2 Contact Hours Cna Documentation

Course overview

Each state develops standards of care, ethical practice guidelines, and sets the scope of practice for the CNA. It is important to follow these directives that will be used to evaluate practice – including requirements for documentation. Documentation is formal communication regarding a patient or resident, entered on a medical chart or similar form. It is a daily assessment of how the individual is doing. This information is reviewed by state agencies, and determines whether or not the facility will be reimbursed for medical expenses associated with recipients of Medicare and Medicaid. Certified nursing assistants (CNAs) perform basic restorative and nursing services related to the safety, comfort, personal hygiene, basic mental health and protection of patient rights. A CNA has important responsibilities to the facility where he or she works and the residents/patients that he or she assists. This cousre explains role of the CNA in resident/patient documentation of daily care. LEARNING OBJECTIVES: 1. Identify and explain the functions of documentation; 2. List requirements for documentation by the CNA; 3. Describe the categories of care and types of observations that must be documented; 4. Identify information that should be reported to the supervisor; and 5. Explain the CNA’s role in maintaining confidentiality of medical documentation.