March 10, 2015 CONFERENCE CALL DOCUMENTATION FOR C.N.A.s Presented by Dwana Jackson, CNA, AIPP Quality Specialist

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1 March 10, 2015 CONFERENCE CALL DOCUMENTATION FOR C.N.A.s Presented by Dwana Jackson, CNA, AIPP Quality Specialist Good morning everyone and welcome to today s conference call, our topic today is documentation for C.N.A.s. Accurate and timely documentation is vital for communication between healthcare professionals for many reasons. It is used by administrators, state surveyors as well as insurers to evaluate the level and quality of care provided. It is a tool used to provide effective interventions, determine level of reimbursement for nursing services provided, and to make decisions regarding treatment options. As a CNA, we must understand the importance of documenting accurately and regularly and we must fully understand the consequences of not documenting properly. Make sure that you are always following your home s policy and procedure when documenting and/or reporting. A person s medical record is a legal document consisting of all documentation regarding care and services provided. The medical record is a communication tool for physicians and nurses to develop the best care plan and treatment possible for our residents. It may be necessary at times for the medical record to be evaluated by external personnel, such as state surveyors or by attorneys. It is critical that the documentation contained in the medical record portray a clear and accurate picture of the care being provided to the resident. Before we go into more discussion on documentation, it is important that we understand what the nursing process means. We can define the nursing process as the sum total of nursing activities which conducts assessment, intervention and evaluation. Acquiring an understanding of the nursing process should bring awareness to the C.N.A. of how important their role is and how important it is to report and document. The nursing process breaks down as follows: Assessment, Nursing Diagnoses, Care planning, Intervention and Evaluation. Assessment involves continuous data collection to identify a resident s actual and potential health problems. This will involve the nurse obtaining a history from the resident, performing a physical examination, reviewing labs and available medical information. The C.N.A. will assist the nurse by obtaining vital signs, height, weight and record fluid intake and output. Accurate information gathered is vital to report a true picture of the resident. From the nursing assessment, the nurse will determine a nursing diagnosis from which the care plan and interventions will be written. Care planning involves forming a legal document that clearly states care that will be provided as written. The C.N.A. can provide valuable information to assist in forming the care plan and should be encouraged to get involved. The C.N.A. plays a large role in caring out and documenting completion of the nursing interventions. Interventions will vary from resident to resident, as each resident has [1]

2 individual needs. Some examples of interventions are turning and repositioning requirements, toileting, restorative and specific bathing routines. At the evaluation stage, nurses can review the care plans to see what interventions are working and which interventions may need adapting. The nursing process is continuous. It occurs on a regularly scheduled basis, at any change in the resident s condition or when we, as the direct care giver, report a concern regarding the resident. Accurate results are vital in evaluating a resident. The C.N.A. will play a large role in obtaining required data and with performing observations. Observations can be objective and subjective. Objective observations are measurable, such as vital signs, bruises, open skin areas and output from a catheter are some examples. Subjective observations are not very measurable but can still be very valuable and usually come from the resident themselves. Your resident may tell you, I feel sick to my stomach today or I ve got a terrible headache. It is still very important to listen to that resident and report to your charge nurse. Remember to also look at the resident s body language and what that may be telling you. Pay attention to things such as changes in the resident s color, mobility, facial expressions, positioning and if hot or cold to touch. Also pay attention if the resident s breathing is noisy or if there is an unusual odor present. Observations are very important, never dismiss what a resident tells you. Even if you think it is nothing to be too concerned about, report it anyway! It is important for the nurse to assess the resident and decide how to respond to the concern. In order to document correctly, it is useful to have good communication skills. All staff should be able to understand exactly what you are reporting. Make sure you know the correct procedure for reporting and documenting at your home. Nursing homes can vary in requirements and methods to document. Some homes have electronic charting for CNAs and some have a paper system. Have all the relevant facts you will need to document fully. Never document on someone else s behalf, you may not have all the relevant facts or you may not have been present to document a situation. Be aware of confidentiality and that discussing a resident with someone outside of the facility is also considered a serious breach of that resident s confidentiality. Let s look at some typical observation statements: Mrs. Smith says she has a headache, she does this at every bath time! It may be true that Mrs. Smith states that she has a headache at every bath time, but instead of accepting this as normal because it happens frequently, we need to look at WHY this may be happening? Ask these questions: Does she dislike her bathing routine? Is it too hot or a too cold experience for her? Does she prefer a certain team member? Would she would prefer a shower? Maybe there is an underlying reason which needs resolving. The more correct way of reporting this observation would be: [2]

3 Mrs. Smith stated she had a headache when I went to assist her with her bath. Mr. Jones says his foot hurts so he doesn t want to walk today, he s being lazy! Mr. Jones may really be having a day where his foot really hurts so he is not wanting to put any extra weight on it unless he has to. We can always try again tomorrow when his foot may not be so painful. The more factual statement could be: Mr. Jones said his foot hurt so he would like to rest today. See how the correct observation statements are free from bias, opinion and are nonjudgmental, which is how we should be reporting and documenting! Here are some tips on making good observations. Observations must be accurate, accuracy leads to better resident care. Observations should be made in a timely manner so that anything discovered can also be addressed in a timely manner. We should make our observations without bias and opinion, Make sure you report any resident statements accurately and without exaggeration. If you discovery something unusual or serious you must report it immediately. Use good communication skills to communicate clearly with residents and staff to avoid misunderstandings which could lead to serious consequences. Similar tips can be applied when it comes to documenting. Always be accurate to ensure that the resident gets prompt, correct care and treatment. Documentation must be done on a regular basis to keep up to date with progress. Never forget to report your findings and Do Not rely on someone else to report on your behalf. It is your responsibility to report information to your charge nurse. Complete documentation demonstrates the resident s physical, mental, social and spiritual condition. Consistent accurate documentation and reporting on a daily basis builds a true picture of the resident that all staff can get to know and follow. We can track patterns of behavior, bowel movements, meal percentages, to see if a problem is occurring, or not. One shift to another can see what has occurred with the residents. Shift to shift reports are vital for continuity of quality care. C.N.A.s must communicate with one another on shift changes to let the incoming staff know what kind of day the resident has had.. Lack of documentation can lead to problems and leave questions unanswered. The resident will not receive appropriate care if documentation is not carried out correctly. It will not give a true picture of the resident and could cause further health and social problems for that resident. Making assumptions about the resident is not a good practice and could lead to errors and misunderstandings. Always follow your facility policy and procedures. Incorrect documentation can also lead to problems. The resident will not be receiving the quality of care they are entitled to if there are errors in their documentation. Staff may get confused by the errors which can lead to stress and conflicts, staff may not be sure [3]

