How do I write my CNA notes?

Eleven Golden Rules of Documentation

If you didn’t write it down, it didn’t happen.
Date, time, and sign every entry.
Chart care as soon as possible after you give it.
Write legibly every time.
Be systematic.
Be accurate.
You absolutely must be objective.

How do you write a good nursing note?

How to write in Nursing Notes

Write as you go. The NMC says you should complete all records at the time or as soon as possible.
Use a systematic approach.
Keep it simple.
Try to be concise.
Summarise.
Remain objective and try to avoid speculation.
Write down all communication.
Try to avoid abbreviations.

Where should a nursing assistant document data?

It is important that you know what else needs to be documented. For example, a patient’s refusal for any care needs to be documented. Usually, the place for this documentation is on the back of the pre- printed “ADL” or “CNA” form.

When should a CNA document?

It is expected that the CNA will perform and document their activities in a timely manner. By the time the CNA is done with the activities that got started at 7am, the documentation may not have been put in until 10am. It would be appropriate to document; “late entry, activity provided at 0700.”

What is the golden rule of chart documentation?

the “golden rule” in documentation is. if it is not documented it was not done.

What are the 3 rules of documentation?

Documentation should be:

Immediate. Managers should take notes right after an incident occurs.
Accurate and believable. When an outside observer (judge, jury or EEO investigator) is called to judge your side of the story, detailed observations add authenticity.
Agreed upon.

When should Charting be recorded?

Communiating with the health team

Question	Answer
When charting, you should record	safety measures performed
The clock shows 11:42 AM. In 24-hour clock time, this is	1142
The clock shows 7:29 PM. In 24-hour clock time, this is	1929
A suffix is	placed at the end of a word