Hi! I'm wondering, for those of you who are working, do you actually chart in the pt's chart or do you write down notes and the RN does the charting? Personally, I would rather chart it myself because information can be lost if you are giving it to another person to chart. JMHO.
When I worked as a CNA (started early/mid 80's) we would fill out our info on our assigned patients on one sheet and the nurse took the info from that. The sheets the CNA's wrote on were not part of the patients chart but the papers were kept for documentation sake.
We had a seperate sheet for things..like an I&O sheet, vitals sheet, etc. But what we did chart on the actual chart was things like how many hrs the patient was awake/asleep, how thaey ate etc. All of that was assigned a number..ie 0 in the appetite section meant at 0-25% of their meal a 1 would be 25-50 etc.
If you're concerned that you will give info and it will/could get lost, do like I did. Do NOT throw out any info you have (vitals, i&o, etc) until your shift is over and you are punching out to go home. That way, you'll still have the info if the nurse needs to double check anything.
Actual narritaves (written statements) were not a part of our job.
Last edit by CT Pixie on Mar 1, '07