Documentation

Is it common for CNA's to chart in the nursing notes? I've only worked in one hospital, but none of the CNA's in any dept ever documented anything in the nursing notes. They would record vitals on the vitals flow sheet but that was it. Also, that's how it was at the various other hospitals that I did clinicals at in school.

Just wondering if it is common or simply something that is done at the OP's facility.

Unfortunately, CNAs are not taught to assess, so, they really don't know what information is silly, versus what is not...but I do know that sometimes, some CNAs try to grate your nerves on purpose. Bottom line, again, is that they are supposed to report and if we start telling them "Only come to me when such and such...", that draws the fine line between reporting and asking them to assess, which is not their function.

I also agree that they should not document that a nurse was notified when they were not, because that is not fair to us. You cannot intervene on something you are not aware of. I have had RNs document that they gave me report and they have not. That leaves me out there, and I hate that. I am an LPN, and I make sure that I inform the RN exactly what is going on and why I am reporting it to them. Also, when I chart that fact that I reported to any medical person, I try to use 'gentler' words, such as 'consulted, informed, collaborated', so that it does not look like an accusation.

Of course, no CNA should be part of discharge planning, teaching about medications, or any nursing functions, because it misinforms the patients and that is not safe.