What should a nurse assistant NOT include in documentation?

In the context of patient care documentation, it is crucial to maintain a professional and objective standard that accurately reflects the patient's condition and the care provided. Including personal opinions in documentation is not appropriate because it can lead to biases and misinterpretations of the patient's status. Documentation should instead focus on factual information, such as measurable observations and specific actions taken related to patient care.

Reports from other healthcare providers, resident observations, and changes in the care plan are all vital components of effective documentation. These elements help ensure clear communication among healthcare team members and provide a comprehensive understanding of the resident's needs. Accurate documentation plays a key role in maintaining continuity of care and ensuring that all team members are informed and aware of the patient's progress and any significant changes in their condition or treatment. By avoiding personal opinions, the integrity and professionalism of the documentation are upheld, fostering a reliable healthcare environment.