100 Essential Forms for Long-Term Care
Julie Ann Kemman, BBA
Heather Stewart, RHIT
Clinical assessment forms
Survey readiness assessments
Documentation forms
MDS tools
Regulatory forms
Accountability reports
Quality Assessment and Performance Improvement (QAPI) forms
Stewart
?
?
?
?
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?
Kemman
This book contains 100 of the most commonly utilized forms in long-term care
facilities, including:
Brewer
The updated content found in this new edition reflects recent regulatory ?changes
to help long-term care providers stay compliant and ensure quality resident care.
The updated forms offer easy-to-understand descriptions of ?implementation
?processes and timing, and can be used as-is or customized to best meet the
?particular needs of nursing home staff.
Marshall
100 Essential Forms for Long-Term Care provides convenient access to a
?compilation of essential forms that will save ?nursing home staff time and improve
the documentation accuracy of every department in the long-term care facility.
100 Essential Forms for Long-Term Care
Carol Marshall, MA
Kate Brewer, PT, MBA, GCS, RAC-CT
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a division
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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
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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
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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
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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
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