Medical Records Documentation and Legal Aspects for CNAs

Your role as a CNA is very important. What you do every day changes the health of your residents. You can be the reason that your residents are well and enjoy life. CNAs are valued healthcare team members who have meaningful daily interactions with residents. Their workload can be demanding and hectic but also meaningful. They are often seen as family members or special people to residents in long-term care facilities and are known for their compassion and kindness. The healthcare system could not exist without CNAs.

Team members work with each other to get things done. Your team expects you to do your work and to ask for help if needed. You help others if needed. Your team will do things based on your reports and documentation. The team’s work is planned for each resident. That plan is written down on the resident’s plan of care. Always follow the resident’s care plan (instructions). You are legally required to follow the care plan. If the care plan is not ready yet, like for a new admission, ask the nurse what to do if you need to know what you can feed the resident or how to toilet them. Ask the nurse if the resident asks for something, not on the care plan.

The Florida Statutes (Laws) are very specific about the role of the CNA in long-term and home health care. They can only work under the direct supervision of a licensed nurse. Direct supervision means the physical presence within the resident care unit of a healthcare facility or physical presence within a healthcare agency of a program instructor who assumes responsibility for the practice of the certified nursing assistant (Title XXXII Chapter 464 Regulations of Professions and Occupations, Nursing Part II Certified Nursing Assistant, 2023). This means that the certified nursing assistant cannot work alone and cannot make nursing decisions regarding resident care.

The Florida Statutes define what the certified nursing assistant can do. This is called the Scope of Practice. CNAs do tasks related to Activities of Daily Living (ADLs). ADLs include:

• maintaining mobility
• feeding
• elimination
• information gathering (Title XXXII Chapter 464 Regulations of Professions and Occupations, Nursing Part II Certified Nursing Assistant, 2023)

The information a CNA collects and documents includes how much the resident has eaten, bowel movements, height and weight, temperature, pulse, and respiration. You must know what is expected and what must be reported to your nurse. This information is very important to the nurse. You are the eyes and ears of the nurse you are working with. For example, if the resident has lost or gained five pounds, it must be reported to the nurse. Just remember to stay within your guidelines (scope of practice) to ensure you will not get into legal trouble. All healthcare facilities have policy and procedure books; the CNA must know and follow them. A CNA may administer some medications if they complete special training.

The CNA must ask questions if they are unsure of the right thing to do. Unprofessional behavior occurs when the CNA does not follow the rules. This may include coming to work after drinking alcohol or using illegal drugs. Although you may not harm the resident, you are still putting them at risk because your judgment is impaired.

Residents have average psychological needs to socialize. They also need to be active to maintain their health. Residents have the right to make decisions regarding their care, including:

• Planning care
• Knowing the risks and benefits
• Refuse or change care
• Access to medical record

Residents have the right to make choices about medical care, daily care, what to wear, how to spend their time, and participation in activities with their families. They have the right to Privacy and confidentiality. Do not discuss the resident with anyone who is not providing direct care to that resident. If the resident loses something in their room, ask them for permission to look through their things to find it. Residents on a toileting schedule should be approached in a private tone when they are in a group. Please do not speak to a resident like they are a child.

Residents have the right to dignity, respect, and freedom. This includes:

• Freedom from abuse
• Think about the resident's needs, desires, feelings, and ideas
• Get permission before looking through the resident’s belongings
• Knock on the door and wait before entering a resident's room
• Respond politely to residents
• Listen to residents
• Security of possessions
• Manage their finances or assign someone else
• Be informed and consent to transfers of discharges
• Complain without retaliation
• Visits
• Social services

Confidentiality is one of the most important issues in resident care. The Health Insurance Portability and Accountability Act (HIPAA) is a federal privacy law. CNAs can only read residents' charts if they need to know some information, and their facilities allow them to read charts. CNAs cannot tell others about their residents. They cannot share stories at home, even if they do not tell the resident's name. When discussing a resident’s care, do it in a private setting. CNAs must keep private things private. You can be fined if you talk about your residents' and residents' private matters.

Adults who are no longer able to care for themselves are vulnerable to abuse or neglect. Abuse is not the right thing to do, and it may be illegal. Physical abuse is a physical act that may result in pain, problems, distress, or death. It includes:

• Striking, hitting, beating, shoving, pushing, shaking, slapping, kicking, pinching, and burning
• Forcing residents to eat or drink against their will and
• False imprisonment by restraining a dependent adult with drugs or physical restraints 

Sexual abuse is any sexual act performed with a dependent adult who does not agree to the sex or who is not able to agree to sexual acts. Neglect is when the dependent adult does not get the care they need.

Emotional or psychological abuse is causing anguish, emotional pain, or distress with verbal or nonverbal acts, including:

• Harassment, verbal assaults
• Threats of harm or restraint
• Intimidation, humiliation
• Involuntary seclusion is isolating a dependent adult from others against their will

Spiritual abuse or neglect restricts or prevents a dependent adult from engaging in their usual spiritual activities, customs, or traditions. It also includes making fun of or attacking the person's beliefs. Financial abuse is stealing, misusing, or hiding a dependent adult's money or property.

Malpractice is an injury to a person due to professional misconduct through negligence, carelessness, lack of skill, or intentionality.Dependent adult abuse is a form of malpractice. You have to be aware of everything you do and say. The consequences of malpractice are that you can be sued, as well as the facility and the nursing department. You could be fired or have your CNA certification removed.  If you lose your certification, you cannot work in the nursing field again. Every facility does a screening background check, looking for abuse and negligence. Malpractice may be seen as a Crime. A CNA could be charged with a misdemeanor or felony.

Medical documentation is used to communicate with other team members about what is happening with the resident and to defend legal cases.If it is not charted, it was not done. CNAs are usually responsible for charting bathing, grooming, eating, elimination, and mobility. You must chart only the facts, just what you see, not what you feel.

If you have poor handwriting, then print. If it cannot be read, it is not useful. Lawyers look at charting by the nursing staff. They consider the chart the most reliable source of information. So, be careful when charting. Never chart an activity until you have completed the task. If you are asked to chart for someone else, do not do it! If this person continues to insist, tell your charge nurse. It is illegal to chart for someone else.

Use only approved abbreviations.  Never make up your own abbreviations. Charts are legal documents. Everything you write may be used in a court of law. This is why being honest and having no feelings interjected into your charting is important.

Scenario

• Ms. Green refuses to take a shower.

Intervention

• You offer her several options and the opportunity to make decisions about the shower, but she refuses. You report it to the nurse. You chart “The resident refused to shower and reported it to the charge nurse. She looked like she did not want to shower, so I left the room.”

Outcomes

• The nurses worked with Ms. Green and made changes to the care plan to provide for cleansing.

Strengths and weaknesses

• The first half of the charting is well written, but the second part is incorrect. Do not include your thoughts and feelings in your charting. Just chart what you see and what you do.

CNAs play a very important role in long-term care and have access to private information about their residents. CNAs must work within their scope of practice and be mindful of the Nurse Practice Act. Treat the residents with respect and dignity. Dignity is an important issue. Residents must be covered during care and have privacy.  The residents must have freedom from abuse, neglect, and abandonment. Even if the alleged abuse is unintentional, it is still abuse. If the CNA works within the legal boundaries and takes good care of their residents in a dignified manner, the residents will be safe.

• Title XXXII Chapter 464 Regulations of Professions and Occupations, Nursing Part II Certified Nursing Assistant (2023). Visit Source.