CAA Documentation Worksheet

Worksheet for documenting each triggered Care Area Assessment (CAA), including analysis, related findings, and the decision to proceed to care planning.

Assessment Context

• Resident Identifier
  Enter the resident's internal identifier or medical record number. Avoid collecting SSN or other unnecessary PII.
• Assessment Date
  Date the CAA documentation was completed.
• MDS Assessment Reference
  Optional internal MDS reference, if used by your facility.
• Triggered Care Area
  Select the care area that triggered this CAA documentation.
• Other Care Area
  Complete only if 'Other' was selected above.

Related Findings

• Summary of Related Findings
  Summarize the relevant observations, history, and current status related to the triggered care area.
• Records Reviewed
  Select the sources reviewed to support this CAA. Choose only what was actually used.
• Other Records Reviewed
  Specify any additional records reviewed.
• Interdisciplinary Input
  Select disciplines that contributed to this assessment, if applicable.
• Supporting Evidence
  Add specific evidence items that support the analysis. Use one row per finding.

CAA Analysis

• Analysis of Triggered Care Area
  Explain why the care area was triggered, what the findings mean, and how they affect the resident's status.
• Contributing Factors
  Select factors that appear to contribute to the triggered care area.
• Other Contributing Factor
  Specify any other contributing factor.
• Proceed to Care Planning?
  Indicate whether the triggered area requires inclusion in the care plan.
• Rationale for Decision
  Explain the decision to proceed or not proceed with care planning.

Plan and Follow-Up

• Immediate Actions Taken
  Document any interventions or actions completed during or immediately after the review.
• Referrals or Consults
  Select any referrals or consults initiated.
• Follow-Up Date
  Date for reassessment or follow-up, if needed.
• Follow-Up Notes
  Document any monitoring instructions or next steps.

Attestation

• Reviewer Name
  Enter the name of the person completing the worksheet.
• Reviewer Role
  Enter the reviewer’s role or discipline.
• Signature
  Electronic signature confirming the documentation is accurate and complete.
• Review Timestamp
  Automatically captured submission time for the audit trail.