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.

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.

https://youtu.be/Em5PwX_C1UQ

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