Bed Mobility
Resident is unable to assist in bed mobility and requires x2 staff for assist. How would you code bed mobility?
Total Dependent and two person physical assist
How would you chart a resident that is ordered to be transfered with a full (hoyer) mechanical lift?
What is Total Dependent with two physical assist
Resident is a quadriplegic and is dependent on staff for feeding. How would you chart eating?
What is Total Dependent with one physical assist
Resident uses a urinal to void. He needs assistance holding the urinal, emptying urinal and assistance with hand hygiene afterwards. How would you chart toileting ADL?
What is limited assistance with one physical assist.
Resident propels self in wheelchair to lunch. She is tired after a full meal and you have to push her back to her room. How would you code wheelchair mobility?
What is extensive with one physical assist
Resident is able to turn and reposition himslef in bed without any help whatsoever.
What is independent with no setup or physical help from staff
Resident is laying in bed and you place her walker at her bedside. She is able to transfer while you observe. How would you chart transfers?
What is supervision with set up help only.
Resident has Parkinson's disease and has trouble guiding food to her mouth due to her shaky hands. You assist by guiding her hands to her mouth. How would you chart eating?
What is limited assist with one person physical assist.
Resident is able to use the toilet by herself but needs assistance with peri care and pulling up her pants. How would chart toilet use?
What is limited assist with one physical assist
Resident has left sided weakness due to having a stroke. While ambulating in halls with use of a rolling walker, you support her left side. How would you chart ambulating?
What is extensive assistance with one physical assist
Is supervising while providing one physical assist appropriate charting for bed mobility?
What is No. You CANNOT be supervised and also provide one person physical assist.
You and another staff member put Mrs. Franks on the toilet via sit to stand mechanical lift. How would you chart transfers?
What is extensive assist with two physical assist. (Never chart resident is total dependent if they are ordered sit to stand mechanical lift).
A resident has arthritis and need you to open his milk container and peel the lid off of the ice-cream cup. He eats the meal on his own using special built up utensils from occupational therapy. How would you chart his eating ADL?
What is independent with set up help.
Birtha is able to ambulate in her room with her walker under supervision. She needs to use the restroom. You open the door for her, put soap and paper towels on her sink and put the call bell where she can reach it. You need to keep an eye on her while she uses the toilet and wipes herself to make sure she doesn't fall. How would you chart the toileting ADL?
What is supervision with set up help only.
Resident is getting dressed and is able to put on his shirt and pants. Has poor dexterity in his hands and so you assist by zipping up his pants zipper. How would you code dressing?
What is limited assist with one person physical assist.
Resident frequently slides down in her bed. Two staff members had to physically lift and reposition her towards the head of the bed while resident assisted by bending her knees and pushing against the bed. How would you code bed mobilty?
What is extensive assistance with two person physical assist
Mrs. Johnson has kidney failure and is a dialysis patient. Today is Monday and is her scheduled dialysis day. Ambulance arrives with two EMT's and they transfer her onto a stretcher. How would you chart transfers?
What is Activity did not occur/not taken into consideration.
After staff deliver Mr. Johnson his tray in the dining room, he consumes all of the food without any cueing or physical help. How would you code eating?
What is independent with no set up or physical help from staff.
Staff prompt resident to toilet frequently during the day. The resident is able to stand and pivot on and off the toilet if you assist her left side. The resident also requires you to provide full peri care after she is finished. How would you chart this activity?
What is extensive assist with one physical assist
The CNA takes Mr. Thompsons toothbrush, comb and toothpaste from the drawer and places them on the bathroom sink. Mr. Thompson is then able to brush his own teeth and comb his own hair while CNA is in the room making his bed. CNA occasionally glances over to make sure Mr. Thompson is doing a good job. How would you chart this ADL?
What is supervision with set up help only
Mrs. Johnson is receiving a bed bath and must roll to left side for her back to be washed. Once you use bed pad to turn Mrs. Johnson on her side, she is able to stay on her side using her own strength or holding onto bed rail. How would you chart this ADL?
What is extensive assist with one physical assist.
Resident independently gets out of bed and walks to the bathroom without using a walker or cane. How would you chart transfers?
What is independent with no set up or physical help from staff.
Mr. Smith gets all of his nourishment via g-tube. He does nothing regarding g-tube care or his feeding. How would you chart Eating ADL?
What is Total dependent with one physical assist.
Resident is totally dependent on staff for all ADLs and uses full mechanical lift for transfers. He wears briefs and has incontinent urination and defecation several times on your shift. How would you chart his Toilet use for ADLs?
What is total dependent with one physical assist.
A resident states they cannot participate in their restorative program because they are having pain. What is the most important intervention you must take next?
What is tell the nurse. Follow up in your charting that resident did not participate due to pain and the nurse was notified.