DateTimeFromToMessage
2020-08-20 07:05:33 PM balvarez no
2020-08-20 07:05:34 PM jillh No.
2020-08-20 07:05:34 PM marisah4 i love the old fashioned way ours is so easy
2020-08-20 07:05:35 PM esmec no
2020-08-20 07:05:35 PM santonya no
2020-08-20 07:05:35 PM tshaw no
2020-08-20 07:05:36 PM julielangenderfer no
2020-08-20 07:05:36 PM thomasodougherty No
2020-08-20 07:05:37 PM sabrina08 no
2020-08-20 07:05:37 PM tashawade no
2020-08-20 07:05:37 PM nicholashuffman No.
2020-08-20 07:05:38 PM paula12 no you can not
2020-08-20 07:05:39 PM maninder we cannot
2020-08-20 07:05:40 PM laurieh If it is not written it didnt happen
2020-08-20 07:05:40 PM lauralehmann no
2020-08-20 07:05:41 PM bonnie no
2020-08-20 07:05:42 PM barbaramclaurin1 You are not supposed to document out of your scope.
2020-08-20 07:05:44 PM arshieta83 i think it depends
2020-08-20 07:05:46 PM michaeld No m'am
2020-08-20 07:05:48 PM brittanyanne24 left the chat room
2020-08-20 07:05:50 PM jocelynp NO
2020-08-20 07:05:52 PM tabithapurcell no
2020-08-20 07:05:58 PM gwenbess I do mine after lunch and then in then after afternoon acitivities.
2020-08-20 07:06:00 PM cchase it's a negative - does not depend
2020-08-20 07:06:07 PM brittanyanne24 enter the chat room
2020-08-20 07:06:15 PM racheldonohoue By scope do you mean department? Like medical?
2020-08-20 07:06:16 PM clcroom enter the chat room
2020-08-20 07:06:16 PM cchase you cannot document what you are not qualified to document
2020-08-20 07:06:18 PM 219999 enter the chat room
2020-08-20 07:06:22 PM marisah4 yes
2020-08-20 07:06:27 PM racheldonohoue Oh yes. Then no.
2020-08-20 07:06:29 PM clcroom sorry, im late. internet issues.
2020-08-20 07:06:31 PM melveniag right
2020-08-20 07:06:32 PM esmec you must have the proper training for the documentation that you do and it should be about what YOU do
2020-08-20 07:06:35 PM santonya true
2020-08-20 07:06:36 PM lbaker1989 That is true.
2020-08-20 07:06:37 PM amyc84 no you have to train in what your job desscription is
2020-08-20 07:06:37 PM paula12 right
2020-08-20 07:06:38 PM barbaramclaurin1 Scope meaning outside of your scope of practice or expertise.
2020-08-20 07:06:48 PM 219999 true
2020-08-20 07:06:54 PM flossie enter the chat room
2020-08-20 07:06:55 PM cchase can you document what someone else has done or heard?
2020-08-20 07:06:57 PM tshaw true
2020-08-20 07:06:59 PM flossie hello
2020-08-20 07:06:59 PM marisah4 no
2020-08-20 07:07:00 PM thomasodougherty No
2020-08-20 07:07:01 PM santonya no
2020-08-20 07:07:01 PM nicholashuffman Nope.
2020-08-20 07:07:02 PM balvarez no
2020-08-20 07:07:02 PM vgreen NO
2020-08-20 07:07:02 PM esmec no way!
2020-08-20 07:07:02 PM lbetts1992 NO
2020-08-20 07:07:03 PM arshieta83 NO
2020-08-20 07:07:03 PM sabrina08 no
2020-08-20 07:07:03 PM tshaw no
2020-08-20 07:07:04 PM michr no
2020-08-20 07:07:04 PM erittenhouse1683 You shouldn't
2020-08-20 07:07:05 PM tashawade No
2020-08-20 07:07:05 PM jillh no.
