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.
