Documenting the details of the patient and the mode of treatment provided during his or her stay in hospital is one of the responsibilities of a registered nurse, or a certified nursing assistant as per the instructions of the RN.
It is very important that the nurse knows clearly and understands categorically what he or she should NOT do as part of documentation than knowing what should be done. Because wrong information or misleading information can be more harmful that one actual fact getting missed out from reporting. The nurse should not miss out the actual data that needs to be recorded. Missing out to report an actual data will be considered only a minor mistake, while documenting unwarranted information will be a blunder and might have bad consequences from the patient’s point of view.
The cna should not do the following things at any point of time.
1. The nurse should always only provide the actual facts. He or she should never document any personal opinions in the chart sheet or patient’s history. The nurse should know that what he or she is documenting will be used as a reference material for future use and for vital decision-making.
2. Documentation refers to the recording of facts or incidents that have already taken place or occurred. Things that will happen at a later date or after some time should be part of a plan and should NOT be in the document chart. The CNA should record only the things that actually took place.
3. Any report or information, once recorded in the chart or documented, should NOT be erased or destroyed from the document or history.
4. The recordings in the chart or the documentation should be written in a continuous manner and no blank space should be left in between the events. There should be NO blank space in the documentation.
5. The CNA or the registered nurse should ensure that the document contains only the medication and treatment measures advised by the doctor attending on the patient. He or she should not record any medication advised by a third person.
The CNA or the qualified nurse should always bear in mind these essential guidelines as to what should not be recorded in documentation.