Reminders
When a resident has a continental breakfast it should be charted under this section.
What is imputing using "Breakfast intake" (Not using the AM snack section).
The resident is unable to assist the the ADL in anyway.
What is Total Assistance?
Staff assist the resident, "Guide" resident's hands to the side rail, Staff do not "Push" or "Pull", No muscle use of any kind is used by staff are examples of this Level of Care?
What is Limited?
The type and level of assistance actually provided for the same resident might fluctuate throughout the day.
What is True
You did not touch the resident during the ADL - you could code these levels of care.
What are Independent or Supervision?
When pushing a resident in a wheelchair (even for a short time) we should code the following.
What is Extensive?
Staff are required to be in the same room as the resident for safety or cueing. Staff are not required to touch the resident.
What is Supervision?
Resident can help somewhat, but needs physical assistance from staff to reposition, The resident attempts to help in any way at all, Staff uses their muscles are examples is this level of care?
What is Extensive?
The resident might be more willing to do certain ADLs for specific staff members and not others.
What is True?
You did touch the resident during the ADL - you could code these levels of care.
Chart, Chart and Chart some more! This is the reason why we want some more information for each resident.
What is accurate and up-to-date information for each resident.
Staff are required to touch and guide the resident. No weight bearing.
What is Limited Assistance?
No physical help or staff oversight, No assistance of any kind required from staff, Staff not present for activity to be completed are examples of this Level of Care?
What is Independent?
When charting it is okay to copy information from other shifts and to record what you believe the resident might be able to do for himself/herself based on demonstrated skills or physical attributes.
What is False?
You did touch the resident and you did use your muscles during the ADL - when charting you could code these levels of care.
What is Extensive or Total?
If you notice a Care Plan does not represent the residents' current needs you should report to this person.
Who is the Charge Nurse (or Viktoria or Kristi)
Staff are required to provide weight bearing assistance. Full staff performance for most but not all of the activity.
What is Extensive Assistance?
The resident is comatose or paralyzed or does not attempt to assist in any way, Staff uses their muscles are examples of this Level of Care.
What is Total?
When charting you do not have to fill out POC as accurately and completely as possible.
What is False?
You did touch the resident but did not use your muscles during the ADL - when charting you could code these levels of care.
What is Limited?
This is how proper POC charting helps the residents.
What is improved and accurate Care Plans (Referrals, assessments, doctor visits etc)
The resident completed the ADL without staff presence or physical contact.
What is Independent?
Staff are present with resident, Staff "cue" resident to complete ADL, No "hands on help" are examples of this Level of Care.
What is Supervision?
When charting it is important to make careful observations of the resident's physical and mental condition during care.
What is True?
You did touch the resident and you did use your muscles during the ADL, the resident did not help out in any way - when charting you could code these levels of care.
What is Total?