CNA's documenting in charts...

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    I am just curious if anyone else has an employer that says it is okay for anyone to document a nurses note in a resident's chart?? I work in personal care but I know when I worked in skilled nursing the CNAs were not even allowed to look in the charts.

    New boss states that anyone including the CNAs, social worker, chaplain etc. should have full access to resident's charts and are allowed to document in the nurses notes. The CNAs don't feel comfortable writing a nurses note and I don't feel comfortable having them do it either. Simply because I am afraid they may chart something that I need to know assuming I will read it and it never gets passed on to me and there is no follow through....you see were I'm going with this.
    Last edit by Joe V on Jun 13, '12 : Reason: spacing
    Blanca R and Joe V like this.
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  3. 22 Comments so far...

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    Certainly the chaplain and social worker do not need full access to the chart. Although I'm not a big fan of crying HIPAA violation (because HIPAA has become a monstrosity that it was never intended to become), there's just no need for them to have much access. Definitely no need for them to chart on the nurse's notes. If they want to chart a progress note, they should have a generic progress note form that other disciplines like PT and OT use.

    I wouldn't necessarily be against the CNA charting in the nurse's notes, but again, there isn't much need for it. They do need access to more information than a chaplain or social worker would need, but they should be reporting anything significant to you. When I used to work SNF, CNA's could only chart vital signs on the chart. Even then, they had to report them to the nurse before writing in the chart, so it was just as well that the nurse charted the VS.

    It really comes down to your CNA scope of practice under the Board of Nursing, as well as your facility policy. You need to have access to a black and white policy that shows who has access to what in the chart and who may chart what.
    merlee likes this.
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    I work at a nursing home. CNAs have their own system to chart in, it doesn't really cross into nurses notes HOWEVER, I have noticed the chaplain charting nurse notes. One incident in particular led to issues when no one but him knew a patient was suicidal. This was not passed on, nor was an incident/behaviour report filed. So, the chaplain had full access to the chart, and he often sits in on nurse meetings. I don't know, doesn't seem right.
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    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.
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    I think it depends on facility policy. Years ago when I worked at a nursing home as a CNA, we were allowed to chart VS and ADLs in patient charts; that's it. Now as a nurse, that same facility has a completely separate system for the CNAs to chart their info; only nurses may write nursing notes in the chart.
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    I think it all depends on where you work.
    I am a nursing aide. I am permitted to look in the charts. I am also permitted to write in them if I need to. I don't often need to.
    I have to tell the RN anything significant anyway, so they can write that they were informed and their assessment findings and actions all in one place. The vital signs and other paperwork I write on are not in the chart.

    I do not have time to be writing extensive notes in charts anyway
    Last edit by JDZ344 on May 14, '14
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    I'm assuming this is only significant in LTC facilities. At the hospital I work at the PCA's chart in the patients record, which is electronic so the patient only has one chart that all those providing care (RN, MD, OT, PT, SW, ST) have access to. But of course everyone only charts things that are within their scope.
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    With electronic documentation CNA's should be able to chart vital signs and basic patient care. RN's are able to view their documentation. The person doing the care should be the one documenting it.
    TLCfromSC and wooh like this.
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    Our techs (CNA's) document full notes in the chart.
    We have had no problems.
    They also have full access to the chart.
    We work in psych and not knowing certain things can be dangerous.
    They really do need to know.
    Again, no problems.
    JDZ344 and wooh like this.
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    Quote from FrazzledButBlessed
    I work at a nursing home. CNAs have their own system to chart in, it doesn't really cross into nurses notes HOWEVER, I have noticed the chaplain charting nurse notes. One incident in particular led to issues when no one but him knew a patient was suicidal. This was not passed on, nor was an incident/behaviour report filed. So, the chaplain had full access to the chart, and he often sits in on nurse meetings. I don't know, doesn't seem right.
    This is one of the issues that led to having interdisciplinary Progress Notes. One thing really important with these is that any significant point documented in Prog.Notes needs to have connection to care. That usually means the note states that the RN was notified. Otherwise it really is a CYA document having total disconnect with the patient that is being reported. If the Chaplain was concerned enough to write it, why not concerned enough to let someone know so a plan of action could be initiated? I am all in favor of having all disciplines connected, especially in long term care, regardless of what level of care it is. With that access comes responsibility. If you have access to info then there should be accountability to that knowledge. So if the chaplain sits in on meetings he is responsible to use a feedback loop for info he has that relates to care. Writing it in a chart is correct but his responsibility is to be sure the info is acknowledged, questions able to be raised, and needed action taken.


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