Charting

CT Pixie, BSN, RN · Mar 1, 2007

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.

RN BSN 2009 · Mar 1, 2007

at the hospital I do rotations at, the CNA's do chart ADL/grooming/Care activities, but no narratives

valifay · Mar 3, 2007

Of the places I have worked, we have had sections in the pts chart where we make our notes. The nursing home I worked in, the CNA's had their own books to do their daily charting. It all depends on where you work. One assisted living place in my area has no paper work for the CNA's and all the nurses chart on are meds unless anything happens to a rsident or changes in the care plan are made.

caliotter3 · Mar 3, 2007

When I worked as a CNA in LTC we had our own official and unofficial papers where we put all our info. None of the CNA info was put directly into the pt chart by the CNA. The nurses referred to our charting for the info they needed.