15 Charting and Documentation Tips for CNAs

Charting is not necessarily the most exciting part of your CNA job, but it’s an essential component. Good CNA charting ensures that care teams are on the same page and helps keep patients safe over time. If you’re a CNA, looking for tips to improve your documentation game, check out these ideas from professionals:

1. Always follow the HIPAA guidelines

Be careful where and when you’re charting, since this information stays in the system for a long time, as well as talking about patient information with others outside of work. Also while I’m at it please stay off social media because patient identification through photos can be risky to their identity confidentiality especially if they have an allergy or condition that’s sensitive enough to post on your timeline!

2. Avoid double charting

The best practice is to avoid double-charting. For instance, if you have an electronic chart with flowsheets, don’t waste your time mentioning it in the narrative unless there’s a picture or context that paints out something different about what happened.

3. Think as a lawyer while charting

Before charting, always ask yourself what an attorney would want to know if this went to court. In a case where you’re working with patients from years ago and the only thing that matters is your medical record, making assumptions could lead to critical errors down the line.

4. Avoid inconsistent charting as much as possible

Charting is an integral part of nursing and it can make or break you. Inconsistent charting will cause problems for the patient, other CNAs on shift with you, your co-workers who may review notes from patients under their care in order to get a better picture of what’s going on throughout the hospital (even if they aren’t working directly), and most importantly – yourself! Never double check that somebody else has noted something before writing down your own assessment findings because then one person might have documented something incorrectly which leads to inaccurate documentation later when reviewing health records.

5. Try to keep some paper handy.

Sometimes, the room will be busy and chaotic. When this happens, you can’t take time to look at your computer screen or chart on paper because there are other priorities that need immediate attention. Therefore it is important to always have a separate piece of scratch paper with you so that when an opportunity arises for data entry – whether through entering numbers into EHRs/EMR’s by hand onto electronic screens or writing down patient information onto multiple forms during rounds-you’ll write them down as soon as possible using whatever method works best for you (i.e., handwriting vs typing).

6. Use color pen

When writing any legal documents, such as your paper charting work at the hospital where you’ve been employed for five years so far, it’s best to use blue or black ink only. Some facilities may not allow patients using other colors of pens. It’s important that you know what color inks are allowed by facility policy before starting this assignment!

7. Chart it as soon as possible.

Charting a patient’s care is important, but it can be difficult to remember when and what was done. We must always chart after we give the care because if not then no one will know that their dressing has been changed or they have just returned from walking around. Patients don’t always tell someone about things like this so you need to document them correctly in order for your records to look correct and accurate at all times.

8. Don’t chart in advance

Don’t be tempted to jump the gun and chart ahead of time. If you try, it’s likely that either your EMR will timestamp something incorrectly or you’ll forget to change a detail later on in the process if things don’t go as planned.

9. Keep your emotion aside while charting

When you’re writing up patient files, try to be as objective and factual as possible. It might seem like this is easier said than done if the case has involved emotional interactions (with either patients or their family members). This tip will especially help nurses in ERs who deal with emotionally charged cases.

10. Stop rambling on and be concise at charting

When making a chart, try to be as concise as possible with the information given. Any additional details should have some relevance and purpose for being included in your notes. It’s best if you can understand when it is necessary to include more context than others (and honestly this comes over time) but remember that these are just quick notes after all!

11. Don’t make your own abbreviations

CNAs, if you use abbreviations in your documentation that aren’t on the Joint Commission’s list of approved acronyms and words it could make a world of difference for legal cases. If lawyers ended up interpreting what you meant to say instead of clearly understanding its meaning, don’t blame them – take accountability yourself by learning from The Joint Commission website how they recommend nurses record their notes without using any random slang or abbreviations.

12. Try to be legible as much as possible

Legibility is an important component in the writing process. Whether it’s filling out paper charts or typing on a computer, legible handwriting should be considered when creating documents to avoid confusion with other health care providers.

13. Don’t chart the another patient’s chart

There are tons of easy mistakes that can be made in the emergency department, but one mistake to avoid is charting with a patient who belongs on another bed. If it’s noticed at all, there will still have to be extra work done for changing charts and fixing paperwork later. As long as you stick with your pattern this shouldn’t happen often!

14. Don’t erase any patient charts

It’s important to know what your facility policy is on correcting any clerical errors. For example, some facilities allow you to make mistakes and correct them immediately without penalty while others don’t want even the smallest of changes made in their record keeping systems that could affect legal proceedings or insurance claims down the line.

15. Do not ever alter patient charts

I know you’re trying to help and keep your job, but it’s a HUGE no-no in the medical field. You might think nobody is going to notice that you removed or falsified documents from patient charts… But someone probably will!

Documentation can be a lot of work, but it doesn’t have to be difficult. We hope you found our post helpful in giving some tips on how to improve your charting. To learn more about how we can help with this process, visit our other blog posts or contact us.