Texas CNA Skills (Part Five): Charting & Documentation for the CNA State Test and Beyond

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Documentation is one of multiple vital tasks that the overwhelming majority of certified nursing assistants (CNAs) are entrusted with completing. After all, many prospective nursing students and nurse aides have heard the olden adage that “if it was not documented, it was not done.” Also, any documentation completed by the nurse aide eventually ends up as a permanent part of patients’ medical records. Patients deserve accurate, complete medical records.

Since nursing assistants perform many care tasks and procedures throughout the course of a typical work shift, it would make sense that these tasks will need to be charted accurately. A correct way of documentation exists for CNAs and other healthcare workers in the medical field. On the other hand, a number of incorrect methods of documentation also exist.

Since documentation is such a vital task, it is of the utmost significance for nursing assistants to know how to complete this duty the right way and in a timely manner. In addition, nurse aide test takers who want to pass the CNA state test for certification as a certified nursing assistant will need to know how to chart their various findings and care in a proper manner in order to be successful on the skills section of the exam.

During the CNA state test, documentation is a task that the nurse aide candidate will need to complete at the testing center in front of the examiner for evaluative purposes. The skills section of the Texas CNA state test requires the nurse aide test taker to be tested on five testable skills that are selected randomly.

The nurse aide will need to perform the five aforementioned randomly selected skills step by step in front of the examiner. The nurse aide must achieve a passing cut score on a minimum of four out of the five procedural skills in order to pass the skills evaluation section of the CNA state test.

Also, most of these procedural skills will call upon the test taker to chart or document his or her findings after completion of the procedure. For example, the procedural skill of measuring a patient’s respiration rate must be documented during the skills portion of the CNA state test. Therefore, the testing site examiner will be eyeballing the nurse aide test taker’s charting for accuracy and completeness.

If the documentation step of the procedural skill is not deemed to be accurate by the testing site examiner, the test taker will fail on this skill. For instance, the nurse aide test taker will fail the skill of measuring and recording respirations if he or she documents a respiration rate of 20 breaths per minute when the examiner records a respiratory rate of 16 breaths per minute. In the eyes of the examiner, the charting was inaccurate, so the test taking candidate fails the skill.

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Nursing assistants chart their findings based on a combination of observations as well as verbal reports from patients and families. Moreover, these findings can be either objective or subjective in nature. Objective findings are ones that the nursing assistant is able to utilize their senses to hear, see, smell and touch. Objective findings can be proven and measured or directly observed, whereas subjective findings cannot be proven or observed because they are merely what the patient or family member has reported to the nursing assistant.

Objective findings are measurable and/or based in provable fact, such as a blood pressure reading of 118/62 mmHg or urine that is clear and light yellow in coloration. Subjective findings cannot be proven or directly observed by the nurse aide, such as a patient reporting that he has a toothache or a family member reporting that her elderly mother passed out near the bed prior to lunchtime.

To recap, objective findings are clearly based on numerical metrics that can be measured. A heart rate of 72 beats per minute is an objective finding because it is obviously measurable. Objective findings are also based on observable data utilizing the nurse aide’s sense of smell, touch, sight and sound. Therefore, a finding of a patient’s skin that is warm and dry to touch also would be objective data since the nurse aide used his or her sense of touch to come up with that finding.

On the other hand, subjective findings include all data that cannot be measured or verified by the nurse aide’s various senses. If a patient tells nursing members of staff that he slipped and fell in a puddle of orange juice near the dining area after breakfast, this is subjective data because the nurse aide did not see the fall and cannot prove it even took place through his or her sense of sight. If a patient says, “My tummy hurts,” this is a subjective finding because the patient is telling the nurse aide what his pain is.

Pain is subjective because it is a feeling that cannot be measured or observed, and even though a facial grimace can be observable, keep in mind that many patients grimace for reasons other than the unpleasant sensations associated with being in pain. So, anything the patient or her family tells the nurse aide is subjective if he or she did not observe it as it supposedly happened or cannot possibly measure it in any meaningful way.

The following list contains a handful of general guidelines for charting and documenting related to the nurse aide role during the CNA state test, as well as beyond (read: the workplace).

