Unit 14
Observing, Reporting, and Documenting
If it wasn’t documented it wasn’t done!
The CNA is the staff member that spends the most amount of time with the residents. They usually have the strongest bonds and are the ones who notice subtle changes that the nurse, housekeepers, or dieticians might never realize are new. This is what makes the documentation and reporting by the CNA so incredibly important. Every member of the care team depends on the documentation by the CNA, and it has a strong impact on the care the resident receives. The doctor reviews the CNA documentation on moods, behaviors, and vital signs to determine which and how much medication to order. The MDS coordinator uses the CNA documentation to fill out the MDS which determines reimbursement to the facility for the resident’s care. The care plan is developed around how much care the CNA reports and documents. So it is vital that the CNA follows guidelines for good documentation and reports things accurately.
Observations
We make observations throughout the day without even thinking about it. We use all of our senses to observe our environment and to observe changes in our residents. For example, we use touch to feel the resident’s skin for a fever; eyes to see how the resident is limping; ears to hear them say they don’t feel well; and smell to notice that the resident’s urine may be infected.
Reporting
It is important the CNA reports any changes or anything “out of the norm” to the nurse as soon as possible. It could something as simple as noticing Ethel is walking slower today that might lead to the discovery that she has pneumonia. If you notice that Alfred needs extensive assistance after dinner but the care plan only states limited assistance, you should report this so that the care plan can be changed to reflect the resident’s level of care more accurately.
In addition, at the beginning of each shift, the off going CNA’s must give report to the on-coming CNA’s to promote consistency in care. Failure to report off to the oncoming shift can lead to errors that can harm a resident and therefore is considered abandonment. Abandonment is a form of abuse and can lead to losing your certification. So never leave your shift without reporting off!
Documenting
Depending on where you work, expectations of the CNA’s documentation will vary greatly. Some will use computers while others still use paper and pen. Some will expect the CNA to document every detail of their day in essay-style progress notes while others need simple check marks in neat boxes. No matter where you work, however, there will most likely be some form of documentation required and it is important that the documentation follows professional guidelines.
Things you may document on each shift:
Care Plan flowsheets
Restorative plans
I&O
VS
Progress notes
Incident reports
Behavioral flowsheets
And many more
The resident’s chart is a legal document and can therefore be used in court. Your signature makes you libel for what you have written and you can be held responsible for it. If it is found to be inaccurate or fabricated this can be considered “false documentation” which can be criminally prosecuted. In addition, your documentation can be used in civil and criminal prosecution of your facility. So it is important to take your documentation seriously, consider your signature as sacred, and know how to document in a professional manner so as not to be purposely misconstrued in court.
Be objective not subjective
When reporting to the nurse or when documenting it is important to be factual, and while you are writing in your own words, it should not include opinions or assumptions. Objective statements are impartial, nonpartisan, and based on facts. Subjective statements are based on one's own opinions and emotions. You could say, “Edith appears to be shivering and is holding a blanket around her tightly” rather than “Edith is cold”. There is no way for you to know for sure that she is cold, you only observe the signs that she is cold. If Edith said she was cold, you document “the patient says she is cold”. But you still can’t say that “Edith is cold”. Here are some other examples of objective vs. subjective:
Subjective: The resident is happy.
Objective: The resident is smiling.
Subjective: The resident fell because the alarm scared them.
Objective: The alarm sounded which appeared to startle the resident and they jumped up from their chair very quickly then fell on the floor.
Subjective: The resident hates green beans.
Objective: The resident grimaced and spit out the green beans.
Subjective: The resident likes jazz music.
Objective: The resident said he likes jazz music.
Charting guidelines
Keep notes on a scrap paper in your pocket so you don’t forget something
For confidentiality, use initials and room numbers instead of names, and shred it before leaving for the day
Chart on your observations as soon as possible so it is fresh in your mind
Start each entry with the date and time the event occured (not the time you documented)
Entries should be written in chronological order
Use appropriate terminology and abbreviations per policy (see appendix B in your textbook)
Use proper spelling, grammar and punctuation
Sign each entry with your name and position (i.e. -J.Doe, CNA)
When charting on paper:
Use black ink
Ensure the resident’s name is on the front and back of each page
Correct errors by drawing a single line through the error and initialing the correction
Use good penmanship, making it easy to read
Draw a single line through empty space (such as at the end) so no one can add to the documentation
State Witness Form
COMPLAINT INVESTIGATION WITNESS STATEMENT OF FACTS
BEFORE THE KANSAS DEPARTMENT FOR AGING AND DISABILITY SERVICES
THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC
State of Kansas, County of _____________________________ Case # ________________
In the Matter of: _______________________________________
(Alleged Perpetrator’s Name)
WITNESS INFORMATION
I was employed as __________________________________ at_____________________________________
(Job title) (Name of Facility)
in _____________________________, Kansas. On or about ________________ in the year 200__, I was
investigated/witnessed the following incident (describe below) involving__________________________
__________________________________________________________________________
(Resident(s) Involved)
EVENT: In your own words, describe what happened: 1) as accurately as possible; 2) telling when it happened, how it happened and what happened; 3) describing any injury or harm done to the resident/s; and 4) listing the names and titles of other witnesses (if any).
I, _______________________________of lawful age, being first duly sworn upon my oath, hereby state as follows: I have read the above and foregoing statements (or have had the same read to me); have personal knowledge as to the contents thereof; and that the statements made herein are true and correct.
(Signature of Witness, Title) (Address)
______________________________________ (Phone Number)
SUBSCRIBED AND SWORN TO before me, the undersigned authority, of this _____ day of
___________________, 20**
(My appointment expires) (Notary Public)