As a certified nursing assistant, charting or documentation is one of your most important responsibilities. It’s how you communicate with other team members about the patient so that everyone can provide the best possible care. In this article, we’ll discuss what CNA charting is all about and what CNAs document to better understand the importance of proper CNA documentation.
What is CNA Charting?
CNAs spend more time with patients than any other healthcare professional. That’s why charting is crucial. A CNA charting sheet is a form that documents everything about the patient’s visit. It’s a useful tool that helps nursing aides track important information regarding their patients. Afterwards, this charting sheet is than reported to the supervising registered nurse (RN) or licensed practical nurse (LPN).
CNA charting and documentation play a crucial role in the nurse aide’s job and the patient’s care plan. Through this documentation, CNAs can record and keep track of the patient’s health and welfare for present and future applications.
CNA charting is usually done during the change of shift report so that the incoming nurse has all of the information they need about the patient.
What Do CNAs Document?
Charting is an important part of being a CNA, and it’s crucial to document everything accurately. By doing so, you’re ensuring that the patient receives the best possible care. There are many things that a CNA should document during their shift, but here are some of the most important items:
- Patient information, such as name and date of birth
- Measurements and vital signs
- Chief complaint
- Level of alertness and consciousness
- Past medical history
- Height and weight
- Medications
- Bowel elimination
- Allergies
- Appetite and food intake
- Diagnoses
- Skin Color, condition, integrity
- Patients’ response to medication, activities, and other forms of care
- Patient statements
- Notes and findings
Charting is a way to communicate with other team members about the patient. For example, if a patient isn’t eating, the CNA can document that on the chart and relay that information to the nurses. This will help them create a care plan that addresses the patient’s needs.
11 Important Tips for CNA Charting and Documentation
When it comes to CNA charting, there are eleven golden rules that you need to follow to ensure the accuracy and completeness of the documentation. They are as follows:
If You Didn’t Write It Down, It Didn’t Happen
This statement is especially important when it comes to charting. As a CNA, you are responsible for documenting everything that happens during your shift. If you didn’t see it, hear it, or do it, then don’t document it.
Chart Every Detail
When documenting, be sure to include every detail, no matter how small it may seem. This information could be important down the road, so it’s crucial to document everything.
Use Legible Handwriting
This one is pretty self-explanatory. If the nurses or other healthcare professionals can’t read your writing, your documentation is useless. So be sure to use legible handwriting and take your time when charting.
Be Systematic
When it comes to charting, always do it the same way every time. This will help make sure that all of the information is recorded consistently. In addition, you’ll less likely commit mistakes when you’re charting the same way. For example, you might consider using a head-to-toe method. That means you’ll start with the patient’s vital signs and level of consciousness. Then, chart your observation, activities, and care given.
Be Accurate With Your Charting
In every CNA charting, accuracy is always of utmost importance. Double-check your work, and if you’re unsure of something, ask a nurse or another healthcare professional. When including a statement from a patient, make sure to use quotation marks and record it word for word.
Be Objective
Objectivity is another important aspect that you need to practice when it comes to charting. Avoid recording your personal opinions and use precise language when documenting.
Charting is a Snapshot of the Patient’s Status
When charting, remember that you’re creating a snapshot of the patient’s current status. The information that you document today may be used to make decisions about the patient’s care in the future. So, be sure to chart everything accurately and completely.
Only Use Facility-Approved Abbreviations
Every medical facility has a list of approved abbreviations usually found in the policy manual. Make sure you are familiar with these abbreviations to make your charting as clear and understandable as you can. Also, keep in mind that your facility may also have a list of “forbidden” abbreviations. Make sure you take note of that as well and avoid using them in your documentation.
Never Change What You’ve Charted
Once an entry is made, it has already become permanent. Health records are legal documents, so you should never alter or change what you’ve already charted. If there is an error, follow the instructions for corrections outlined in your policy. Most facilities will accept a single line correction given that you correct a mistake and label it with the time, date, and your initials. NEVER erase any mistake using correction fluid or blacking it out with your pen ink.
Chart in Real-Time
Whenever possible, try to chart as things happen. This will help ensure the accuracy, integrity, and completeness of the documentation. It can be difficult to remember everything that happened at the end of your shift, so charting in real-time can help prevent any inaccuracies.
Avoid Charting For Someone Else and Vice Versa
It’s important to avoid charting for someone else and have someone else charting on your behalf. This can lead to confusion and inaccurate information. Instead, ask the nurse or another healthcare professional if you’re unsure about something.
Charting is an important part of a CNA’s job description. By following these tips, you’ll be able to produce accurate and clear documentation for your patients.
How DataMyte Digital Clipboard Can Help
The DataMyte Digital Clipboard is an amazing software that you can use to conduct CNA charting and documentation. We offer a variety of tools and features to help improve your charting process. With our digital clipboard, you can easily create and manage patient charts and track care plans and other important tasks.
Specifically, the DataMyte Digital Clipboard lets you do the following:
- Create actionable workflows that help you track patient care.
- Easily manage and share patient information with other team members.
- Integrate with EHRs to get real-time updates on patient care.
- Create checklists that help you track patient care and tasks.
- Create your very own CNA charting mobile app to make charting fast and convenient.
- And more!
To learn more about our digital clipboard and its many features, visit our website today. We would love to help you make your charting process easier and more efficient!
Conclusion
As a nurse aide, you should never take CNA charting and documentation lightly. The information that you document can directly impact the patient’s care and treatment. By following the tips and advice that we mentioned in this article, you’ll be able to produce accurate and clear documentation for your patients. And with the help of the DataMyte Digital Clipboard, you’ll be able to make charting easier than ever. Good luck!
