{ Daily Responsibilities Lesson 29 1

1. Student will be able to explain the importance of prioritization, organization, and time management while providing resident care 2. The student will be able to explain the role of the interdisciplinary team and care plan revision based on changes in the resident’s condition and/or needs Objectives 2

 shift begins with getting from prior shift and needs to be thorough each time  Beginning of Shift Report- shift begins with getting report from prior shift and needs to be thorough each time  Assignment sheet will tell the NA what residents he/she will be taking care of (names/room #s), tasks to complete, and any other pertinent info (appointments, mental status/safety checks)  Documenting- NA documents all completed work and verbally reports any incomplete assignments to the nurse and/or incoming shift  notify new shift staff of immediate needs and give thorough details about any changes  End of Shift Report- notify new shift staff of immediate needs and give thorough details about any changes *Remember: some situations require immediate reporting and should not be held off until the end of your shift* Planning & Organizing 3

 Take care of immediate needs/issues then make a plan and set goals for each resident for the rest of the shift (A written list/plan helps, rather than a mental plan)  Written Plan:  Should be realistic and attainable  Schedule in your breaks (2-15 min & 1-30min)  Expect the unexpected=Be flexible  Multitask  Continue revising the plan accordingly  Take a few minutes to visit each resident, introduce yourself and explain how long you are going to be there “ Plan your work and work your plan” 4

 The NA is legally responsible to accurately and completely document care he/she gives each shift ***What is not charted, legally was not done***  Documenting varies facility to facility, but is part of the facility orientation/training upon hire Documentation 5

Correct Documentation 6 1.Resident’s name on each page 2.All entries in BLUE or BLACK ink, neat and legible 3.Entries are accurate and in chronological order as they occurred 4. Never document before a procedure is completed 5.Use facility-approved abbreviations 6.No ditto marks 7.Time and date entries; sign with name and title, unless initials are acceptable per facility policy. 8.Never document for someone else

Correcting an Error 7 -If correcting an error, draw a single line through the error, print word “error” above entry and initial and date the correction -Late entries: circle the late entry to indicate it is out of chronological order, write the words “late entry” (below examples) -Never erase, Never use liquid correction fluid, Never scratch or scribble out an entry Examples: 11/11/ Mrs. Smith voided 300cc of clear brown urine. MM 11/11/ Mrs. Smith vomited yellow colored emesis MM Mickey Mouse, CNA/MM

Military Time 8 HOW? For the hours between 1:00 p.m.to 11:59 p.m., add 12 to the regular time. Otherwise write without : For example: 1) To change 2:00 p.m. to military time, add The time would be 1400 hours. 2) 10:25am would simply be 1025 hours Let’s Try…

Electronic Medical Records (EMR) 9 Most, if not all facilities use computers/electronic medical records. Don’t forget about HIPAA (patients privacy) -When using, make certain information seen on the screen is not visible to others. -Do not share confidential information with anyone except other caregivers on the team. -Be sure you are documenting on the correct resident

Care Plan Revisions done at least quarterly, but also when any significant changes occur in the resident’s condition -Provides an accurate, up to date reflection of the resident’s condition -Must be accessible to all healthcare team members and utilized when assignment sheets are made out for the NA Who attends? May include, but not limited to: the resident if able, family member(s), POA/HCR, nurse, unit manager, DON, Social Worker, Activity Director, Dietician, PT/OT, chaplain, and of course a CNA Interdisciplinary Care Plan Meetings 10

1. Explain the procedure for correcting an error in documentation. 2. Describe information that should be communicated to the oncoming shift during report. 3. How often should a resident’s care plan be revised? 4. True or False? To avoid overtime, it is permissible to ask someone to finish your charting. 5. True or False? The resident is a member of the Interdisciplinary care team. Review Questions 11