Tips on charting for CNA's

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Charting was one thing I did not learn when taking my certification classes. I've been an aide for over 6 years working on med surg and ICU. I like to chart in the nurses notes. Not only does it not happen if it isn't charted, but the dr can read my notes knowing that I see pt's more than the nurses and the nurses can read up on what is going on with their pt's. Of course I tell them important things such as abnormal vs, bs, etc, but I think you all know what I mean.

Can anyone give me do's and don'ts of charting? Mostly my charting is related to how the pt ambulated, if he/she was short of breath, etc. I stick to the facts - that's the right thing to do I hope.

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Specializes in Cardiac Telemetry, ED.

I'm not sure I understand what you mean. In all my time as a CNA and now as a nurse, CNA charting is limited only to whether delegated tasks were completed or not. Assessing and documenting the patient's condition is the nurse's role, and is not within the CNA scope of practice.

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We are expected to chart ambulation, turns, etc. and how pt handled these tasks. Our NM stressed that aides need to do more charting in nurses notes.

For ex: pt's BP is high. I chart that under vitals and then go to nurses notes and write what BP was and what nurse was notified. And if a glucose was low, I chart the results, nurse notified, and whether OJ, snack, etc was given (after notifying nurse and asking him/her what their preference is).

I don't assess.

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Just curious - are you charting during the shift? Most nurses don't get to sit down and chart until they're on a euphemistically-named "break" or until the next shift has relieved them. If you are charting during the shift, like when things actually happen, which, BTW, is ideal but unrealistic in most settings tody, who is working the floor?

As for your question - why not ask your manager. If she wants you to chart, she should teach you how, it seems to me. How does she expect you to know this if she doesn't teach you/send you to charting class?

In a way, you are assessing. You are determining presence of absence of or degree of tolerance the patient had for ambulating or whatever, with regard to SOB, dizzyness, sweating, weakness, and so on. You really need to go by facility policy and procedure so I think getting the manager to maybe put it in writing and teach you how to comply with her wishes is the way to go.

I'm glad to hear you are quickly informing the nurses of abnormal VS, glucose readings, untoward events while ambulating, etc., and not charting these first.

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Just curious - are you charting during the shift? Most nurses don't get to sit down and chart until they're on a euphemistically-named "break" or until the next shift has relieved them. If you are charting during the shift, like when things actually happen, which, BTW, is ideal but unrealistic in most settings tody, who is working the floor?

I *try* to chart as I go. If I get a minute I'll chart. I'll chart on my breaks - but I guess that wouldn't be a break would it? :) If a call light goes off, I finish my charting and answer it. My notes are short and sweet, they're not long paragraphs that some nurses write. And nurses and the other aides will gladly answer lights if they see I'm busy charting. I'm not the only one capable of answering call lights.

I understand your concern re: assessing. But, if I see a patient who is obviously short of breath and RR are 60 I can assume that that pt is in distress. Would that be considered an assessment? If so, I've been assessing for over 6 years. I wouldn't slap O2 on them without first consulting the nurse ever.

I'm not trying to be difficult or start a war. Just want to do a good job. As far as asking my NM, she is the one who told me "I don't know how to do floor nursing". She's been a nurse for over 25 years.

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Specializes in Community Health, Med-Surg, Home Health.

I used to chart when I worked in psych as a tech. I did the same, charted what my duties were and what was reported to the nurse, that is all. For example: "Blood pressure 186/102, pulse 98, Resp 22, Nancy Nurse, RN notified", document their fingersticks, the patient's activity ie, sleeping, sitting, watching television, fighting, etc... We also documented every 15 minutes on patients that are on one to one, close observation or in restraints. Very basic. As a CNA, I would just document the facts, no assessments, and then, tell the nurse. If there is a policy for CNAs to document, then, make sure you do, even if the nurse has already written her note. This way, you are covered in case they try to say that you didn't report. And, sure, I would ask the supervisor what they expect you to chart and how.

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Specializes in progressive care telemetry.

Where I work we chart on the nursing notes and it's all fill-in-the-blank type charting. There's a (teeny) box for pretty much everything we chart and not much else unfortunately.

I do remember from PCA class that you only write your observations and don't put any value on them. Like if you drain a foley and the urine has blood in it you don't write "bloody urine" but rather "red tinged urine" or something like that. Even though everyone and their brother can see there's blood in the urine you don't know that for certain so you don't put it down. Same thing for any valuables that you are documenting. Never write "gold chain" or "diamond earrings". They taught us to write "yellow metal chain" and "earrings with clear stones" or something like that.

HTH!

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I *try* to chart as I go. If I get a minute I'll chart. I'll chart on my breaks - but I guess that wouldn't be a break would it? :) If a call light goes off, I finish my charting and answer it. My notes are short and sweet, they're not long paragraphs that some nurses write. And nurses and the other aides will gladly answer lights if they see I'm busy charting. I'm not the only one capable of answering call lights.

I understand your concern re: assessing. But, if I see a patient who is obviously short of breath and RR are 60 I can assume that that pt is in distress. Would that be considered an assessment? If so, I've been assessing for over 6 years. I wouldn't slap O2 on them without first consulting the nurse ever.

I'm not trying to be difficult or start a war. Just want to do a good job. As far as asking my NM, she is the one who told me "I don't know how to do floor nursing". She's been a nurse for over 25 years.

OMG!!:no::bugeyes::confused: What ever did she mean that she doesn't know how to be a floor nurse???

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OMG!!:no::bugeyes::confused: What ever did she mean that she doesn't know how to be a floor nurse???

One holiday we were short staffed and she took one easy pt and was charge.

She had to ask how to do assessments. How to use the pyxis. How to use the computer charting system.

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