What type of information should a CNA document after care?

• A. Subjective opinions about mood
• B. Objective observations and actions taken
• C. The nurse's conclusions about the resident's condition
• D. The family's observations

Answer: (B)

The main idea is that after providing care, a CNA should record objective observations and the actions taken. Documentation should capture only what you directly observed and did, with factual details that another caregiver can understand and trust.

Explain that you’re noting observable facts: how the resident looked, any measurements you took (like vitals or intake/output), and the concrete care you performed (assisting with bathing, turning, dressing, feeding, wound care) along with how the resident responded and the time these events occurred. This creates a clear, reproducible record of care and supports continuity and safety in ongoing treatment.

Subjective opinions about mood aren’t the best choice for this entry because mood is internal and can be interpreted differently by different people. The nurse’s conclusions about the resident’s condition are professional judgments that belong in the nurse’s assessment notes, not the CNA’s checklist. Family observations can be valuable, but they belong in the resident’s history or the nurse’s documentation; the CNA’s portion should focus on objective data and concrete actions unless the family member’s report is directly observed or stated by the resident.