Documentation is legally required for nursing assistants and other health care team members to record client observations and care provided in the medical record. Documentation is used to ensure continuity of care across shifts and among health care team members, to monitor standards of care for quality assurance activities, and to provide information for reimbursement purposes by insurance companies and Medicare or Medicaid. Documentation may also be used for research purposes or, in some instances, for legal concerns in a court of law.^[1] For these reasons, always document the care you provide and never document for someone else. Review Chapter 1, “Documenting and Reporting” for details on how observations should be recorded. The facility or employer should provide training on how to document according to their expectations and what should be included in the client’s record.

Charting by exception (CBE) is a common type of health care documentation indicating routine care and collection of data were completed. Notes are only written for abnormal findings or anything out of the ordinary. CBE is designed to keep documentation concise and reduce the amount of time required for documentation. CBE may include checklists and flowsheets as efficient means of documenting that standards of care have been provided. For example, nursing assistants may document activities of daily living (ADL) or vital signs on a flow sheet. See an example of an ADL flowsheet using the information in the following box. Keep in mind that documentation is reviewed and submitted by agencies for insurance reimbursement, so it is imperative that charting is accurate and up-to-date.

In addition to documenting client cares and data collected, nursing assistants also report findings to the nurse. When observations are normal, they can be reported at routine times such as during shift change report. However, abnormal vital signs or significant changes in client status pertaining to breathing, circulation, cognition, pain, or falls should be immediately reported to the nurse for rapid assessment and intervention to ensure client health and safety.

Nursing assistants use critical thinking skills to determine what should be immediately reported to the nurse. If you are unsure about the significance of a finding, it is best to report it to the nurse and allow them to determine what is needed for the resident. It is never incorrect to report information to the nurse. However, waiting to report an important finding can negatively impact the client’s health, so use a cautious approach and report anything that seems out of the ordinary. As you gain experience, your critical thinking skills will grow and improve.

Throughout this textbook, observations are described that should be immediately reported. Review Chapter 3.2 (“Emergency Situations”) and Chapter 6.3 (“Pain”) for additional information. The “Normal Ranges for Vital Signs” section in this chapter can be used to determine when vital signs are out of range and should be reported to the nurse.