Which statement best reflects how a CNA should document observations?

• A. Record subjective impressions as facts.
• B. Record interpreted conclusions rather than raw data.
• C. Record objective data and clearly separate observations from interpretations.
• D. Record only what you think is important.

Answer: (C)

Accurate CNA documentation hinges on recording objective data and clearly separating what you observe from any interpretations. You should note facts you can see, hear, or measure—things like vital signs, color, swelling, wound drainage, movement, or changes in skin temperature. If the patient tells you how they feel, record that as the patient’s report rather than as your own conclusion. For example, you might write that the patient reports pain at a level X or that the patient states they feel dizzy, and you would separately document objective signs such as pale skin or a rapid pulse. By keeping observations factual and distinguishing them from judgments or conclusions, the record stays clear, reliable for others to continue care, and legally sound. This avoids turning subjective impressions into facts, prevents inferring problems from data, and ensures you’re documenting what’s truly observed and what the patient has reported.