2020-08-20 07:07:05 PM paula12 no never
2020-08-20 07:07:06 PM barbaramclaurin1 No
2020-08-20 07:07:06 PM julielangenderfer noo
2020-08-20 07:07:06 PM amyc84 no
2020-08-20 07:07:06 PM tabithapurcell nope
2020-08-20 07:07:06 PM cchase seen or heard
2020-08-20 07:07:11 PM ehorton no
2020-08-20 07:07:12 PM thomasodougherty No
2020-08-20 07:07:12 PM melveniag no
2020-08-20 07:07:13 PM lbaker1989 no
2020-08-20 07:07:13 PM paula12 no never
2020-08-20 07:07:14 PM vgreen no
2020-08-20 07:07:15 PM marisah4 no
2020-08-20 07:07:16 PM esmec none
2020-08-20 07:07:17 PM michaeld If you have proof
2020-08-20 07:07:18 PM arshieta83 NO
2020-08-20 07:07:19 PM amyc84 we can document per report like when we are documenting behaviors
2020-08-20 07:07:20 PM maryneals48 no
2020-08-20 07:07:20 PM racheldonohoue No. Because you don't know all of the specifics.
2020-08-20 07:07:20 PM clcroom I think they would have to.
2020-08-20 07:07:21 PM santonya no
2020-08-20 07:07:24 PM maninder nope
2020-08-20 07:07:25 PM marisah4 they should
2020-08-20 07:07:33 PM jillh If it is your staff reporting something to you, then yes
2020-08-20 07:07:40 PM clcroom I won't document for anyone else.
2020-08-20 07:07:46 PM barbaramclaurin1 You should document what you have seen or you should document that it was reported by so and so
2020-08-20 07:07:49 PM cchase what does Authentication mean
2020-08-20 07:07:56 PM amyc84 what is true and accurate
2020-08-20 07:07:57 PM lbaker1989 I only document what is in my department
2020-08-20 07:08:00 PM paula12 me either if i didnt see it or hear it
2020-08-20 07:08:01 PM amyc84 factual information
2020-08-20 07:08:01 PM tabithapurcell accurate
2020-08-20 07:08:04 PM lbaker1989 accurate
2020-08-20 07:08:07 PM maninder validating something as true
2020-08-20 07:08:08 PM ehorton accurate
2020-08-20 07:08:11 PM esmec signing
2020-08-20 07:08:12 PM julielangenderfer accurate
2020-08-20 07:08:12 PM tshaw valid and true
2020-08-20 07:08:13 PM thomasodougherty Something that can be verified.
2020-08-20 07:08:13 PM summerlane accurate.
2020-08-20 07:08:15 PM balvarez Accurate
2020-08-20 07:08:17 PM brittanyanne24 accurate
2020-08-20 07:08:17 PM nicholashuffman It's proving something is accurate or true.
2020-08-20 07:08:17 PM jillh validation
2020-08-20 07:08:17 PM paula12 accurate
2020-08-20 07:08:19 PM 219999 accurate and valid
2020-08-20 07:08:19 PM arshieta83 facts truth
2020-08-20 07:08:19 PM vgreen It's accurate from the person writing the note
2020-08-20 07:08:20 PM pjbell to sign
2020-08-20 07:08:20 PM racheldonohoue Accurate, authentic information
2020-08-20 07:08:23 PM deneehough accurate, factual
2020-08-20 07:08:24 PM michaeld Accurate
2020-08-20 07:08:26 PM lauralehmann your own words
2020-08-20 07:08:27 PM melveniag accurate
2020-08-20 07:08:32 PM clcroom It's proof something is acurate.
2020-08-20 07:08:35 PM lbetts1992 ONLY DOCUMENT WHAT YOU HAVE WITNESSED AND ITS TRUE AND FACTUAL
2020-08-20 07:08:38 PM jocelynp NO
2020-08-20 07:08:39 PM cchase Authentication is an attestation that something, such as a medical record is genuine
2020-08-20 07:08:40 PM erittenhouse1683 Something you can verify as true
2020-08-20 07:08:57 PM lbaker1989 yes, if its true
2020-08-20 07:08:58 PM cchase how do you authenticate a document?
