100 Essential Forms for Long-Term Care

100

Essential Forms for

Long-Term Care

Carol Marshall, MA Kate Brewer, PT, MBA, GCS, RAC-CT

Julie Ann Kemman, BBA Heather Stewart, RHIT

100 Essential Forms for Long-Term Care is published by HCPro, a division of BLR

Copyright ? 2014 HCPro, a division of BLR

All rights reserved. Printed in the United States of America. 5 4 3 2 1

Download forms and tools from this book with the purchase of this product.

ISBN: 978-1-55645-227-7

No part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, or the Copyright Clearance Center (978-750-8400). Please notify us immediately if you have received an unauthorized copy.

HCPro provides information resources for the healthcare industry.

HCPro is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks.

Carol Marshall, MA, Author Kate Brewer, PT, MBA, GCS, RAC-CT, Author Heather Stewart, RHIT, Author Julie Ann Kemman, BBA, Author Olivia MacDonald, Managing Editor Adrienne Trivers, Product Manager Erin Callahan, Senior Director, Product Elizabeth Petersen, Vice President Matt Sharpe, Production Supervisor Vincent Skyers, Design Manager Vicki McMahan, Sr. Graphic Designer Jason Gregory, Layout/Graphic Design Kelly Church, Cover Designer

Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions.

Arrangements can be made for quantity discounts. For more information, contact:

HCPro 75 Sylvan Street, Suite A-101 Danvers, MA 01923 Telephone: 800-650-6787 or 781-639-1872 Fax: 800-639-8511 E-mail: customerservice@

Visit HCPro online at: and

Contents

About the Authors.....................................................................................vii Section 1: Audit Forms................................................................................. 1

Form 1.1: Quality auditing form: Nursing documentation................................................................ 3 Form 1.2: Triple-check form........................................................................................................... 8 Form 1.3: Resident care status survey tool.................................................................................... 12 Form 1.4: Preadmission screen.................................................................................................... 17 Form 1.5: Dysphagia audit........................................................................................................... 19 Form 1.6: Psychotropic audit .......................................................................................................21 Form 1.7: Urinary catheter reminder order................................................................................... 24 Form 1.8: Urinary catheter checklist............................................................................................. 26 Form 1.9: Medical staff documentation audit ............................................................................... 28 Form 1.10: Safety rounds audit.................................................................................................... 30 Form 1.11: Kitchen/dietary audit.................................................................................................. 34 Form 1.12: Discharge record documentation audit.......................................................................... 7 Form 1.13: Skilled nursing facility self-audit................................................................................. 40 Form 1.14: MDS chart audit tool.................................................................................................. 42 Form 1.15: Compliance audit worksheet....................................................................................... 45 Form 1.16: CAA completion audit tool......................................................................................... 56 Form 1.17: Quarterly Medicare compliance guide......................................................................... 58 Form 1.18: Policy and procedure: Medicare Part A triple-check process.......................................... 60 Form 1.19: Policy and procedure: Medicare Part B triple-check process.......................................... 64 Form 1.20: Assessment itinerary announced site visit.................................................................... 67 Form 1.21: Sample checklist for unannounced audit...................................................................... 69 Form 1.22: Resident review worksheet..........................................................................................71 Form 1.23: Quality of life assessment resident interview............................................................... 73 Form 1.24: Quality of life assessment family interview.................................................................. 75 Form 1.25: Quality of life assessment group interview................................................................... 77 Form 1.26: Statement of deficiencies and plan of correction.......................................................... 79

?2014 HCPro

iii

100 Essential Forms for Long-Term Care

Section 2: Documentation Forms............................................................... 81

Form 2.1: Admission database assessment................................................................................... 83 Form 2.2: Nursing care flow sheet................................................................................................ 92 Form 2.3: Monthly psychoactive summary................................................................................... 97 Form 2.4: Restraint elimination/reduction assessment..................................................................100 Form 2.5: Fall response assessment.............................................................................................102 Form 2.6: Care plan meeting education form...............................................................................105 Form 2.7: Fall risk assessment....................................................................................................109 Form 2.8: 48-hour post-fall monitoring form................................................................................ 111 Form 2.9: Incident/accident form................................................................................................ 114 Form 2.10: Pain assessment for those with communication barriers/dementia............................... 116 Form 2.11: Pain management tracking form................................................................................. 118 Form 2.12: Pain management assessment....................................................................................120 Form 2.13: ADL/restorative nursing flow sheet............................................................................122 Form 2.14: ADL data collection form...........................................................................................125 Form 2.15: Cognitive/mood/behavioral data collection flow sheet................................................127 Form 2.16: Restorative nursing flow sheet...................................................................................129 Form 2.17: Wandering assessment..............................................................................................132 Form 2.18: Product evaluation form............................................................................................135 Form 2.19: Transfer checklist (subacute to LTC units)..................................................................137 Form 2.20: Infection control tracking form...................................................................................139 Form 2.21: Readmission documentation pull list..........................................................................141 Form 2.22: Hospital readmission tracking tool.............................................................................143 Form 2.23: Rehospitalization tracking tool...................................................................................145 Form 2.24: Weight loss communication tool................................................................................147 Form 2.25: Against medical advice acknowledgment....................................................................149 Form 2.26: Anti-psychotic drug use assessment...........................................................................151 Form 2.27: Dehydration prevention checklist...............................................................................154 Form 2.28: Elopement drill.........................................................................................................156 Form 2.29: MDS therapy minutes................................................................................................159 Form 2.30: Swallowing protocol-feeding precaution checklist.......................................................161

Section 3: Accountability Reports............................................................ 165

Guidelines for monthly reports (forms 3.1, 3.2, 3.3, 3.4)..............................................................166 Form 3.1: Sample monthly report: Director of nursing..................................................................167 Form 3.2: Sample monthly report: Assistant director of nursing....................................................170 Form 3.3: Sample monthly report: Non-nursing manager.............................................................172 Form 3.4: Sample monthly report: Maintenance director..............................................................174 Form 3.5: Task management sheet..............................................................................................176 Form 3.6: Utilization review/discharge meeting worksheet...........................................................179 Form 3.7: Satisfaction survey response tracking...........................................................................181

iv

?2014 HCPro

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download