ADL DOCUMENTATION for CNAs
Contents
1. BED MOBILITY how the resident is able to move around in bed recliner or other furniture resident sleeps in reposition self hold onto rail moves to from lying position turns from side to side TRANSFER how resident moves between surfaces to from bed chair wheelchair standing position exclude transfers to from bath and toilet CODES and definitions 0 Bathing Codes 0 Resident is totally independent and needs no help or supervision to perform this ADL includes self administered tube feeding helped the Resident by reminding cueing them or directing them opening cartons or food packages cutting meat encouraging them to perform by themselves cueing reminding to use their walker go to the toilet etc No physical contact or touching is needed NOTE PT language Stand by assist provided hands on assistance to the Resident but did not lift any of their weight Guided arms into sleeves feet into shoes body into chair food into mouth etc PT language Contact guard assist provided assistance to the Resident by lifting part of their weight lifted their head or body for repositioning picked up their arm to put it on a bed rail or into a sleeve picked up their feet and put them on or off the bed lifted their arm to guide food into mouth etc had to hold the leg up to put Ted Hose on PT language Minimum moderate maximum assist provided all the needs of the Resident2. Resident on each shift The 4 Late loss ADL s see Resident Performance page must report changes to charge nurse immediately for further assessment 0 No setup or physical help Resident performed this ADL independently and did not require any assistance from staff 1 Set up help only no physical contact staff opened milk carton carried food tray for Resident cued Resident to eat instructed on bathing reminded to use or handed to walker etc 2 One staff person is needed to physically assist the Resident weight bearing or non weight bearing Weight bearing means lift a part of the resident non weight bearing is guiding the hand without having to lift it 3 Two staff people are needed to complete or assist in ADL s for Resident weight bearing or non weight bearing 8 This activity did not occur during my shift Resident did not leave unit No elimination occurred When an 8 code is used for Support Provided it should also be used for Self Performance ADL CODE Bed Mobility Eating Toileting Transfer Dressing Walk in room Walk in corridor Locomotion on unit Locomotion off unit Personal hygiene Bathing When toileting your Resident on this shift did you find them wet or soiled Yes No Adapted from MDS 2 0 User s Manual Elizabeth Sutherland MSN RN Updated June 2009 by Clara S Boland PhD RN QIPMO University of Missouri
3. ADL DOCUMENTATION for CNAs BA INSTRUCTIONS The ADL Documentation form for CNAs was developed to aid in clarifying the language used to describe and code Section G of the MDS It is to be used during the MDS 7 day look back period The CNA from each shift assigned to a resident during a 7 day look back period should complete a separate form for that resident during each of the 7 days The MDS coordinator can then determine more accurately the actual extent of resident participation and staff involvement If you are using electronic documentation this tool will serve as an additional guide to assist in clarification of how the CNA documents and codes the individual ADLs Adapted from MDS 2 0 User s Manual Elizabeth Sutherland MSN RN Updated June 2009 by Clara S Boland PhD RN QIPMO University of Missouri ADL DOCUMENTATION Resident Performance What the Resident does in my care only not what think they are capable of or what see them do with other caregivers therapy nurses etc ADL Definition Activity of Daily Living ADL an activity that a person performs on a daily basis for self care There are 11 ADL s Must report changes in any of the following 4 ADLs to charge nurse immediately for further assessment EATING how resident eats drinks regardless of skill Includes tube feeding and TPN TOILETING transfers to and from toilet adjusts clothing voiding cleanses self changes pads uses urinal etc
4. to perform the ADL task The Resident was not able to help in any way performed total lift total transfer fed resident etc had to move resident while in bed on off unit Resident unable to use toilet commode bedpan urinal clean themselves change pad or adjust clothes after toileting unable to manage Ostomy or catheter PT language Dependent This ADL did not occur The Resident did not perform this ADL with or without my assistance Primary use is with bed bound residents who do not transfer from bed nor move between locations Resident had no output urine or stool and no intake by any means Resident wore no clothing or did not have bath shower When an 8 code is used for Self Performance it should also be used for Support ADL CODE ADL CODE Bed Mobility ee Walk in room _ Eating oe Walk in corridor coe Toileting ae Locomotion on unit o Transfer o Locomotion off unit o Dressing s Personal hygiene n Independent No help provided 3 Assistance for part of bath only 1 Supervision Oversight cueing help only 4 Total assistance for bathing 2 Assistance needed only for transferring 8 No bathing occurred ADL CODE Bathing Adapted from MDS 2 0 User s Manual Elizabeth Sutherland MSN RN Updated June 2009 by Clara S Boland PhD RN QIPMO University of Missouri ADL DOCUMENTATION Staff Performance What do to assist the resident with the ADL We need to document the amount of support provided to the
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