2020-08-20 07:09:02 PM arshieta83 yes
2020-08-20 07:09:04 PM lbetts1992 SIGN
2020-08-20 07:09:06 PM lbaker1989 signing it
2020-08-20 07:09:08 PM barbaramclaurin1 Medical record information is genuine. Assigning authorship and responsibility for an act event or condition that has been documented.
2020-08-20 07:09:08 PM esmec signiture
2020-08-20 07:09:09 PM vgreen sign
2020-08-20 07:09:12 PM maninder by signing it
2020-08-20 07:09:12 PM tabithapurcell signing off
2020-08-20 07:09:13 PM erittenhouse1683 Signature
2020-08-20 07:09:14 PM santonya sign
2020-08-20 07:09:15 PM arshieta83 Sign it
2020-08-20 07:09:15 PM amyc84 by signing and putting your credientals
2020-08-20 07:09:16 PM clcroom verifiying the infor and signing it.
2020-08-20 07:09:17 PM deneehough sign it
2020-08-20 07:09:17 PM lbetts1992 AND DATE
2020-08-20 07:09:18 PM esmec signature imeant
2020-08-20 07:09:18 PM racheldonohoue Initial or sign
2020-08-20 07:09:18 PM ehorton sign it
2020-08-20 07:09:19 PM balvarez siginature
2020-08-20 07:09:20 PM melveniag sing
2020-08-20 07:09:21 PM nicholashuffman Sign/date
2020-08-20 07:09:23 PM lauralehmann sign it at the end with your password
2020-08-20 07:09:24 PM paula12 sign off
2020-08-20 07:09:25 PM jillh Name of resident and medical record number
2020-08-20 07:09:25 PM 219999 sign off on it
2020-08-20 07:09:27 PM susandziegenbein enter the chat room
2020-08-20 07:09:29 PM sabrina08 sign off
2020-08-20 07:09:33 PM esmec def date it!
2020-08-20 07:09:34 PM marisah4 sign it
2020-08-20 07:09:35 PM laurieh and title too
2020-08-20 07:09:43 PM tashawade By writing it yourself and signing it
2020-08-20 07:09:43 PM brittanyanne24 sign
2020-08-20 07:09:43 PM lyndsayt enter the chat room
2020-08-20 07:09:48 PM cchase can you use initials?
2020-08-20 07:09:53 PM marisah4 yes
2020-08-20 07:09:54 PM lbetts1992 NO
2020-08-20 07:09:57 PM 219999 no
2020-08-20 07:09:57 PM julielangenderfer sure can
2020-08-20 07:09:58 PM maninder no
2020-08-20 07:09:58 PM tashawade yes
2020-08-20 07:09:58 PM balvarez no
2020-08-20 07:09:59 PM esmec in some cases i
2020-08-20 07:09:59 PM santonya no
2020-08-20 07:10:00 PM barbaramclaurin1 Within the scope of the professional authority and training.
2020-08-20 07:10:01 PM lauralehmann no
2020-08-20 07:10:02 PM jillh no
2020-08-20 07:10:02 PM amyc84 in what context
2020-08-20 07:10:02 PM michr signing it
2020-08-20 07:10:03 PM susandziegenbein No
2020-08-20 07:10:04 PM paula12 no i never do
2020-08-20 07:10:05 PM nicholashuffman No idea, I just sign it full name.
2020-08-20 07:10:05 PM melveniag no
2020-08-20 07:10:05 PM tshaw no
2020-08-20 07:10:07 PM lyndsayt no
2020-08-20 07:10:10 PM arshieta83 no
2020-08-20 07:10:13 PM racheldonohoue On my electronic system, my signature came off as RAD
2020-08-20 07:10:13 PM brittanyanne24 yes if you have your signature else where on the page
2020-08-20 07:10:16 PM clcroom yes, but written signature is better and preferred.
2020-08-20 07:10:16 PM esmec depending on what it asks for
2020-08-20 07:10:17 PM summerlane not on most things
2020-08-20 07:10:17 PM cchase Authentication of medical record entries may include written signatures, initials, computer signature key, or other code. Submitted documents must be signed with your name and title (first initial and full last name with title is acceptable).
