1. Annual Compulsory Education
Point of Care (POC)
Annual Compulsory Education

2. Learning Objectives
Understand & appreciate the importance of accurate coding
To increase understanding of POC codes & how codes are applied to the Activities of Daily Living
To have a deeper knowledge of each Activity of Daily living definition & how it influences coding
To have a deeper understanding & knowledge of how to recognize & code for mood and behaviors
To understand what the expectations are for nursing rehabs

3. About the RAI-MDS 2.0
The RAI-MDS 2.0 utilizes clinical competence, observation skills, & assessment expertise from all disciplines to develop individualized care plans by gathering information on a resident’s strengths & needs. As HCAs you have daily contact with residents that enable you to be a reliable source of information about the resident. This is indicated daily through your POC documentation that contributes to the Residents MDS assessment, identifying strengths & needs, as well as helps to develop the care plan.

4. About POC
HCAs are responsible to have the knowledge & understanding to complete POC coding for the residents
POC documentation must be completed with honesty & must reflect your work with the resident
POC can be audited at any time to ensure accuracy of the coding & documentation. As an HCA it is important to understand the coding & ADL definitions so that you can code accurately

5. Coding Definitions
Similar colours can be coded together, not mixed. I.e. If you choose activity did not occur on one side you must choose activity did not occur on the other side.
Self Performance (Resident Performance)
Support Provided (Employee Performance)
Independent: No help or staff oversight.
No set-up or Physical help from staff:
Supervision: Oversight, encouragement or cueing. Using your eyes and mouth.
Set-up help only: Resident is provided with materials or devices necessary to perform the ADL.
Limited Assistance:
Received physical help in guiding and maneuvering of limbs or other NON-weight-bearing assistance.
Not using your strength, this is light touch.
One person physical assist:
Once you have applied touch and physically assisted the resident.
Extensive Assistance:
Resident able to help in part of activity but physical weight-bearing support was provided. Using your own strength to lift or move resident’s body, leg and/or arm.
Two or more physical assist:
You and another staff member physically assist the resident.
Total Dependence:
Full physical assistance provided for ADL. Resident did not help with activity.
Activity did not occur

6. Activities of Daily living that are coded
Bed mobility
Dressing
Personal Hygiene
Toilet Use
Transferring
Walking in Room
Walking in Corridor (Hallway)
Locomotion on Unit
Locomotion off unit
Eating
Bathing

7. New Entries
You must code anytime the resident with or without support from staff performs any of the activities listed in the ADL definitions on an ongoing basis throughout your shift.
In other words:
If an activity happens several times during your shift use the “New Entry” tab & code each time to capture the activities.

8. New Entries
Examples:
You are working a morning shift & assist a resident to dress; then you would code for dressing. Later you then bathe that resident & assisted in undressing & dressing a resident again on the same shift, new action would be considered a New Entry & should be coded again in POC (re: dressing).
If a resident throughout the majority of your shift has been transferring with limited assistance & then ½ hour before the end of your shift falls & needs a full body mechanical lift to help them up, you must indicate this using a New Entry for transfer & code what occurred.

9. Bed Mobility definition & practice question
Bed Mobility Definition: How the resident moves to and from a lying position, turns side to side and positions body while in bed.
Scenario:
Mr. Doug is usually able to reposition himself in bed. Tonight he was having some difficulty breathing so we raised the head of bed to 30° to help him breath. Mr. Doug slid down towards the foot of bed & the night HCA needed to help boost him up. Mr. Doug assisted the HCA by bending his knees & pushing up off of the mattress.
How would you code and why?

10. Bed Mobility Practice question - Answer
Self Performance: Extensive Assistance
Support provided: One Person Physical Assist
Was your answer different?
Ask yourself did I physically assist the resident? If yes, then we know that we must code either Limited, Extensive or Total & you either physically assisted with 1 person or 2 or more.
Ask your self did I provide any weight bearing assistance. If yes, then you know it is NOT Limited but rather Extensive or Total.
Then ask yourself did the resident help. If yes, then we know it is NOT Total.
Thus, for Bed Mobility we provided weight bearing assistance (Boosting up in bed) but the resident helped by pushing up off the mattress. There was only one staff member present.

