Charting Basics
What does PCC stand for?
Point Click Care
What does “ADL” stand for?
Activities of Daily Living
You are caring for a resident who is a total mechanical lift for transfers, because they are unable to stand and transfer.
How do you document sit to stand?
What is N/A Non- applicable
Mr. McGee eats all meals without any physical assistance or supervision from a helper. He has a gastrostomy tube (G-tube), but it is no longer used, and it will be removed later today.
How is this documented?
What is Independent.
During survey, how should staff respond if asked, “Did you chart this?”
What is Yes
When should documentation be completed?
As soon as possible after care is given — in real time if possible
Name 5 items included in lower body dressing
What are: Underwear, incontinence brief, pants, shorts, skirt, pajama bottoms, knee brace.
How do we measure distance walked?
What is count the floor tiles?
In the morning and at night, Mrs. F brushes her teeth while sitting on the side of the bed. Each time, the certified nursing assistant gathers her toothbrush, toothpaste, water, and an empty cup and puts them on the bedside table for her before leaving the room. Once Mrs. F is finished brushing her teeth, which she does without any help, the certified nursing assistant returns to gather her items and dispose of the waste.
How is this documented?
What is SET UP or CLEAN UP ASSISTANCE.
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)
Mrs. Harris is care planned as transfers with Touching Assist x1 with a w/w and gait belt. Today she had a medical event, after discussing with the nurse manager, the resident is transferred using a total mechanical lift.
How would you document Chair/bed-to-chair transfer?
What is Supervision or touching assistance.
Mrs. L uses the toilet to void and have bowel movements. Mrs. L is unsteady, so the certified nursing assistant walks into the bathroom with her in case she needs help. During the assessment period, a staff member has been present in the bathroom, but has not needed to provide any physical assistance with managing clothes or cleansing.
What level of assistance is this?
What is Supervision or touching assistance?
What are common PCC survey citations?
Missing documentation, late entries, uncharted refusals
What does ADL stand for?
What is Activities of Daily Living
What happens if a CNA leaves a box blank in PCC?
It looks like care was not provided
Mrs. Peterson is care planned as transfers with Touching Assist x1 with a w/w and gait belt. Today she is exhausted after an outpatient appointment, you feel she needs more assistance to be safe, so you ask another CNA to assist in her transfer.
How is this documented?
What is DEPENDENT
What should you do if a task doesn’t match the resident’s current care needs?
What is Report to the Nurse Manager or Supervisor for clarification?
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
Mr. Parker who is dependent for transfers, because he cannot stand, drops his glasses while sitting in his wheelchair, without any assistance he reaches down and picks them up off the floor.
What would you document for picking up an object?
What is N/A Non-applicable
Picking up an object definition: The resident’s ability to bend or stoop from a standing position to pick up a small object, such as a spoon, from the floor
If a resident refuses care, how should this be documented
What is refused
What’s the best defense against survey citations in PCC?
Accurate, timely, complete documentation every shift