Texas Certified Nursing Assistant (CNA)

Which of the following statements is true of electronic/computer documentation?

1. The NA should have someone else enter the information for her

2. The NA should ensure data is encrypted

3. The NA should not have someone else enter the information for her, even if it is more convenient

4. The NA should always save changes automatically

The correct answer is: The NA should not have someone else enter the information for her, even if it is more convenient

The correct answer highlights an important principle in nursing documentation concerning personal accountability and integrity in patient care records. Certified Nursing Assistants (CNAs) are expected to enter their own documentation to ensure accuracy and authenticity of the information provided about patient care. Having someone else input data could lead to inaccuracies, misinterpretation of facts, and a general breakdown in the continuity of care, as each individual has a unique understanding and perspective on the patient's needs and observations. Maintaining personal responsibility in documentation is key to providing high-quality care and ensuring that accurate records are kept for the healthcare team to reference. This also aligns with principles of professional ethics and regulations that govern healthcare documentation practices. Preventing another person from entering information not only protects the patient’s rights but also upholds the integrity of the healthcare record, which can significantly impact diagnosis, treatment, and overall patient outcomes. This approach reduces the risk of errors that could arise from miscommunication or misinformation if someone else inaccurately interprets or records data intended for the patient’s care.