A patient's chart or record is a compilation of information about their healthcare journey. Healthcare workers, including nursing assistants, write down what they did for the patient, their observations and findings, as well as the patient's responses, to create a comprehensive account of a patient's health condition.
So, if you're going to ask, "Is documentation that of a big deal?" then the answer to that is a resounding YES!
Documentation is a type of communication tool that the healthcare team uses to plan for patient care. Without it, it's hard to organize care procedures, and errors are likely to happen. Some tasks might also be redundant or omitted, and the staff may fail to provide care at the right time. What disaster that would be for the patient!
Everything that happens to the patient must be tracked accurately and in real-time, and this is the reason why documentation is one of the most critical responsibilities of the healthcare team, CNAs included.
Here's a fun trivia for you:
Did you know that there are other uses of documentation other than for patient care?
See which of these below are familiar to you:
1. Credentialing, regulation, and legislation.
Facilities need to reach certain standards for the quality of services they provide. The management uses patient records to check and improve patient care as mandated by the law and regulatory boards.
Compliance is crucial, and one of the things credentialing bodies look at is how healthcare teams perform documentation.
Of all the other uses of documentation, perhaps it's the legal purposes that should concern you the most. Should a patient file a legal suit that involves you and the team, any entry that is inaccurate, incomplete, or illegible can get you in trouble with the law and cost you your license. Even the facility is at risk of facing legal sanctions for faulty documentation.
Facilities use patient documentation to apply for reimbursements of health care services that they provided.
4. Research Data.
Patient records are a rich source of materials that researchers use for their evidence-based studies.
1. What do nursing assistants usually document?
CNAs record their observations of the patient's level of alertness, appetite, amount of food intake, and skin condition.
They also describe any significant complaints of the patient and write them down word for word. CNAs plot vital signs, height and weight measurements, intake and output, and the number of bowel movements.
And, of course, nursing assistants also record what care procedures and preventive measures they did for the patient.
2. What are the characteristics of proper documentation?
All entries in the paper chart or electronic records must be accurate, relevant, and complete. The information entered must be clear, concise, and easily readable. Prompt documentation is also important.
The golden rules.
Golden rules are primarily created for safe patient care. Workers need to know what these rules are and follow them strictly and without fail. Let's review some of the golden rules of documentation.
1. Ensure that you are using the correct chart or electronic record.
Before charting, double-check if the record belongs to the right patient.
2. If you did not document, it did not happen.
Sorry, there is no excuse for breaking this rule. Remember that other members of the healthcare team rely on only one record, and if a procedure's not written, it only means you did not do it.
Did the patient develop pressure sores while on your shift? Even if you repositioned the patient but forgot to document it, then you may be held liable for 'not' doing it.
3. Date, time, and sign every entry.
This step will not be a problem for electronic entries because the program automatically does this for you when you log in. But this is required for paper charts.
4. Write legibly.
Your handwriting must be readable, or else whatever you wrote would be of no use to the healthcare team. Poor handwriting could also lead to medical errors.
5. Record notes immediately.
In real life, this may seem difficult because you usually cluster activities and put off documentation for later to save time. The problem with procrastination is that you tend to forget details of the care that you did early in your shift.
As a workaround, keep a small notebook with you to write down particulars immediately after obtaining them. Allocate time for recording at least twice in your shift.
6. Never enter details ahead of time.
You can anticipate what you'll do for the day, but you cannot enter information about any procedures that you haven't done yet, even if you are sure to do them later.
7. Use only facility-approved abbreviations.
If you can help it, do not abbreviate at all.
8. Never alter entries, not yours or anyone else's.
You should not erase any information that you enter in paper records. Always follow agency policies for correction of entries.
9. Be objective with your descriptions.
Do not include your opinion. For example, write, "The patient refused her bath twice." instead of "The patient was acting very immature and refused her bath many times."
With measurements, you need to be precise, too. Write, "The patient ate ¼ of the food on their tray." instead of "The patient ate only a small portion of their food."
Do not include your own 'diagnosis.' Even if you think the patient's wound is infected, never write, "The patient's wound is infected." because determining infection is beyond your scope of practice as a nursing assistant. Describe the wound in detail instead.
10. Enter patient responses verbatim.
Noteworthy statements from the patient must be documented word for word. For example, if the patient says, "I don't feel like living anymore." write it as is. Do not interpret for the team and say, "The patient is depressed and feeling suicidal."
11. Do not let anyone enter notes for you and vice versa.
Any information that you record is yours alone and no one should write for you even if you affix your signature in the end. It is highly unethical and illegal. In the same way, you cannot also document on another person's behalf.
Documentation is every CNA's responsibility, and you must perform this duty properly to the last detail. Whatever you record reflects your contribution to patient care, so make your every effort worthwhile.
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