He was able to hold on to the hand grips during the transfer. According to the care plan, Mr. What about if this resident got up once during the middle of the night and needed two person assist to transfer to the bedside commode — would that change your coding??? Kline prefers to sleep in his recliner as stated in his care plan. As the name suggests, they are the last that a person looses the ability to participate in and they are most predictive of resource use. Patient ambulates to the bathroom and is independent with toilet use for bowels. Scenario one: Take the case of a resident who needs to reposition herself in bed.
You bring him his plate, cup of coffee and provide him no other assistance during the meal. She provided no assistance during the transfer. The staff member will most likely remember the care provided the previous day and can complete a late entry. If a resident requires very minimal assistance then they will not group into the level despite having the clinical condition. There cannot be enough nursing assistant training on this issue. Even if the resident could roll independently from side to side, the assistance the resident requires to sit up would still place her in the '3, 2' category for bed mobility, said Shephard, who is also the chair of the American Association of Nurse Assessment Coordinators.
Do not include emptying of bedpan, urinal, bedside commode, catheter bag or ostomy bag. Coding: The patient is an Extensive Assist as the highest level of support over the shift is extensive while in the dining room. The staff boosts the patient to the top of the bed, utilizing the lift sheet and assisting in lifting the legs. Different disciplines contradict each other in the documentation. Occasional in-services definitely don't work, colorfully printed graphics explaining the difference between independent, supervision, limited assistance, extensive assistance, and total dependence don't seem to work. The keys to Section G, as McDonald related, are to correctly identify what the resident can do without assistance and then to note when the resident requires help. Rubble is a post right ankle fracture and has orders for non weightbearing to her right foot.
Scenario eight: Finally, let's look at the example of a resident who needs verbal cueing and reminders to get up and go to meals and activities. Davis has right sided weakness due to her recent stroke and needs assist of 2 staff to transfer using the mechanical lift. I made up some of my own examples for coding. The documentation doesn't include all three shifts per 24 hours. There are a couple of other potential codes — to use when the activity does not happen at least three times — we will review those on the next couple slides. A nursing assistant may not realize that putting on Mrs. Patient is an Extensive Assist for eating if participated in any fashion.
The staff responds to the alarm to ensure that the patient safely transfers. When I have adequate documentation from Therapy and Nursing that makes it clear the resident could not ambulate, I code an 8, but always worry that their rushing through is going to cause an inaccurate code. I have tried looking up coding examples and senarios online and found a whole lot of nothing. Dressing includes putting on and changing pajamas and housedresses. Code a '2' for assistance provided, representing a one-person physical assist. He is able to lean forward so you can place a pillow behind his back. If the patient needs help with any of the steps involved in toileting, as described above, he is not independent in toileting.
Weight bearing support or dependence for fluid intake occurs during this time only. During your shift, you and another staff transferred Mr. How do you code this transfer? Electronic documentation systems can revolutionize coding. Staff bring the chair next to the bed and then remind her to hold on to the chair and position her body slowly. How do you code toileting based on the assistance you provided? Staff manages the indwelling catheter and leg bag.
You need to get out on the units and demonstrate what you mean. If someone excels in a specific area, ask that person to coach their co-workers. Scenario two: A different resident cannot sit up in bed at all. The resident was then able to complete the meal. Any new hire received education as part of orientation. During your shift, he asked you to remove the pillow from under his feet which required you to lift both legs up to remove the pillows.