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. The information on an ADL sheet can help a care-giving team find out if a residents condition is remaining the same, getting worse or improving. A nurse aides documentation can be critical to the development of an ongoing care plan that addresses a residents 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 program provides an understanding of why documentation is such an important part of a nurse aides 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 residents 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
Price: $149.00 USD

Product ID: MED722
Media: DVD
Year: 2014
Duration: 15:00 minutes
Language: English
Tags: Nursing Assistant Skills, Legal Aspects of Nursing
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