Nursing Care Plans and CAA Documentation

The goal in documenting the Care Area Assessment process is to identify what needs to be care-planned, and why or why not. The documentation should include the problem, contributing and risk factors, and state if improvement is possible or decline can be minimized. 

CAA Summary notes should be brief but cover the essential points. Documentation for each triggered CAA should generally describe:

 Nature of the issue or condition (may include presence or lack of objective data and subjective complaints).

Complications and risk factors that affect the staff’s decision to proceed to care planning. 

Factors that must be considered in developing individualized care plan interventions. Include appropriate documentation to justify the decision to care plan or not to care plan for the individual resident. 

Need for referrals or further evaluation by appropriate health professionals. 

Written documentation of the CAA findings and decision-making process may appear anywhere in the resident’s record. 

The documentation can be located anywhere in the resident’s chart, and any form of CAT Summary Note is acceptable. 

It can be written in discipline specific flow sheets, progress notes, in the care plan summary notes, in a CAA summary narrative, on a CAA questionnaire, etc.

No matter where the information is recorded, use the “Location and Date of CAA Assessment Documentation” column on the CAA Summary form to note where the CAA review and decision-making documentation can be found in the resident’s record.  Also indicate in the column “Care Plan Decision” if the triggered problem is addressed in the care plan.

Refer to the location and date of this documentation on the CAA Summary Form, which is section V of the MDS. 

Using the right CAA Modules in this manual will make the process much easier.

Care Area Assessment Book with Triggers and Modules

CAA Nutritional Status

CAA Cognitive Loss – Dementia