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

?

?

?

?

?

?

?

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

PUB CODE

Barcode

a division

of BLR

75 Sylvan Street | Suite A-101

Danvers, MA 01923



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