Documentation and Charting

When & Why?

Documentation creates an accurate record of resident care, observations, and changes in condition.

Clinical records support:

• Communication between healthcare workers.
• Continuity of care.
• Monitoring resident progress.
• Accountability and legal requirements.

Documentation must be accurate, complete, confidential, and organized.

Before You Start

• Confirm the correct resident and chart.
• Review the care provided and observations made.
• Check that measurements and times are accurate.
• Use authorized paper or electronic documentation systems.
• Follow facility charting procedures.
• Protect resident confidentiality.

Steps

Routine Documentation

1. Confirm the correct resident record.
2. Document the care actually provided.
3. Record the date and time accurately.
4. Use factual, specific, and objective language.
5. Include relevant measurements with units.
6. Record resident statements accurately, using quotation marks when helpful.
7. Include the resident’s response or relevant changes.
8. Record care refusals and incomplete care accurately.
9. Authenticate the entry according to facility procedure.
10. Report significant findings to the nurse without waiting for documentation.

Timing: Chart promptly after care or observations, following facility procedure. Avoid relying on memory at the end of a long shift.

Commonly Charted Information

Category	Examples
Nutrition	Percentage of meals eaten, fluid intake
Elimination	Bowel movements, urine measurements
Mobility	Ambulation distance, transfers, assistance level
Restorative care	Range-of-motion exercises, assigned activities
ADLs	Bathing, dressing, toileting, hygiene
Behavior	Specific observed actions and resident statements
Refusals	Care offered, resident response, nurse notification
Changes	New symptoms, measurements, or unusual observations

Good vs. Poor Charting

Avoid	Prefer
Resident was difficult	Resident declined bathing and stated, “I don’t want a shower today”
Ate poorly	Ate approximately 25% of lunch
Walked well	Ambulated 40 feet with walker and assigned assistance
Was aggressive	Resident struck the bedside table twice with an open hand
Seemed sick	Resident reported nausea and vomited once

Paper Charting

• Use approved writing instruments and formats.
• Follow facility rules for ink color.
• Write legibly.
• Do not erase, obscure, or overwrite an incorrect entry.
• Follow the approved correction procedure, which may require a single line through an error, initials, and a corrected entry.
• Never chart for another person’s work as though it were your own.

Electronic Health Records (EHR)

• Use your own authorized credentials.
• Select the correct resident record.
• Verify entries before submission.
• Use the system’s approved correction or addendum process.
• Do not share passwords or leave an unlocked record accessible to unauthorized persons.
• Follow facility policy for documenting late entries.
• Never attempt to bypass an audit trail.

Incident Reports

Incident reports document unexpected events or events with potential for injury or harm.

Examples:

• Resident falls or injuries.
• Suspected abuse or neglect.
• Employee injuries.
• Blood or body-fluid exposure.
• Injuries involving visitors.
• Other events identified by facility policy.

CNA Responsibilities

1. Ensure immediate resident or personal safety.
2. Notify the nurse or supervisor promptly.
3. Follow emergency procedures when needed.
4. Record relevant resident observations and care in the clinical record.
5. Complete or contribute to the incident report as required by your role and facility policy.
6. Provide accurate, factual information without speculation.

Important: An incident report does not replace resident charting. Follow the facility’s rules about the documentation of incident reporting and investigations.

Suspected abuse or neglect also requires following applicable mandatory-reporting procedures.

Safety & Precautions

• Do not chart care before performing it.
• Do not chart care that was not provided.
• Do not document another staff member’s care as your own.
• Do not falsify dates or times.
• Never silently alter a completed entry.
• Avoid judgmental or speculative language.
• Protect confidential resident information.
• Use only approved abbreviations.
• Notify the nurse promptly of urgent findings.

What Should I Remember?

Good documentation is:

• Accurate.
• Factual.
• Timely.
• Complete.
• Legible or clearly entered.
• Properly attributed.
• Confidential.

Important distinction:

• Reporting communicates information requiring attention.
• Charting creates a lasting record.

Both may be required for the same event.

Related

• Observation & Reporting
• Medical Terminology & Abbreviations
• Measuring Intake & Output
• Patient Refusal of Care
• Abuse, Neglect & Rights Violations
• Vital Signs

Practice

• Studied
• Observed
• Practiced
• Passed checkoff

Sources

• CNA Module 15 — Written Documentation
• 42 CFR §483.70 — Medical Records
• The Joint Commission — Information Management Standards
• Facility charting, incident-reporting, privacy, and correction policies

Flashcards

What are the core qualities of good charting?01-foundations / clinical-skills

Answer

Accurate, factual, timely, complete, and confidential.

Should documentation be delayed until the end of every shift?03-application / clinical-skills

Answer

No. Chart promptly according to facility policy.

May a CNA document care before performing it?03-application / clinical-skills

Answer

No. Chart only care actually provided.

What should a CNA do after making a paper charting error?03-application / clinical-skills

Answer

Follow the approved correction procedure; never erase or conceal the entry.

How are EHR errors corrected?03-application / clinical-skills

Answer

Through the authorized correction or addendum process.

Does an incident report replace clinical documentation?03-application / clinical-skills

Answer

No. Relevant resident care must still be charted.

Should a CNA write personal judgments in the resident's chart?03-application / clinical-skills

Answer

No. Record observable facts and relevant direct statements.

What should a CNA document when a resident refuses care?03-application / clinical-skills

Answer

Care offered, resident's response, and actions taken.