Independent
Resident completed activity with no help or Supervision from staff.
Supervision
No hands on; you did not touch the resident in any way, you may encourage, cue, or give directions.
Limited assist
Resident highly involved in activity and only received guided maneuvering of limbs or other non- weight bearing assistance
Extensive Assist
Weight Bearing Assistance provided by the staff
Total Dependent
Resident did not participate. You performed the entire task.
Did Not Occur:
This did not occur during your shift.
DO NOT CHART A TASK UNTIL
it is completed.
If you chart and uncompleted task it is considered
Fraudulent charting.
If you chart a limited assist you never say
2 assist
Bed Mobility
How resident turns from side to side, moves from a lying position, and how the resident positions their body in bed.
Transfer
How well the resident transfers to and from bed, geri-chair or wheel chair.
If used a Hoyer Transfer it is charted as
Total Dependent
If used a Vera-Lift it is charted as
Extensive Assist
Types of Locomotion
Cane, walker, crutches and if resident walks by pushing a wheel chair
Modes of Locomotion:
Geri- chair and wheel chair
How resident moves about in wing:
How well resident walks in hall unit or uses wheelchair to move around. If the resident is in a heel chair indicate how the resident moves around in their chair.
How resident moves about off wing
How well resident gets from wing/ nit to church, or another floor and return to own floor.
Eating
How well resident eats or drinks regardless of skill. Just because they an chew or swallow does not make them an extensive assit.
Toilet Use:
How resident uses the toilet, commode, bedpan, or urinal, transfers on and off toilet, cleanses themselves, changes pad, pull-up or brief, manages catheter or ostomy and adjusts clothing
TOILET USE ABOVE SHOULD NEVER BE CHARTED IF
the resident has not void
Ir a resident skin gets wet with urine, or whatever is next to the skin, it should be counted as
incontinence
A foley and ostomy are counted as
continent unless there is leakage.
Dressing
Howe well resident puts on fastens and takes off all items of clothing, including underwear socks and shoes. THis includes putting on and taking off prosthesis
Personal Hygiene
How resident maintains personal hygiene including combing hair, brushing teeth, apply make-up, washing hands and face and perineum.
Bathing
How resident takes full body bath shower or sponge bath, and how well resident transfers in and out of tub or shower.
Bathing documentation does not include
washing back and washing hair
Bathing Independent
no help or oversight
Bathing Supervision
Oversight, encouragement, cueing help only, all verbal.
Bathing Physical Help Limited to Transfer Only
Resident needs assistance only in transferring to and from shower or whirlpool
Bathing Physical Help
Physical help in part of bathing activity
Total Dependent
Resident was totally dependent on staff for bath.
Not charting accurately can cost
as much as $50.00 a day.
You must chart mood and behavior daily
even if they occur day after day.
Make a nurse's note if
delusion or hallucination occurs.
Hallucination:
False sensory sensations. Ex. Angels Singing, feeling bugs crawl on them that aren't there
Delusion:
fixed false belief. Must be able to communicate their own thoughts. Ex. they think they are being poisoned with their food.
Document Follow Statements:
on next slides
Negative Statements
Let Me Die! Nothing Matters!
Repetitive Questions:
Why are you doing that? What did I do?
Repetitive Verbalization:
Help Me! Help Me! Resident says the same thing over and over.
Persistent Anger:
easily annoyed, anger at care received, anger at placement.
Self Deprecation
I am no use to anyone! I feel like I'm useless!
Unrealistic Fears:
Fear of being alone and abandoned
Something terrible is going to happen
false belief that something is going to happen them
Repetitive Health Conern
persistently seeks medical attention
Repetitive Anxious Complaints:
Persistently seeks attention or reassurance.
Behavior Symptoms Include:
Wandering, Verbal Abuse, Physical Abuse, Socially Inappropriate Behavior, Resident resists care.
Wandering
moving without a purpose or goal or a way to get out
Verbal abuse
resident threatens, sceams at or curses at others
Physical Abuse
resident hits, shoves, scratches, kicks, or sexually abuse others
Socially inappropriate behavior
disruptive sounds, excessive noises, screams, self abuse acts, rummaging in other things, hoarding, or disrobing in public
Resident resists care
Resist taking medications/injections, ADL, assistance or help with eating.
Measurements to record
Location where resident ate meals.
Record meal and snacks intake
record weights
record vital signs
additional fluids
In order for rehab to be counted it needs to be a
combination of staff and resident being involved
Do not record minutes with
independent transfers
do not record minutes with
total assist with transfers
do not record minutes with
ambulation
ACTIVE ROM
exercise performed by the patient with cues of supervision. you have given directions only