2.3 Documentation and Reporting

2.3 Documentation and Reporting

Quick Answer: Good CNA documentation is objective, factual, timely, and signed. Errors are corrected with a single line, "error," and your initials - never erased. Vital signs, ADLs, and intake/output are charted every shift. Falls, injuries, errors, and unexpected events require an incident report. Acute changes are reported verbally to the nurse first, then charted.

Why This Matters

In long-term care, the chart is the legal record of what was done. If care was not documented, the legal assumption is that it did not happen. The exam tests whether the CNA can document in a way that protects the resident, the facility, and the CNA's own certificate.

Core Documentation Principles

Use this checklist when charting any entry, paper or electronic.

Objective vs. Subjective Information

• Objective = what you see, hear, smell, count, or measure. Examples: vital signs, intake/output, skin color, what the resident said in quotation marks.
• Subjective = what the resident tells you about their own experience. Examples: pain level, nausea, anxiety. Subjective data is always charted in the resident's own words in quotation marks: Resident states, "My stomach hurts here," pointing to the right lower abdomen.

A CNA never charts opinions or diagnoses. "Resident appears depressed" is an opinion. "Resident sat alone in room, declined activities, stated, 'I do not feel like talking today,'" is documentation.

Correcting Errors on Paper Charts

When the exam asks how to fix a wrong entry on a paper chart, the only correct method is:

1. Draw one single line through the incorrect entry so it is still readable.
2. Write the word "error" above or next to it.
3. Write your initials and the date.
4. Enter the correct information immediately after.

Wrong methods - the exam will offer these as wrong answers:

• Using white-out, correction tape, or correction fluid
• Scribbling out so the original cannot be read
• Erasing (paper charts are never in pencil)
• Tearing out the page or starting a new one
• Backdating or squeezing in an entry between existing lines

For electronic health records (EHR), use the system's built-in addendum or late entry function. Never share your password or chart under someone else's login.

EHR vs. Paper Charts

24-Hour (Military) Time

Most NC long-term care facilities chart in 24-hour time. The exam expects you to convert quickly.

Rule: from 1:00 PM onward, add 12. Always use four digits; no colon.

What a CNA Documents Every Shift

• Vital signs (T, P, R, BP, pulse ox if ordered), with site and method noted
• Weight on scheduled days (same scale, same time, similar clothing)
• Intake and output in milliliters when ordered
• Percent of meal eaten (0, 25, 50, 75, 100%)
• ADL care completed (bath type, oral care, perineal care, bed change)
• Bowel and bladder activity
• Activity/ambulation (distance, assist level, device used)
• Restorative or range-of-motion exercises
• Resident's response to care, including refusals

Incident Reports

An incident report (sometimes called a variance or occurrence report) is a separate internal form completed any time something unexpected happens. It is not part of the resident's medical chart and is not referenced in the chart.

Complete an incident report for:

• Any fall, even if the resident is uninjured (a resident found on the floor counts as a fall).
• A medication error (e.g., a resident received a med belonging to another resident).
• An injury of unknown origin (a new bruise, skin tear, or burn).
• An error in care or a near miss.
• Equipment failure that affects resident safety.
• A resident-on-resident or staff-on-resident altercation.
• Suspected abuse or neglect (in addition to mandatory external reporting).
• An elopement or unauthorized exit.

The incident report records what happened, when, who was present, and what was done, in objective language. Do not speculate on cause or blame, and do not chart "incident report filed" in the medical record.

What to Report to the Nurse IMMEDIATELY

These findings require a verbal report to the charge nurse the moment they are observed - before charting.

• Acute pain (new pain, chest pain, severe abdominal pain, sudden headache)
• Bleeding of any source (wound, mouth, rectum, urine, vomit)
• Vital signs out of the resident's normal range (e.g., BP > 160/100 or < 90/60, HR < 60 or > 100, T > 100.4 F, RR < 12 or > 24, pulse ox < 90%)
• Sudden change in mental status - new confusion, lethargy, agitation, slurred speech, one-sided weakness
• Shortness of breath, choking, or stridor
• Refusal of care, food, fluids, or medications
• Falls or any new injury
• Suspected abuse, neglect, or exploitation
• A skin tear, pressure injury, or wound noticed during care
• Signs of dehydration (dry mouth, dark urine, sunken eyes)
• Resident threats of self-harm or to harm another

Internal Links

• See Section 2.2 Effective Communication for SBAR structure when delivering the verbal report.
• See Section 2.5 Legal, Ethical, and Abuse Reporting for reporting suspected abuse beyond the facility chain.