CNA questions

i_love_patient_care · Feb 15, 2014

It depends on how busy you are, whether you should be charting as you go or charting at the end of the shift. I find it's better to keep a piece of paper with me to jot notes down if I don't have time to chart. Typically what I do is put all the room numbers on there and then leave space for vitals, I/O's (how much fluids in and out) + BMs, stuff like that.

If you answer another CNA's call bell, just tell them what you did. That's typically how it is in most facilities. Some facilities are more specific than that, but really as long as it gets charted.

CNAs can fill out incident reports, and where you fill it out varies from facility to facility. It really depends on if you are using paper to chart or if there is a computer being used.

Typically, the nurses don't really ask for a report when we leave. They usually want to have the vital signs charted right away so they can fill out their paperwork. If there is an unusual vital sign (high or low BP/temp/resp, low oxygen), they will want to know right away and may want to recheck it or have you recheck it.

All of this stuff will depend on your facility, and when you have orientation they will tell you how things operate. I wish I could be more specific.

Missingyou, CNA · Feb 18, 2014

You can chart as you go or you can do it all at the end of the shift. You will find what works best for you. Personally, I chart BM's and I&O immediately so I don't forget. Vitals are written on a piece of paper and handed to the nurse since where I work CNA's do not document in residents medical file. (every facility is different, you will learn what is expected). Everything else is done at the end of shift or as I have time (sometimes while I wait on my hall partner to assist me with a transfer).

If you answer the other aides call light, just tell them what you did or if the resident had a BM or anything important. I usually chart the BM's for the aide and tell them I did so it's not forgotten.

In the facility where I work, CNA's are not allowed to fill out incident reports. We go get the nurse when an incident occurs so they can observe the resident. They will ask what happened, they fill out the report. The DON follows up with the CNA within 24 hrs to review what happened. Again, every facility is different and you will find out how it works during orientation.

I report any unusual behaviors, bruises or such, resident complaints, and any other health concerns I, or my resident may have. I don't wait until the end of the shift to report these things. I go to the nurse as needed throughout the shift. They generally don't want you to wait until the end of the shift with concerns....then it's too late! Anything else such as BM's is already charted so I don't bother the nurse unless they ask.

JDZ344 · Feb 18, 2014

It depends on your facility policy. We can only answer from our own facility POV, so you should ask your DON or one of the nurses.

Charting: Where I work, its expected to be as soon as possible.

Regarding another CNA call bell, I would just put what I did.

We do fill out incident reports, sometimes.

Reporting off: Just say what you observed or what the patient told you. For example "I just turned Mrs. X and I think her heels are getting a little red" or "Mr. Z says he has a headache".

wonderchic24 · Feb 20, 2014

When I first started, I charted immediately since I was afraid that I would forget what I had just done. As I have worked more with the patients, I can now chart all at once and remember what I have done.

At our facility, we can either tell the other CNA or can chart it for them. Again, it is just important that it gets charted!

Incident reports are charted through a computer program - it will be different at your place!

I try to see the next CNAs at shift change to tell them about the patients and anything that is unusual. I definitely tell nurses about serious issues or changes with the patients. I let the CNAs know everything else!

Great questions - you sound like a good CNA!

Brook

mstearns09 · Feb 20, 2014

I made myself a "brain" sheet. It's difficult to describe but I have it set up to record patients' names, room numbers, whether they have vitals that need charted and how often, if they are on i&o, have a Foley, and a place to chart anything else I need to know and what I do for them during the day. The only time I stop to chart during shift is if I am charting their vitals on q8 or q4, or if they refuse care multiple times and I need to cover myself and the nurse. Everything else I wait to chart at the end of my shift.

At the hospital where I work, CNAs sit in on the nurses' shift report at the beginning of shift but report off to incoming CNAs at the end of shift. We fill out incident reports with our side of what happened. It is a much simpler form than what I had to do in LTC. But, as others have said, your mileage may vary depending on building policy.