Medical Record Documentation and Legal Aspects Appropriate to Nursing Assistants
The patient`s medical record is the only place where patient information is legally stored. Documentation is not difficult, but it must be done well. Your charts are just as important as those of any other member of the healthcare team. At each layer, your observations provide a basis for each patient`s condition and can be critical in determining a change in the patient`s condition. Remember, your patients rely on you, so take pride in your records. One of the most important aspects of CNA`s training is the creation of appropriate documentation. Licensed practical nurses should keep an eye on all relevant information such as vital signs and the patient`s food intake when caring for patients. Here are five essential rules for licensed practical nurses. Mapping makes it easier for all members of the medical team to communicate. As a licensed practical nurse, you need to find the right balance between precision and conciseness. You should always check the contents of your letter before signing it, and you should provide all relevant information. Florida`s laws are very specific about CNA`s role in long-term and home health care.
You can only work under the direct supervision of a registered nurse. Direct supervision means the actual presence in the patient care unit of a health care facility or the actual presence within a health authority of a program manager who assumes responsibility for the practice of the licensed practical nurse (Nursing Practice Act, 2009). This means that the certified caregiver cannot work alone or make nursing decisions regarding resident care. Keeping track of everything that happens to each patient is an essential part of documentation, also known as a record. As a CNA, since you spend more time with patients than anyone else, you should be able to keep a detailed spreadsheet. Failure to correctly understand care could lead to two serious consequences. If you can`t read your notes, you`ll never get anything. It is important that you are objective in everything you do. You need to use precise terminology and describe exactly what you see. A patient with severe pain or a pain level of nine out of ten on a 10-point scale is acceptable. According to Florida state regulations, a licensed practical nurse means caring for and assisting people with tasks related to activities of daily living.
These include personal care, residents` or patients` rights, and documentation of nursing assistance services (Florida Legislature, 2009). If laws are not followed, CNA may be liable and may lose its licence. Legal documentation requires careful mapping. The old adage “if it`s not mapped, it won`t be done” is very important. CNAs are usually responsible for mapping bathing, care, feeding, excretion and mobility. Learning to record facts, only what you see, not what you feel, is difficult. A CNA is a certified licensed practical nurse. A CNA operates under the direction of a registered nurse.
CNAs help care for patients, including bathing, dressing and eating. They also record patients` vital signs and track their medical records. A certified practical nurse (CNA) is a person who has completed a training program and passed a state-administered examination. CNAs are also known as nurse aides, patient care technicians, home care assistants and nurse aides. They work in a variety of settings, including hospitals, nursing homes, assisted living facilities and home health organizations. CNA`s duties include providing basic nursing care to patients, assisting with activities of daily living and recording vital signs. One of the most important tasks of all health professionals is to produce proper documentation. Documentation, also known as mapping, is a clear and accurate way to track everything that happens to each patient. It`s part of CNA`s job description, a way to communicate with other team members about the patient so the team can plan and deliver the best care. Never.
Once an entry is made, it must be permanent. Electronic health records do not allow for change, but paper cards should not be changed either. If you make a mistake, follow your institution`s guidelines. Many institutions accept a single line by error with the date, time and your initials. Never remove, blacken or use corrective fluid. Vital signs are crucial in patient management. It is important that the team understands the patient`s health and can help plan and provide the best possible care. You can help monitor a patient`s progress and adjust required care by recording vital signs and measurements. As electronic health records become more widespread, written documentation will decrease. However, it is likely that the patient`s record will always contain paper forms or other written documents.
If your note cannot be read, it is useless. The Nursing Practice Act and Standards of Care define what a licensed practical nurse can and cannot do, even with supervision. Activities of Daily Living (ADL) duties include maintaining mobility, feeding, disposal and information gathering (Nursing Practice Act, 2009). Information collected by a CNA may include the amount of food consumed by the resident, bowel movements, height and weight, temperature, pulse and breathing. You need to know what is normal and what needs to be reported to your nurse. As you can see, this information is very important for the nurse. These are the eyes and ears of the nurse you work with. Remember to follow your guidelines (scope of practice) to make sure you don`t get into legal trouble.
