Medical Record Documentation For

We hope you enjoy this course. Most folks print a copy of the test and circle the answers while reading through the course. You can then log into your account (if you created one), enter your answers online, and print your certificate. If you have not created an account… … go to this link: http://CNAZone.com/CourseDescription.aspx?testNumber=C004C And click on the “Take Free Course” button. You will be taken through the steps to create an account. When you have created your account… … click on the “My Account” link. (http://CNAZone.com/MyAccount.aspx) On that page you will see the link to take the test. Medical Record Documentation and Legal Aspects Appropriate to Nursing Assistants Introduction Learning to document in the proper way on a patient’s medical record is absolutely vital if you want to have a successful career as a certified nursing assistant (CNA). It is also vital if you want to deliver good care to your patients. Hospitals, clinics, skilled nursing facilities, and other health care facilities can be very busy and hectic. There is a lot going on and the pace of the environment can be very fast. There is simply no way that good care could be delivered without a single, centralized place where the essential facts about each patient have been recorded. So for the patient to receive the best care possible, all of the information on the medical record must properly documented. The patient’s medical record is the only place where all of the important information about that person can be found. It is also the place where health professionals communicate to each other about the patients and what has been done for them. The basic purpose of documentation is to produce a clear, concise, and accurate record that allows everyone involved in the care of a patient to know what has happened, what is planned, and what needs to be done. Documentation - proper documentation - is essential. Some people find documentation to be intimidating. But proper documentation is not difficult: it is simply a skill that must be learned and practiced. After time, documenting the correct way will become second nature, and you will instinctively know when to document, what to document, and how to document. cnaZone.com cnaZone.com cnaZone.com cnaZone.com cnaZone.com cnaZone.com When the student has finished this module, he/she will be able to: 1. Identify the first and most important rule of medical documentation. 2. Identify three reasons why everything concerning a patient’s care must be documented. 3. Identify three aspects of proper documentation. 4. Identify the four “do’s” of proper documentation. 5. Identify the three “don’ts” of proper documentation. 6. Identify a CNA note that is an example of poor documentation. 7. Identify a CNA note that is an example of good documentation. 8. Identify three things that a CNA may document about his/her patients. 9. Identify the proper way to document a note that is entered late. 10. Identify what is important to document when performing a therapeutic activity. The Basics of Documentation: If It Wasn’t Documented, It Wasn’t Done “If it wasn’t documented, it wasn’t done.” That phrase is one you might have heard before, and it is certainly not new. But it is the first and one of the most important rules of medical documentation. It is also one of the most crucial pieces of information you need to remember if you want to have a successful career as a CNA. All of the information about the patient - what is done for him or her, what the plan of care is, how the patient responded to this care, what needs to be done on his/her behalf, what the future plans for the patient are, etc. - must be documented. If it wasn’t documented, it wasn’t done. What does this rule mean? It means that all of the important information and events that pertain to patient care must be recorded on the patient’s medical record, because if this information and those events are not recorded, no one is caring for the patient will know what has happened and patient care will suffer. Several examples that illustrate this concept are provided later in this section: these examples will clearly show you the importance of “not documented, not done.” This “first rule” of documentation - if it wasn’t documented it wasn’t done - is important and must be kept in mind. However, this simple rule can be a big source of confusion for some CNAs who are learning how to document. During the course of your working day as a CNA you will perform many important tasks, you will make many important observations, and you will discuss patient care with many other health care professionals. If all of these tasks, observations, and conversations are important then they all have to be documented. If the responsibility of documentation is looked at in that manner, documentation can seem like an impossible task because: 1) there would be a very large amount of information to document, and 2) how can you be sure you haven’t forgotten to document something important? And what is considered important? This rule of documentation can make it seem as if you have to document everything. Not true. The phrase not “not documented, not done” is so often stressed because it reminds people to document what is important in terms of patient care. You do not have to include every last detail of everything you see, do, and say. The following examples illustrate this point. cnaZone.com cnaZone.com cnaZone.com cnaZone.com cnaZone.com cnaZone.com Example #1: The patient you are caring for has an in-dwelling urinary catheter and catheter care is scheduled to be done once a day. You have been instructed in the proper way to do the procedure, and you have performed it many times before. After you have finished you document what you have done. If you took the idea of “not documented, not done” to an extreme your note might look like this: “I entered the patient’s room at 13:00 and advised him I was going to perform catheter care. I removed the bedding and lifted the patient’s gown in order to expose the area. I examined the meatus and the skin around the area: I did not observe any redness, swelling, or drainage. I checked all of the catheter connections, and ensured that the catheter was firmly secured to the patient’s leg and that there was no tension on the catheter tube that would affect or irritate its insertion site. The urinary collection bag was secured to the bed with two hooks, and it was approximately 12-14 inches below the level of the bladder. There were no kinks or loops in the collection tube. The urine color was pale yellow; I did not observe any blood or sediment in the tube or the bag. I washed my hands using soap and water, scrubbing for 2 minutes. I dried with paper towels, and then put on disposable gloves. I washed the area around the insertion site of the catheter with soap and water and a gauze pad, moving from the inside to the outside in a circular manner. This took approximately two minutes, and the patient did not complain of pain or discomfort during the procedure. After discarding the gauze and the disposable gloves in a hazardous waste container, I repositioned the gown, replaced the bedding, and made sure the patient’s call light could be reached. The procedure was completed at 13:10.” Example #2: You are checking the temperature, blood pressure, pulse, and respirations of a patient. The blood pressure, pulse, and respirations are within normal limits and they are normal for the patient, but the temperature is 100.9°F. The patient is awake, alert, and oriented, and he does not have any specific complaints. His skin color and temperature are normal and he is not diaphoretic. The vital signs are charted in the appropriate place, and you inform you supervisor of the patient’s elevated body temperature. A note with a lot of unnecessary detail might read like this: “I entered Mr. F’s room at 12:00 to check his vital signs. I checked his pulse by palpating his left radial artery for 30 seconds and multiplying the result by two: the pulse rate was 80. After making sure that the patient had not had recently anything to eat or drink, I placed the thermometer probe under his tongue and held it in place until a reading was obtained: the temperature was 100.9°F. Respiratory rate was obtained by counting the number of breaths for 30 seconds and multiplying times two: the respiratory rate was 20. The patient’s skin color was normal, no cyanosis noted. The respiratory rhythm was regular and no respiratory accessory muscles were used. The blood pressure cuff was assessed to make sure it was the proper size, and the cuff was applied to the left arm with the leading edge approximately one inch above the brachial artery. The patient’s arm was positioned at the level of the heart, and the blood pressure was measured: the blood pressure was 128/70. The patient was noted to be awake, alert, and oriented, his skin color and temperature were normal and no diaphoresis was noted. He had no specific complaints. I notified the nursing supervisor, Susan L., R.N., at 12:15 of the elevation of cnaZone.com cnaZone.com cnaZone.com cnaZone.com cnaZone.com cnaZone.com body temperature, 100.9°F, and of my other observations.

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