North Carolina CNA Written Practice Exam

In what situation should a CNA document their observations?

1. Only when requested

2. At the end of the shift

3. As soon as changes are noticed

4. After talking with the patient

The correct answer is: As soon as changes are noticed

Documenting observations as soon as changes are noticed is essential for several reasons. Immediate documentation ensures that the information is recorded accurately while it is still fresh in the caregiver's mind. This prompt action helps maintain the integrity of patient records, allowing for timely response to any changes in the patient's condition. In the healthcare environment, changes in a patient's status—be it physical, emotional, or behavioral—can significantly impact their care plan. A timely note allows healthcare teams to adjust treatments or interventions quickly, which is critical in maintaining patient safety and providing effective care. Recording observations at the end of the shift or only after speaking with the patient may lead to vital information being forgotten or inaccurately portrayed and can also delay necessary medical responses. Similarly, limiting documentation to instances when requested creates gaps in patient records that could hinder effective communication between the care team. Therefore, the practice of documenting observations as soon as they are noticed is a best practice in patient care, ensuring that the healthcare team is always informed of the patient's current condition.