Charting Basics
What does PCC stand for?
Point Click Care
What does “ADL” stand for?
Activities of Daily Living
What section in PCC is used for skilled nursing documentation?
Progress Notes or eMAR/eTAR
What icon shows a new task or alert in PCC?
A red exclamation mark or notification bell
During survey, how should staff respond if asked, “Did you chart this?”
Yes, and I can show you in PointClickCare
When should documentation be completed?
As soon as possible after care is given — in real time if possible
What should a CNA do if they provided care but the system is frozen or unavailable?
Tell the nurse and write it down for later entry
What should be included in every nurse note?
Date, time, objective facts, interventions, resident response, signature
What does a “yellow triangle” usually indicate?
A warning or incomplete item
How often should CNA charting be reviewed by the nurse?
Every shift
What color in PCC often means a task is overdue?
Red
Name three ADLs CNAs must document every shift.
Bathing, dressing, toileting, eating (and more)
What should you avoid writing in a nurse’s note?
Personal opinions or blame statements
How do you assign a task to another staff member?
Use the task list, select the staff name, and click assign
What are common PCC survey citations?
Missing documentation, late entries, uncharted refusals
What is the difference between a “Task” and a “Note”?
Tasks are checklist items; Notes provide narrative documentation
What happens if a CNA leaves a box blank in PCC?
It looks like care was not provided
When should a nurse complete a new assessment?
After a fall, change in condition, new admission, or new order
What should you do if a task doesn’t match the resident’s current care needs?
Report to nurse or care plan coordinator for update
What should staff do if a surveyor is watching them chart?
Stay calm, chart accurately, and don’t skip steps
Why is timely charting important for survey and legal protection?
If it’s not documented, it wasn’t done
Who is responsible for verifying CNA charting accuracy?
The nurse or charge nurse on the shift
Why is it important to use clinical language (“resident denies pain”) instead of casual language (“looks fine”)?
Surveyors require objective, measurable documentation
If a resident refuses care, how should this be documented
Mark as refused and note who was notified and the resident’s reason
What’s the best defense against survey citations in PCC?
Accurate, timely, complete documentation every shift