CAAS summary language how

Karen,

If you explain the problem simply, you are meeting the requirements. Example:

"Jane had a total knee replacement on 10/10/10, and continues to have complaints of pain when ambulating. She participates in PT 3x week and nursing rehab walking and strengthening exercises 6x week. She has scheduled Ibuprofen QID and may have Lortab Q 4-6 hours PRN. She may have heat packs as needed. Her pain is assessed Q shift by the charge nurse. CNAs are instructed to report c/o pain or non-verbal expressions of pain." The nurse's notes for that shift should explain any complaints and treatments offered. Be brief and to the point. We also summarize our RAPs/CAAs in an IPN at the end of the care plan process and attach that to the MDS in the chart. Good luck!

Dori

My facility wants us to follow the following format: So when I try to address each area the wordage mixes me up. Does anyone have a way to clarify what should go in each area. I cannot just write a summary as the boses say NO but to follow this.

Nature of the issue or problem

Causes and contributing factors

Complications affecting or caused by the care area

Risk factors related to the presence of the condition

Analysis of the identified triggered area

Simple.

Nature of the problem: Acute pain following joint replacement

Causes/cont factors: surgical repair, arthritis, delayed healing due to poor nutritional intake...etc.

Risk factors: increased fall risk,impaired physical mobility, risk for constipation, depression, impaired surgical healing, anorexia.....

Analysis: Complaints of pain have decreased resulting in 2 requests per day for PRN pain meds on day 10 versus 6 requests/ day on day 2 following surgery. Jane walks approx. 100 feet per episode with rehab now versus only 5-10 feet on day 2. Jane refused scheduled pain meds as she states she did not want to become dependent upon them, and will ask when she feels she needs medication. Jane plans to return home when she is able to ambulate independently without pain.

Simple, to the point:>) Besides, the only ones who really read or use this info are the surveyors once a year. Your summary of the CAA tells a story.

Dori