Wisconsin Certified Nursing Assistant (CNA) Practice Exam

Which of the following is a guideline for documentation performed by nursing assistants?

1. Document cares before they are done

2. Use colored ink to highlight important information

3. Use facts and avoid opinions in documentation

4. Make documentation as lengthy as possible

The correct answer is: Use facts and avoid opinions in documentation

The guideline for documentation performed by nursing assistants emphasizes the importance of using facts and avoiding opinions. Accurate documentation is critical in healthcare because it provides a clear, objective account of the patient’s condition, the care provided, and any changes observed. This factual approach ensures that all team members can rely on the information for continuity of care, legal purposes, and quality improvement. Including personal opinions can lead to misunderstandings or misinterpretations of a patient's status, potentially compromising care. In contrast, documenting cares before they are done can lead to inaccuracies, as it presents information that may not have been verified. Highlighting information with colored ink may create confusion or might not be allowed in all facilities, as standardization of documentation is important for clarity and professionalism. Finally, making documentation lengthy can detract from its effectiveness; concise, relevant entries are preferred to ensure quick reference and communication among healthcare team members.