  1. The nursing assistant should utilize the correct chart, paperwork, or ADL form.
  2. The nursing assistant should always avoid the use of felt tipped markers when recording findings in the medical record.
  3. The nursing assistant must bring three sharpened no. 2 pencils to the testing center to take the CNA state test.
  4. The nursing assistant must record all vital signs in the appropriate sections on the paperwork provided.
  5. The nursing assistant should correct mistakes by crossing them out with one line. The nursing assistant should proceed to write his or her initials next to the error.
  6. The nursing assistant must write his or her initials next to all skills that he or she has performed.
  7. The nursing assistant must record all intake and output findings in cc or mL increments and percentages (e.g., 50% of meal was consumed; 750mL of urine output obtained, etc.).
  8. The nursing assistant should document that he or she notified the nurse of any abnormal patient findings or observations.
  9. The nursing assistant should utilize only approved abbreviations and terms when charting.
  10. The nursing assistant should chart subjective findings utilizing quotation marks as stated by the patient (e.g., patient states, “I have a really throbbing headache.”).
  11. The nursing assistant should avoid charting procedures and care that has not yet been provided. The nursing assistant should not record any care before it has actually been delivered.
  12. The nursing assistant should initial the bottom of the paperwork. The nursing assistant must sign the bottom of the document with his or her first name, last name, and title (N.A.). The nursing assistant must date the document.

REFERENCES

Brit2829537. (n.d.). I went into nursing for the charting (image). Retrieved from https://www.someecards.com/usercards/viewcard/i-went-into-nursing-for-the-charting-said-no-nurse-ever–9f173/?tagSlug=workplace

 

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Texas CNA Skills (Part Four): Ending Steps, a.k.a. “Closing Procedures” After Completion of Each Skill on the State Test

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In the vast majority of U.S. states, Texas included, a nurse aide candidate who intends to be successful on the the CNA state-approved examination for certification as a certified nursing assistant will need to demonstrate his or her abilities to correctly perform a series of hands-on procedural tasks during the skills section of the state test.

Of course, the demonstration of skills competency is occurring at the testing center in the midst of a simulated scenario. Additionally, an examiner is carefully eyeballing the test-taking candidate for evaluation purposes while he or she is performing the myriad of steps required to complete each skill performance from beginning to conclusion.

A grand total of 22 testable skills exist on the skills portion of the CNA state test in Texas that a test taker might be called upon to perform. Furthermore, five of the 22 skills are chosen randomly for the test taker to perform from start to finish in the presence of the examiner to demonstrate competency.

The test taker will pass the skills section of the CNA state test if he or she correctly performs four out of five of the randomly selected skills that have been assigned. Hence, it is imperative for the test taker to be completely prepared prior to the testing date by possessing thorough knowledge on how to accurately perform all 22 testable skills.

As a reminder, the test taker is permitted to miss a small, predetermined number of steps that have been deemed not critical and still be able to pass the skills section of the CNA state examination for certification. The main idea is that examiner is observing to ensure that the test-taker knows how to complete all steps associated with each procedural skill.

Nonetheless, be advised that the nurse aide candidate is strictly not permitted to miss or fail to perform any critical steps of a procedural skill during the skills portion of the Texas CNA state test. Customarily, provisions related to infection control (read: hand hygiene), maintenance of a safe environment (read: bed in low position and side rails up), upholding patient privacy (read: keeping doors and privacy curtains closed) and ensuring a signaling device or call light remains within reasonable reach are considered critical steps.

To recap, critical steps are ones that need to always be performed when demonstrating skills competency at the testing center during the CNA state test. A test taker will fail the skills competency section of the CNA state examination if any critical steps associated with a particular skill are missed or forgotten. For instance, forgetting to wash one’s hands after removal of gloves would be a missed critical step since hand hygiene is an essential aspect of infection control.

Ending steps are known by a number of differing names, including post-steps, completion steps, ending procedures and closing procedures. Due to the fact that the skills section of the CNA state exam is normally completed as part of one simulated scenario, the closing procedures must be completed once, usually when the scenario is ending. To reemphasize, test takers need to carry out these closing procedures at the end of each CNA state test.

Closing procedures tend to entail routine nursing care steps such as making sure that the patient’s call light or signaling devise is within easy reach, ensuring comfort measures, lowering the bed to a safe position, raising or lowering the bed’s side rails in accordance with the patient’s plan of care, performing hand hygiene, and documenting. According to Professional Healthcare Development (2011), the closing procedures should be completed in the following sequence:

  1. The nursing assistant should utilize proper body mechanics during the performance of all skills.
  2. The nursing assistant should position the patient for comfort. The nursing assistant should position the patient in appropriate body alignment.
  3. The nursing assistant must adjust the bed’s side rails per physicians’ orders and lower the bed.
  4. The nursing assistant should ensure the patient has everything they will need. The nursing assistant should take the time to thank the patient.
  5. The nursing assistant should maintain the cleanliness of the patient’s room per facility policies.
  6. The nursing assistant must remove his or her gloves and wash the hands as the situation dictates.
  7. The nursing assistant should offer to open privacy curtains and doors in accordance with the wishes of the patient.
  8. The nursing assistant must observe the environment for safety, always ensuring that the call light remains within reasonable reach.
  9. The nursing assistant must report any abnormal findings to the nurse.
  10. The nursing assistant must document per facility policies and procedures.

