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Sunday, March 27, 2022

Documentation Tips for Nursing Assistants

These slides focus on documentation tips for nursing assistants. Providing health care in today's world requires not only excellent hands on skills at the bedside but also accurate and complete documentation of care provided. How do you measure up?

Directions

  1. Click on the first slide below.
  2. Click on each slide or on the next thumbnail to advance to the next slide.

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Documentation Tips for Nursing Assistants

Basics of Documentation

Examples of What a Nurse Aide Documents

Important Concepts about Charting

If it is not documented, it did not happen


Include the date, time, and signature on all documentation

Chart as soon as possible after care and never chart before you do something

Write legibly

Be systematic



Be accurate

Chart only objective data

Use quotation marks for statements

If you report something outside of normal limits, include that in your documentation

Only use abbreviations approved by the facility

Correct entries by facility policy

Only chart care you provided

Documentation Tips to Assist with Extraordinary Care