CNA being asked to go through patient med records

texastaz · Apr 8, 2009

Interesting! I think you should post this on under "Specialty"-LTC Care for the nurses to answer or under "Legal" nursing. Overall I agree with you. Sounds like something that started at the top - and they never put into thought who are they going to pay to take the time to do it. It roles down hill - and will eventualy back up again.:pntrghi::pntlft:

Long Term Care Columnist / Guide · Apr 8, 2009

Totally out of the CNA's scope of practice, IMO. You are spot on.

Updating resident Kardexes or ADL forms is essentially writing a care plan, which is the job of the resident care manager and/or the unit charge nurse, not the CNA staff. It's one thing when the aides are asked to fill out forms on each resident as to their current ADLs (this helps the RCM to accurately code each resident's Minimum Data Set, which is the document that determines payment for the services they receive).

But it's not appropriate to have CNAs combing through confidential medical records to update care plans, even if it's only for other CNAs. "Cheat sheets" or "brains" can be made from the ADLs/care plans and given to each aide, but this sounds more involved than that. I would seriously consider discussing it with your DON or administrator, and if you get no satisfaction from them, your state Board of Nursing may have some guidelines.

sonomala · Apr 9, 2009

I agree it sounds outside your scope of practice. I'd go to your DON unless you know thats who it flowed directly to the cnas from, then I'd go to the state board of nursing.

fuzzywuzzy, CNA · Apr 9, 2009

How are you expected to have time to do that anyway? We have those cheat sheets at my job and one of the office nurses does it.

elite · Apr 9, 2009

I would think these cards would be updated shift to shift, if needed. I am assuming this is in a nursing home, so a lot of the info wouldn't change that frequently. And any med changes (or other changes) that you would need to know about should be communicated to you by the nurse anyways and then you can just add it to the card. Therefore it wouldn't be nessessary for a weekly review/update. The info is a need to know. But don't you go into each of the resident's charts anyway to do your charting? I don't believe this is out of a CNAs SOP. If ther are CNAs that can't be trusted to look into the residents chart for info YOU DO NEED to know about, then those CNAs shouldn't be working with residents to begin with!!

In general, I believe that the issue could be solved (and many others) by the CNAs and RNs, at the beginning of their shift, have a quick report -go over anything from the previous shift and then again at the end of each shift in case there. Any updates to cards could be done then. I mean, we are not talking about a full plan of care review, just of a diet or med change etc. You wouldn't have to go through each resident, only the ones with any changes. And again, the nurse should be updating you throughout the shift if any changes are made. Honestly, that is only good nursing practice. A lot of the changes you would know away. Ex: if the resident went from using a cane to a walker. Or if they needed more help feeding themselves.

ZanatuBelmont · Apr 9, 2009

The powers-that- be at work are now trying to implement a new duty for CNAs. We are supposed to go through the patient's charts-their medical records and fill out updated Assignment Cards weekly. We are to go through the patients' records and check off on the assignment card their diagnosis, what kind of transfer they are, do they use assistive devices, dentures, hearing aids, any kind of rehab therapy (splints, heel booties), meal assistance/ diet, continent or incontinent, if they are on blood thinners (to watch for bruising). Then we have the nurse sign it off. The rationale for this is that so people who float will have an up- to- date assignment card from which to work.
I'm pretty sure that this is not my responsibility as a CNA. I'm a nursing student, so I do have some experience with charts, however as CNAs we have not been trained to interpret the information in a chart. If I fill out the wrong info the blame will be on me. Also, shouldn't the patient information we get as aides be on a need- to- know only basis? We shouldn't have access to patients personal information. A few of the aides I work with are not very trustworthy. The charts have private stuff- SS#, addresses, medical history. As a patient, I would not want anyone but the doctors or nurses taking care of me to be able to access my chart.
Where can I go to find out if this is allowed? And if it is not, how can I report it?

What state do you live in? You need to open google and search the rules and regulations for CNA duties. As others have said, filling out the kardex as you are being instructed is essentially writing a care plan. Sounds to me - and I could be wrong - that your area is trying to lessen the load of nurses but at the expense of patients, which is NEVER a good thing! CNAs are simply not trained to read through charts and even the one's with 30+ years experience have difficulty interpreting the charts.

dnp2004 · Apr 9, 2009

State Board of Nursing for this on.

caliotter3 · Apr 9, 2009

I can see having someone update this material, but it obviously is not within the job description of the CNA. No facility where I have ever worked allowed the CNAs to peruse the charts for any reason. The closest we have ever come to this was to mention to the CNAs that they could look at the spine of a chart to see the colored stickers for necessary info. And that practice ended when they pulled the stickers from the spines when someone said they weren't supposed to be there. It is always distressing when your employer asks you to do something that you know is wrong.

beck_79 · Apr 9, 2009

Thanks for the replies, everyone. To clear things up a bit: this is both a LTC and Rehab facility. I am on the Rehab floor, so patients are always coming and going, therefore assignment cards need to be updated regularly. As CNAs we do know the patients very well, and could probably fill out most of the information accurately (with the exception of medications and any very recent PT evals) HOWEVER, we are being asked to go through the medical records themselves and record what is written there. We typically don't even touch these records- we have our own CNA flow sheets which are kept in its own ADL binder. It was my understanding that we were never to touch the patient medical records.

Another thing- there is no time on the shift to even do this. We work our tails off right up to the end of the shift, and barely have time to get our own paperwork done.

I'll double check to see if the DON decided to implement this (so far I've only heard it from the charge nurses) But first I will check with my state BON so I have something to back me up. (I'm in MA, btw)

Thanks again!

CNA2day · Dec 8, 2009

We were told we were NEVER to look at patient reccords,ever. Anyone caught looking at them is automatically terminated.

NurseCubanitaRN2b, BSN, RN · Dec 9, 2009

CNA's don't usually look at the chart. I'm mortified that you're having to check off something on diagnosis. As a CNA you're not trained to do that type of paperwork. You're job is bed baths, bed making, feeding, turning, etc, you don't deal with their diagnosis, medications, transfer methods (although you do transfer), rehab therapy, dr orders etc, that's all for nurses or therapists. I would bring this up because someone is going to blame you if something goes wrong.