CDDN common mistakes
CDDN · Understand the traps and how to avoid them.
When documenting a medication administration, the candidate writes only 'given as ordered' without recording the time, dose, route, or any refusal or side effect, and then signs the MAR at the end of the shift for multiple residents.
Candidates treat documentation as a memory aid rather than a legal record, and they batch entries to save time, overlooking that each administration is a separate event requiring contemporaneous, individual documentation.
What to do instead
Document each medication immediately after administration, including time, dose, route, and any observation (e.g., refusal, held dose, adverse reaction). Never pre-sign or batch-sign. If a dose is refused or held, record the reason and notify the supervisor per protocol.
In a supervision scenario, the candidate addresses a staff member's performance problem by immediately issuing a disciplinary write-up without first gathering facts, observing the behavior, or providing clear expectations and feedback.
Candidates confuse supervision with punishment and skip the progressive steps of observation, coaching, and documentation, often because they fear being seen as too lenient or are uncomfortable with confrontation.
What to do instead
Follow the agency's progressive supervision model: observe and document the specific behavior, meet privately to discuss, state the expectation and rationale, offer training or support, set a follow-up date, and only escalate to formal discipline if the behavior persists. Document each step.
When developing an ISP or IEP, the candidate writes goals that are vague and non-measurable (e.g., 'improve communication skills') and does not include the consumer's own preferences or a method for tracking progress.
Candidates focus on compliance paperwork rather than person-centered planning, and they lack practice in writing observable, measurable goals with baselines and criteria.
What to do instead
Use a person-centered approach: base goals on the consumer's stated priorities, write them in observable, measurable terms (who, what, when, how often, at what criterion), include a baseline, and specify data collection methods and review dates. Involve the consumer and team in drafting.
During an interdisciplinary team meeting, the candidate presents only their own discipline's perspective and does not solicit input from the consumer, family, or other team members, then records decisions without noting dissenting opinions or action items.
Candidates see the meeting as a report-out rather than a collaborative problem-solving forum, and they may be uncomfortable managing group dynamics or time.
What to do instead
Prepare an agenda that includes consumer and family input, explicitly invite each discipline to contribute, summarize decisions and action items with responsible persons and deadlines, and record dissenting views. Use a facilitator role to ensure all voices are heard.
When a consumer refuses a service or treatment, the candidate documents 'non-compliant' and does not explore the reason, offer alternatives, or inform the consumer of their rights to refuse and appeal.
Candidates default to a compliance mindset and may not know the legal and ethical requirements for informed consent, refusal, and due process.
What to do instead
Treat refusal as communication: explore the reason, educate about consequences and alternatives, document the discussion, and inform the consumer of their rights (including the right to refuse and the grievance process). Notify the supervisor and team as appropriate.
In a direct care scenario, the candidate performs a task for the consumer (e.g., dressing, feeding) that the consumer could do with support, rather than promoting independence and choice.
Candidates prioritize efficiency and task completion over habilitation and consumer autonomy, sometimes due to time pressure or a desire to be helpful.
What to do instead
Apply the least restrictive, most enabling approach: assess the consumer's abilities, provide just enough support (prompting, adaptive equipment, partial assistance), offer choices, and document the level of assistance provided. Reinforce independence rather than dependence.
When coordinating services, the candidate fails to verify that a referral was received and acted upon, and does not document follow-up attempts or share information across providers.
Candidates assume that sending a referral completes the task and do not build in tracking or closed-loop communication.
What to do instead
Maintain a service coordination log with referral date, contact, response, and outcome. Follow up within a set timeframe, document all attempts, and confirm receipt and action. Share relevant information (with proper consent) among team members.
In a quality assurance review, the candidate identifies problems but does not trace them to root causes, develop a corrective action plan with measurable outcomes, or re-audit to verify improvement.
Candidates treat QA as a checklist exercise rather than a continuous improvement cycle, and they may lack training in root cause analysis or PDSA cycles.
What to do instead
Use a structured QA process: define the standard, measure performance, analyze causes (e.g., fishbone, 5 whys), implement an evidence-based corrective action, assign responsibility and timeline, and re-measure to confirm the fix worked. Document the full cycle.
When training staff, the candidate delivers a one-time lecture without assessing learning needs, providing hands-on practice, or evaluating competency and retention.
Candidates equate training with information delivery and may not know adult learning principles or competency-based training methods.
What to do instead
Conduct a needs assessment, set measurable learning objectives, use interactive methods (demonstration, role-play, return demonstration), and evaluate with pre/post tests or skills checklists. Follow up with coaching and refresher training, and document competency.
When documenting a significant incident (e.g., injury, medication error, restraint use), the candidate records subjective opinions or blame (e.g., 'staff was careless') and omits objective facts, timestamps, and notifications made.
Candidates write incident reports as narrative stories with personal judgments, not realizing that incident documentation must be factual, objective, and legally defensible.
What to do instead
Write incident reports using objective, behavioral descriptions: who, what, when, where, how, and immediate actions taken. Avoid opinions, blame, or speculation. Include notifications (supervisor, physician, family) and signatures. Complete promptly and per policy.