Oregon Certified Nursing Assistant State Practice Exam

When should documentation be recorded?

1. Immediately after care is given.

2. At the end of the shift.

3. Whenever there is time.

4. Before the care is given.

The correct answer is: Immediately after care is given.

Documentation should be recorded immediately after care is given to ensure accuracy and completeness. When a caregiver documents right after providing care, they capture the details while the information is still fresh in their memory. This practice helps to minimize errors and omissions, as events can be easily forgotten or misremembered if there is a delay. Recording documentation promptly also enhances communication among the healthcare team. It allows other caregivers to have up-to-date information on a patient's condition and any interventions that have been performed, which is critical in ensuring continuity of care. In contrast, documenting at the end of the shift may lead to a backlog of information that can become overwhelming, increasing the likelihood of mistakes. Documenting whenever there is time might result in crucial details being missed, and recording before care is given does not reflect what has actually occurred, which can jeopardize patient safety and quality of care.