Documentation and Reporting

Accurate documentation and timely reporting are essential CNA responsibilities. Documentation creates a legal record, communicates patient information, and supports quality care.

Why Documentation Matters

Legal Protection:

• Creates a permanent legal record
• Proves care was provided
• Protects you and the facility in lawsuits
• "If it wasn't documented, it wasn't done"

Communication:

• Communicates patient status to other caregivers
• Ensures continuity of care across shifts
• Provides information for care planning
• Documents patient responses to treatment

Quality Care:

• Tracks patient progress
• Identifies changes in condition
• Supports decision-making
• Meets regulatory requirements

Documentation Principles

The FACT System:

What to Document

Documentation Guidelines

Do:

• Write legibly (or type accurately)
• Use black ink only (for paper records)
• Include date, time, and your initials/signature
• Be specific (not "good appetite" but "ate 75% of lunch")
• Use approved abbreviations only
• Sign off appropriately
• Document immediately or as soon as possible

Don't:

• Use correction fluid (white-out)
• Erase or scribble over errors
• Leave blank spaces
• Chart in advance (before care is given)
• Chart for someone else
• Use vague terms ("good," "normal," "adequate")
• Include personal opinions or judgments

Correcting Documentation Errors

Paper Records:

1. Draw single line through error
2. Write "error" above it
3. Initial and date the correction
4. Write correct information nearby

Electronic Records:

• Follow facility policy for corrections
• Use addendum feature
• Never delete original entry
• Document reason for correction

Reporting

Reporting is verbal communication of patient information to the nurse or supervisor.

When to Report:

What to Report to the Nurse

Use SBAR for organized reporting:

Shift Report (Change of Shift)

At shift change, outgoing CNAs report to incoming CNAs:

• Patient's condition
• Care provided
• Any changes during shift
• Special instructions or needs
• Upcoming appointments or tests
• Family visits or concerns

Common Documentation Abbreviations

Important: Only use facility-approved abbreviations. Some abbreviations are on the "Do Not Use" list.