What should a CNA do if they make a mistake in their documentation?

When a CNA makes a mistake in their documentation, the appropriate course of action is to report it immediately and follow the facility’s established protocols for corrections. This approach ensures that the record remains accurate and maintains the integrity of the documentation process. Immediate reporting allows for prompt correction, preventing potential issues that could arise from inaccurate information, which is vital for patient safety and proper care.

Following facility protocols is essential because each healthcare organization has specific guidelines on how to handle documentation errors, often including steps for making corrections without compromising the legal integrity of the document or affecting patient care. This ensures that actions taken are consistent with policies in place, promoting accountability and transparency within the healthcare team.

In contrast, waiting until the end of the day or ignoring the mistake can lead to confusion or miscommunication regarding patient care. Erasing the error is not advisable, as it can create questions about the accuracy and authenticity of the medical record and is often against facility policies. Proper documentation is critical in nursing and aide practice as it forms a legal record of the care provided.