Certified Nursing Assistant (CNA) Prometric Practice Exam

During which phase of resident care is it essential to document changes observed during the shift?

1. After administering medication

2. At the end of the shift

3. Before meals

4. During the assessment

The correct answer is: At the end of the shift

Documenting changes observed during a shift is crucial at the end of the shift. This timing allows the outgoing caregiver to provide an accurate and comprehensive account of the resident's condition to the incoming staff. Such documentation ensures continuity of care, allowing the next caregiver to be fully informed of any changes that may have occurred, including vital signs, behaviors, or any other significant observations. Accurate end-of-shift documentation is essential for maintaining patient safety, improving treatment outcomes, and facilitating effective communication among the care team. This practice helps to ensure that all caregivers are aware of the resident's current status and can respond appropriately to any needs or changes in condition. Other options, such as before meals or after administering medication, do not encompass the entire scope of care and may only pertain to specific situations. The assessment phase is also important for gathering initial data, but ongoing documentation is essential to capture changes throughout the shift, making end-of-shift documentation the most comprehensive and informative time for charting observations.