2020-08-20 07:10:18 PM michaeld singing
2020-08-20 07:10:21 PM erittenhouse1683 Yeah
2020-08-20 07:10:22 PM barbaramclaurin1 yes you can use initials
2020-08-20 07:10:23 PM lbaker1989 I sign my password on PCC
2020-08-20 07:10:28 PM jillh electronic documentatio
2020-08-20 07:10:45 PM jillh automatically signs your name
2020-08-20 07:10:49 PM brittanyanne24 me too with pcc my password
2020-08-20 07:10:54 PM cchase good
2020-08-20 07:10:54 PM tabithapurcell same
2020-08-20 07:10:54 PM ehorton pcc
2020-08-20 07:10:55 PM tshaw me too
2020-08-20 07:10:57 PM gwenbess I alwayts intial and place a line through an error
2020-08-20 07:10:58 PM esmec same on my computer i just check a box
2020-08-20 07:11:02 PM jocelynp SIGIN IT
2020-08-20 07:11:04 PM maryneals48 me tto
2020-08-20 07:11:07 PM melveniag password
2020-08-20 07:11:09 PM lauralehmann i dont think that is allowed in our facility
2020-08-20 07:11:14 PM 219999 i sign it
2020-08-20 07:11:16 PM pjbell left the chat room
2020-08-20 07:11:30 PM jocelynp NO
2020-08-20 07:11:33 PM paula12 i can not use initals
2020-08-20 07:12:11 PM cchase it varies from facility to facility - but you may have a on file copy of your authenticated sig. which can be intials that will be accepted
2020-08-20 07:12:16 PM janinereyesad enter the chat room
2020-08-20 07:12:32 PM marisah4 good to know!
2020-08-20 07:12:35 PM michaeld Correct
2020-08-20 07:12:38 PM balvarez thank you
2020-08-20 07:12:41 PM cchase some facilites do not approve of initials - ofcourse the computer password work as it should
2020-08-20 07:12:45 PM susandziegenbein got it
2020-08-20 07:12:50 PM janinereyesad hello
2020-08-20 07:12:52 PM michaeld my facility does
2020-08-20 07:12:53 PM arshieta83 right
2020-08-20 07:12:55 PM 219999 oh ok
2020-08-20 07:12:55 PM tashawade yes
2020-08-20 07:12:56 PM lauralehmann all of our signatures go through pcc
2020-08-20 07:13:02 PM melveniag yes
2020-08-20 07:13:09 PM jocelynp ME TO PCC
2020-08-20 07:13:13 PM clcroom We electronincally sign with our passwrod on pcc
2020-08-20 07:13:13 PM arshieta83 i have a 4 digit to sign with
2020-08-20 07:13:14 PM paula12 i must use my signature
2020-08-20 07:13:22 PM cchase what is the first document that you will need to prepare for the resident??
2020-08-20 07:13:32 PM esmec assessment
2020-08-20 07:13:32 PM marisah4 mine is a facd sheet
2020-08-20 07:13:32 PM brittanyanne24 assesment
2020-08-20 07:13:33 PM tashawade their assessment
2020-08-20 07:13:34 PM santonya assessment
2020-08-20 07:13:37 PM ehorton assesment
2020-08-20 07:13:38 PM clcroom the Actvity Assessment
2020-08-20 07:13:39 PM balvarez assessment
2020-08-20 07:13:39 PM jillh initial assessment
2020-08-20 07:13:40 PM michr assessment
2020-08-20 07:13:40 PM erittenhouse1683 Initial Assesment
2020-08-20 07:13:41 PM paula12 fact sheet
2020-08-20 07:13:41 PM maninder assessment for the resident
2020-08-20 07:13:42 PM lbetts1992 CARE PLAN
2020-08-20 07:13:42 PM summerlane assessment
2020-08-20 07:13:42 PM susandziegenbein RAI
2020-08-20 07:13:43 PM 219999 assesment
2020-08-20 07:13:43 PM thomasodougherty Initial Assessment
2020-08-20 07:13:44 PM arshieta83 activities assessment
2020-08-20 07:13:44 PM gwenbess F portion of MDS
2020-08-20 07:13:44 PM lyndsayt Initial recreational assesment
2020-08-20 07:13:51 PM paula12 then an assessmeent
2020-08-20 07:13:51 PM racheldonohoue Initial assessment
2020-08-20 07:13:52 PM barbaramclaurin1 Baseline care plan
