CNA's documenting in charts... - Page 2

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  1. Guide
    Jun 14, '12 by
    at this level, everywhere i have worked the cna's were allowed to chart on pt's charts within their scope of practice, for example: charting v.s. i & o etc. and they were expected to follow the policies of the facility when charting. therefore, we never encountered any problems with this matter
    Altra likes this.
  2. Guide
    Jun 14, '12 by
    I fully support ancillary staff having access to the chart, and the ability to chart things within their scope. It shouldn't be a problem that it leads confusion ... for example, it is standard that if a CNA is charting "found patient on floor" or abnormal vital signs, then it is expected that the note include _________, RN notified.
  3. Jun 14, '12 by
    Quote from caliotter3
    Have never worked anywhere that CNAs charted in, or had access to, the charts. They always had their own charting forms that were kept separate from the patient chart.
    This is so very weird to me. Have all the facilities you've worked at had electronic charting? Or do these places still use paper charting?
  4. Jun 14, '12 by
    Whoever does it should be the one to chart it. So yeah, CNAs should be able to chart. It's a completely separate matter if they (or any other discipline) aren't informing the nurse.
    Hygiene Queen likes this.
  5. Jun 14, '12 by
    I don't see what the problem is. It's not like the chart is a magic book that only the wizard gets to touch. If somebody provides care to a patient then they need to document it.
    starmickey03, KatieP86, aknottedyarn, and 2 others like this.
  6. Jun 14, '12 by
    Quote from FlyingScot
    I don't see what the problem is. It's not like the chart is a magic book that only the wizard gets to touch. If somebody provides care to a patient then they need to document it.
    LOVE THIS POST. This really is what some people act like with the chart. HIPAA doesn't prohibit caregivers from knowing what's going on with the patients. I think some people see it as a power thing, that they're important enough to be within a 10 foot radius of the chart, but the peons must stay away!!
    starmickey03, Hygiene Queen, and aknottedyarn like this.
  7. Jun 14, '12 by
    Quote from wooh
    LOVE THIS POST. This really is what some people act like with the chart. HIPAA doesn't prohibit caregivers from knowing what's going on with the patients. I think some people see it as a power thing, that they're important enough to be within a 10 foot radius of the chart, but the peons must stay away!!
    I was looking in a chart one night at my CNA job. One of the other CNA's made a remark about it. That is when the cat left the bag that I had been hired to move into a licensed nurse position and was preparing for the time when I would have that responsibility toward the resident. Personally, if there were a valid reason, I could see CNA's being allowed access to the charts. However, most of the time, most of them could not be relied upon to accurately list vital signs or BM occurrences on the sheets they were allowed access to. There was little to no interest in learning anything that could have helped in CNA duties, so little need for them to be looking at the charts. They could find other ways to waste their time.
  8. Jun 14, '12 by
    Quote from starmickey03
    This is so very weird to me. Have all the facilities you've worked at had electronic charting? Or do these places still use paper charting?
    This was in the days of the dinosaurs, there was no electronic charting back then.
  9. Jun 14, '12 by
    Ancillary staff (social worker, chaplain, PT/OT, etc.) should be documenting the the progress notes section of the chart.
    They aren't nurses, so they aren't writing "nurse's notes."

    Maybe you only have one section of the chart where you write updates about the patient's care/status. If that's the case, as long as the note is clearly signed by the writer, it doesn't really matter to me where it's written.

    If you're concerned about missing updates on the patient, simply communicate with your CNAs at the beginning of the shift and ask them to report any significant changes directly to you. Check in with them a couple of times throughout the shift and make sure nothing needs to be reported.
    wooh likes this.
  10. Jun 14, '12 by
    Quote from wooh
    LOVE THIS POST. This really is what some people act like with the chart. HIPAA doesn't prohibit caregivers from knowing what's going on with the patients. I think some people see it as a power thing, that they're important enough to be within a 10 foot radius of the chart, but the peons must stay away!!
    Just an FYI...I would NEVER consider a CNA or any other member of my team a "peon". And I certainly don't feel the chart is a "magical book". My concern is that information may be written in the chart and not given to me directly therefore interfering with the care of the resident.