11. Dressing definition & practice question
Dressing Definition: How resident puts on, fastens, & takes off all items of street clothing, including donning/removing prosthesis.
Scenario:
Mrs. Jody is a new resident is admitted to the secured unit due to her dementia & elopement risk. She is very mobile & talkative woman who likes to wake up early in the morning. You assist Mrs. Jody with her personal hygiene needs. You take her to the closet & have her choose what she would like to wear. Once decided you take the items out of the closet & hand each article to her beginning with the undergarments, then shirt, pants, & shoes. You noticed prior to leaving the room that she has mis-buttoned her shirt. You explain to her what she needed to do to correct it.
How would you code & why?

12. Dressing Practice question - Answer
Self Performance: Supervision
Support provided: Set-up Help Only
Was your answer different?
Ask “Did I physically assist the resident?” If the answer is No, you know that it is either Independent or Supervision. Therefore support provided is either No staff performance or Set-up Help only.
Ask if the resident performed the activity (Dressing) completely on their own or did you need to verbally explain a procedure, remind them to do something, or encourage them to complete a task. If you verbally helped or monitored them, you know it’s NOT Independent but rather Supervision.
Finally ask if you helped set them up to do the task by handing them the clothing or set them aside for the resident to use. If yes, you know you provided set-up help.
Thus, for dressing we verbally explained to the resident how to button her shirt & handed her all the items of clothing.

13. Personal Hygiene definition & Practice question
Personal Hygiene Definition: How the residents maintains personal hygiene, including combing hair, brushing teeth, shaving, applying make-up, washing/drying face, hands, & perineum. (Exclude baths & showers when coding). Scenario: You are providing morning care Mr. Smith. Today he required staff to wash his face, hands, chest, and back. Peri-care & putting on his pants are completed in bed with two staff members because he has left-sided paralysis & right-sided weakness. Mr. Smith assists you in putting on his shirt by leaning forward, is able to brush his teeth, and shave with his right hand as long as staff can place it in his hand, but needs staff assistance to comb his hair. How would you code and why? Take your time & think it through…….

14. Personal Hygiene Practice question - Answer
Self performance: Extensive Assistance
Support provided: Two or more physical Assistance
Was your answer different?
Remember that you need to take specific information out of everything you do for a resident specific to the definition. This means that aspects of dressing should NOT be considered here.
Ask “Did I physically assist the resident?” If yes, we know that we must code either Limited, Extensive, or Total & you either physically assisted with 1 person or 2 or more.
Ask “Did I provide any weight bearing assistance?” If yes, you know it is NOT Limited, but rather Extensive or Total.
Finally ask if the resident helped out. If yes, we know it is NOT Total.
For personal hygiene we provided weight bearing assistance (with the peri-care), but the resident helped with other activities of personal hygiene. During peri-care we required 2 staff to help.

15. Toilet Use Definition & Practice Question
Toilet Use Definition: How the resident uses the toilet room, commode, bedpan, or urinal, transfers on/off toilet (Include when coding), cleanses, changes pad, manages ostomy or catheter, & adjusts clothing. Scenario: Mr. Peter is a pleasant man who requires light physical assistance with a transfer belt to guide him onto the toilet seat for toileting. When he is finished, you hand him a wash cloth for him to complete his peri-care. He then stands up from the toilet & you physically assist him by pulling up his underpants, hip protectors & pants. Finally you remind him to complete his hand hygiene. How would you code & why?

16. Toilet Use Practice Question - answer
Self performance: Extensive Assistance
Support provided: One person physical AssistanceWas your answer different?
Ask “Did I physically assist the resident?” If yes, we know that we must code either Limited, Extensive, or Total & you either physically assisted with 1 person or 2 or more.
Think if you provided any weight bearing assistance. If yes, you know it is NOT Limited, but rather Extensive or Total. (Where did you provided the weight bearing assistance?)
Then think did the resident help. If yes, we know it is NOT Total.
Thus, the resident required Limited assistance for the transfer (which is included in the toileting definition). However he required that we pull up his pants which is a WEIGHT BEARING activity. Therefore we need to code extensive assistance & NOT Limited.