4 what has or has not occurred. Inaccuracies may result in mis-diagnoses and family members may become unhappy at the treatment their loved one is or is not receiving. Training and education on a regular basis will continue to emphasize the importance of good documentation. Good training ensures all staff know how to document properly and understand the importance of doing so. The home can monitor documentation themselves to ensure care that is provided is being documented, care that is not provided is not being falsely documented as being completed, and care is both completed and documented. Staff need to be motivated to document completely and accurately every time! If you are documenting and reporting accurately and regularly you are doing your job correctly. Examples of mistakes staff sometimes make in documentation and reporting are waiting until the end of an eight to twelve hour shift to document care provided to six or more residents during the course of a shift. This can lead to inaccurate documentation and potential negative healthcare outcomes for the residents. By quickly and carelessly filling out documentation, errors can occur, such as documenting on the wrong resident, or not providing a clear statement that will be understood by others. Re-read what you have written. Does the message have the meaning that you intended? Failing to document changes in condition could prove to be significant information needed to provide quality care. As the direct care giver, you are the first person to recognize critical information about your resident such as changes in skin condition, changes in appetite and/or weight, complaints of pain, changes in urinary and bowel elimination, abnormal vital signs, and changes in mental status. The consequences to not documenting, incomplete documentation, or inaccurate documentation are: Residents do not receive quality care which may lead to injuries, and even death. Nurses and CNAs do not receive information needed to provide quality of care. Nursing Supervisors do not get the information needed to determine if care has been effective. The home may be citied for a deficient practice related to lack of documentation and the home may even suffer legal ramifications. Accurate reporting means that your residents will receive more appropriate care, staff will be more knowledgeable about their residents care. There will be less time for assumptions and errors to occur. The most positive outcome of all will be better care for our residents, more satisfied families and well informed staff. And as a whole, these changes will lead to a reduced amount of complaints! If you see something you think is not correct, question it! You will either learn something that you did not know or you will prevent something from perhaps becoming an issue. Here are some errors that need avoided: When verbally reporting, don t be in a position where you have to say.. Oh, I forgot to tell you If you report findings promptly you will not forget! [4]

5 Know which resident you are talking about so it doesn t lead to a situation where you say.. Did I say Mrs. Brown? I really meant Mrs. Smith. Two different residents, who may have very different care needs, always clarify which resident you are talking about. There are occasions where residents have similar names or the same last name, again, clarify which particular resident you are referring to. Inaccurate documentation can have a direct effect on your residents. Guessing an outcome is also not accurate or professional. Avoid saying I think Mrs. Thomas ate 60% of her lunch but I m just guessing. This is not a defined result. Remember that making false documentations can be a punishable offense and that you should always follow home s policy and procedures on how to document. Defamation of character is making false or slanderous comments about another person. Libel is a derogatory written statement. Slander is a negatively spoken statement. Make sure you are professional in your work to avoid these areas. In order for a resident to receive appropriate care, there must be appropriate documentation taking place. In healthcare, If it is not documented, then it did not happen. It is much harder to prove an incident occurred if there is no documentation to follow or the documentation is inaccurate. Always do your documentation every shift, it is a legal form of evidence that you are providing the care that is stated in the care plan. Therefore ADL care plans should not be used as notepads or have artistic doodles added to them. They are a legal document promising care as it has been written and could be used as evidence in a legal case. Many homes are now utilizing computerized documenting which includes inputting the ADL care as it is provided. Make sure when using this method that you access areas you are allowed to obtain, record all your information accurately and do not share with others your password or identification code. Follow your home s policy and procedure on using the electronic charting of records as it relates to the CNA. It is very important you report and document what you see, hear, smell or feel when caring for your residents. Remember as a C.N.A., you may be the first to encounter something as you see and assist your residents every day. As the direct care staff, you are the eyes and ears of what is going on with your resident. Even if you think something has already been reported, do check and report anyway, to find out what is going to be the next step. Your Charge Nurse will tell you, they would rather hear something from five different staff members than not to hear it at all. Always follow your home s policy and procedures and check with your charge nurse if you are unsure about anything. AIPP has resource tools for nurses and C.N.A.s to assist with improving documentation and reporting which can be accessed at our website, aipp.afmc.org. You will also find the minutes for today s conference call. Our website once again is aipp.afmc.org. [5]

6 In closing, be inspired to correctly document and report every shift! Your residents depend on you to ensure care is provided and to be their voice when necessary. Know your residents and their individual plan of care. And I challenge you to get to know your resident, personally, beyond the plan of care. Communicate with your charge nurse on a regular basis each shift and follow up where necessary. Observing your residents is a continuous process and we must all document accordingly. Thank you all for the hard work you do and thank you all for listening to today s conference call, have a great day. [6]