Description includes
- client/resident/patient medical record (chart)
- admission sheet
- health history
- examination results
- physician’s orders
- physician’s progress notes
- health team notes
- lab test results
- special consents
- hard copy of health records or electronic health record (EHR)—condensed version of medical record
- Minimum Data Set (MDS)
- assessment tool
- provides structured, standardized approach to care
- helps identify a client/resident/patient healthcare problems
- person-centered care plan
- outlines care that the healthcare team must perform to assist a client/resident/patient to attain optimal level of functioning
- written by a nurse (RN or LPN)
- CNA contributes by observing and reporting signs and symptoms.
Refer to Unit II in Nurse Aide Curriculum, Virginia Board of Nursing, Virginia Department of Health Professions, 2018.
Process/Skill Questions:
- What documentation should a CNA review before giving care?
- Why is it important to follow the care plan?
- What documents are available to a CNA for viewing and documentation?
- Why is it important to document care in a healthcare setting?
- What documentation formats might a CNA encounter?