17. Coding toilet use Tips
Remember toileting happens however toileting happens If you have a resident who is unable to use the toilet & their incontinent pad is changed by staff on the bed, you DO NOT code Activity Did Not Occur because toileting has occurred. You would code in accordance to the coding definitions.

18. Transferring Definition & Practice Question
Transferring Definition: How resident moves between surfaces to/from: bed, chair, wheelchair, standing position (Exclude to/from bath/toilet) Scenario: Mrs. Baker has dementia & forgets to use her walker & leaves it around the unit. You go on the hunt & find the walker by the nursing station. You bring it & place it in front of her with the brakes on. Mrs. Baker loves to attend recreations baking activities so you ask her if she would like to go. She becomes excited & says “Yes”. You ask her to stand by pushing off of the chair armrests instead of the walker to prevent unsteadiness & falling. Once she is up you take her to the activity. How would you code & why?

19. Transferring Practice Question - Answer
Self performance: Supervision
Support provided: Set-up Help Only
Was your answer different?
Ask “Did I physically assist the resident?” If No, you know that it is either Independent or Supervision. Thus you know that support provided is either No Staff Performance or Set-up Help only.
Did the resident do the complete activity (Transfer) on their own or did you need to verbally explain a procedure, remind them to do something, or encourage them to complete a task. If you verbally helped or monitored them, you know it is NOT Independent but rather Supervision.
Finally ask if you helped set them up to do the task by handing them articles, or set them aside for the resident to use. If yes, you know you provided Set-up Help.
You monitored to see if the resident had the walker to transfer safely by bringing it to her & applied the brakes. This set her up for the transfer but you needed to verbally explain how to do the transfer procedure safely.

20. Walking in Room Definition & Practice Question
Walking in Room Definition: How the resident walks between locations in their room
Scenario:
Mr. Charles is watching TV in his room & calls for assistance to use the bathroom. Mr. Charles can stand up from his wheelchair without assistance, but is unstable on his feet & must use his walker to walk to the bathroom located in his room. Due to his unsteadiness on his feet, his care plan states that staff must use a transfer belt around his waist & hold it while he is walking for safety. You help toilet Mr. Charles & walk with him back to his wheelchair.
How would you code & why?

21. Walking in Room Practice Question - Answer
Self performance: Limited Assistance
Support provided: One Person Physical Assistance
Was your answer different?
Ask “Did I physically assist the resident?” If yes you know that it is either Limited, Extensive, or Total and either the activity required 1 or 2 or more persons to assist.
Ask if you provided any weight bearing assistance? If No, then you know that it must be Limited Assistance.
Since you lightly held the transfer belt for safety & did not provide any weight bearing assistance while walking in the room, the resident only required one person to assist.

22. Walking in Corridor (Hallway) Practice Question
Walking in Corridor (Hallway) Definition: How resident walks in corridor (hallway) on unit
Scenario:
Mr. Smith has a diagnosis of COPD. He walks short distances in his room with his 4-wheel walker. However to go to the dining room or recreational activities, he requires the assistance of one person to pick him up from his room & porter him down the halls to the activities or dining room in his wheelchair.
How would you code & why?

23. Walking in Corridor (Hallway) Practice Question - Answer
Self performance: Limited Assistance
Support provided: One Person Physical Assistance
Was your answer different?
Ask “Did the resident walk in the hallway?” If No, you know that the activity did not occur. If you choose Activity Did Not Occur for self performance you MUST choose Activity Did Not Occur for support provided.
The resident did not walk in the hallway, he was pushed in his wheelchair.
Would your coding change if the resident used his feet while sitting in the wheelchair (propelled) to take himself down the hall to the activity? The Coding would remain “Activity Did Not Occur”. A resident propelling themselves in the wheelchair is NOT walking.

24. Coding for walking Tips
Walking can never be coded as total dependence as the resident needs to assist with walking. Total dependence is coded when the resident doesn’t participate in the activity.
Think of it this way, “Can we walk for a resident?”
Walking can NEVER be coded a Total Dependence.

