CNA charting is one of the most important aspects of healthcare. Its primary use is to enable long term care facilities to track all manners of resident care from admittance to administering medication to tracking ADLs. Proper documentation is an essential part of long term care, and it is the job of CNAs (Certified Nursing Assistants) to accurately enter and monitor resident data. For this reason, CNA charting is often taught during the early stages of CNA training, equipping future CNAs with the necessary skills needed to work on the facility floor.
When CNAs start their CNA training, they receive a CNA curriculum handbook, similar to this student training handbook from the College of DuPage. These student handbooks outline a CNA’s role, responsibilities, healthcare policies, procedures. Of course, the formats may differ depending on the faculty. Still, most handbooks will place great emphasis on proper documentation.
CNAs and other healthcare practitioners must meet the CMS’ requirements for medical documentation, which states the importance of proper documentation to ensure the specific requirements for reimbursement are met.
During CNA training, trainees are shown a charting system to ensure everyone is on the same page and stays organized. CNAs must understand the importance of CNA charting, as a moment of carelessness can result in medical errors leading to potential liability cases. So as trainee CNAs develop their identities as caregivers, they must simultaneously learn the best practices for accurate documentation.
What Information is Documented?
Some of the essential resident data that a CNA needs to include on a resident’s chart is:
- Alertness and consciousness
- Vital signs (body temperature, pulse rate, respiration rate, and blood pressure)
- Weight (appetite and food intake)
- Bowel movements (solid, semisolid, or liquid waste)
- ADLs (ambulation, range of motion, catheter care, bandage changes, compresses, and bathing)
- Response and attitude toward activities and care
- Conversations between the healthcare team and family members
All this information is entered into the nursing home management software, enabling nurses and physicians to create a personalized care plan for each resident.
As part of CNA training, trainees are sent to a long term care facility. There, it is expected that they gain first-hand experience of what it’s like to care for residents. Depending on the facility, some may use traditional paper charting, while others may have implemented a state-of-the-art long term care EHR.
The chosen charting method for each facility will be different, especially if a long term care software system has been implemented. Efficient long term care EHR systems will have a point of care charting module, which helps CNAs easily track and update resident data. This helps reduce medical errors while maximizing compliance with regulations. In facilities that have implemented a long term care EHR, CNA training will include exercises that use the nursing home software and the related software tools.
7 Tips to Improve CNA Charting Sheets
When it comes to CNA charting sheets, new and experienced CNAs stand to benefit from improving their charting processes and their documentation accuracy. Some tips they can follow to improve their CNA charting sheets include:
Resident medical records are legally-binding documents. Therefore, it is essential to chart everything. Neglecting to chart medical care means there will be no evidence that care needs were provided, and this can have dangerous consequences. For example, suppose a CNA does not update a resident chart to include treatment or medication. This can create a problem during a handover shift, as the next CNA will not know what care has taken place. This can result in medication being administered twice, which can negatively affect the resident’s health.
- Chart Immediately
It’s best practice for CNAs to update their CNA charting immediately after administering care. If treatments are not charted immediately, there is a high chance the CNA will forget certain details or even forget that treatment was provided to the patient or resident. The staffing crisis has only exacerbated this problem, as nurses are more shorthanded than ever. Immediate charting is far easier in a long term care software system, which can be accessed through portable devices that allow CNAs to update resident care plans while still with the resident.
- Be Systematic and Accurate
It cannot be stressed enough just how important it is for CNAs to be systematic and accurate when updating their CNA charting sheets. CNAs should double-check data entries and pay attention to details like spelling, name, dates, and time. It can be challenging for CNAs to enter this data, especially if they use paper documentation, which is prone to human error and illegible handwriting.
A long term care EHR software system ensures clear and concise CNA charting. Further, long term care software provides a comprehensive view of what care has taken place. Nursing home software systems with a point of care Kardex tool can help facilities save two to three hours every day from tiresome administrative tasks like sifting through documents. An electronic Kardex gives nurses a convenient view of critical resident information on a single screen, allowing them to spend more time caring for their residents.
- Be Objective
The purpose of CNA charting is to provide accurate documentation for resident care. For CNAs, this means being objective when entering data into resident charts and being precise with the terminology they use. This makes it easy for all staff members to understand what care has taken place. Note that when CNAs in the same facility are trained to use the same terminology throughout the charts, medical errors can be minimized.
- Practice responsible Charting
Sometimes, it can be tempting to help other CNAs with their charting, especially when they are busy with other responsibilities. However, CNAs must avoid filling in a chart on behalf of another CNA, especially if they did not provide care to the resident. Otherwise, charting errors are likely to occur.
- Communication is Key
Communication between medical staff is vital to ensure a high quality of care. For example, if a CNA observes bad documentation practices, they should report it to a senior nurse or a physician. This helps ensure that all documentation in the care plan software is accurate and complies with regulations.
- Embrace Technological Advances in Charting
Long term care EHR software systems simplify CNA charting by storing resident data in a centralized location. Only authorized staff can access resident information when needed. This improves efficiency and workflow, thus allowing CNAs to spend more time with their residents.
As was mentioned earlier, a long term care EMR software with a built-in Kardex tool allows CNAs to view resident data on a single screen. Also, a Kardex screen comes color-coded for critical information like DNRs and pop-up warnings giving CNAs a real-time understanding of a resident’s condition. This allows physicians and nurses to be quickly notified when there is a change in a resident’s condition, thus offering better care.
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Using CNA Charting Examples in Nursing Homes
Facilities will generally provide CNA charting examples to be shared with trainee CNAs. These allow them to visualize the CNA charting process. A recent development is that nursing home software systems with a Kardex tool allow CNAs to print color-coded CNA reports, giving CNA trainees a mock physical copy of CNA charting sheets. This way they can study and identify any inaccuracies during training sessions.
Of course, one of the most effective ways to teach trainee CNAs about CNA charting is through first-hand experience. By being on the floor, assisting residents, and experiencing real-life obstacles CNAs face when providing care, trainees put theory into practice. This ultimately leads to them learning to use CNA charting sheets and gaining confidence in using a CNA documentation sheet. Free online EHR training is another good resource for CNAs.
The Value of CNA Charting
As we know, the long term care industry is highly regulated. Hence, facilities must adhere to the many quality and safety regulations to produce accurate CNA charting. Producing accurate documentation can be time-consuming, especially if a facility uses paper documentation. This is why many facilities have transitioned to using long term care software to ease the process.
Beyond the regulations, CNA charting also helps to improve the interpretation of resident data. Although new CNAs may struggle with their administrative duties, they should note that CNA charting will become easier and more fluid with time and practice.
Facilities must prioritize training sessions that help improve CNA charting, as it can affect efficiency and resident outcomes. The CMS has also published a documentation toolkit to support healthcare providers with a checklist of resources to review for further documentation information.
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