On-Time Implementation

On-Time Quality Improvement Manual for Long-Term Care Facilities

Step 1: Standardize CNA Documentation Data Elements and Redesign Workflow

This section describes the steps to confirm whether your facility's Certified Nursing Assistant (CNA) daily charting standardized documentation includes the data elements needed to implement the On-Time program. CNA elements required for On-Time populate the weekly On-Time reports and therefore must be a part of routine documentation. This section discusses three documentation processes that may be affected by potential changes in CNA charting.

This section provides an overview of the key steps for a team to consider:

  • Conduct inventory of current CNA documentation.
  • Conduct gap analysis between facility and On-Time data elements.
  • Identify impact of On-Time documentation and transition to electronic CNA documentation on processes relevant to On-Time quality improvement (QI):
    • Weight documentation and review.
    • Behavior observations and followup.
    • Skin observations and followup.

Conduct Inventory of Current CNA Documentation

The first step in establishing or confirming standardized data elements for CNA daily documentation is to review existing documentation requirements.

  • If CNAs are documenting on paper, then ask the team to furnish a packet of forms that CNAs are responsible for completing on a daily or weekly basis. Any form that CNAs fill out should be included in this packet, including checklists or other forms that may be kept on clipboards or in logbooks; forms may vary for day, evening, and night shifts.
  • If CNAs are documenting electronically, then ask the team to provide screenshots of each screen a CNA accesses to complete required charting for each shift. In some cases, the vendor can provide a list of documentation elements or show nursing how or where to access the information in the system.

Conduct Gap Analysis

The next step is to conduct gap analysis of CNA documentation elements required for the On-Time program. Elements that must be included in CNA daily or weekly documentation to meet minimum program requirements are reviewed with the team. Most teams find this review very helpful to provide the "big picture." Often, teams offer feedback that many of the elements are part of their current charting. Required data elements are linked to best practices and are the result of research that analyzed factors associated with fewer residents developing pressure ulcers.


To conduct the gap analysis, compare CNA documentation elements required for the On-Time program against elements currently available on existing CNA documentation forms or electronic documentation. Using the worksheet (Table 1.1), mark whether each On-Time required element is available or not available in your facility's CNA documentation; all elements not available represent the documentation gap.

In reading Table 1.1, note the following column heading definitions:

  • Row #. Row numbering for easier navigation of the document.
  • On-Time Requirement. Information required for the On-Time program. An X indicates the information must be included in your new computer system for CNA documentation.
  • Data Element. Data that display on paper forms or electronic documentation screens.
  • Facility: Element Available. The element is currently included in facility's CNA documentation.
  • Facility: Element Not Available. The element is not included in facility's CNA documentation.

CNA documentation review process helped in the transition from our paper documentation to the new software. The CNA data elements review process forced us to really look at what we were asking the CNAs to document for feeding, nutrition, and behaviors. We took extraneous elements out of the system.

—Director of Nursing

Completing the data elements grid and analyzing CNA documentation at a data element level provides a comprehensive view of what is documented and enables the team to see the following:

  • Redundancies in data documentation.
  • Inconsistencies in data elements.
  • Unclear or ambiguous elements.
  • Elements required for On-Time that are missing or inconsistent with current documentation.

Before moving forward, the team addresses the identified gaps and confirms plans to include required data elements in CNA documentation.

Frequently Asked Questions

Question: Who should be involved in conducting and reviewing the gap analysis?

Answer: A core team representing multiple disciplines is involved. Consider including representation of any user of CNA documentation data elements. For example, dietitians and MDS (Minimum Data Set) nursesii are users of meal intake documentation; social work is a user of behavior observations.

Question: Why is it helpful to include the CNAs in this process?

Answer: CNA staff are more accepting of documentation changes when they are included in the revision process. In addition, CNAs are valuable resources because they can identify points for clarification and items missing from documentation. Issues or challenges that CNAs experience with specific components of their documentation and system inefficiencies often surface during these discussions and pave the way toward identifying opportunities for improvements.

