Wisconsin Certified Nursing Assistant (CNA) Practice Exam

Which guideline should a nursing assistant follow when documenting patient care?

1. Write detailed opinions

2. Document only after care is performed

3. Use ink of any color

4. Document care before it is completed

The correct answer is: Document only after care is performed

Documenting patient care accurately is essential for maintaining clear and effective communication among healthcare team members, and it ensures continuity of care for the patient. Following the guideline to document only after care is performed is crucial because it allows the nursing assistant to provide an accurate and comprehensive account of the procedures undertaken, the patient's response, and any observations made during the process. When documentation occurs after care, it enables the nursing assistant to reflect on the care provided, ensuring that all pertinent details are included. This approach reduces the likelihood of errors or omissions that can arise when documentation is done prematurely or based on incomplete information. Additionally, proper timing of documentation adheres to professional standards and legal requirements, which emphasize the importance of accurately and truthfully recording patient interactions and care processes. This promotes accountability and helps protect both the healthcare worker and the patient in any future assessments or audits. In contrast, writing detailed opinions is not advisable because documentation should be objective, sticking to factual information rather than personal views. Using ink of any color could lead to issues with legibility or permanency; typically, standard protocol recommends using black ink for formal documentation. Finally, documenting care before it is completed can lead to inaccuracies, as it may not reflect the actual care provided or the patient's real-time