I was never a CNA (STNA in the state I resided in). I would have had to have been certified or completed state testing, but the regulatory agencies in the state I resided in at the time waived the testing requirement for students enrolled in pre-licensure nursing programs
. We had to have finished our first clinical skills based course to be eligible for this exemption. Conversely we were allowed to take the STNA exam following the first clinical skills class in school (as opposed to taking a separate STNA program). We had to submit documentation from our school certifying all the things we'd learned, that we'd passed the school skill based exams. The facility employing us then had their own competency checklists for us.
Most of our charting was on flowsheets - hourly rounding, vitals, blood glucose monitoring, I&Os, turn/repositioning, 1:1 or 1:2 sitter forms (patient observations documented at minimum q15 minutes (sleeping, awake, agitated, things like that). Some units within the hospital system I worked in were on electronic medical records (ED, ICUs (adult and NICU), PACU, select inpatient "floor" units), most floors were on paper charting. While we were on mostly paper we had CPOE throughout the system, and printed our "worklists" from the CPOE program (each patient's VS frequency (including parameters set by providers), code status, lab draws as applicable, turn/reposition orders, accuchecks if needed, activity and diet orders).
We WERE allowed to write observations down as an entry in the nursing notes section. I was in the house-wide float pool. If something was missed and had been delegated to the PCA/SNA the first person to be thrown under the bus would be the float PCA/SNA. Honestly worse than the unit managers and staff was the float pool manager - that woman had no mercy on anything. We were encouraged to write pertinent information down. Any time any patient had vitals outside of the "accepted parameters" - you can believe I wrote who I notified in the notes section (patient's primary RN with name or if they were unavailable, the charge RN with their name and time). Patients who tried to refuse lab draws, turns, vitals, etc - that was documented and it got a similar entry in the notes about the RN being notified. If patients had complaints - for example I went in to get vitals and they complained of chest pain - I would call their nurse. Depending on the nurse sometimes they wanted us to document the initial complaint and our actions, others they put it in their notes (and as an RN, I've done it both ways too). It's not assessment to document a quote from a patient.
As a PCA/SNA, I had a situation where I had to document WAY more about a patient - but that *was* the night I was sitting 1:1 with the patient the patient in a fit of rage busted a hole in the wall and attempted to kill the staff in the room. But that was documenting the behaviors observed - example hitting, kicking, spitting, etc. I don't remember if the patient was criminally charged or not (we had to fill out a hospital police report because of the nature of the incident - both property damage, and the threat of violence / patient having staff cornered in the room and threatening to use the phone and/or remote to beat staff). Ah...memories...