Final answer:
An NA/R should document data in flowsheets or progress notes, with flowsheets used for routine data and progress notes for more detailed patient information. Nurses notes and the plan of care are typically updated by nursing staff.
Step-by-step explanation:
A Nursing Assistant/Registered (NA/R) should document data primarily in flowsheets or progress notes. Flowsheets are useful for recording routine and repetitive data such as vital signs, intake and output, and daily care activities. Progress notes, on the other hand, are used to document more detailed information on the patient's condition, significant changes, or events related to their care. Nurses notes or the plan of care are usually handled by licensed nursing staff, although in some settings, the NA/R might contribute information that will be included by the nurse in these areas.
It is important for the NA/R to ensure any data recorded, especially during or after procedures, includes necessary details such as procedure names, completeness of needle, sponge, and instrument counts, correct labeling of specimens with the patient's name, and any issues with equipment.