Texas Certified Nursing Assistant (CNA)

When should documentation be recorded?

1. At the end of the shift

2. Immediately after care is given

3. Once a day

4. After all residents are cared for

The correct answer is: Immediately after care is given

Documentation should be recorded immediately after care is given to ensure accuracy and completeness. This practice allows the CNA to capture details while the information is still fresh in their mind, minimizing the risk of forgetting important observations or specifics about the care provided. Prompt documentation also enhances communication among the healthcare team, allowing other caregivers to have up-to-date information about the patient or resident's condition and the care they have received. Timely documentation is crucial for maintaining continuity of care and ensuring that any changes in the resident's condition are promptly noted and addressed.