Hubbs Pre- CNA
SP2- AP1
Documenting Care Unit
Documenting Care
(Use with Basic Skills for Nursing Assistants in Long-Term Care –Chapter 9)
1. Use the information on page 169 to complete the diagram on Objective and Subjective data.
Objective Data
Subjective Data
Both
4. (p. 169) ______________________________ is the oral account of care and observations.
______________________________ is the written account of care and observations.
What is another word for recording? _______________________________________________________________
5. Read about reporting on page 169. List six rules for reporting.
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____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________
6. (p. 171) The nurse gives a report to the nursing team of the oncoming shift. This report is called the
______________________________________________________________________________________________________________.
7. (p.171) The medical record (chart) is a ______________________________________ of a person’s ________________
and _____________________________ to _________________________________ and care.
The record is a ___________________________________ and ____________________________________ document.
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8. (p. 171) You must communicate clearly and thoroughly when recording information on a person’s
chart. Anyone who reads your charting should know:
 ______________________________________________

______________________________________________

______________________________________________
9. Read about recording time on pages 171-172. Draw and label a picture of the 24-hour clock.
10. Write the following times correctly in military time (24 hour time).
Standard Time
12:00
1:00 AM
2:00 AM
3:00 AM
4:00 AM
5:00 AM
6:00 AM
7:00 AM
8:00 AM
Military Tim
Standard Time
9:00 AM
10:00 AM
11:00 AM
12: 00 AM
1:30 PM
2:30 PM
3:30 PM
4:30 PM
5:30 PM
Military Time
Standard Time
6:30 PM
7:30 PM
8:45 PM
9:45 PM
10:50 PM
11:50 PM
12: 30 AM
Military Time
11. (p.173) Ruth brought her Aunt Sue to Bethel Nursing Home for rehabilitation after Aunt Sue fell and
broke her hip. Aunt Sue had to complete a form when she was first admitted. It contained identifying
information about Aunt Sue.
What is the form called? ____________________________________________________________________
12. (p.173) Progress notes are written accounts of __________________________________________,
____________________________, and the person’s ____________________________________________________
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13. (p.173) Flow sheets are used to record frequent measurements or observations. Name four
observations or measurements that are recorded on a flow sheet:

______________________________________________

______________________________________________

______________________________________________

______________________________________________
14. Look at the Medical Terminology box on p 175. Write the meaning of the following prefixes, roots, and
suffixes:
Prefix
Root
Suffix
olig ___________
urin ___________
hypo __________
glyc ___________
emia _______________
derma __________
itis ________________
laparo __________
ostomy ______________
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Use the Power Point Presentation to answer the following questions about
Admitting, Discharging, and Transferring.
15. List the steps for admitting a new resident into the nursing home:
 _______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________
16. What Measurements do you take when a resident is admitted to the Nursing Home?
________________________________________________________________________________________________________________
17. How are baseline measurements used?
________________________________________________________________________________________________________________
18. List the steps to assist a resident in being discharged:
 ______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________
19. List the steps in assisting a resident in transferring to a different unit:
 ______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________
20. Reflect back on “Maslow’s Hierarch of Needs”. What needs should you focus on when admitting a new
resident? _______________________________________________________________________________________________________
___________________________________________________________________________________________________________________
21. What needs do you need to focus on when transferring or discharging a
resident? _________________________________________________________________________________________________________
Answer Key:
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Documenting Care
(Use with Basic Skills for Nursing Assistants in Long-Term Care –Chapter 9)
1. (p. 169) Observation is using the senses of sight, hearing, touch, smell
to collect information.
2. (p. 169) What is objective data? Information that is seen, heard, felt, smelled
3. (p. 169) What is subjective data? Things a person tells you about; things you cannot observe
through your senses
4. (p. 169) reporting is the oral account of care and observations.
Recording is the written account of care and observations.
What is another word for recording? documenting
5. Read about reporting on page 169. List six rules for reporting.






