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 caregiving 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

Program Info:

Product ID: MED722
Duration: 15:00 minutes
Year: 2014

For more information about this program and other programs in this series, please click on the link below:

https://www.heatinc.ca/thenursingas...

This program is meant for previewing purposes only! Please contact Heat Inc. at [email protected] or visit our website at www.heatinc.ca