Communication is imperative for any certified nursing assistant. In fact, there are entire courses within your CNA training dedicated to fine-tuning your communication methods (learn more about training at CNA Certification Scoop). To help promote transparent and accurate communication between CNAs and other medical staff members, many institutes utilize three specific documentation methods to record activities and monitor the health and status of a patient. Although your employer may feature slightly different documentation requirements, the following is considered universal among all major health care facilities.
The Three Primary Communication Documents
Your supervising nurse is required by law and employer to have written records of all care a patient has received. Because of this, you are responsible for contributing information into these records. All three of the following documentation methods are designed to streamline communication between health care professionals while ensuring the type of care and observations made throughout your shift are accurately transferred to other medical team members. Remember, your specific facility will feature unique documentation requirements. Therefore, it's important to master your understanding of these three documents, while remaining flexible with how they're implemented and handled.
Patient Care Plan - At the beginning of every shift, the first documentation tool you'll use is known as the patient care plan. Within this document, patient care given from doctor's to nurses are written in this plan, and you (a CNA) must refer to this patient care document to determine how the patient much be tended to. Within this document you'll find: Patient Name, Age, Religion and Admission Date; Diagnosis; Diet; Activity Level; Special Procedures and Dates of Procedures; Current/Recommended Activity Level; Needed Treatments; Special Equipment Needs.
Flow Sheet - All caregivers, from CNAs to Registered Nurses, utilize a flow chart to track the progress or patient changes. The flow chart is typically kept near the patient for quick and easy review and updates. It's essential that you document patient vital signs, intake, output, measurements, weight, procedures and treatment. These notes are imperative to track the changes and health progress, or decline, of a patient. Often times these notes are used by physicians and nursing staff to adjust treatment plans or to help diagnose and unknown ailment.
Nursing Notes - Nursing notes are just that, notes from nursing staff. This essential level of communication between nursing staff and physicians help track changes in the patient as well as provide in-depth notes regarding activity with the patient. Information gathered throughout this process includes, but is not limited to: the patient's current condition, care provided during the specific visit and any significant observations made during a particular interaction or visit with the patient. This information is imperative when determining if a treatment program is working or if the patient is showcasing new signs and symptoms.
For more information about these documents or other things you will study as a CNA, see here.
The Three Primary Communication Documents
Your supervising nurse is required by law and employer to have written records of all care a patient has received. Because of this, you are responsible for contributing information into these records. All three of the following documentation methods are designed to streamline communication between health care professionals while ensuring the type of care and observations made throughout your shift are accurately transferred to other medical team members. Remember, your specific facility will feature unique documentation requirements. Therefore, it's important to master your understanding of these three documents, while remaining flexible with how they're implemented and handled.
Patient Care Plan - At the beginning of every shift, the first documentation tool you'll use is known as the patient care plan. Within this document, patient care given from doctor's to nurses are written in this plan, and you (a CNA) must refer to this patient care document to determine how the patient much be tended to. Within this document you'll find: Patient Name, Age, Religion and Admission Date; Diagnosis; Diet; Activity Level; Special Procedures and Dates of Procedures; Current/Recommended Activity Level; Needed Treatments; Special Equipment Needs.
Flow Sheet - All caregivers, from CNAs to Registered Nurses, utilize a flow chart to track the progress or patient changes. The flow chart is typically kept near the patient for quick and easy review and updates. It's essential that you document patient vital signs, intake, output, measurements, weight, procedures and treatment. These notes are imperative to track the changes and health progress, or decline, of a patient. Often times these notes are used by physicians and nursing staff to adjust treatment plans or to help diagnose and unknown ailment.
Nursing Notes - Nursing notes are just that, notes from nursing staff. This essential level of communication between nursing staff and physicians help track changes in the patient as well as provide in-depth notes regarding activity with the patient. Information gathered throughout this process includes, but is not limited to: the patient's current condition, care provided during the specific visit and any significant observations made during a particular interaction or visit with the patient. This information is imperative when determining if a treatment program is working or if the patient is showcasing new signs and symptoms.
For more information about these documents or other things you will study as a CNA, see here.
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