Describe the documents that are used by the healthcare team to communicate information and needs of a client/resident/patient.
Description includes
- client/resident/patient medical record (chart)
- admission sheet
- health history
- examination results
- physician’s orders
- physician’s progress notes
- health team notes
- lab test results
- special consents
- hard copy of health records or electronic health record (EHR)—condensed version of medical record
- Minimum Data Set (MDS)
- assessment tool
- provides structured, standardized approach to care
- helps identify a client/resident/patient healthcare problems
- person-centered care plan
- outlines care that the healthcare team must perform to assist a client/resident/patient to attain optimal level of functioning
- written by a nurse (RN or LPN)
- CNA contributes by observing and reporting signs and symptoms.
Refer to Unit II in Nurse Aide Curriculum Links to an external site., Virginia Board of Nursing, Virginia Department of Health Professions, 2018.
Process/Skill Questions:
- What documentation should a CNA review before giving care?
- Why is it important to follow the care plan?
- What documents are available to a CNA for viewing and documentation?
- Why is it important to document care in a healthcare setting?
- What documentation formats might a CNA encounter?