Data Collection & Reporting
Most of the time, CNAs spend their entire working time giving the care to the residents. By doing that they observe the patients and are able to determine problems that needs to be solved as early as possible. Some of these problems need to be found out as early as possible in order to save the resident’s life.
It is necessary for CNAs to have the ability to assess and observe changes in resident’s physical, emotional, mental and social conditions. A resident who might not be socializing well with others may have emotional problems or even deep depression thus noticing reporting it to the nurse can make a big difference in the resident’s outlook in life and well-being.
Even if such changes maybe small, it is important to solve them early before they worsen and complicate the condition of the resident. Vital signs are equally important and should be monitored vigilantly because a dramatic change might be a warning sign that an infection, illness or depression is developing.
Assessing the resident through his or her verbal statements without seeing a physical sign is known as subjective assessment (SA). SA confirms that there is something wrong with the client due to its verbal signals, which can portray pain and emotional distress.
You should keep in mind not to underestimate even the faintest signs of change because this can lead to devastating results in the residents’ health conditions.
Whenever in doubt follow your gut and intuitions based on the previous encounters or experiences and perform a suitable course of action.
When collecting important information regarding the status of resident’s health, keep in mind to immediately report a change in the resident’s present condition to RN or supervisor. If unsure what the exact signs are, ask the patient to repeat himself/herself (subjective assessment) or measure/review the signs again (objective assessment).
Physical changes can be usually seen in the skin in the form of lesions, bruises, rashes, swelling and others. Other objective signs that can be visually observed are body weakness, coughing, vomiting, mood changes.
Documenting changes in resident’s health is an important daily task and it requires skill, especially if the facility uses computers and other devices in recording. The use of abbreviations should also be in accordance to the facility’s guidelines in using medical terms and abbreviations.
If the facility requires observations to be written, use only blue or black ink in writing and print it in a way that they are clear, precise and complete.
All entries should be signed by the person documenting it and if corrections are made then do it according to the guidelines of the facility.
A resident’s chart is a legal record, which has their medical information and condition, therefore do not erase or use an eraser in correcting them. To avoid such mistakes, you can use first a scratch paper to serve as a draft. To make sure that what you chart is correct and concise, you can get help from supervisors or nurses.