CNA's documenting in charts...

[luvmy2angels]

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.

[starmickey03, MSN, RN]

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?

[wooh, BSN, RN]

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.

[FlyingScot, RN]

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.

[wooh, BSN, RN]

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!!

[caliotter3]

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.

[caliotter3]

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.

[Double-Helix, BSN, RN]

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.

[luvmy2angels]

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.

[FlyingScot, RN]

Luv, my post wasn't directed at you but at the posts where people seem horrified that CNA's would be allowed to chart.

[luvmy2angels]

Luv, my post wasn't directed at you but at the posts where people seem horrified that CNA's would be allowed to chart.

Thank you!!

[Lynx25, LPN]

They aren't allowed to chart in the actual chart, they have their own book and paperwork for that, and it goes into medical records, I think.

There's plenty of CNA's I would not want doodling in the chart...

- The one that came up to me, "SHE SNEEZED AND SHE HAS PNA AND YOU MUST CALL THE DOCTOR NOW! HE SHOULD PUT HER ON LEVAQUIN IMMEDIATELY!" What? No lady, calm down, she's got seasonal allergies.

- The one that got SUPER offended when a nurse did not run out of a isolation room attend to a skin tear that was "gushing blood", and instead called for another nurse. When the tx nurse came flying around the corner, it was discovered that a small skin tear had trickled down and stained about a half inch spot on the ladies sock.

Like some other people have mentioned, I'd be afraid stuff would get put in that was either blown up out of proportion, or just was not communicated to nurse at all.