Be prompt
Be thorough (clear, precise, accurate)
Give name and room number/bed number
Give the time you made the observation
Report only what you observed
Report as often as the nurse requests or as the person’s condition changes.
6. (p. 171) The nurse gives a report to the nursing team of the oncoming shift. This report is
called the end of shift report
7. (p.171) The medical record (chart) is a written account of a person’s condition and response to
treatment and care.
The record is a permenant and legal document.
8. (p. 171) You must communicate clearly and thoroughly when recording information on a person’s
chart. Anyone who reads your charting should know:
 What you observed
 What you did
 The persons response
9. Read about recording time on pages 171-172. Draw and label a picture of the 24-hour clock.
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10. Write the following times correctly in military time (24 hour time).
Standard Time
12:00 AM
1:00 AM
2:00 AM
3:00 AM
4:00 AM
5:00 AM
6:00 AM
7:00 AM
8:00 AM
Military Tim
2400
0100
0200
0300
0400
0500
0600
0700
0800
Standard Time
9:00 AM
10:00 AM
11:00 AM
12: 00 AM
1:30 PM
2:30 PM
3:30 PM
4:30 PM
5:30 PM
Military Time
0900
1000
1100
1200
1330
1430
1530
1630
1730
Standard Time
6:30 PM
7:30 PM
8:45 PM
9:45 PM
10:50 PM
11:50 PM
12: 30 AM
Military Time
1830
1930
2045
2145
2250
2350
0030
11. (p.173) Ruth brought her Aunt Sue to Bethel Nursing Home for rehabilitation after Aunt Sue
fell and broke her hip. Aunt Sue had to complete a form when she was first admitted. It
contained identifying information about Aunt Sue.
What is the form called? Admission Sheet
(p.173) Progress notes are written accounts of observations Care giving and the person’s response
12. (p.173) Flow sheets are used to record frequent measurements or observations. Name four
observations or measurements that are recorded on a flow sheet:




Vital signs
Daily weight
ADL’s
Bowel movements
13. Look at the Medical Terminology box on p 175. Write the meaning of the following prefixes,
roots, and suffixes:
Prefix
Root
Suffix
olig small, scant
urin urine
hypo low
glyc sugar
emia blood
derma skin
itis inflamation
laparo abdomen
ostomy opening (incision)
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Use the Power Point Presentation to answer the following questions about Admitting,
Discharging, and Transferring.
14.








List the steps for admitting a new resident into the nursing home:
Gather the equipment you need for admitting and bring to residents room
Explain what happens in the admitting process
Ask pt what she would like to be called
Fill out a personal belonging list
Label clothing
Provide a pitcher of water for pt
Take baseline measurements
Give pt and family a tour of home
15. What Measurements do you take when a resident is admitted to the Nursing Home? Baseline
measurements
16. How are baseline measurements used? To compare with future measurements taken of the
pt17.
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





List the steps to assist a resident in being discharged:
Explain what you are doing
Help pt gather belongings and pack
Recheck closets and drawers for missed things
Help pt into wheelchair and bring to front door
Assist resident to vehicle
Return wheelchair to unit cleaned
Strip bed, pick up discarded items, and report any observations to nurse
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18.







List the steps in assisting a resident in transferring to a different unit:
Explain what you are doing
As you pack check closets/drawers for items
Pack all equipment to take with (bedpan washbasin)
Assist to wheelchair and move to new room- along w/belongings
Return w/c to unit and clean it
Sweet residents old room; remove equipment and discarded items
Strip bed of dirty linens
Reflect back on “Maslow’s Hierarch of Needs”. What needs should you focus on when
admitting a new resident? Safety and security (ask them where they would like their
belongings to be unpacked- label clothing); social needs; physical need (give something to
drink).
19. What needs do you need to focus on when transferring or discharging a
Resident? Social need (tell them how much you enjoyed helping them);
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