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CNA-NIC F25 CH 3.8
Describe a standard resident chart
| Question | Answer |
|---|---|
| MEDICAL CHART | legal record of residents care - is a legal document |
| another name for medical chart | clinical or medical record |
| why is the information on the chart important | what is included in the chart is considered to be what actually happened |
| how long is the medical chart saved | as long as the law dictates that it be kept |
| why is the medical chart saved | it is saved in case other care providers need to refer to it |
| why would other care providers need to refer to a medical chart | a provider may need medical history or information about an advanced directive |
| who else can request to see a medical chart | lawyers or judges may also request to see the chart if there is legal need |
| what information can be found on the medical chart (part 1) | admission forms, residents history and results of physical examinations, care plans, doctors orders, doctors progress notes, nursing assessments, nurses notes, notes from physical therapists, occupational therapists and other specialists |
| what information can be found on the medical chart (part 2) | flow sheets (check off sheets for documenting care; may also be called an ADL sheet), graphic record, intake and output record, consent forms, lab and test results, surgery reports, advance directives |
| what is the NA responsibility with regard to the resident chart | gather information and report it to the nurse |
| what is CHARTING | noting observations about residents and their care |
| how can charting be recorded | manually or electronically |
| how do NA chart | some facilities allow NA to chart in the medical record. Others limit NA charting to certain forms. (NAs should follow their facilities policies and remember that all of the information listed in a medical record is confidential) |
| what are the observations that NA gather about residents | private information |
| who can NA share private information with and who can they not share information with | they cannot be shared with anyone except specific members of the care team |
| keeping resident information confidential is part of | honoring dignity and being respectful ; ;keeping residents information confidential is the law (all healthcare workers must obey it) |
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