What is ADL for CNA?
ADLs – This stands for “activities of daily living” and includes basic activities of daily life. Examples of ADLs include: bathing, dressing, eating, transferring, toileting, and walking. A Personal Care Aide (PCA) or Certified Nursing Assistant (CNA) can assist with these activities.
What documents do I need for CNA?
What do CNAs document? Plenty!
- Level of consciousness or alertness.
- Measurements of vital signs.
- Height and weight.
- Intake and output.
- Bowel elimination.
- Appetite and food intake.
- Skin: color, condition, integrity.
What is a flow sheet CNA?
CNA Report Sheet, CNA daily flowsheet “Includes information on: Rm#, Nurse, Weight/Height, Precautions, Accuchecks, Vitals, and Other. Color-coded to differentiate between patients.
When should documentation be recorded CNA?
It is expected that the CNA will perform and document their activities in a timely manner. By the time the CNA is done with the activities that got started at 7am, the documentation may not have been put in until 10am. It would be appropriate to document; “late entry, activity provided at 0700.”
How do you assess ADL?
Several types of approaches have been used to quantify level of independence in ADLs. ADLs may be measured by self-report, proxy/caregiver/informant report, and/or direct observation. These tools obtain a general sense of the level of assistance needed and the type of setting that is most appropriate for the patient.
How do you assist patients with ADLs?
Examples. When assisting with basic ADLs, use common sense, non-challenging body language, and a quiet, confident tone of voice. Whatever the activity, move slowly, give clear, simple commands, limit choices, and allow plenty of time to complete the task.
What are the basic rules of documentation in nursing?
Be clear, legible, concise, contemporaneous, progressive and accurate. Include information about assessments, action taken, outcomes, reassessment processes (if necessary), risks, complications and changes.
How do you document as a nurse?
Tips for Great Nursing Documentation
- Be Accurate. Write down information accurately in real-time.
- Avoid Late Entries.
- Prioritize Legibility.
- Use the Right Tools.
- Follow Policy on Abbreviations.
- Document Physician Consultations.
- Chart the Symptom and the Treatment.
- Avoid Opinions and Hearsay.
What does a flow sheet consist of?
A flow sheet is simply a one- or two-page form that gathers all the important data regarding a patient’s condition, in this case diabetes. The flow sheet is housed in the patient’s chart and serves as a reminder of care and a record of whether care expectations have been met.
What are graphic forms used for?
Graphics are visual elements often used to point readers and viewers to particular information.
What are the 3 rules of documentation?
Documentation should be:
- Immediate. Managers should take notes right after an incident occurs.
- Accurate and believable. When an outside observer (judge, jury or EEO investigator) is called to judge your side of the story, detailed observations add authenticity.
- Agreed upon.
What are the two basic rules of documentation?
Basic rules of documentation: 1. Date and time all notes.