Be Specific

With the CMS Guidelines that went into effect last year, we now need to be specific when we assess, care plan and note on the resident's. For example, if a resident enjoys listening to the radio what type of radio and the specific radio station does the resident enjoy. If someone else enjoys playing cards, which card games does he/she play?
By being specific and addressing the specific interests of your resident will assist you in devleoping their care plans and addressing their specific needs in their progress notes. You will need to review your assessments to ascertain if you are actually gathering the correct information for your documentation.