RAI-HC Tracking Tool for use in Supportive Living

Transcription

1 Start Date: Start Time A Mood Check all that apply (describe in detail in comment section) Makes negative statements e.g. life is not worth living, what s the use, nothing matters Shows constant anger with self or others e.g. easily annoyed, anger at care received, all the time Has unrealistic fears e.g. scared of being abandoned/left alone/being with others Repeats comments about health concerns e.g. obsesses about body functions, seeks medical attention Repeats anxious complaints/concerns e.g. needs reassurance about schedules, meals, rings call bell frequently Sad, pained, worried facial expressions e.g. frowning Repeatedly crying or being tearful Less interest or participation in usual activities e.g. loss of interest in family, friends or usual activities Less social than usual e.g. less talkative, spends more time alone B Behaviour Y or N (for any that apply) If yes, describe in detail in comment section Wandering (may happen in wheelchair) e.g. with no purpose, no concern for their safety or physical needs (do not include pacing) Was client verbally abusive? e.g. others were threatened, cursed at, screamed at Page 1 of 7

2 B Behaviour - Continued Y or N (for any that apply) If yes, describe in detail in comment section Was client physically abusive? e.g. hit others, shove, scratch, strike out, or sexually abusive Was Client socially inappropriate or disruptive? e.g. making disruptive sounds, disrobing, smearing or throwing food or feces, hoarding, rummaging, or pacing Was Client resistive to care? (can be verbal or physical) e.g. resists taking medication, pushes caregiver during ADL assistance in eating or position changes C ADL Self Performance (Describe in coment section if needed) A = Did not need help B = Set-up help only. Example: article placed within reach, or cut up food C = Needed supervision, includes encouragement, cueing, or stand-by assistance D = Hands on guiding. Example: guiding arm into shirt, but no lifting or supporting of arm Mobility in Bed Include moving to and from lying position, turning from side to side, positioning body while in bed/recliner (if used for sleep) Transfer Include moving to and between surfaces: to/ from bed, chair,wheelchair, or standing position (note: does not include to and from bath/toilet) Inside How client moves around in their room/suite/ building (e.g. walking, scooter, wheelchair, etc.) Do not include stairs Outside How client moves outside, off site (e.g., walking, scooter, wheelchair) Do not include stairs Locomotion E = Hands on help with less than half of task, including lifting of arms/legs etc. Example: physically supporting arms when putting through shirt sleeve F = Hands on help with more than half of task, including lifting of arms/legs etc. Example: applying compression stockings while physically supporting legs G = Hands on help for everything, client NOT helping. Example: use of a mechanical lift for transfer H = Activity did not occur For categories B H, record actual time spent in minutes assisting clients, e.g. F 7 Page 2 of 7

3 C Dressing ADL Self Performance (Describe in coment section if needed) - Continued Upper Body How client dresses and undresses (street clothes, night wear, underwear) above the waist. Includes prostheses, orthotics, fasteners, pullovers, but not glasses, dentures, or hearing aids Lower Body How client dresses and undresses (street clothes, night clothes, underwear) from the waist down. Include prostheses, orthotics, antiembolic stockings, belts, pants, skirts, shoes and fasteners Toilet Use Includes using toilet room, commode, bedpan, transferring on and off toilet; cleaning self after toilet use and after incontinence, managing ostomy/catheter, adjusting clothes Eating How client eats & drinks regardless of skill. Include tube feeding Personal Hygiene Include combing hair, brushing teeth, shaving, applying make-up, washing/drying face, but not baths or showers Bathing (include getting in and out of bath/shower) How client takes a full bath/shower/sponge bath. How each part of body is bathed (e.g. arms, upper and lower legs, chest, abdomen, peri area. (Do not include washing of hair and back) D Primary Mode of Locomotion Check which aid is used most often No Aid Cane Walker/Crutches Scooter (e.g. Amigo) Wheelchair (include electric wheelchair) Activity did not occur Indoors Page 3 of 7

4 D Primary Mode of Locomotion - Continued Check all that apply Outdoors No Aid Cane Walker/Crutches Scooter (e.g. Amigo) Wheelchair (include electric wheelchair) Activity did not occur (client did not go out) E Bladder Control Check all that apply Continent (no wetting of urine) Continent with indwelling catheter Incontinent (Bladder incontinence includes any level of dribbling, or wetting of urine or leaking catheter) F Bladder Devices Check all that apply Use of Pads/Briefs to Protect from Wetness (Do not include panty liners or routine use of pads on bed or chair when client is never/rarely incontinent) Use of indwelling catheter G Bowel Control Check all that apply - May have both Continent & Incontinent Episodes Continent (full control of bowels) Continent with Ostomy Incontinent (no bowel control) include an ostomy that leaks Had bowel movement (record each shift) Page 4 of 7

5 H Problem Conditions Check all that apply (describe in comment section if checked) Diarrhea (frequent watery stools) Difficulty Urinating Urinating 3 or more times at night Vomiting Chest Pain Dizziness or light headedness sensation of unsteadiness, turning, or surroundings are spinning around Hallucinations seeing, hearing, smelling, feeling, or tasting something that is not there I Pain Check all that apply - (describe in comment section if checked) Complains of Pain includes crying, wincing, frowning, moaning, or decreased activity Complains of pain in more than one area J Nutritional / Hydration Status Y = Yes, N = No (for any that apply) If yes, describe in detail in comment section Change in Usual Eating & Fluid Intake Weigh Client (once in 8 day period - bath day) Weight - Previous Date of Previous Weight (yyyy-mon-dd) K Skin Condition / Problem Check all that apply - (describe in comment section if checked) Rash Itchiness Bruises Skin Tears / Cuts Scrapes Open Sores Burns Page 5 of 7

6 L Other Time Spent Caring for The Client Check all that apply - (describe in comment section if checked) MAP Wound Care Other Total Time - Add up all time spent caring for client at the end of your shift Total HCA Time Total LPN Time Comments Include Date and Time Reviewed by Supportive Living Clinical leader Check here if comments continue on to page 7 SL signature: Received by Case Manager CM signature: Page 6 of 7

7 Comments Include Date and Time Reviewed by Supportive Living Clinical leader SL signature: Received by Case Manager CM signature: Page 7 of 7