pt changes


i work at a hospital as a CNA and i'm going to school so my scheduled work days can be spaced out. and there are times were i come on and a pt has deteriated mentaly from the last time that i was on. last week i had a pt that had gone from being able to feed, wash, and care for her self in general, to a total care. and due to a poor turnover i didn't know about the change. long story short she missed breakfast, whitch was normal for her "she didn't like to be bothered befor 8:00", and then she didn't eat lunch her tray was left untouched. after telling the nurse i was told she had to be feed. any way i looking for an easy and accurat way to chart in our cna charts to show mental status. i've been given the ok from the don to added to the chart but it has to be understandable for all our aides. i was already told no on the Glasgow coma scale. any suggestions welcome. i don't like that it happened and i want to prevent it from happening again. thank you.


634 Posts

Specializes in ICU. Has 1 years experience.

Our printoffs for our patients include an "alert and oriented" section where nursing staff can fill in the LOC, mental status, etc.

Also on the "diet" sectopm there is a place to add on "feeding assistance required" where we also add things like "thicken liquids" etc.

What about something like this?


4 Posts

our sheets have both the "alert and oriented" and space on the diet section to inducate that. but no one is useing the "alert and oriented line." i'm looking for somthing as simple as i can that way there is no ecuse to why its not used. i think the nurses use that system you linked to but that is in the pt's chart and aides only have axeccs to the cardex

and with the diet line, not realy night shifts fault there aren't any meals that they cover so they wouldn't know to show that unless the prevous day shift told them. i think the big problem is turnover policy and practice. which were in the middle of changeing the policy.

really all of the aides do a good job charting but on everyone of them the alert and oriented line is blank, it may just be me but thats something i would like to know before i start helping someone.

i'll see if i can get that link printed out and see if thats what the nurses are using now if it is than i'll see if they could just add that to the cardex. the worst she can do is say no. thank you