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Care Area Assessments (CAA) for Long Term Care Assessments/Documentation

Practice Consideration

Care Area Assessments (CAA) for Long Term Care Assessments/Documentation

Chapter 4 of the CMS RAI Manual describes the type of conditions that are classified as Care Area Triggers and what type of documentation is required.   The manual also includes the descriptions of the Twenty Care Areas and tables listing the Care Area Trigger (CAT) logical specifications. The logic tables describe exactly what responses in the MDS Forms are used to identify the need for an assessment in the care area (depending on whether the responses are check marks or numerical).  Some of the care areas are much more specific to nutrition care issues than others and may be assigned by the institution for dietitian input/completion, e.g. 12.  Nutritional Status,  13 Feeding Tubes , and 14 Dehydration/Fluid Maintenance 

The manual also describes the clinical problem solving/decision making process as shown in the Table below from the manual.   The last column in the table includes examples of information from one specific Care Area Assessments (CAA),12 Nutritional Status.  

 

Example from CAA 12,Nutritional Status

Review of Indicator  of Nutritional Status

Recognition/ Assessment

  • Current eating pattern (foods offered consistent with residents' food choices/needs, proportion of foods left uneaten, intervals between meals, willingness to accept food supplements
  • Functional problems that affect ability to eat (e.g. swallowing, need for special diet or altered consistency, vision, inability to sit up or perform Activities of Daily Living (ADL))
  • Cognitive, mental status, and behavior problems that can interfere with eating, e.g. dementia, requires frequent/constant cueing, throwing food, very slow eating)
  • Dental/oral problems
  • Other diseases and conditions that can affect appetite or nutritional needs
  • Abnormal laboratory values
  • Medications
  • Environmental factors (from direct observation and clinical record)

Problem Definition/Diagnosis /Cause-Effect analysis

  • Analysis of findings e.g. Nutrition Diagnosis and PES statement

Identifying goals/objectives and Interventions/planning

  • Care Plan Considerations. e.g. nutrition prescription,aim, diet order

Monitoring of progress

  • Care Plan Considerations, e..g. monitoring indicators weight changes, % meals consumed)

 

 

 

References

1.  MDS 3.0 RAI Manual. Centres for Medicare and Medicaid Services. Accessed on July 20, 2020. Available from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual

Updated November 14, 2022
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