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CNA responsibilities include: Recording vital signs, including blood pressure and pulse rate, as requested by staff. Reminding patients to take medications and other nutritional supplements as needed. Checking patient vital signs each day and keep precise records in the patients chart.
What is the golden rule of nursing documentation?
By carefully and faithfully charting everything you do, you insulate yourself from any accusations of fault. Be aware of the golden rule, if its not documented, its considered not done. Certain times and circumstances are especially crucial when it comes to thorough, timely documentation.
What should you remember when you are documenting CNA?
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.
What are CNAs not allowed to do?
They are typically not allowed to perform sterile wound care, assess wounds, or administer medications, including topical treatments that require a nurses judgment. These tasks require the advanced training and clinical judgment of RNs or LPNs.
How do I document CNA notes?
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.
Nursing assistants collect and document client data such as vital signs, height, weight, intake, and output. While performing cares and collecting data, nursing assistants spend a lot of time with residents and may observe subtle changes in behavior, mood, mobility, and cognition, as well as signs of discomfort.
What is a flow sheet in CNA?
The CNA/STNA Functional Abilities Flow Sheet is used to record personal care provided as well as the amount of assistance needed to perform those tasks: Eating. Oral Hygiene.
What should a CNA chart?
CNAs are usually responsible for charting bathing, grooming, eating, elimination, and mobility.
cna flow sheet template
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