Cna charting 2025

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  1. Click ‘Get Form’ to open the cna charting document in the editor.
  2. Begin by entering the patient’s name in the designated fields for LAST, M.I., and FIRST. This ensures accurate identification.
  3. Fill in the vendor name and your employee details, including your name and employee number, to maintain proper records.
  4. In the 'DAY' and 'DATE' sections, indicate the week of service by filling in each day from Monday to Sunday along with the corresponding dates.
  5. Record 'TIME IN' and 'TIME OUT' for each day, ensuring you specify AM or PM clearly for accurate time tracking.
  6. Complete the various care tasks by checking off activities under NUTRITION, ACTIVITY, VITALS, PROCEDURE, and HYGIENE/GROOMING as applicable.
  7. Add any comments related to patient care in the comments section, making sure to date each entry for reference.
  8. Finally, sign and date at the bottom of the form to validate your entries before saving or sharing it through our platform.

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Charting, in the context of a CNAs duties, involves the meticulous documentation of care provided to patients, including but not limited to vital signs, activities of daily living (ADLs), patient observations, and any changes in patient conditions.
Documentation is a legal record of patient care completed in a paper chart or electronic health record (EHR). It is also referred to as charting. Checklists and flowcharts completed in the residents room may also become part of the paper chart.
Documentation is a legal record of patient care completed in a paper chart or electronic health record (EHR). It is also referred to as charting.
Eleven Golden Rules of Documentation If you didnt write it down, it didnt happen. Date, time, and sign every entry. Chart care as soon as possible after you give it. Write legibly every time. Be systematic. Be accurate. You absolutely must be objective.
Youll begin with the patients level of consciousness and vital signs. Then youll chart your observations, care given, and activities. Youll be less likely to skip something if you always do your charting the same way.
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It is very important to avoid documenting ones opinions about patient care outcomes. Whatever is written down should be factual. Not only will being objective help with a patients care, it can protect the CNA, as well.
Vital signs include temperature recorded in Celsius or Fahrenheit, pulse, respiratory rate, blood pressure, and oxygen saturation using a pulse oximeter. Obtaining a pain rating is often considered a sixth vital sign.

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