3.1 Role Scope and Reporting
Key Takeaways
- Maryland CNA practice is delegated, supervised work: the certified nursing assistant (CNA) collects routine data, provides assigned care, reports changes, and does not assess, diagnose, or revise the care plan independently.
- The National Nurse Aide Assessment Program (NNAAP) Role of the Nurse Aide domain is 26% of the 70-item written exam, covering communication (7%), client rights, legal and ethical behavior, and membership on the health care team.
- Code of Maryland Regulations (COMAR) 10.39.05 requires CNAs to report changed condition or behavior to the nurse and to request help when unsure, in an unfamiliar situation, or beyond their knowledge and experience.
- Documentation should be factual and timely: record what was observed, measured, said, and done, not opinions, blame, diagnoses, or unsupported conclusions.
- A CNA may suggest care-plan concerns based on observations, but the licensed nurse retains responsibility for assessment, clinical judgment, and any change to the plan.
Scope Is A Safety Boundary
The Maryland CNA role is built around delegation. The Maryland Board of Nursing (MBON) defines CNA work as routine nursing tasks delegated by a registered nurse (RN) or licensed practical nurse (LPN), and COMAR 10.39.05 states the CNA works under delegated authority, assists the nurse with data collection, and remains under nurse supervision. That single rule explains why so many exam items that look like vital signs, behavior, skin, intake, or family communication are actually scope questions in disguise.
On the NNAAP written exam, the Role of the Nurse Aide domain is 26% of the 70 multiple-choice items (10 of which are unscored pretest items). It bundles communication (7%), client rights, legal and ethical behavior, and membership on the health care team. The Maryland angle is not to memorize a slogan; it is to pick the action that protects the resident without pretending to be the nurse.
CNA Action Map
| Situation | CNA action | Nurse-owned decision |
|---|---|---|
| Routine assigned care | Follow the care plan and facility policy | Decide whether the plan should change |
| Vital signs or output | Measure, record, and report abnormal or changed findings | Assess clinical meaning and treatment response |
| Resident statement | Listen, quote or summarize accurately, report concerns | Evaluate symptoms and notify provider if needed |
| New skin breakdown, pain, confusion, fall, or bleeding | Keep resident safe and notify the nurse promptly | Assess, document clinical findings, update interventions |
| Family asks for medical details | Protect privacy and refer to the nurse | Decide what may be disclosed and to whom |
| Task feels unsafe or unfamiliar | Stop, explain respectfully, ask for direction | Reassign, teach, supervise, or revise delegation |
Report Before You Interpret
A CNA reports facts in plain, useful language. "The resident says, 'My chest feels tight,' and is breathing faster than usual" beats "I think the resident is having a heart attack." The first gives the nurse objective and subjective data; the second crosses into diagnosis and may hide details that matter.
For urgent events, use a simple SBAR (Situation, Background, Assessment, Recommendation) mental script:
- Situation: what is happening right now ("Mr. Lee is short of breath").
- Background: the relevant care-plan item, recent change, or baseline ("he walked to lunch fine an hour ago").
- Assessment data: what you observed, measured, or heard ("pulse felt fast, lips look pale, he says his chest is tight").
- Recommendation/Request: the help you need, usually nurse evaluation now.
For nonurgent matters the same logic applies. Report repeated meal refusal, new sadness, family concerns, missing glasses, loose dentures, pain during range of motion, new drainage, unsafe equipment, or a resident's request to change part of the care plan. COMAR specifically allows the CNA to give feedback and make suggestions based on observations and resident statements. That is advocacy, not independent care planning.
Documentation Rules That Win Exam Questions
Chart after care is performed and according to facility policy. Use exact numbers for measurements, the actual time when required, and neutral wording. Write "urine dark amber with strong odor" rather than "resident has a urinary tract infection." Write "resident refused shower and stated, 'I am too tired'" rather than "resident was difficult." If care was not completed, document the reason and report it.
Never chart care before doing it, chart for another person, erase or alter records improperly, or include gossip. A correctly worded entry is objective (measured or directly observed), timely, specific, and signed. The exam loves to offer one chart entry that adds a diagnosis or an insult and call it wrong.
Confidentiality is also scope. Share resident information only with staff who need it for care and only in appropriate settings. Hallway conversations, social-media posts, casual family disclosures, and unsecured records can violate privacy even when the facts are true.
What CNAs May And May Not Do
A recurring exam pattern asks you to sort tasks into "within scope" versus "requires the nurse." Memorize these clusters. Within CNA scope: bathing, grooming, oral care, feeding (not tube feeding), toileting, repositioning, transfers, ambulation, measuring and recording vital signs, intake and output, weights, applying ordered elastic stockings, simple range of motion, making beds, and reporting observations.
Outside CNA scope: assessing a wound or a fall, deciding whether a symptom is serious, administering medications (in most Maryland settings without a separate medication-aide credential), inserting or removing tubes, sterile dressing changes, accepting a verbal medication order, and changing the care plan.
The exam often hides a scope violation inside a kind-sounding action. "The CNA gives the resident an extra blanket" is fine; "the CNA gives the resident an extra dose because they seem in pain" is not. "The CNA writes down a blood pressure of 168/96" is fine; "the CNA tells the resident their blood pressure means they have hypertension" crosses into interpretation. Train yourself to spot the verb: report, record, observe, assist, follow are CNA verbs; assess, diagnose, prescribe, evaluate, decide, revise are nurse verbs.
Final Scope Check
Before choosing an answer, ask three questions. Is the task in the care plan or delegated by the nurse? Is the resident stable enough for the assigned task? Do I know how to perform it safely? If any answer is no, the CNA should pause and seek nurse direction. Refusing an unsafe or untrained assignment is not insubordination; performing it anyway is the real violation. The exam consistently rewards the aide who is observant, honest, timely, and safe over the one who acts fast and alone, so when two options both seem reasonable, choose the one that keeps the licensed nurse in the loop.
A Maryland CNA is helping a resident dress when the resident says, "My chest feels tight," and appears short of breath. Which response best fits CNA scope?
A CNA is assigned to perform a care task they have never been trained to do. What should the CNA do first?