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Essential Guidelines for CNA and RN/LPN Service Notes and Timesheet Documentation

This document outlines the critical procedures for Certified Nurse Aides (CNAs) and Registered or Licensed Practical Nurses (RNs/LPNs) when tracking service notes and documenting timesheets. CNAs must daily check off completed tasks in service notes to ensure validity. RNs and LPNs are responsible for writing narrative notes detailing the care provided during their shifts. Timesheets are vital for recording clock-in and clock-out times. This guide includes examples of actual task sheets and timesheets to assist in proper documentation practices.

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Essential Guidelines for CNA and RN/LPN Service Notes and Timesheet Documentation

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  1. CAP/CService Notes &Time Sheets 3/2/12

  2. Service Notes Task Sheet:  Certified Nurse Aide must track the necessary tasks daily in the service notes by checking off the tasks as he or she completes them. In order for a service note to be considered valid, the individual tasks must be checked. Narrative Notes:  Written by the registered or licensed practicalnurse (RN or LPN) providing care Describe the type of care the nurse provides throughout the shift.

  3. Time Sheets A timesheet is used by the aide or the nurse to document time in and time out for each shift worked. Often, if the caregiver is an aide, the timesheet is on the same paper as the service notes.  Some providers leave a timesheet in the home each week for nurses and aides to sign in and out. Some agencies use an electronic timesheet that is sent in with the claim.

  4. The following slides are of actual CNA task sheets and time sheets within one document.

  5. CNA Task Sheet & Time Sheet Task Sheet Time Sheet

  6. CNA Task Sheet & Time Sheet Time Sheet Task Sheet

  7. The following slide is an actual CNA time sheet, submitted separately from the CNA task sheet.

  8. CNA Time Sheet Time Sheet

  9. The following slides are of actual RN/LPN narrative notes and time sheets within one document.

  10. RN/LPN Narrative Notes & Time Sheet (Page 1 of 2) Time Sheet

  11. RN/LPN Narrative Notes & Time Sheet (Page 2 of 2) Narrative Notes

  12. RN/LPN Narrative Notes & Time Sheet Time Sheet Narrative Notes

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