25. Locomotion on Unit Definition & Practice Question
Locomotion on Unit Definition: How resident moves between locations in his/her room and adjacent corridor on same floor
If in wheelchair, self-sufficiency once in chair.
Scenario:
In morning report you were told that Mrs. Brown needs to be taken upstairs to the hair dresser for her appointment at 1415H. Mrs. Brown walks independently in her room. When she needs to go to the dining room on the unit, she takes her wheelchair & self propels herself down the hall to her table for meals. For the long trip to the hair dresser she asks to be pushed in her wheelchair upstairs for her appointment.
How would you code & why?

26. Locomotion on Unit Practice Question - Answer
Self performance: Independent
Support provided: No Staff Performance
Was your answer different?
Ask “What is considered to be on unit?” Is the salon on or off the unit? Is the dining room on or off the unit? Is the residents room & adjacent hallways on the unit? Once this is clear, determine what assistance if any the resident required in these areas.
Ask “Did the resident require physical assistance in the room or adjacent hallways?” If no, the coding is either Independent or Supervision. Did the resident require monitoring or verbal cueing how to move about the unit? If no, it is independent.
Ask “Did I need to set up anything for the resident?” If no, you would code No Staff Performance under Support Provided.
The scenario states that she can walk independently in her room & self-propel down the unit hallways to the dining room that is on the unit. The salon is considered to be off unit & is not a part of the coding. Instead it would be coded under “Locomotion Off unit”.

27. Locomotion off unit Definition & Practice Question
Locomotion Off Unit Definition: How resident moves to & returns from off unit locations (i.e. areas set aside for dining, activities, or treatments). If facility has only one floor, how resident moves to & from distant areas on the floor. If in a wheelchair, self-sufficiency once in chair.
Scenario:
In morning report you were told that Mrs. Brown needs to be taken upstairs to the hair dresser for an appointment at 1415H. Mrs. Brown walks independently in her room. When she needs to go to the dining room on the unit, she self-propels on her wheelchair down the hall to her table for meals. For the long trip to the hair dresser, she asks to be pushed in her wheelchair upstairs for her appointment.
How would you code & why?

28. Locomotion off unit Practice Question - Answer
Self performance: Total Dependence
Support provided: One Person Assistance
Was your answer different?
Ask “What is considered to be Off-Unit”? Is the room, adjacent hallways, dining room, or is the salon off unit? Once this is clear, determine what assistance the resident needs in these areas.
Ask “Did the resident require physical assistance to get to the off- unit area”? If yes, it is Limited, Extensive ,or Total with either one or two or more person assist.
Ask “Did the resident help”? If No, code Total Assistance.
The salon is the only off-unit location is the scenario. The resident required to be pushed by one person to the salon. The resident does not help for the activity, so we would code Total.

29. Eating Definition & Practice Question
Eating Definition: How resident eats & drinks (regardless of skill). Includes intake of nourishment by other means (i.e. tube feeding, total parenteral nutrition). Does Not include food or fluids taken with medication and/or transporting food to the resident.
Scenario:
Mr. Franklin is a resident with moderate to severe dementia. During meal time he becomes tired. Verbal encouragement to eat did not work. You physically assist the resident by supporting his hand & bring food to his mouth & verbally cue him to chew & swallow. This staff member then left to assist another resident. A different staff member came to Mr. Franklin & assisted him the same way as the first person. Due to staff assistance Mr. Franklin was able to complete his meal.
How would you code & why?

30. Eating Practice Question - Answer
Self performance: Extensive Assistance
Support provided: One Person Assistance
Was your answer different?
Ask “Did I physically assist the resident?” If yes, we must code either Limited, Extensive, or Total & you either physically assisted with 1 person or 2 or more.
Ask “Did I provide any weight bearing assistance”? If yes, it is NOT Limited, but rather Extensive or Total.
Ask “Did the resident help”? If yes, it is NOT Total.
Ask “How many staff did it require to complete the activity AT THE SAME TIME”?
For the eating activity the resident does NOT require two staff at the same time to perform this activity but only one at a time. Thus, for support provided we code one person physical assistance. In the scenario both staff needed to bear the weight of the resident hand to bring food to their mouth and the resident helped at the beginning of the meal to eat on their own thus, we would code Extensive assistance.