Question: How long will a gap analysis take us?

Answer: Analyzing the gap between current CNA documentation elements and On-Time required elements typically takes one or two meetings. The subsequent discussions to eliminate redundancies and nonessential elements and agree on the final list of standardized documentation elements generally take an additional three or four working sessions with the core project team.

Question: Do we have to include all the On-Time required data elements?

Answer: Skin and Behavior observation elements are two optional documentation components for On-Time; all other elements are required. If a facility opts not to include Skin or Behavior elements in the initial stage of On-Time implementation, then they can be added at a later date.

Question: Can we include data elements not on the On-Time required list?

Answer: Yes. On-Time does not limit elements that a facility may want to capture in day-to-day documentation; the objective of the process is to ensure that On-Time elements are included in documentation.

Question: Are there areas where most teams get stuck?

Answer: No. Teams often choose to spend additional time on the data elements review to confirm that all elements are essential and not redundant, in order to gain efficiencies. Also, team discussions often reveal process issues to be included in the next step of process redesign, such as, "Is the element documented more than once or repeated by other disciplines?" For example, it may be discovered that CNAs, nurses, and dietitians each record resident weights. This is an example of an opportunity to redesign the process by eliminating duplicative effort and reducing risk of errors.

Review New CNA Documentation Processes

Three CNA documentation processes might change when switching from paper to electronic documentation and implementing On-Time. If CNA staff are already charting electronically, then these process changes were likely addressed previously. The documentation processes that could be affected by CNA documentation changes are:

  • Resident weight.
  • Skin observations [optional documentation requirement].
  • Behavior observations [optional documentation requirement].

Resident Weight

Weights are an essential element to support the On-Time Program; therefore, it is necessary to ensure that accurate weight values are entered into the system. Facilities have varying processes to capture and record resident weights. In some cases, CNA staff or restorative aides capture weights and then record values in a weight logbook or other record. Subsequently, licensed staff review weights for variances and determine if weights are acceptable or if any need to be repeated and validated.

Teams should consider the following if entering resident weights into an electronic module for the first time:

  • Who will capture resident weight?
  • Who will enter weight into the new computer system?
  • Will weights be recorded in a logbook or other form before entry into the computer system?
  • What mechanism will be in place to confirm weights were entered into the system? Is there a checklist or signoff sheet?
  • Will licensed staff confirm that weights are accurate before values are entered into the system?
  • Will there be a mechanism in place to confirm weights are entered correctly? Is there variance checking? Does the computer alert the user if weights are out of range upon entry? Is there a report to view weight variances?

Skin Observations

Many facilities require CNA documentation of skin observations, with documentation required either each shift, daily, or on shower days only. When incorporating On-Time skin observations into electronic documentation, teams are instructed to consider the following:

  • Will CNAs record skin observations each shift of each day by recording what is observed during his/her shift, whether observation is new or previously observed? In this scenario, if a CNA observes red areas for 3 consecutive days, then red areas would be recorded for 3 days.
  • Will CNAs record skin observations only if they are new to the CNA? In this scenario, if a CNA observes red areas for 3 consecutive days, then red areas would be recorded once, upon first observation only. The remaining documentation would indicate no new observations.
  • Will CNAs be required to inform licensed staff of red areas observed before charting? In this scenario, the licensed staff confirms the observation before it is entered into the system.
  • Instruct CNAs to chart no observations noted when there are no observable red areas of the skin. If a CNA chooses to leave skin observation blank instead of charting no observations noted, then it would count as incomplete or missing documentation.

Behavior Observations

CNA documentation of resident behaviors is often a new process for a facility. As with documentation of skin observations, processes and training are established to support the CNAs completing the new documentation. When incorporating On-Time behavior observations into electronic documentation, teams are instructed to consider the following:

  • Will CNAs record behavior observations each shift of each day by recording what is observed during his/her shift, whether observation is new or previously observed?
  • Will CNAs be required to inform licensed staff of behaviors observed before charting?
  • Will CNAs chart no observations noted when there are no observable behaviors? If a CNA chooses to leave behavior observation blank instead of charting no observations noted, then it would count as incomplete or missing documentation in a summary report.

