ADL Charting
What do you chart if resident completes task without assistance or supervision
Independent
Bill is bed bound but uses the urinal every time on your shift.
How do you code urinary continence
Continent
Name three things you should check before leaving resident room
Bed lowered
Call light in reach
Water pitcher in reach
Before you enter a room to provide care, what should you be familiar with to help you provide the most accurate and appropriate care
Kardex/careplan
What does the red cooler on bed side table mean?
Thickened Liquids.
This level of support means the resident receives materials or devices but no physical help to perform the ADL.
setup help only
What do you chart for transfer when using a hoyer lift
Dependent
Bill did not have a bowel movement during your shift but is usually continent.
How do you code bowel continence
No Bowel Movement
What departments/clinicians pay attention to "amount eaten" charting.
Dietician to explore weight loss.
NP/MD to explore needs for appetite stimulant.
NP/MD to determine need for IVF
Families frequently ask about intake.
Wound team - need intake to heal properly.
Before the end of your shift, name the most important administrative task that should be completed.
POC Charting/skilled charting
What does "Code Grey" mean
Resident needs to be located, go to nursing station for information.
You are documenting the ADLs at the end of your shift. For eating, Mrs. Reynolds has a g-tube and takes nothing by mouth. She did not come to the dining room for the meal. What do you document for eating?
(88) activity did not occur
Ms Lucy has a knee brace on. She can sit on edge of bed and almost lie down but needs help getting one leg onto bed.
How do you chart Sit to Lying
Min Assist
Ms Betty has a urinary catheter due to spinal cord injury.
How is urinary continence coded?
Not rated due to catheter.
Name three areas of body at risk for pressure ulcers
Sacrum Heels
Spine Occiput (back of head)
Elbows Ears (from 02 tubing)
Hip Bones
I have a wound and a foley catheter. You should use these PPE items when caring for me.
gloves and gown
Which is NOT considered in the Quality Measure
Weight loss Deaths in Facility
Wounds Change in Continence
UTIs Vaccination Rates
Deaths in Facility
What should you do if the tasks don't match what the patient is currently doing?
Chart based on actual performance
Alert nursing of change in status.
Therapy and/or MDS need to adjust tasks and determine reason for change.
Ms Gina is on the toilet, she cleans her self and says "Let me try to get my pants up". She stands and pulls her pants up while you have your hand on her back.
How do you code toileting hygiene?
Supervision or touching assist
Ms Julie has had an amputation but can use a sliding board to transfer to a bed side commode without any assistance.
How do you code toilet transfer?
How do you code sit to stand?
Toilet transfer- independent
Sit to stand - (88) did not occur.
Name some complications of poor dental hygiene
Heart disease Pain
Respiratory Infections Diabetes complications
Loss of taste Weight loss
Which is NOT a question on MDS?
Is Resident Samoan?
Mother's Maiden Name
Is resident on insulin?
Does resident feel like they are moving in slow motion?
Mother's Maiden Name
What three areas are considered for the 5 star rating
Bonus: How many stars is Bethany
Health Inspection, Staffing and Quality Measures
Bonus: Three stars.
Why does task charting matter, who is looking at POC charting?
Monitoring for change in patient status.
Referrals to therapy
Reimbursement purposes
Quality measure scores
PAE application to determine whether a resident can stay.
Ms Betty requires two people to roll over and be cleaned after toileting.
How is rolling and toileting hygiene coded
Dependent
Resident asks for and uses bedpan for all bowel movements.
How do you code bowel continence?
Continent
How can you help prevent pressure ulcers
Frequent repositioning Adequate nutrition
Skin cleanliness/dryness Adequate hydration
Floating heels
Ensuring cushion in wheelchair
How many minutes are required to be charted to count as a respiratory therapy session
15 minutes
What does MDS stand for ?
Minimum Data Set