2020-08-20 07:13:53 PM melveniag assesment
2020-08-20 07:13:54 PM vgreen Comp assess
2020-08-20 07:13:54 PM tshaw assessment
2020-08-20 07:13:55 PM esmec prefrence sheet then theraputic rec
2020-08-20 07:13:59 PM lbaker1989 initial assessment
2020-08-20 07:13:59 PM laurieh We do almost everything on computer. Incident reports are the only hand signed
2020-08-20 07:14:00 PM cchase good Barbara
2020-08-20 07:14:01 PM michaeld 48hr care plan, Admission Assessment
2020-08-20 07:14:03 PM deneehough assessment
2020-08-20 07:14:03 PM jocelynp ASSESSMENT
2020-08-20 07:14:04 PM taherrens enter the chat room
2020-08-20 07:14:06 PM sabrina08 Assessment
2020-08-20 07:14:07 PM amyc84 initial assessment, care plan
2020-08-20 07:14:10 PM lauralehmann assessment then care plan
2020-08-20 07:14:14 PM rachelordille enter the chat room
2020-08-20 07:14:16 PM cchase the answer is baseline care plan - why?
2020-08-20 07:14:35 PM tshaw gives you a foundation
2020-08-20 07:14:39 PM michaeld yes baseline
2020-08-20 07:14:40 PM rachelordille Sorry im late, just got off of work!
2020-08-20 07:14:41 PM esmec to get them started
2020-08-20 07:14:44 PM 219999 to know where to start
2020-08-20 07:14:44 PM laurieh before the assessment in case of emergency
2020-08-20 07:14:47 PM lbetts1992 BECAUSE YOU HAVE TO HAVE SOMEWHERE TO START
2020-08-20 07:14:48 PM paula12 you get inital information
2020-08-20 07:14:52 PM barbaramclaurin1 It must be completed withing 48 hours of admission
2020-08-20 07:14:52 PM lbaker1989 the care plan tells you everything and gives you a foundation and where to start
2020-08-20 07:14:56 PM susandziegenbein To know where they are and get them off to a good start
2020-08-20 07:15:01 PM amyc84 i try to gt basic information when they first walk in
2020-08-20 07:15:01 PM lbetts1992 HAVE BASIC INFORMATION ON THE RESIDENT
2020-08-20 07:15:06 PM lbaker1989 You can get all of your information in the care plan section
2020-08-20 07:15:06 PM marisah4 sets everyhting up
2020-08-20 07:15:09 PM paula12 then you go back and add details
2020-08-20 07:15:11 PM santonya immedate needs upon admission
2020-08-20 07:15:11 PM jocelynp THANKS GOOD TO KNOW
2020-08-20 07:15:16 PM maninder so you know where to get started
2020-08-20 07:15:19 PM erittenhouse1683 I've always done both at the same time
2020-08-20 07:15:20 PM michr To k.now where they are at when they start out
2020-08-20 07:15:23 PM balvarez good to know
2020-08-20 07:15:29 PM barbaramclaurin1 It begins the admission process
2020-08-20 07:15:35 PM tabithapurcell initial careplans are like the first block when building an accurate careplan
2020-08-20 07:15:36 PM cchase good santonya - it provides for the immediate needs of the resident
2020-08-20 07:15:36 PM rachelordille I love care plans because they help you know everything about the resident
2020-08-20 07:15:37 PM arshieta83 good to know
2020-08-20 07:15:49 PM clcroom I do all asssessment, care plans and notes the same day.
2020-08-20 07:15:56 PM esmec catering to residents needs! yes!]
2020-08-20 07:15:56 PM vgreen Proves to the state that you have a plan for the resident in place then yuou build on it as you learn about the person
2020-08-20 07:16:10 PM julielangenderfer They are always subject to change, but its a good starting point
2020-08-20 07:16:16 PM thomasodougherty Is that not the Initial Assessment? I was under the impression the Initial Assessment is what was used to populate the Base Line Care Plan.
