front 1 Independent | back 1 Resident completed activity with no help or Supervision from staff. |
front 2 Supervision | back 2 No hands on; you did not touch the resident in any way, you may encourage, cue, or give directions. |
front 3 Limited assist | back 3 Resident highly involved in activity and only received guided maneuvering of limbs or other non- weight bearing assistance |
front 4 Extensive Assist | back 4 Weight Bearing Assistance provided by the staff |
front 5 Total Dependent | back 5 Resident did not participate. You performed the entire task. |
front 6 Did Not Occur: | back 6 This did not occur during your shift. |
front 7 DO NOT CHART A TASK UNTIL | back 7 it is completed. |
front 8 If you chart and uncompleted task it is considered | back 8 Fraudulent charting. |
front 9 If you chart a limited assist you never say | back 9 2 assist |
front 10 Bed Mobility | back 10 How resident turns from side to side, moves from a lying position, and how the resident positions their body in bed. |
front 11 Transfer | back 11 How well the resident transfers to and from bed, geri-chair or wheel chair. |
front 12 If used a Hoyer Transfer it is charted as | back 12 Total Dependent |
front 13 If used a Vera-Lift it is charted as | back 13 Extensive Assist |
front 14 Types of Locomotion | back 14 Cane, walker, crutches and if resident walks by pushing a wheel chair |
front 15 Modes of Locomotion: | back 15 Geri- chair and wheel chair |
front 16 How resident moves about in wing: | back 16 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. |
front 17 How resident moves about off wing | back 17 How well resident gets from wing/ nit to church, or another floor and return to own floor. |
front 18 Eating | back 18 How well resident eats or drinks regardless of skill. Just because they an chew or swallow does not make them an extensive assit. |
front 19 Toilet Use: | back 19 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 |
front 20 TOILET USE ABOVE SHOULD NEVER BE CHARTED IF | back 20 the resident has not void |
front 21 Ir a resident skin gets wet with urine, or whatever is next to the skin, it should be counted as | back 21 incontinence |
front 22 A foley and ostomy are counted as | back 22 continent unless there is leakage. |
front 23 Dressing | back 23 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 |
front 24 Personal Hygiene | back 24 How resident maintains personal hygiene including combing hair, brushing teeth, apply make-up, washing hands and face and perineum. |
front 25 Bathing | back 25 How resident takes full body bath shower or sponge bath, and how well resident transfers in and out of tub or shower. |
front 26 Bathing documentation does not include | back 26 washing back and washing hair |
front 27 Bathing Independent | back 27 no help or oversight |
front 28 Bathing Supervision | back 28 Oversight, encouragement, cueing help only, all verbal. |
front 29 Bathing Physical Help Limited to Transfer Only | back 29 Resident needs assistance only in transferring to and from shower or whirlpool |
front 30 Bathing Physical Help | back 30 Physical help in part of bathing activity |
front 31 Total Dependent | back 31 Resident was totally dependent on staff for bath. |
front 32 Not charting accurately can cost | back 32 as much as $50.00 a day. |
front 33 You must chart mood and behavior daily | back 33 even if they occur day after day. |
front 34 Make a nurse's note if | back 34 delusion or hallucination occurs. |
front 35 Hallucination: | back 35 False sensory sensations. Ex. Angels Singing, feeling bugs crawl on them that aren't there |
front 36 Delusion: | back 36 fixed false belief. Must be able to communicate their own thoughts. Ex. they think they are being poisoned with their food. |
front 37 Document Follow Statements: | back 37 on next slides |
front 38 Negative Statements | back 38 Let Me Die! Nothing Matters! |
front 39 Repetitive Questions: | back 39 Why are you doing that? What did I do? |
front 40 Repetitive Verbalization: | back 40 Help Me! Help Me! Resident says the same thing over and over. |
front 41 Persistent Anger: | back 41 easily annoyed, anger at care received, anger at placement. |
front 42 Self Deprecation | back 42 I am no use to anyone! I feel like I'm useless! |
front 43 Unrealistic Fears: | back 43 Fear of being alone and abandoned |
front 44 Something terrible is going to happen | back 44 false belief that something is going to happen them |
front 45 Repetitive Health Conern | back 45 persistently seeks medical attention |
front 46 Repetitive Anxious Complaints: | back 46 Persistently seeks attention or reassurance. |
front 47 Behavior Symptoms Include: | back 47 Wandering, Verbal Abuse, Physical Abuse, Socially Inappropriate Behavior, Resident resists care. |
front 48 Wandering | back 48 moving without a purpose or goal or a way to get out |
front 49 Verbal abuse | back 49 resident threatens, sceams at or curses at others |
front 50 Physical Abuse | back 50 resident hits, shoves, scratches, kicks, or sexually abuse others |
front 51 Socially inappropriate behavior | back 51 disruptive sounds, excessive noises, screams, self abuse acts, rummaging in other things, hoarding, or disrobing in public |
front 52 Resident resists care | back 52 Resist taking medications/injections, ADL, assistance or help with eating. |
front 53 Measurements to record | back 53 Location where resident ate meals.
|
front 54 In order for rehab to be counted it needs to be a | back 54 combination of staff and resident being involved |
front 55 Do not record minutes with | back 55 independent transfers |
front 56 do not record minutes with | back 56 total assist with transfers |
front 57 do not record minutes with | back 57 ambulation |
front 58 ACTIVE ROM | back 58 exercise performed by the patient with cues of supervision. you have given directions only |