Avoid arguing, changing the subject, giving your personal opinion, or offering medical advice that belongs to the nurse or provider.

Communicating With Impaired Residents

Sensory and language impairments are common in long-term care. Adapt your approach to the deficit rather than talking louder to everyone.

Objective vs Subjective Observation

Every shift the SRNA collects data for the nurse. Knowing the difference is heavily tested.

• Objective data (signs) are what you can observe or measure: a temperature of 101.4 F, a reddened sacrum, 50 percent of a meal eaten, a swollen ankle, cloudy urine.
• Subjective data (symptoms) are what the resident tells you and you cannot measure directly: 'My stomach hurts,' 'I feel dizzy,' 'I'm nauseated.' Chart these in the resident's own words in quotation marks whenever possible.

SRNAs observe and report; they never diagnose. Noticing white patches in the mouth is your job; deciding it is thrush and treating it is not.

Documentation & Charting

Documentation makes care official and defensible. In Kentucky facilities (paper or electronic health record) the rules are the same:

• Record facts only, not opinions or labels ('resident is difficult'). Write what you saw, measured, and did.
• Chart promptly after care, never in advance. If it is not documented, it is treated as not done.
• Be legible and specific with time and date. Never chart for another aide.
• Correct an error by drawing a single line through it, writing 'error,' and adding your initials and the date, then entering the correct information. Never erase, use white-out, or write over an entry — that looks like falsification and is a serious violation.
• Protect confidentiality: records are shared only with the care team on a need-to-know basis.

Reporting to the Nurse — SBAR & Red Flags

Routine information goes in the chart and end-of-shift handoff; a change of condition goes to the nurse right away using SBAR:

• Situation — what is happening now
• Background — relevant history
• Assessment — what you think is going on
• Recommendation — what you are requesting

Example: 'I'm calling about Mrs. Smith (S). She has COPD and was stable this morning (B). Her respirations are now 28 and labored (A). I think she needs to be assessed (R).'

Report immediately — do not wait for handoff — for: chest pain, shortness of breath, a fall, any change in mental status or new confusion, abnormal vital signs, new or worsening skin breakdown, bleeding, choking, or a resident who refuses ordered care.

Medical Terminology & Abbreviations

You do not need to be fluent, but you must read a care plan and diet card. Common terms: a.c. (before meals), p.c. (after meals), NPO (nothing by mouth), PRN (as needed), BID/TID (twice/three times daily), ADL (activities of daily living), ROM (range of motion), I&O (intake and output), c/o (complains of), amb (ambulate), and q2h (every 2 hours). When an abbreviation is unclear or on a facility do-not-use list, ask the nurse rather than guess.

Common Exam Traps

Two communication traps appear often on the KCTCS exam. First, count respirations discreetly — do not announce that you are counting, because residents who know they are being watched change their breathing pattern, which makes your data inaccurate; keep your fingers on the wrist as if still taking the pulse. Second, chart facts, not conclusions. Writing 'resident is combative' or 'resident is confused' is an opinion; instead record the observable behavior — 'resident pushed away the wash basin and said, No, leave me alone.' Objective, behavior-based charting is defensible in a CHFS survey and gives the nurse usable data, while labels invite bias and reveal nothing measurable.