Frequently Asked Questions

Question: What do teams find works best for the weight documentation process?

Answer: Teams find that establishing a process to validate accuracy of a resident's weight prior to entering weight into the Health IT system does two things:

  • Eliminates eventual steps required to remove an incorrect weight entry from the system and saves staff time;.
  • Prevents incorrect weight entries from being included in weight calculations (e.g., weight loss calculations) and acted upon. Licensed staff responding to inaccurate weight loss calculations may create mistakes in care planning.

Question: What validation and data entry processes are implemented to confirm accuracy of weight entries?

Answer: Validation and data entry processes can be implemented in a variety of ways. Examples of options outlined at a high level for consideration include the following:


  • Lead CNA checks new weights and notifies nurse of needed followup. In this scenario, CNA compares recent weight to previous value and reports to licensed staff based on agreed-on parameters, such as weight change of 1 pound, 2 pounds.
  • Nurse manager checks new weights, signs off if weight is ready for entry into system, and follows up if reweight is needed.
  • Dietitians check new weights, sign off if weight is ready for entry into system, and follow up if reweight is needed.

Data Entry

  • CNA, nurse, or dietitian enters weights into system.

Question: Why are skin and behavior observations optional?

Answer: Facilities may not want to change current processes. CNAs may not be in the habit of documenting skin and behavior observations and facility leadership may opt to postpone including an entire new component of documentation until On-Time implementation is underway.

Summary of Key Points

  • Confirming CNA documentation data elements is necessary to implement the On-Time program.
  • While a minimum set of On-Time data elements is required, each facility can include facility-specific elements to meet CNA daily documentation requirements of the facility.
  • Reviewing three documentation processes that may be affected by the potential changes in CNA charting will help teams as they transition from paper to electronic documentation.
  • While the focus is on CNA documentation, a core group of multiple disciplines (nursing, CNAs, dietary, social services) must be involved in review and redesign of CNA documentation elements and processes.

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Step 2: Monitor CNA Documentation

This section describes the On-Time Completeness Report and how it is used to monitor completeness of Certified Nursing Assistant (CNA) daily documentation. Ensuring documentation completion by the CNA staff is an important first step in implementation of the On-Time program. All On-Time reports use CNA documentation; therefore, complete daily documentation by CNAs is essential for successful implementation of the program.

The report information helps staff monitor CNA documentation completeness trends and identify areas that may require followup. Nurse managers, charge nurses, staff educators, MDS (Minimum Data Set) nurses, and other members of the multidisciplinary team can use the report to monitor documentation completeness at the unit or shift level, provide feedback to staff, and focus inservice sessions. The report displays the amount of documentation completed each week but can be used to complement efforts to improve documentation accuracy. We will distinguish between documentation completeness and accuracy and will describe how both completeness and accuracy are addressed in On-Time processes.

This section provides:

  • An orientation to the Completeness Report.
  • Examples of process improvements using Completeness Report information to monitor CNA documentation.
  • Implementation tips from nursing homes that have integrated the Completeness Report into daily and weekly practice.
  • Frequently asked questions about using the Completeness Report.

Orientation to the CNA Documentation Completeness Report

What Is the Completeness Report?

The Completeness Report provides nursing home staff with a way to audit the completeness of CNA documentation on a weekly basis at the facility and nursing unit level. The Completeness Report displays weekly documentation percentages for the documentation elements required for the On-Time program:

  • Meal Intake.
  • Bowels.
  • Bladder.
  • Behaviors.
  • Skin Observations.

The Completeness Report provides a trended view of completeness rates displaying 4 weeks of data for the current and previous 3 weeks. Nurses can review trends to determine if CNA staff are documenting better, worse, or about the same as previous weeks. By displaying completeness percentages by specific areas of charting, nurse managers and staff educators can focus education and target inservices on areas with low completion rates. Ongoing use of the report provides feedback to staff on CNA progress.


