Documentation (CNA)

Calculation Methods

Understanding the numbers behind documentation (cna) is important for accurate assessment. Vital signs provide objective data: temperature (97.8-99.1 F oral), pulse (60-100 bpm), respirations (12-20/min), and blood pressure (under 120/80 normal). Report any values outside a resident's established baseline to the nurse immediately.

Exam Focus Areas

On the Cna Nnaap exam(s), questions about documentation (cna) typically test:

1. Observations that must be reported to the nurse immediately
2. Proper procedure for activities of daily living (ADLs)
3. Body mechanics and safe transfer techniques
4. Resident rights and appropriate responses to violations

Documentation

CNAs document documentation (cna) findings by reporting to the nurse and recording in the medical record. Key observations to document:

• Weight changes: report gain/loss of 2+ lbs in a day or 5+ lbs in a week
• Report to nurse: elevated temperature, blood pressure outside baseline, new pain, skin breakdown
• Fall risk factors: history of falls, medications (sedatives, diuretics), mobility impairment, cognitive decline
• I and O (intake and output): measure and record all fluids consumed and excreted in mL

Differential Diagnosis

When studying documentation (cna), carefully distinguish it from related but distinct concepts: vital signs, intake output, scope of practice. Exam questions often test your ability to select the most specific and appropriate answer when multiple options seem partially correct. Look for the option that most completely addresses the scenario presented.