2020-08-20 07:16:23 PM racheldonohoue I feel like you learn something new every week!
2020-08-20 07:16:28 PM clcroom same, thomas.
2020-08-20 07:16:33 PM jillh We do a basic care plan then intial assessment and Sect. F questionnaire
2020-08-20 07:16:41 PM brittanyanne24 i thought the same
2020-08-20 07:16:42 PM tashawade thanks good to know
2020-08-20 07:16:48 PM thomasodougherty The Initial Assessment is then followed up by the Activities Assessment, which is required within 2 weeks of admission.
2020-08-20 07:17:02 PM lavelar13 enter the chat room
2020-08-20 07:17:03 PM clcroom So you go back a second time and do the activity asessment?
2020-08-20 07:17:04 PM lbaker1989 We do the assesment first in our department
2020-08-20 07:17:07 PM cchase a brand new admit - needs a care plan right off the bat - like dietary needs - range of motion issues
2020-08-20 07:17:24 PM jillh We have to do our Sect. F by day 8 at my facility
2020-08-20 07:17:25 PM lbaker1989 oh thats right
2020-08-20 07:17:26 PM lavelar13 hello
2020-08-20 07:17:27 PM tshaw yes
2020-08-20 07:17:27 PM clcroom Our activity assessment has to be done withing 5 days of admission.
2020-08-20 07:17:28 PM marisah4 yes that makes sense
2020-08-20 07:17:28 PM arshieta83 yes
2020-08-20 07:17:29 PM maninder makes sense
2020-08-20 07:17:30 PM cchase when is that baseline care plan due?
2020-08-20 07:17:35 PM esmec even for activities??
2020-08-20 07:17:35 PM susandziegenbein got it
2020-08-20 07:17:38 PM janinereyesad so its like a guide
2020-08-20 07:17:38 PM vgreen 48 hrs
2020-08-20 07:17:39 PM tshaw 24 hrs
2020-08-20 07:17:40 PM ehorton 48 hrs
2020-08-20 07:17:41 PM barbaramclaurin1 within 48 hours of admission
2020-08-20 07:17:43 PM erittenhouse1683 With in 48 hours
2020-08-20 07:17:44 PM arshieta83 with 48hr
2020-08-20 07:17:45 PM lyndsayt 48 hours
2020-08-20 07:17:46 PM nicholashuffman 48 hours or so.
2020-08-20 07:17:47 PM tabithapurcell They do, but i feel its hard to accuretly set goals for some residents
2020-08-20 07:17:47 PM paula12 within 72 hrs
2020-08-20 07:17:47 PM julielangenderfer 48 hras
2020-08-20 07:17:48 PM erittenhouse1683 of admission
2020-08-20 07:17:48 PM melveniag 48
2020-08-20 07:17:48 PM balvarez 48 hours
2020-08-20 07:17:50 PM brittanyanne24 48 hours
2020-08-20 07:17:51 PM 219999 within 48 hrs
2020-08-20 07:17:52 PM lbaker1989 I dont know for sure
2020-08-20 07:17:54 PM santonya 48 hrs
2020-08-20 07:17:55 PM maryneals48 24 hr
2020-08-20 07:17:55 PM lbetts1992 48
2020-08-20 07:17:58 PM susandziegenbein 48 hours
2020-08-20 07:17:59 PM hastingsamy enter the chat room
2020-08-20 07:18:02 PM cchase well - awesome follks - yes 48 hrs
2020-08-20 07:18:02 PM esmec i thought it was assesment, care plane mds sec f
2020-08-20 07:18:03 PM summerlane 48,but not exactly sure
2020-08-20 07:18:04 PM tabithapurcell 48
2020-08-20 07:18:04 PM janinereyesad 48hrs
2020-08-20 07:18:06 PM michaeld Correct. Being alert and oriented, their vision and hearing, religion etc
2020-08-20 07:18:07 PM maninder 48
2020-08-20 07:18:22 PM amyc84 48 hours
2020-08-20 07:18:28 PM cchase so what comes next in line of documentation?