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A medical chart is simply a complete record of a patient's clinical data and medical history. Patient charting keeps patient information on file, including demographics, vital signs, diagnoses, medications, allergies, lab/test results, treatment plans, immunization dates, progress notes and more.
The four kinds of documentation are: learning-oriented tutorials. goal-oriented how-to guides. understanding-oriented discussions. information-oriented reference material.
A CNA's daily responsibilities will be to deliver direct care to patients (bathing, toileting, feeding, grooming, etc.) as directed by the RN or LPN in charge. Their role will be to maintain patient comfort and safety.
What is Good Documentation Practices? Legal documents \u2013 business records, audit statements, and company policies. Customer information \u2013 contact numbers, email addresses, and transaction history. Procedural documents \u2013 standard operating procedures (SOPs), work instructions, and training documents.
A certified nursing assistant, also known as a nurse assistant or CNA, provides health care for clients and patients at home, hospitals, and other facilities under the direction of a nurse. They often help people under their care perform day-to-day tasks and play a vital role in hospitals and other facilities.
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To create a timely and accurate account of all care given to a client, as well as the client's response to the care.
The main role of a certified nursing assistant (CNA) is to provide basic care to patients and help them with daily activities they might have trouble doing on their own, such as bathing and getting dressed.
Charting in nursing provides a documented medical record of services provided during a patient's care, including procedures performed, medications administered, diagnostic test results and interactions between the patient and healthcare professionals.
CNA TRAINING: 5 Rules of Documentation If There Are No Records, It Didn't Happen. Without proper documentation, it's impossible to keep the whole medical up to speed with what's happening with a patient. ... Write Down Your Notes Legibly. ... Follow A System. ... Never Change Your Entries. ... Be Accurate, Yet Concise.
But honing your charting skills can make all the difference in your patient's care and the quality of your work....It's a living record of what's going on with a patient and can include things like: Procedures performed. Medications administered. Diagnostic tests performed. Test results.

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