Reporting Observations and Documenting Care

The Nurse Aide's Role in Observation and Communication

As a nurse aide, you spend more direct time with residents than almost any other member of the healthcare team. Because you assist residents with their daily care, you are in the best position to notice subtle changes in how they look, act, or feel. The nurse aide is responsible for observing, measuring, recording, and reporting resident information. Observing involves paying close attention during routine activities, measuring includes gathering vital signs or fluid output, recording means entering these facts into the chart, and reporting means communicating findings to the supervising nurse.

It is equally important to understand what falls outside your professional role. The nurse aide does not assess, diagnose, or interpret clinical findings. You do not determine what illness a resident has, nor do you evaluate what a particular symptom means clinically. When a resident need or task falls outside the nurse aide's scope of practice, the aide must notify the nurse. Your primary responsibilities are keeping the resident safe and comfortable, noting what you see and hear, and reporting all observations and changes in resident condition to the supervising nurse.

Record relevant observations according to facility policy and report changes or concerns to the nurse; observations entered in the chart become part of the resident's medical record. The resident medical record is a confidential, legal document that reflects the ongoing care and status of the individual. Because this record serves as an official legal account of resident care, every piece of information you report and record must be completely truthful, factual, and accurate.