Data Collection & Reporting - Online CNA Class
Learn essential observation and documentation skills. Understand what to measure, how to record findings, and when to report changes to the nursing staff.
Syllabus & Study Guide
1. Measuring Vital Signs
Accurate measurement of temperature (oral, axillary, tympanic, rectal), pulse, respirations, and blood pressure. Normal ranges and abnormal findings to report immediately.
2. Height, Weight & BMI
Accurate measurement techniques using scales and measuring devices. Importance of weight monitoring in certain conditions. Converting between pounds and kilograms.
3. Intake and Output (I&O)
Measuring and recording fluid intake and urine output. Using graduated containers. Understanding why I&O monitoring is ordered. Calculating totals for shift reporting.
4. Observation Skills
What to observe: skin color, breathing, behavior changes, pain levels. Using your senses: look, listen, smell, touch. Objective vs. subjective observations.
5. Documentation Principles
Writing factual, objective notes. Using approved abbreviations. Timeliness of documentation. Legal importance of accurate records. What NOT to document.
6. Reporting Changes
What changes to report immediately vs. at shift change. Using the chain of command. SBAR reporting format. Documenting that you reported findings.
Ready to test your knowledge?
Take a practice quiz to see how well you understand Data Collection & Reporting.