The report information is displayed for each unit in two sections: All shifts combined (Table 2.1) and shift detail (Tables 2.2, 2.3, and 2.4). The all shifts combined view displays the five sections of charting required for the On-Time program and 4 weeks of completion percentages for all shifts. The shift-detail view displays documentation completeness for each shift. Table 2-5 presents completeness report definitions.

What Questions Does the Completeness Report Answer?

  • What are the completeness percentages over the past 4 weeks for each section? Are areas improving?
  • Are any sections of documentation consistently low?
  • For sections with low percentages, are low rates shift related or staff specific?
  • Are there differences across shifts? For example, is meal documentation consistent for day (breakfast and lunch) and evening (dinner) shifts?

Process Improvements Using Documentation Completeness Report

Each unit establishes a process for using the Completeness Report to audit CNA charting. Consistent followup will promote early identification of declines in charting completeness. Teams can follow up to determine problem root cause, shift issue, or specific individuals who are having problems documenting and then schedule appropriate inservices or one-on-one education.

Recommended steps include:

  • Assign responsibility to monitor all or specific sections of charting using the Completeness Report. For example:
    • Dietitians often take the lead in monitoring meal consumption.
    • MDS nurse or social worker may monitor behavior documentation.
    • MDS nurse or staff educator may assume responsibility for bowel and bladder documentation.
    • Wound nurse may monitor documentation of skin observations.
  • Schedule weekly review of the Completeness Report until rates are consistently above 75 percent for 8 consecutive weeks.
  • Establish a schedule for ongoing monitoring using Completeness Report.
  • Once completeness percentages are consistently above 75 percent, establish a schedule for routine followup, such as biweekly or monthly for each nursing unit.
  • Determine and implement followup process to confirm complete documentation each shift.

Implementation Tips

  • Develop a structured process with clear accountability to monitor CNA documentation completion rates. Start with weekly review of Completeness Report until high completion rates are sustained, and then continue review monthly.
  • Involve director of nursing or nurse manager in monitoring CNA documentation. Active involvement of management results in more successful implementation than if teams rely solely on staff educators.
  • Involve CNAs in team meetings from the start of the project. An effective monitoring process focuses on learning "where and why" completeness is an issue. It also helps target interventions (education and new processes) to address specific issues on a shift or on a particular documentation data element. Report information is not punitive.
  • Use CNAs for documentation mentoring.
  • Develop procedures to ensure that documentation is completed by agency staff.

"Following up on Completeness Report results has been helpful to identify staff with knowledge deficits and focus discussions on specific areas of charting that require followup."

—Staff Educator

"We always suspected that we had documentation completeness issues but the Completeness Report brings it out in the open; now it is easy to see the big picture and specific areas with issues. We weren't able to review charting easily with previous paper charts."

—Director of Nursing

Frequently Asked Questions

Question: Our health information technology (Health IT) system provides a CNA documentation compliance report. Can I use this report?

Answer: Your facility's clinical application may provide a feature to monitor documentation completeness more frequently than the weekly On-Time Completeness Report. It may also have a feature to monitor other components of CNA daily documentation. These vendor reports may be helpful for day-to-day compliance monitoring of all CNA daily documentation. The trended views of the On-Time Completeness Report provide insights into documentation patterns over time and show weekly improvement or problems in specific areas of CNA charting required for On-Time.

Question: Can we assign the nurse manager to monitor the Completeness Report?

Answer: Each facility determines who is responsible for monitoring the report; it varies by facility. The essential step is the assignment of responsibility and routine followup. In many facilities, the staff educator either takes the lead or coleads the process.

Question: Our completeness rates are good for all sections except bowel documentation. We do not understand why this is happening.

