CAA Documentation Worksheet

Worksheet for documenting analysis, findings, and care planning actions for each triggered Care Area Assessment (CAA) area in the MDS process.

Resident and Assessment Context

• Resident Identifier
  Use the facility's resident identifier or medical record number. Avoid entering unnecessary PII.
• Assessment Reference Date
  Date the MDS assessment or CAA review is being documented.
• Triggered CAA Area
• Trigger Source
  Select all sources that caused this CAA to trigger.

CAA Analysis

• Trigger Summary
  Briefly describe what triggered the CAA and the key facts supporting the review.
• Resident Strengths and Supports
  Document abilities, preferences, supports, or protective factors relevant to this care area.
• Contributing Factors
  Identify factors that may be contributing to the triggered area.
• Current Severity / Impact
  Rate the current impact of the triggered area on the resident's function or well-being.
• Clinical Analysis
  Provide the interdisciplinary analysis of the issue, including why it is present, how it affects the resident, and any relevant patterns or trends.

Risks, Goals, and Interventions

• Identified Risks
  Select the primary risks associated with this care area.
• Care Plan Update Needed?
• Planned Interventions
  List each intervention or monitoring action planned for this triggered area.
• Follow-Up Timeline

Interdisciplinary Review and Attestation

• Reviewed By Role
• Interdisciplinary Input
  Select disciplines that contributed to the analysis, if applicable.
• Attestation
  I attest that this CAA documentation reflects the resident-specific analysis and supports the care plan and audit trail.