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The Nursing Assistant: Documentation

Documentation serves as a legal record of the care received by a resident. As a result, it can be used in a court of law to prove if a resident received appropriate care that is in accordance with State and Federal regulations. The primary form of documentation that nurse aides are responsible for is the Activities of Daily Living sheet.

Duration 15 min
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PRICE:  $0.00

Documentation serves as a legal record of the care received by a resident. As a result, it can be used in a court of law to prove if a resident received appropriate care that is in accordance with State and Federal regulations. The primary form of documentation that nurse aides are responsible for is the Activities of Daily Living sheet. The information on an ADL sheet can help a caregiving team find out if a resident’s condition is remaining the same, getting worse or improving. A nurse aide’s documentation can be critical to the development of an ongoing care plan that addresses a resident’s individual needs. Other types of documentation that may be expected of nurse aides include charting vital signs and recording whether or not a resident is experiencing pain.

This revised and updated program provides an understanding of why documentation is such an important part of a nurse aide’s job, focusing on three main topics:

  • The purpose of documentation
  • Documentation & reporting
  • The consequences of improper documentation
After completing this course, the learner should be able to:
  • List 4 things that are required to provide proper documentation
  • Provide 3 reasons why documentation is important
  • Describe 2 situations of how your documentation can help a resident
  • Provide 3 examples of changes in a resident’s condition that should be immediately reported as well as documented
  • Describe what can happen if documentation is not properly done
  • Describe the actions you should take when a resident refuses care
Products Specifications
Formats Available DVD
Duration 15 min
Supporting Materials
Language English
Languages Available English
Copyright 2014
Product Categories
Healthcare, Medical Assistants