CNA Module 15: Observation and Charting

These modules are free for all our YAYA CNA students. If you are a current YAYA student, please contact us to we can provide you with free access to these courses.

Statement of Purpose:

The purpose of this unit is to prepare students to know how, when, and why to use objective and subjective observation skills. They will report and record observations on appropriate documents using medical terms and abbreviations.

Terminology:

1. Abbreviation

2. Activities of Daily Living (ADL)

3. Assessment

4. Assessment Reference Day (ARD)

5. Incident report

6. Kardex

7. Minimum Data Set (MDS)

8. Objective

9. Observation

10. Paraprofessional Healthcare Institute (PHI) http://phinational.org/about/

11. Prefix

12. Range of Motion (ROM)

13. Resident Assessment Instrument (RAI)

14. Resident Assessment Protocol (RAP)

15. Patient/resident care plan

16. Root word

17. Subjective

18. Suffix

Patient, resident, and client are synonymous terms referring to the person receiving care

Performance Standards (Objectives):

Upon completion of the four (4) hours of class plus homework assignments and four (4) hours of clinical experience, the learner will be able to:

1. Define key terminology

2. Identify word elements used in medical terms

3. Identify medical terminology and abbreviations commonly used in medical facilities

4. Define observation and list the senses used to observe a patient/resident.

5. Describe objective and subjective observations

6. List types of charting documents and the use for each

7. Explain how to accurately complete ADL assessment for MDS

8. Discuss procedures to use when recording on a patient’s/resident’s chart