COMPREHENSIVE NURSING ASSESSMENT (CNA)

The Comprehensive Nursing Assessment (CNA) is paperless, reduces transcription errors and saves nurses vast amounts of time by pulling previously entered information from multiple sources within the software. Following the creation of the first CNA for a consumer subsequent CNAs are super quick and easy to generate as we can pull information from the most recent CNA to populate fields.

To create a CNA, from the consumer’s main information page, first click on the “Medical Assessments” big tab (red circle) then when it is highlighted click on the “Comprehensive Nursing Assessment” tab (blue circle).

Click on “+Add New Comprehensive Nursing Assessment (purple circle).”

When creating a new CNA it is to be filled out in the order the tabs appear. So, the first part to be completed is the “Current status/Vital Signs” data (blue circle). The date is required for all sections regardless of whether any other information is incorporated or not.

If you choose to import vital signs, lab results, and disorders/surgical occurrences into a CNA, the values will be the most recent found in the progress notes section according to the date entered in the CNA. Subsequently if the CNA date is changed you must request for any updates to vitals, labs etc. by importing the most recent assessment data in each appropriate tab (labeled in red).

Once all the information is filled for each tab scroll to the bottom of the pop-up window and click on “Next” button (red circle).

This will save the data entered and automatically take you to the next step of the CNA “Labs/ Neurological” (blue circle).

                                                                                                       IMPORTANT TIPS:

Current Status/Vital Signs –Current vital sign data MUST be dated within 12 months of the CNA. Example if a CNA is dated 12/12/2017 it will NOT import values/notes dated before 12/13/2016. Any changing values such as notes/logs, vital signs and lab values appearing in the CNA should be those that have occurred within the last 12 months.

Labs/Neurological – The lab values (not comments) are pulled from any labs stored in progress notes dated on or before the date of the CNA. However they MUST be dated within 12 months of the CNA.

Review of Physician’s Order – The most recent reviews for one practitioner in each specialty will be automatically imported based on note date. For example, if a client has 2 ‘Reviews of Physician Orders’ from doctors both registered as Family Practitioners/PCP – Dr Seuss (last note dated 05/01/2018) and Dr Love (last note dated 08/08/2018) then a CNA will only import Dr Love’s 08/08/2018 note NOT Dr Seuss’ since they are both registered Family Practitioner/PCP’s. As always, remember the practitioner notes MUST be dated within 12 months of the CNA. 

 

Choosing N/A for any question in the CNA will mean neither Yes nor No box will be checked off. Some auditors may take exception!!  The N/A option should rarely be used and never without an explanatory comment; we always recommend a “Yes” or “No” answer over N/A.

 

Nurse Supervision – You have the ability to document nurse supervision data for multiple unlicensed personnel separately by clicking on the “Add More button” and it will let you add additional staff.

Review of Comprehensive Nursing Assessment – Only a staff member with a title of Registered in the Focused Software system can perform a review of a previously created CNA.

Once all of the fields in this tab are filled scroll to the bottom of the pop-up window and save work by clicking on “Save/Next” (blue circle). If there is no information to be put in any of the sections of the CNA simply scroll to the bottom of the page and hit “Skip This Page” (red arrow). This will automatically take you to the next tab.

! If you have to log out before the CNA is complete click “save” on the page, you are working on so the data is saved then log out.

To return to do additional work to the CNA simply choose from the list of CNA  dates (blue

To return to do additional work to the CNA simply choose from the list of CNA  dates (blue circle) listed and click on the appropriate date you wish to work on.

If the consumer has a previous CNA in the system and his/her condition has not changed significantly since the last CNA was performed, consider using the following short cut. Click on “Fill this page in with last assessment data” (blue circle) to populate the fields for that specific section of the CNA and then simply edit any fields where the consumer information has changed. This feature is available on all CNA tabs when prior CNAs exist in the system. Remember to click “Save” to retain the data entered.

 Continue to enter data for each tab until you reach the final “Summary” tab (blue circle).

In the “Summary tab” to add Implementation Strategy Objectives (blue circle below) data needs to be added in all fields including “Calculation of units” and “Total units” (green arrows). Once this is done click on “Add Strategy” (red circle) and the newly added strategy will appear just above the work area (red arrow).

Once all of the information required is in the CNA you must check off the signature box (blue circle) for the CNA to be finalized.

Confirmation that the CNA has been signed will then appear (blue circle). If you wish to make edits to the CNA click on Resign (red arrow) and you will be able to edit details. Otherwise click on the “Submit/Finalize” button (green arrow) to finalize the CNA; this will also allow the generation of a report.

To generate a paperless CNA click the “Participants” button to the right of the chosen CNA (green circle).

When the “Participants in CNA” pops open click on one of the options (red circle) – Individual OR CRA (Client Responsible Adult) OR PAC (Provider Advocate Committee).

Once the participant is chosen, check off and the appropriate responses. Whichever participant you chose – the Registered Nurse (RN) section must be completed for each consumer. Remember to click the “Submit” button to retain the entered data.

To import paperless signatures into the CNA it is best to use a tablet and stylus (or finger) to sign. From the CNA list – click on the “Sign” button (red circle) to the right of the chosen CNA.

When the signature window opens have the appropriate participant (Individual OR CRA) sign on the gray horizontal line (green arrow) and fill out their name and the date (blue circle). Keep the signature within the black lines of the rectangle (red arrow); to redo a signature simply click “Delete” below the signature. Once completed click “Submit” below the signature to save. The system has retained the signature when the gray horizontal line and the back rectangle surrounding the signature disappear. Click on the X in the upper right-hand corner (yellow arrow) to return to the consumer’s chart.

SIGNING THE “REVIEW OF COMPREHENSIVE NURSING ASSESSMENT” SECTION

! Only a staff member with a title of RN in the Focused Software system can log-in and save information in the “Review of Comprehensive Nursing Assessment”. Once the RN logs into the system they can access the “Review of Comprehensive Nursing Assessment” section by clicking on the “Review” button (purple circle) beside a previously created consumer’s CNA.

When the “Review of Comprehensive Nursing Assessment” window opens fill out the date and other required fields then click “Add Review” (blue circle) to retain the information.

To create additional review(s) simply scroll down and fill out another review section. To remove a previously created review simply click “Remove” (blue circle). When you have saved all data entered click on the X (red arrow) in the upper right-hand corner to return to the consumer’s
CNA screen.

 

THESE ARE THE CONSUMER CHART SECTIONS THAT NEED TO BE COMPLETED BEFORE THE SYSTEM CAN PULL INFORMATION TO GENERATE A COMPLETE COMPREHENSIVE NURSE ASSESSMENT (CNA)

  1. EDIT DETAILS
  2. ADD’L INFO
  3. DISORDERS/SURGICAL OCCURNCES
  4. CONTACT AND SUPPORT
  5. MED MANAGER
  6. REVIEW OF PHYSICIAN’S ORDERS
  7. PROGRESS NOTES