Answer: Facilities frequently report having low completeness rates for bowel documentation during the early implementation phase. Often, teams report that CNAs are leaving the bowel section blank if a resident does not have a bowel movement during their shift. The On-Time program requires the charting option "no bowel movement" to be included in the bowel documentation section of the CNA charting module. Without this option, it is unclear if the CNA is indicating that the resident did not have a bowel movement or if the CNA failed to chart the information during the shift. If your software is On-Time compliant, a low completion rate for bowels indicates CNAs are not documenting.

Question: If we have zeros or 3 percent for our behavior documentation, does this mean that we have little to no behavior issues on that nursing unit?

Answer: If you have included behavior documentation in your CNA module, then your CNA staff is not charting behavior information. As with bowel and bladder sections of documentation, the On-Time program requires the option "no behaviors observed" in the behavior section. This eliminates any confusion about report results; low completeness percentages indicate incomplete documentation.

Question: We have been using the Completeness Report and our rates have been improving but we find that some of our documentation is not accurate. Can the Completeness Report help with accuracy?

Answer: The Completeness Report does not provide specific details of charting accuracy. It is common for inaccuracies in documentation to surface during followup with CNA staff on completeness questions. Facilities often uncover accuracy issues that may have gone undetected if they had not been following up on completeness problems. Teams report that establishing a routine process of monitoring CNA documentation completeness helps improve completeness and starts to identify and help address accuracy issues. The process helps identify the need to reeducate staff on proper documentation and clear up staff misunderstandings.

For example, one facility discovered that not all CNAs understood what was meant by incontinence; another facility learned of gross inconsistency among staff on documentation of meal intake. Another facility learned that CNAs did not understand which resident behaviors were to be reported. It is important to note that documentation accuracy will be addressed throughout the On-Time process as clinical reports based on CNA documentation are used in daily practice.

Question: We have been monitoring completeness rates each week for months, following up with CNA staff on each shift, having pizza parties, and offering other incentives for CNAs to complete their documentation yet we struggle to obtain high completeness rates. What else can we do?

Answer: In On-Time, the first step to improve CNA documentation is establishing a routine process to monitor CNA documentation completeness. However, for some facilities we have found that this step alone may not be enough to achieve or sustain high completion rates. We encourage the team to move on to the next On-Time implementation step after 1 to 2 months.

The next process improvement incorporates the use of the Nutrition Report and implementing weekly 5-minute stand-up meetings, or huddles, with CNA staff. In this process improvement, CNA staff begin to see the link between their daily documentation and clinical reports used by the multidisciplinary team. CNAs report feeling valued by team members and ultimately become more accountable for their documentation when they see how licensed staff use it. Therefore, it is common to see a dramatic improvement in documentation as On-Time is implemented, not just when focusing on CNA documentation completeness.

We will provide more details about the use of the Nutrition Report and the 5-minute stand-up process in the section on the Nutrition Report.

Completeness Report Tracking Tool

The Completeness Report Tracking Tool helps the team monitor CNA documentation completeness and better understand the root cause of low completeness. The tool can be used to support initial implementation of CNA documentation monitoring and then to conduct random checks once completeness rates stabilize at 75 percent or above.


A sample Completeness Report tracking tool is shown in Table 2.6. Teams are instructed to track documentation areas that are below 75 percent complete and note reasons for the low rates. Weekly trends and patterns can be detected and appropriate training or other interventions scheduled.

Summary of Key Points

  • Establishing processes to use the Completeness Report as part of routine practice helps CNAs improve documentation completeness and accuracy.
  • CNA documentation completeness and accuracy will improve as the information is used on a regular basis by the entire team.
  • It is okay if a facility does not achieve 100 percent completeness. Move on to the next steps in the On-Time implementation process once a monitoring process is established.
  • Routine review and feedback to CNAs about their documentation help identify misunderstandings and areas for further education. When reviews are punitive, there is less focus on learning and understanding how to improve.

ii The MDS nurse collects information required by the Centers for Medicare & Medicaid Services.

Page last reviewed January 2011
Internet Citation: On-Time Implementation: On-Time Quality Improvement Manual for Long-Term Care Facilities. January 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/ontimeqimanual/qimanual4.html