Slide Presentation of the 2007 Annual Meeting of AHRQ

Lessons Learned: CNA documentation

• CNA documentation previously has not been closely monitored on weekly basis: contained knowledge deficits, inaccuracies
• CNA documentation of ADLs is new and requires time to learn the coding
  • CNA codes differ from MDS codes on new form
    • One-person assist is represented by "1" on CNA form
    • One person assist is represented by '2" for MDS nurse documentation.
  • MDS nurses have to adjust to change in codes.
• CNA documentation requires ongoing monitoring and follow-up by staff to maintain accuracy and high documentation completion rates