RESOURCES

Lindsey, Carol. (2010). Ending Procedures (video). Retrieved from https://www.youtube.com/watch?v=TzgyjUcC080

Professional Healthcare Development, LLC. (2011). Performance Skill Procedures. Retrieved from http://www.profhd.com/Skills%20procedures.pdf

Texas CNA Skills (Part Three): Measuring and Recording Respirations

Screenshot 2018-12-01 at 12.22.36 PMRespiration, also known as breathing, is one of the four main vital signs that nursing assistants, nurses, respiratory therapists, paramedics, emergency medical technicians and other healthcare workers must know how to accurately obtain and record. Of course, the other three vital signs include temperature, pulse and blood pressure.

Alternately worded, a patient’s respiratory rate is his or her breathing rate. It is the number of breaths that he or she takes over the course of one full minute (60 seconds). Generally, a respiration rate that falls between 12 and 20 breaths over the course of one whole minute is considered a normal and expected finding in an adult who is resting.

Remember the concept in this manner for enhanced ease of recollection and lack of confusion: the process of respiration is more commonly known as the process of breathing. Respiration is a very high-priority basic need because a patient who stops breathing will be dead in a matter of minutes without timely outside intervention. Fortunately, taking and recording a patient’s respiratory rate is one of the technically easier procedural skills for a healthcare worker to carry out.

Respiration is an enormously complex activity that is comprised of two differing processes called inspiration and expiration. Through inspiration and expiration, the cells of the body continually exchange two gases called oxygen and carbon dioxide. The body simultaneously breathes in oxygen and expels carbon dioxide. Inspiration is the process of inhaling air into the lungs; likewise, it occurs when a patient breathes in. Expiration is the process of exhaling; therefore, it takes place when a patient breathes out.

Inspiration and expiration are massively important processes to the continual functioning of all human bodies since they are responsible for keeping the blood, organs and tissues rich with oxygen (read: inspiration) while ensuring that excess carbon dioxide leaves the body (read: expiration).

Furthermore, the procedure of measuring and recording a patient’s respiration rate is a testable skill on the Texas CNA state test. It is also a testable procedural skill in most other states. Therefore, a nurses aide who wants to pass the CNA state test to obtain certification as a certified nursing assistant will need to know how to accurately take and record a patient’s respiratory rate in the presence of an examiner at the testing site.

According to Pearson Vue (2018), a patient’s respirations should be counted and recorded using the following listed sequence of steps during the skills portion of the state CNA examination:

  1. The nursing assistant should explain the procedure to the patient in a slow and clearly understandable manner while maintaining regular face to face contact as needed.
  2. The nursing assistant must measure the patient’s respiratory rate for one entire minute (60 seconds).
  3. The nursing assistant should ensure that the patient’s call light or signaling device is within easy reach prior to ending the skill.
  4. The nursing assistant must wash his or her hands prior to recording the patient’s one-minute respiratory rate.
  5. The nursing assistant must document a respiratory rate number that is within two breaths of the examiner’s recorded reading. For instance, the nursing assistant will pass this skill if he or she records a respiratory rate of 16, even if the examiner had  documented a respiration rate of 14.

To pass the procedural skill of measuring and recording respirations on the CNA state exam, the test taker’s documented one-minute respiration rate must fall within a predetermined range of plus or minus two breaths of the test site examiner’s recorded reading. Here are a handful of additional tips that can potentially help with obtaining a respiration rate from patients in clinical settings:

  1. Perform the opening procedures before starting the skill.
  2. Count it as one respiration each time the patient’s chest rises.
  3. Count the respirations for one entire minute (60 seconds) to obtain the one-minute respiratory rate.
  4. Record the respiratory rate as indicated.
  5. Perform the closing procedures after ending the skill.

