Record Keeping

Record keeping is a very important part of working as a certified nurse assistant. Our records are what allows nurses and doctors to keep tabs on the health of residents. From blood pressure to fluid intake – it is all vital to the health of your residents.

I remember quite a few times that co-workers in my facility would ‘fudge’ on vitals. We did not have the digital blood pressure/temp machine, so it was all done manually. We were all well aware that doing vitals at the start of the shift took up time, but there were some aides that had a system…for cheating. They would look at the charts while doing the vitals rounds and put down numbers that were similar to the previous.

This sure sounds like a time saver trick, but what if a resident had a fever or their heart rate had increased significantly? No one would know until later in the shift or unless there was an emergency. This is a dangerous practice!

The same goes for intake and output records. It is very important to keep records of how much fluid intake and output that a resident has per shift. This can fluctuate widely depending on the person and the day. In the summer it is even more important as the elderly can become dehydrated very quickly. Dehydration can lead to confusion, urinary tract infections, and even death.

It is your job to keep track of this so that your supervisors always know what is going on with the residents in your care. If a resident is not eating or drinking enough, action can be taken. Symptoms can first manifest in a refusal to eat or drink. You can often tell how much a person is drinking by the amount of urine they are producing – unless that person is drinking a large amount of fluids, yet not urinating. A nurse will know when to consult a doctor so that the health of the resident is not compromised.

Not keeping good records can lead to discipline, termination of employment, investigation by the state health department, and could even result in a loss of your certification in extreme cases. If a resident has had falsified records, you may even face jail time. It is a crime to falsify medical documents and this should be remembered by any aide that is tempted to skip doing vitals, even once.