Documenting the sequence of events that took place as part of the treatment of a patient in a hospital as in-house patient or as an out-patient, is one of the essential responsibilities of a certified nursing assistant or the registered nurse.
It is this documentation that will guide the doctor or specialist physician to plan and administer the right type of treatment.
The CNA should follow some very basic or general reporting guidelines while documenting the patient’s health record or history.
The document should be brief and concise. In other words, unwanted or unnecessary information about the patient need not be part of the documentation. The history or the patient’s record will be reviewed and used for further analysis and planning of treatment by the doctor attending on the patient. As such, brief but relevant particulars should be enough and more detailed information need not be warranted.
The reporting style should be an organized one. The report, or chart, or documentation, in whatever way you, the details should have been recorded in an organized manner in a legible and clear manner. By organized manner, I refer to the sequencing of the events, the medication, the reactions, and such other things that took place in an orderly manner, such that the doctor or the registered nurse can decide on how to move ahead in the treatment.
The document should always contain the relevant data which is pertinent to the present situation. By providing unwanted data, the doctor will get confused and might even take more time to review the patient history.
One important thing that the CNA should bear in mind is that he or she should follow the report by exception method. The document need not contain all the things. Normal course of activities that take place or entrusted for action need not be recorded in the document. But only such things that warrant record and action need to be specifically highlighted, along with the response as well as reactions from the patient for the said course of treatment. Giving normal routine information and missing out on important things is not correct. The nurse should document the essential developments, reactions, or response to the treatment from the patient, such that the attending doctor can take informed decisions about the patient.