1. Annual Compulsory Education
Community rai
Annual Compulsory Education

2. What is rai – hc? Resident Assessment Instrument
A system that informs & guides comprehensive planning of care & services in community settings
Focuses on the individual’s functioning & quality of life by assessing needs, strengths, & preferences
Facilitates referrals when appropriate
Gives an outcome based assessment of the person’s response to care &/or services provided

3. What is a tracking tool?
Records relevant information about a client for eight (8) days prior to a case manager’s RAI – HC assessment
Communicates valuable information to the case manager of the care that is provided to the client
Assists in care plan development
Notifies the case manage of the client’s status
Is a consistent tool in all supportive living sites

4. Note: LPN time includes Medication Passes, wound care, etc
Who completes the tool?
LPNs/HCAs who work in supportive living (SL3, SL4, & SL4D) facilities & assist/observe clients in their daily routines
Must be accurately completed as this tool forms the client’s care plan
Complete with honesty & is to reflect your work with the client
May be audited at any time by BSF management & Alberta Health Services for accuracy
Note: LPN time includes Medication Passes, wound care, etc

5. When will you use the tool?
The case manager will set a date & time to start tracking (communicated to the RN/LPN who will then initiate the tool)
You record your observations, assistance, & care provided for eight (8) days
The assessment cannot have missing spaces. This means that tracking must be completed at all times
No guessing on assessments
If there is a change in the client’s status let the case manager know in addition to the program manager & director of care

6. Describe pain & skin conditions in comments section
What is tracked?
Moods & Behaviours
Physical Functioning
Nutrition & Hydration
Bathing
Locomotion (Indoor & Outdoor)
Continence (Bladder & Bowel Control)
Problem Conditions/Symptoms
Skin Condition
Pain
R All that apply
Describe pain & skin conditions in comments section

7. DO NOT confuse personality traits with actual moods
Moods may be expressed verbally or non-verbally
Client has feelings of sadness, anger, anxiety, or depression
ie: VERBAL – client may say “Life is not worth living.”
ie: NON-VERBAL – client is frowning or teary
All moods must be recorded regardless of why, why, &/or when it is displayed
DO NOT confuse personality traits with actual moods

8. behaviours All behaviours have meaning & this must be recorded
All behaviours must be recorded regardless of when, why, &/or where it is displayed
Pacing is not wandering
Wandering can be done in a wheelchair
Client may move without any obvious purpose
Client swings out at others
i.e. verbally abusive – client has screamed at or threatened others
i.e. physically abusive – can include swinging out with intent to hit

9. Behaviours continued…
Questions to ask:
Were these behaviours easily altered?
Was the client easily removed or re-directed from the situation?
Basically ask if you were successful in re-directing the client &/or preventing one client from hitting or pushing another person
Very important to code as this could be the cause of other problems
Note: Pacing is not included in wandering. If the pacing is disruptive to others include this as “client was socially inappropriate or disruptive.” The same statement may be used with hoarding.

10. Activities of daily living (ADL) self-performance
Record what the client actually does on their own or what help is needed in activities of daily living
This category includes:
Transfers
Mobility in bed
Locomotion (How the client moves around)
Dressing the upper & lower body
Eating
Toileting
Personal Hygiene
Bathing

11. Activities of daily living (ADL) self-performance Continued…
What to record/code (Choose one of the following):
Did not require help
Required supervision, cueing, encouragement, or set-up help
Required “hands on” help & touches resident
Activity did not occur
Mobility in bed would also include “recliners” as there are clients/residents who prefer to sleep in their chair.
Some days or shifts client can do more for himself than others.
Record what actually occurs.

12. Primary modes of locomotion
The aid or device the client most often uses to get around both indoors & outdoors
What to record/code (Choose one of the following):
No assistive device
Cane
Walker/Crutch(es)
Scooter
Wheelchair (includes electric wheelchair)
Activity did not occur (i.e. outdoors)
If not too sure what to code, think about what the
client uses more than 50% of the time

13. Bladder continence (Control)
Incontinence includes any level of dribbling or wetting of urine
Leaking indwelling catheter = incontinence
R All that apply
Bladder Devices
Incontinent Product
Do not include panty liners &/or pad placed on the bed routinely if the client is never or rarely incontinent
Note: Leaking or bypassing of catheter should be reported right away to nursing supervisor as per policy

14. Bladder continence (Control)
Does not include the client’s ability to toilet themselves
Leaking ostomy = incontinence
Record each time a client has a bowel movement (BM)
What would you record if the ostomy leaks?
Note: Leaking ostomies should be reported to the nursing supervisor as per policy

15. Note: New, sudden, or continued symptoms should be reported right away
Problem Conditions
Diarrhea – frequent watery stools
Difficulty urinating or urinating 3 or more times at night
Vomiting
Chest Pain
Dizziness or light-headedness
Hallucinations – Seeing/hearing/touching/smelling things that
are not really there
Note: New, sudden, or continued symptoms should be reported right away

16. Describe pain & location in the comment section
Complains of pain – may be verbal &/or non-verbal
i.e. wincing or favoring the affected site
Complains of pain in more than one area
Change in behaviour i.e. clients with dementia
R All that apply – then describe in comment section
Very important to assess & record/code as it could be a sign of other issues
Describe pain & location in the comment section

17. Weigh client once over the eight (8) day period (bath day)
Nutrition/hydration
Percentage of food eaten at meal &/or snacktime
75-100
50-75
25-50
0-25
Client did not drink/eat all/almost all of food/drink
Enteral Tube Feeding
CHECK R All that apply or %
Weigh client once over the eight (8) day period (bath day)

18. Skin conditions Itchiness Rash Bruises Skin tears/cuts Scrapes
Open sores
Burns
R All that apply & describe in comment section

19. Reminders Accurately record observations, assistance, & care provided
Report any sudden changes &/or concerns
Record your time spent with the client
Round time off to the nearest increment of 10 minutes
Add up minutes at the end of your shift before rounding off
Sign your initials at the end of your shift
Add any comments regarding any unusual event(s) – be sure to document the date & time it happened