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What are the five rules of documentation?

CNA TRAINING: 5 Rules of Documentation If There Are No Records, It Didnt Happen. Without proper documentation, its impossible to keep the whole medical up to speed with whats happening with a patient. Write Down Your Notes Legibly. Follow A System. Never Change Your Entries. Be Accurate, Yet Concise.

What do you document as a CNA?

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.

What is required for nursing documentation?

Documentation by nurses includes recording patient assessments, writing progress notes, and creating or addressing information included in nursing care plans. Nursing care plans are further discussed in the Planning section of the Nursing Process chapter.

Do you take vitals as a CNA?

As a CNA, you will assist the clinical team in both patient care and patient assessment. One of the most frequent and routine tasks is collecting and recording vital signs and measurements.

What is the difference between a CNA and a phlebotomist?

CNAs help patients with basic care such as bathing, grooming, and wound care while patients reside in nursing homes, assisted living facilities, or hospitals. Phlebotomists draw blood from patients for various reasons including tests, research, and donations.

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What is CNA full form?

A CNA or certified nursing assistant is an important position in any hospital setting.

What are the examples of documentation in nursing?

Common examples of documentation in clinical nursing include patient assessments, vital signs, weight, height, medication administration, intravenous and blood product therapy, nurses notes, physician/provider orders and notes, laboratory values, radiology reports, surgery reports, and therapy notes.

What should a CNA report include?

A CNA/Nurse Aide is legally obligated to immediately report to a licensed nurse any observation or incident for which the facility or organization might be liable. They can include injuries, such as needle sticks, falls, dropping residents, or any accidental injury to a visitor.

Can a CNA do blood pressure?

Checking vital signs: CNAs are able to monitor vital signs like heart rate and blood pressure.

Can CNAs document vital signs?

Certified nursing assistants are required to competently measure and record patient vital signs for all age groups, and to know how to report when patient vital signs are not within normal ranges. Abnormal vital signs obtained by a CNA should be immediately documented and reported to a Registered Nurse or supervisor.

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