Why is the documentation principle 'not documented = not done' important?
Explanation
Under 42 CFR §483.70(i) and Title 22 CCR §72543, facilities must maintain complete, accurate, accessible records on each resident. The medical record is a legal document. If care is not documented (or is documented late, falsely, or vaguely), it cannot be defended in court, audits, or surveys — and the facility/CNA may face citations, civil liability, and disciplinary action. CNAs must chart promptly, factually, in the resident's own words when quoted, and never document a task before performing it. Late entries are made as 'late entry' with current date/time.
Law Reference: 42 CFR §483.70(i); Title 22 CCR §72543This topic, taught in full in the Certified Nursing Assistant (CNA) guide. CNA — Complete Study Guide (2026) — PDF + EPUB, $19.99 · 14-day refund →
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