Communication and Documentation
The record is a legal document
Everything you write may be read by surveyors, the next shift, and a court. Chart only what you did, saw, heard, or measured - at the time it happened, not in advance and not from memory at the end of the shift. Sign and date each entry. Use black or blue ink, print clearly, and correct an error with a single line through it, your initials, and the date - never erase or use correction fluid.
Objective versus subjective: 'Resident stated, My knee hurts, at 0800. Refused breakfast' is chartable. 'Resident is being difficult' or 'seems depressed' is an opinion, not an observation. Quote the resident when their words matter. Do not chart an incident report; you report the facts to the nurse, and the report is a separate document.
Reporting
Report changes promptly to the charge nurse: new pain, skin breakdown, refusal of care or medication, falls, abnormal vital signs, mood changes, family concerns. Use a clear structure - who the resident is, what you observed, what you need. Never assume someone else reported it.
Communicating with residents
Face the resident, make eye contact, and speak at eye level. For hearing loss, lower your voice and speak clearly - do not shout. For aphasia, be patient, use yes/no questions, pictures, or gestures, and do not finish sentences. Use plain language, not jargon, and confirm understanding. Respect confidentiality: discuss care only with the care team, never in hallways or with another resident's family. Knock before entering and do not talk about a resident as if they are not there.
Traps
- Charting care you did not give, or pre-charting at the start of a shift.
- Writing opinions or blame, such as 'uncooperative'.
- Giving information to a caller without verifying who they are.
Rule of thumb
If you did not see it, measure it, or hear it - do not chart it.