Documentation for CNAs
LTC Nursing Assistant Trainer, February 14, 2008
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Documentation takes place on a patient's medical record-usually called the chart. Most CNAs document primarily on flow sheets. Every space must be filled in unless it is the policy of your facility to do otherwise. Most long-term care facilities have flow sheets for the following:
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ADLs
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Behaviors
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Bowel movements
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Fluid intake/output
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Weight
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Meal intake
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Vital signs
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Restraints
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Positioning
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