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Guidelines for Accurate Documentation
Guidelines for Accurate Documentation
To ensure documentation is legally sound and clinically useful, you must follow these rules:
Confidentiality: Charts are strictly confidential and should only be shared with staff directly involved in the resident's care. Always log out of computers and ensure screens are not visible to others.
Fact vs. Opinion: Always use objective facts rather than subjective opinions. For example, instead of writing "the resident is grumpy," document a factual observation like, "The resident refused their meal and stated they were not hungry".
Timing: Document care immediately after it is completed to ensure accuracy.
Measuring Tools: Use tools like graduated cylinders or scales whenever possible to provide precise data. If you must estimate, use a comparison, such as "drainage the size of a quarter".
Correcting Errors: If charting on paper, use black pen. To fix a mistake, draw a single line through the entry, write "mistaken entry," and add your initials. Never use correction fluid or blackout an entry
CNA__Docs_&_Reporting.mp4The Role of the Minimum Data Set (MDS)
In long-term care, documentation is used to complete the Minimum Data Set (MDS), a standardized assessment tool used for Medicare and Medicaid reimbursement. RNs rely on a nursing assistant’s accurate documentation regarding a resident's:
Sensory abilities (hearing, vision, and communication).
ADL assistance levels (how much help is needed for eating, dressing, or toileting).
Skin observations made during care
Guidelines for Effective Reporting
When giving an oral report, you must maintain confidentiality by speaking in private areas, such as a closed room or a nurse's station away from common areas. You must immediately notify a nurse of the following:
Physical changes: Patient reporting difficulty breathing, chest pain, or reddened/warm skin.
Strong odors: Unusual smells from urine, wounds, or the mouth.
Unusual behavior: Any conduct that is out of the ordinary for that specific resident
TYPES OF INFORMATION: Objective vs. Subjective
Objective
Objective
Data collected through your four senses (sight, touch, hearing, smell) that can be verified by others using measuring tools, such as a temperature of 98.6°F
Subjective
Subjective
This is information reported by the client or family. It should be documented using the exact wording provided, enclosed in quotation marks (e.g., Resident stated, “I have a headache”)
Objective_vs.mp4Using Military Time
Facilities use military time to avoid confusion between morning and evening hours.
AM Hours: Add a zero in front of the hour (e.g., 9:24 a.m. is 0924).
PM Hours: Add 12 to the hour (e.g., 1:46 p.m. is 1346).
Midnight: Documented as 2400 or 0000.
Pronunciation: Morning hours start with "zero" or "O" (e.g., 7:00 a.m. is "zero seven hundred")
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A score of 80% or higher is recommended before moving on to the next section!
For more info, read Chapter 1.
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