31. Eating Practice Question - Answer
Self performance: Extensive Assistance
Support provided: One Person Assistance
Was your answer different?
For the eating activity the resident does NOT require two staff at the same time to perform this activity; only one at a time. For the support provided, we code one person physical assistance.
In the scenario if both staff needed to bear the weight of the residents hand to bring food to their mouth & the resident helped at the beginning of the meal to eat, we would code Extensive Assistance.

32. Coding amount Eaten
0-25% code - if resident came to dining room, but did not eat or did not eat in their room (due to isolation) just had their drinks, or ate 25% of their meal.
Ate 26-50% of meal
Ate 51-75% of meal
Ate % of meal
Code “Resident Refused” if the resident refused to come to the dining room.
Code “Resident Not Available” if the resident went out with family over a meal time & ate with them.
Code “NPO” if resident is having nothing by mouth
Code “Tube Feeding” if the resident was tube fed.

33. Bathing
Bathing Definition: How resident takes full-body bath/shower, sponge bath, & transfers in/out of tub/shower (Exclude washing of back/hair) Bathing has its own codes
Self Performance (Resident Performance)
Support Provided (Employee Performance)
Independent: No help provided
No setup or physical help
Supervision: oversight help ONLY
Setup help ONLY
Physical help limited to transfer ONLY
One person physical assist
Physical help in part of bathing activity (do not include washing of hair or back)
Two or more person physical assist
Total Dependence
Activity did not occur.
Activity did not occur

34. Bathing Practice Question
Scenario: It is bath day for Mrs. Betty. She requires extensive physical assistance with one person to be transferred onto the commode and then taken into the shower. The resident is able to wash her chest, arms, face, & thighs, but requires physical assistance to wash hair, back, lower legs, feet, and perform peri-care. How would you code & why? ***Remember bathing has its own set of codes, please refer to previous slide***

35. Bathing Practice Question - Answer
Self performance: Physical Help in Part of Bathing Activity
Support provided: One Person Assistance
Was your answer different?
Ask “Did the resident require physical assistance in bathing byond washing of the hair and back (these areas are NOT included when coding as described in the definition)”?
Ask “Did the resident help during the bathing activity”? If yes, to both questions, you know that the code is physical help in part of bathing activity. It is NOT total because the resident helped you.
Consider how many staff did it take to perform the activity. In the scenario, one staff member assisted with bathing.

36. Coding for Bathing tips
If you bath a resident that is not on there scheduled day for whatever reason, remember that you MUST CODE using the same principles, but code under PRN Bathing. Remember that before & after a bath/shower, that the activity incorporates dressing & personal hygiene activities. It should be coded again under Dressing & Personal Hygiene by using the NEW ENTRY tab.

37. Nursing Rehab Background
Nursing Rehabilitations are nursing interventions that promote a resident’s ability to maximize their functional potential & increase their independence
Nursing rehabs are above the daily assistance provided NOT daily nursing care. It is spending time with the resident, teaching, encouraging, & supporting them with specific repetitive actions as outlined in the care plan. This is designed to increase the residents self-performance on an activity.
The care plan will state the nursing rehab goal to be achieved within a particular time frame. The care plan will also provide instructions as to how the nursing rehab is provided.

38. Nursing Rehab Requirements
Funding for Nursing Rehab is received if:
There is at least 15 minutes per day spent on nursing rehab. This does not need to occur daily at the same time, but the 15 minutes must be completed within the day (24 hour period).
This time is split up between the day & evening shift. The minimum amount of time that must be spent on a nursing rehab on your shift is 8 minutes. When both day & evening shift have completed the minimum 8 minutes, we have met the requirement of 15 minutes within 24 hours.

39. Nursing Rehab your role as an HCA
At start of shift, determine resident assignments that have nursing rehab. You must review the nursing care plan as required.
Provide the nursing rehab service & document same in the POC (minimum 8 minutes on each shift).
If a resident is refusing to participate in Nursing Rehab, ensure that you re-approach several times throughout the day. If unsuccessful, you must notify the RN/LPN & notify the next shift to try to capture the 15 minute time frame. Document in POC resident refusal.
HCAs must also notify the RN/LPN immediately if the resident is unable to participate in nursing rehab. The resident may have to be re-assessed by the MDS coordinator.

