Hello and welcome to our guide on CNA Charting Sheet.
In this article, we will go through CNA Charting Sheet and how Registered Nursing Assistants need to address them in their health care careers.
We will touch on the following topics:
- What are essential tools and supplies for CNAs?
- What is a CNA Charting Sheet?
- What are the parts of the CNA Charting Sheet?
- How do you use the CNA Charting Sheet?
- Where can you find CNA Charting Sheet?
To get a better idea of how CNA Charting Sheets are structured and their use in day-to-day nursing operations, stick with us until the end of this article!
What are essential tools and supplies for CNAs?
CNA supplies equip Nursing Aides with the ability to do their duty correctly and efficiently.
One of the Nursing Assistant’s main roles has been to support their supervising nurses not only with the labor of patient care but with the observance of the patient’s condition as well.
There is other relevant documentation that fills in the role of Nursing Charting Sheets, such as flow sheets and brain sheets.
Daily charting and note-taking can consume a lot of time and effort, and that’s why one person must be dedicated to this art and science.
However, in this article, we will focus on the CNA Charting Sheet, and how useful it has become in hospitals, nursing homes, home health situations, and the like.
A CNA Charting Sheet is a useful tool that helps Nurse Aides keep track of vital information about their patients, which needs to be reported to the supervising Licensed Practical Nurse (LPN) or Registered Nurse (RN).
CNA Charting Sheets are part of the caregiver and Certified Nursing Assistant’s toolkit, and they are helpful for patient care operations.
This is a critical task that is fulfilled by a CNA, especially when dealing with long-term care patients who need utmost attention.
Charting or documentation is a critical process in the Nurse Aide’s role, as well as the care plan of the patient.
Keeping track of the day-to-day through these documentations is important because it creates records that can help track the patient’s health in the future.
They are usually done during the change of shift report so that the Nurse manning the night shift receives pertinent information about the patient in what happened during the day shift, and vice versa.
Because CNA Charting Sheets can become so technical, Nurse Assistants must be knowledgeable on how to use these documentations wisely, including understanding various terms and abbreviations.
Aside from having proper information for the use of the health care team, they are also critical notes when dealing with the insurance company and the like.
For example, in Medicare, the United States’ national health insurance program, they require that the clinical assessment of certified nursing homes must be compliant with the Minimum Data Set (MDS).
Given this requirement, the hard work of the Nursing Assistant on charting does not go unnoticed.
What are the Parts of the CNA Charting Sheet?
While there is no standard CNA Charting Sheet in use by the worldwide industry, there are a number of sections and lines of information that the typical chart includes in its format.
Templates for the documentation can be found provided by the administration of your institution, but they can also be designed from scratch or downloaded from free resources online.
Here are the typical parts you will find on such CNA Charting Sheets:
Patient Identification Details
The CNA Charting Sheet is dedicated to one patient as part of their medical records.
The correct patient name should be cleared at all times, to make sure that the medications and procedures are being performed on the correct person.
Patient Pertinent Medical Information
What is the reason that the patient is admitted?
With this consideration in mind, you can keep track of any day-to-day symptoms in the charting sheet, and this will help registered nurses and doctors understand the progress of the patient’s condition.
This can also include any symptoms observed in the patient.
Other things like menstruation and the condition of the patient’s excrement are also critical information.
Vital signs are critical information that measures the state of the patient.
The following are measured to give an accurate picture of the patient’s situation:
- Temperature, whether measured via axillary, oral, or rectal methods
- Oxygen and Breathing
- Blood Pressure
Typical for bedridden patients, nurse assistants need to take care of the daily procedures of the patient.
The following may be done in the duration of the day:
- Dressing (mention state of the wound, presence of discharge, and the like)
- Medications (when they were taken, the schedule of administration)
Nurses can also log the meals that the patient has had, and also make notes about how the food has followed the diet prescribed to the patient.
Activities of Daily Living
Other than the typical procedures that are being done on a daily basis, it’s also important to track the daily living habits that are enforced during the admission of the patient.
There are five important ADL daily tasks that nursing assistants typically take care to note.
Bathing and Hygiene
This refers to helping the patient take a bath and other hygiene and self-care activities, such as brushing teeth and grooming hair.
This refers to helping the patient get to the toilet, clean up, and get back to the bed or the room.
Any notable matters should be paid attention to, such as episodes of incontinence and the like.
If the patient has any dressings which need to be changed or reinforced, the schedule of these activities is also recorded.
Ambulation, of the independent ability to walk from point A to point B, is an important measure.
Functional mobility can also refer to the ability to walk or to get up from a bed or a chair.
This refers to the eating habits that the patient has during their admission or bed rest.
This does not include their ability to chew or to swallow, just their ability to feed themselves.
If there is other relevant information that should be reported to the nurses and doctors, but doesn’t necessarily fit into any of the categories listed above, it can be added to the notes section to indicate the nature of the memo.
In this section, you identify yourself as the employee who is completing the daily documentation, and you confirm the veracity of these figures.
This signature needs to be visible, but should not interfere with the rest of the chart’s contents.
Aside from the resident’s name, you need to apply your signature on the sheets that you have prepared.
How Do You Use the CNA Charting Sheets?
CNA charting sheets are usually filled up at the end of the nurse’s shift.
Despite being filled up at the end of a shift, it’s important to take notes throughout the duration of the time range, because you might forget important details that are necessary for the nurse covering the next shift.
Always make time for charting within the busy schedule, so that you can give ample attention to your handwriting and the exact figures and details that you have observed in the patient.
Nurses are also advised to keep their sheets neat and free of erasures – even to the point of restricting the color of the pens used in charting, as to avoid distracting colors and unnecessary differences in the presentation of the data.
Always remember to use objective observations in your charting duties – while nurse assistants can help with making sure the patient is comfortable and humanized, they should not give opinions and should reflect the facts.
Where Can You Find CNA Charting Sheets?
If you are a nursing assistant, it’s important for you to find a charting sheet that is helpful to your day-to-day operations.
While you need to submit the proper sheets on the mandated charting system and perhaps even on electronic medical records, it helps to have your own charting sheet and take notes throughout your shift.
Provided by the Institution
There may be charting sheets that you are mandated to use by the health care team in your institution.
They may even be specialized for the department you are working in, like the ICU and the like.
Free downloads online
There are a lot of free options made available by fellow nurses online. You can see that they have the basic layout with some typical categorization.
These printable options also come in a variety of templates and formats – and more often than not, they are designed by real nurses so you can be sure of their trustworthiness.
Customized by Yourself
Thanks to word processing software and even online document creation tools, you can also have customized sheets done by yourself, according to your needs and preferences.
CNAs have an important job that requires a lot of attention to detail and careful tracking of details.
Thus, one of their most critical tools includes the CNA charting sheet, which requires full attention and a knack for communicating issues and concerns properly.
While it may seem a tiring and thankless job, charting is one of the activities that ensure the safety and protection of a patient at all times.
Where should a CNA document data?
A CNA should document data in the correct sheets, signed, and without erasures. The sheets should be well-organized, have sections for each expected type of patient care being administered, and be completely legible by anyone who has come across the sheet.
What is a flow sheet?
A flowsheet is a one to two-page document that summarizes the patient’s condition and is used within the patient’s chart. It helps doctors look back to the appointment and understand if the patient care has been administered properly and professionally.
What is a brain sheet?
A brain sheet is basically a written system that a nurse has devised for themselves to collect important data about the patient throughout their shift. This could be as simple as jotting down notes throughout the day and updating these notes as the situation of the patient changes.
Centers for Medicare and Medicaid Services