Do you chart what you do?

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This topic contains 3 replies, has 4 voices, and was last updated by Profile photo of RNHiker RNHiker 10 months, 4 weeks ago.

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    CNAs doing actual patient care in my ER is fairly new (Before they were monitor techs and hardly ever left the desk) so I was wondering how much charting you do as a CNA. Some CNAs will do the vitals and then hand me a piece of paper with the vitals on them, and want me to enter them into the chart or they will tell me that the patient has a red spot on their buttocks they noticed while cleaning up after a bed pain (If they told me this, I would actually go look for myself and chart what I saw, but either way, I think the CNA should be charting.)

    For a long time, the CNAs didn’t even have access to the e-chart, but now that they do, I find it more helpful if they chart what they actually do.

    Any thoughts on what should be charted by the CNA and what is ok to verbally report to the RN?

    Profile photo of Mike510

    Absolutely yes. I worked at a nursing home to start, then transferred to a hospital in my same healthcare system. Charting is a must. I’ve gone through everything from a headset to paper charts to computers all in 3 years

    Penny P

    I work as a student nurse in a University Hospital and they treat us the same as the CNAs. In our facility our nurses have a 1:5 ratio and we can have up to a 1:8 ratio. Normally I have a 1:6 ratio on my unit and I am expected to chart input,output (in detail i.e. 50% of sandwich and 100ml water), baths, walks, dressing changes, linen changes, output from drains and description of that output, safety precautions, and vital signs of course. Sometimes I think that we should not be charting a description of output from drains or wounds when we do a dressing change. In nursing school they always emphasize that the nurse is the one who assesses things not the nurse assistant. I also have nurses who hound me all day about completing my charting when I am running from room to room. I know the extreme importance of charting and it’s legal implications, but when they are constantly giving me things to do and then act surprised that it’s not done yet, it’s really frustrating.

    Profile photo of RNHiker

    Charting is the monster of medicine, however, EMR (Electronic Medical Records) are great in comparison to the old paper charts–but you have to be able to chart on both.

    However, while I appreciate the CNA who charts their participation, it is ultimately my responsibility as the RN to be sure it is done. With that said, this ends up being my choice whether to hound the overworked CNA who is, in my opinion is a God Send, or to let them get their job done and let me take care of the charting. If my CNA and I are effectively communicating, the charting chore can be easily completed.

    Why do I take this position? Because I have not forgotten when it is like to be a CNA.

    Personally, I believe every RN should perform a shift as CNA to help them remember, and I more forcefully believe hospital managers who no longer perform patient care, perform an RN shift once every two weeks to understand what they expect others to accomplish.

    The maxim, “If it isn’t charted, it didn’t happen,” has become an insidious as well as ravenous consumer of the nurses daily life.

    Do I agree with it… surprisingly yes. Accurate, quality charting can not only save your career, but clearly account for those over-time hours you will consume doing just that.

    What is a great tool to keep all of this in check? Take the time to learn to type well. This will take time and will not always be perfect–just look at thsi emaill!!!

    Good luck.

    – Luis, ICU RN

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