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