In our article TIPS & TIMESAVERS, we advise new aides to keep a small notebook on their person. To write down answers to questions; to write down phone numbers and other info needed for the job.
Seasoned aides can also make use of a small notebook. They’re cheap, can be bought almost anywhere and come in so handy for CNA’s. A great resource, the little notebook.
I have one…pocket size that fits nicely in my scrub pockets. What do I do with it? A lot. When the nurse asks for VS on a resident/patient, I have paper to record the results. When a weight is needed; when a height is needed; when intake and output need to be recorded- these little pads come in real handy.
- At the top of the page I write the date…day, month, year and shift I am working.
- I record the times I clock in and out– so if there is a discrepancy in my pay I can go back and check.
- I record what unit I’m working on, and the initials of the staff working with me. Even the nurses. And I note who is and agency staff as well.
- I record my assignment– resident’s names. No need for more info; names are enough.
- Any falls or other incidents are recorded in my notebook as well…the vital stats are documented. Who. What. When. Where. Witnesses.
- Any family visits and any issues/concerns arising from visit.
Some aides will go to the effort to write in certain info about their residents: BM’s, voids, showers, turning and the like.
Many aides use their assignment sheets to record all this info…and that’s fine. But I like to keep a personal record of these things. It can help you keep a clear record of your daily work and one never knows when this information can become necessary to defend one’s actions. Some aides prefer to write notes about their workday at home, away from prying eyes and nosy bosses. No matter where you do this, it’s pretty important to DO IT.
The legal environment in today’s nursing homes demand we keep clear records of the care we give. Most nursing home management can be trusted to not alter records, but not all. Aides can and have gotten into seriously hot water over issues and incidents that were not properly documented; flow sheets have been “corrected” to suit the best looking picture. Since aides are the lowest people in the chain of command, its way too easy to blame us for problems, issues, accidents and the like.
Who hasn’t been called at home, by the DON, demanding to know details about some incident that occurred last week? And who among us has a truly clear recollection of the events? If we had written down all the details, it would certainly help us during this call.
A little notebook can keep a lot of vital information. I wouldn’t go around telling everyone I have one though…management often doesn’t take well to such things. And we have to be extremely careful to respect HIPAA rules, but it is within our right to keep notes about our workday. I strongly advise all aides to do this.