This week's tip: Documentation for CNAs
LTC Nursing Assistant Trainer, June 21, 2007
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Documentation takes place on a patient's medical record, also called the chart, while most CNAs document primarily on flow sheets. Remember, 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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