40. Bladder Continence & Incontinence
Each time you toilet a resident, you need to code whether the toileting episode was continent or incontinent. Simply Remember Wet or Dry. Continent is Dry & Incontinent is Wet. Any amount of dropelets is considered to be wet & would be documented as incontinent. Residents with indwelling catheters would be coded as continent when they are dry. If the pad is wet during toileting time, the catheter is bypassing and would be coded incontinent. You MUST inform your nurse if the catheter is bypassing.

41. Bladder Continence & Incontinence
Again simply remember Wet or Dry
Code “Incontinent” of stool when stool is found on the pad, pants and/or undergarments or the resident has had an accident.
Code “Continent” if stool is in the toilet, commode, or bedpan.
Residents with a colostomy or an ileostomy. Code for a Bowel Movement each time the bag is emptied/changed. If the bag/apparatus is not leaking code continent, if it is leaking code incontinent.

42. Coding Behaviours
Check off each of the behaviours that occurred during your shift. For each behaviour, you must answer the second question “Was the Behaviour Easily Altered”? (i.e. changed by interventions or distraction strategies)
If the resident does not have any behaviours, document “None of the Above Observed”. The second question is then answered as N/A. Do NOT say “NO”.
Ensure that even if a behaviour only happens once during your shift that it is documented.
Document any behaviour every time you see it. Do not forget about the ones that have become “normal” or that we are used to, they still need to be documented each time. i.e. yelling out

43. Coding behaviour tips Wandering:
Wandering is more than a resident walking or self propelling in a wheelchair on the unit. Wandering is occurring when there is no reason or purpose behind the resident’s movement (i.e. they are not looking for a washroom, their room, or in search of food) and/or may not pay attention to safety/concerns.
Pacing is not coded as Wandering, but documented under
Repetitive Physical Movements under “Mood”.

44. Coding behaviour tips Resisting Care:
Document when the resident is resisting care. Care does not only happening during the morning or evening care, but also during toileting, bathing, meal times, during nursing rehabs and other treatments such as administering medications.
If a resident is resisting care during other times (other than those listed above), we need to document this under “Behaviours”.

45. Mood
It is important to document the mood of the resident & if they are showing signs of any distress. Distress maybe expressed verbally or non-verbally & is identified through resident observation.
Mood distress is a serious condition that is associated with significant morbidity - poor adjustment to the facility, functional impairment, resistance to daily care, isolation, & an increase to pain sensitivity.
Monitor your residents closely each shift & document in POC if you observe any verbal or non-verbal expressions of distress. Also notify your nurse in charge of same.

46. Mood coding tips
Withdrawal from activities of interest & reduced social interaction is ONLY coded when there is a change from the resident’s normal behaviour. Withdrawal from activities of interest: This is coded when we see a resident who once was interested in an activity is no longer interested in doing that same activity. For example, a resident who loves to go to BINGO is now not going, or someone who loves to paint or watch TV in their room is no longer participating in those activities. ***Remember if someone is sick or not feeling well they might not participate in activities for this reason, NOT that they have LOST the interest in doing the activity***

47. Mood coding tips
Withdrawal from activities of interest & reduced social interaction is ONLY coded when there is a change from the resident’s normal behaviour. Reduced Social interaction: Do not confuse a quiet/shy personality for reduce social interaction if this the person’s normal behaviour. Document when there is a change. For example, someone who came for meals, enjoyed talking to table mates now does not want to go. ***Remember if someone is sick or not feeling well they might not participate in activities for this reason NOT that they have LOST the interest in doing the activity***

48. Mood coding tips
Persistent anger with self or others: A resident maybe easily annoyed, frustrated, and/or angry at placement in facility and/or care received. “Persistent” means this behaviour(s) continuing into overtime i.e. all the time. Document if you see this mood over the majority of your shift. Expressions of unrealistic fears: The fear of falling is NOT unrealistic for this elderly population and should not be coded. However a resident that is afraid to be left alone or being with others is unrealistic. If you are unsure if something is a realistic or unrealistic fear, please ask your nurse.

49. References
Resident Assessment Instrument (RAI) RAI-MDS 2.0 user manual, September 2010, Canadian Version.