REFERENCES

All About Medical Training. (2015). Count and Record Respirations – CNA Skill Video AAMT. Retrieved from https://www.youtube.com/watch?v=VS0adbHFneA

BioSpine Institute. (2018). Breathing (picture). Retrieved from https://biospine.com/diaphragm-back-pain/

Pearson Vue. (2018). Texas Nurse Aide Candidate Handbook. Retrieved from https://home.pearsonvue.com/getattachment/73a0c524-4cbe-401a-aa5c-fe1ebf4e2517/Texas

Texas CNA Skills (Part Two): the Initial Steps, a.k.a. “Opening Procedures,” That Must Be Performed Before Demonstrating Skills on the State Examination

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In most U.S. states, including Texas, a test-taker who wants to pass the state-approved CNA examination must demonstrate his or her ability to successfully complete several hands-on procedural tasks during the skills portion of the state test. This all takes place as an examiner carefully observes the steps associated with each skill performance from start to finish.

Out of 20+ possible testable skills on the CNA state test, five skills will be selected at random for the test-taker to perform in front of the examiner. In order to pass the skills portion of the CNA state test, four out of five of the randomly selected skills must be completed successfully and by the book. It is advisable to know how to perform all 20+ testable skills for maximal test preparation.

Each testable skill possesses an assigned value that shall correspond to each step associated with the complete, successful performance of the skill. For instance, a skill such as hand-washing that requires a number of steps from start to finish would be worth multiple points. If all steps of the hand-washing skill are performed properly and in the correct order by the test-taker, then all points will be awarded for the performance of that particular skill.

Keep in mind that the test-taker is allowed to miss a small number of steps that are considered not critical and still successfully pass the skills portion of the CNA state examination. The overriding point is that examiner wants to see that the test-taker knows how to execute the procedural skill from start to finish.

On the other hand, the nurse aide test-taker is absolutely not allowed to miss or forget to perform any critical steps of a procedural skill during the skills portion of the CNA state test. Generally, measures such as infection control, safety, privacy and provision of a signaling device or call light within reach are regarded as critical steps. In essence, these steps must always be performed. After all, they are considered critical steps.

Initial steps are known by various names, including pre-steps and opening procedures. Since the skills section of the CNA state exam is usually performed as one single scenario, these opening procedures need to be completed once, typically when the scenario starts. To reiterate, test-takers must carry out these opening procedures at the beginning of each test.

Opening procedures normally involve routinized steps such as knocking on the patient’s door, introducing oneself to the patient, identifying the correct patient, and ensuring privacy. According to Lewis-Clark State College (2013), the opening procedures should be carried out in the following order:

  1. The nursing assistant should get instructions from the nurse concerning the patient’s needs, functional limitations, and what the patient is able to do.
  2. The nursing assistant needs to knock before going inside the patient’s room. If applicable, await permission to enter the room if the patient is verbal in the scenario that has been assigned.
  3. The nursing assistant must refer to the patient by name. The nursing assistant must confirm the patient’s identity to ensure it is the right patient.
  4. The nursing assistant needs to identify himself or herself. The nursing assistant needs to identify his or her workplace title (e.g., “I am Joy. I am going to be your nurse aide for the day.”
  5. The nursing assistant should clearly explain the procedure in language the patient can understand. The nursing assistant should encourage the patient to complete as much as he or she possibly can.
  6. The nursing assistant should gather supplies and examine equipment prior to the start of the skill or procedure.
  7. The nursing assistant must properly wash his or her hands.
  8. The nursing assistant must ensure the patient’s privacy is upheld by keeping doors and/or privacy curtains in the closed position.
  9. The nursing assistant needs to keep the bed’s side rails in the ‘up’ position before elevating the bed to an appropriate height. The nursing assistant is to lower the side rails on the side of the bed where the care is being delivered.
  10. The nursing assistant should adhere to standard precautions by gloving up as needed.
  11. The nursing assistant should perform all skills while utilizing appropriate body mechanics. Maintain correct body alignment while working.

REFERENCES

4YourCNA. (2018). The Opening – a 4 YourCNA Lesson. Retrieved from https://www.youtube.com/watch?v=OOMXB_ahFyE

Lewis-Clark State College. (2013). Student Skills Packet. Retrieved from http://www.lcsc.edu/media/117278/2013-Student-Skills-Packet.pdf

Los Angeles Mission College. (2016). General Information, Exam Requirements, and Skills Steps Review Packet. Retrieved from https://www.lamission.edu/alliedhealth/docs/SkillsReview%20Rev02-16.pdf