A CNA's documentation should include ...

A CNA's documentation should include ...

• A. Speculation about the resident's future health.
• B. Objective observations about care provided and changes observed.
• C. Medical diagnoses.
• D. Personal opinions about prognosis.

Answer: (B)

The main idea is to keep CNA documentation objective, factual, and focused on care given and what is observed. A CNA should record what was done for the resident and any changes in their condition or responses to care. This type of note supports clear communication among the care team, continuity of care, and a reliable record for accountability and legal purposes. It’s important to avoid including speculation about future health, medical diagnoses, or personal opinions about prognosis, since those are responsibilities of licensed professionals. For example, you might document: the care provided (assisted with bathing and dressing) and the resident’s responses (tentered cooperated; skin intact; tolerated procedure without distress; any changes noted in appetite or condition).

The main idea is to keep CNA documentation objective, factual, and focused on care given and what is observed. A CNA should record what was done for the resident and any changes in their condition or responses to care. This type of note supports clear communication among the care team, continuity of care, and a reliable record for accountability and legal purposes. It’s important to avoid including speculation about future health, medical diagnoses, or personal opinions about prognosis, since those are responsibilities of licensed professionals. For example, you might document: the care provided (assisted with bathing and dressing) and the resident’s responses (tentered cooperated; skin intact; tolerated procedure without distress; any changes noted in appetite or condition).