What is required when documenting patient care performed by a CNA?

When documenting patient care performed by a CNA, a clear account of care provided and observations made is essential. This practice ensures accurate communication among healthcare team members, facilitating effective patient management and continuity of care. Detailed and precise documentation reflects the care rendered, allowing for an understanding of the patient's condition, progress, and any potential changes requiring further action.

Good documentation also serves as a legal record and is crucial for assessing the effectiveness of the care provided. It may include vital signs, changes in the patient's condition, responses to treatments, and any other relevant observations. This thorough approach helps to safeguard both the patient’s well-being and the CNA’s professional accountability.

Other responses do not encompass the complete requirement for effective documentation. For example, simply noting the date and time would not sufficiently convey the quality and specifics of the care provided. Listing medications, while important, does not cover the broader scope of patient care and specific observations necessary for comprehensive documentation. Relying solely on verbal communication fails to create a permanent record that can be referred back to, which is critical in a medical setting.