There are two basic kinds of reporting that certified nurses’ aids are responsible for. Residents’ charts are legal documents that will go to court in the event of a lawsuit. Oral reporting lets your supervisor and the next shift know how the resident is doing and what you have done for him or her during your shift.
Charting: Everything you do for the resident should be reported on the chart. If you do not document what you do there will be no way of proving that you did it. Many institutions have forms to make your job easier by giving you places to check to show that you gave routine care. If you are faced with a blank piece of paper you will have to write everything you did individually. In addition to routine care, you will note any activities you assist with, such as helping a resident walk down the hall, and anything the resident does unassisted, such as going to the dining hall on his or her own. This will give the reader an idea of what was done for the resident and what his or her capabilities were at any given time.
When you take vital signs at the beginning of your shift, write them down in your notebook and take them to the nurses’ station, where there will usually be a form for writing down all residents’ vital signs. Later you or the ward clerk can copy them into the chart, but vital signs should become available as soon as possible in case the doctor or nurse needs to get a quick idea of how the resident is doing.
Remember that the chart might go to court some day, and what you wrote could protect your certification, so be careful not to leave anything out. If you change the linens, for instance, before leaving the room you would put the side rails back up and lower the bed. Charting this information could be important if the chart were to go to court. If the resident were to fall out of bed you would need to prove that you acted correctly in providing the resident with the safest possible environment.
Change of shift report: Oral reporting is done routinely at the end of each shift so that the incoming people will know what has been done for the residents during the last shift and how well the residents are doing. If the resident has been restless during the night, for instance, and you report this, the day shift will understand when they see the resident acting tired during the day. If your resident refuses to take a bath or shower during the day, the evening shift might be able to persuade him or her to wash at that time.
Emergency reporting: Oral reporting might also be necessary if an emergency should occur. If your resident falls, for instance, you will need to find out if there is any pain or bleeding, and report this immediately to your supervisor.
Incident Reports: When something goes wrong, such as a fall, your supervisor will need to fill out an incident report, and you will be asked to state everything you observed and did. The report could go to court, so be sure to include everything accurately and precisely.
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