60 Essential Forms

[Pages:33]60

Essential Forms

For Long-Term Care Documentation

Kathleen Martin, RN, MSN, MPA, LNHA

Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Section one: Audit forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Form 1.1: Quality auditing form: Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Form 1.2: MDS auditing form: Documentation for reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . 6 Form 1.3: Resident care status survey tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Form 1.4: New admission documentation audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Form 1.5: Dysphagia audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Form 1.6: Psychotropic audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Form 1.7: Nursing audit: Urinary catheter use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Form 1.8: Medical staff documentation audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Form 1.9: Safety rounds audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Form 1.10: Kitchen/dietary audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Section two: Documentation forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Form 2.1: Admission data base assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Form 2.2: Nursing care flow-sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Form 2.3: Monthly psychoactive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Form 2.4: Restraint elimination/reduction assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Form 2.5: Restraint needs assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Form 2.6: Interdisciplinary health education form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Form 2.7: Fall risk assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Form 2.8: 48-hour post-fall monitoring form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Form 2.9: Incident/accident form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Form 2.10: Pain assessment for those with communication barriers/dementia . . . . . . . . . . . . . . 63 Form 2.11: Pain management tracking form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

60 Essential Forms for Long-Term Care Documentation

Contents

Form 2.12: Pain management assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Form 2.13: ADL/restorative nursing flow sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Form 2.14: ADL data collection form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Form 2.15: Cognitive/mood/behavioral data collection flow sheet . . . . . . . . . . . . . . . . . . . . . . . . . 74 Form 2.16: Restorative nursing flow sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Form 2.17: Wandering assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Form 2.18: Product evaluation form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Form 2.19: Transfer checklist (sub-acute to LTC units) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Form 2.20: Infection control tracking form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Section three: Accountability reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Guidelines for monthly reports (Forms 3.1, 3.2, 3.3, 3.4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Form 3.1: Sample monthly report: Director of nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 Form 3.2: Sample monthly report: Assistant director of nursing . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Form 3.3: Sample monthly report: Non-nursing manager . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Form 3.4: Sample monthly report: Maintenance director . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Form 3.5: Task management sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Form 3.6: Utilization review/discharge meeting worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Section four: Regulatory forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Form 4.1: Gantt chart for regulatory planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Form 4.2: Standing meeting/committee guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Form 4.3: Root-cause analysis worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Form 4.4: State department of health survey preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

Section five: Performance improvement forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

CQI and PI form: Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Form 5.1: CQI and PI form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Form 5.2: CQI and PI form: Pain management sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Form 5.3: CQI and PI form: Fall reduction sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Form 5.4: CQI and PI form: Transfers to hospital sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

60 Essential Forms for Long-Term Care Documentation

Contents

Form 5.5: CQI and PI form: Psychoactive drug use monitoring sample . . . . . . . . . . . . . . . . . . . . 121 Form 5.6: CQI and PI form: Restraint reduction sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Form 5.7: CQI and PI form: Infection control and surveillance sample . . . . . . . . . . . . . . . . . . . . 123 Form 5.8: Pain management data collection form for performance improvement program . . . 124 Form 5.9: Interdisciplinary action committee (IAC) form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126

Section six: Other forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

Credentialing and privileging physicians and nurse practitioners: Procedures . . . . . . . . . . . . . . 131 Form 6.1: Request for application intake form: General appointment . . . . . . . . . . . . . . . . . . . . . 134 Form 6.2: Request for application intake form: Temporary appointment . . . . . . . . . . . . . . . . . . . 135 Form 6.3: Credentialing cover letter: Initial appointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Form 6.4: Credentialing cover letter: Reappointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Form 6.5: Credentialing checklist: Initial appointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 Form 6.6: Credentialing checklist: Temporary appointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139 Form 6.7: Credentialing checklist: Reappointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 Form 6.8: License verification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Form 6.9: Credentials phone verification form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142 Form 6.10: Reappointment evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Form 6.11: Temporary appointment form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

60 Essential Forms for Long-Term Care Documentation

SECTION ONE

Audit forms

? Form 1.1: Quality auditing form: Documentation ? Form 1.2: MDS auditing form: Documentation for reimbursement ? Form 1.3: Resident care status survey tool ? Form 1.4: New admission documentation audit ? Form 1.5: Dysphagia audit ? Form 1.6: Psychotropic audit ? Form 1.7: Nursing audit: Urinary catheter use ? Form 1.8: Medical staff documentation audit ? Form 1.9: Safety rounds audit ? Form 1.10: Kitchen/dietary audit

Form 1.1

Quality auditing form: Documentation

Purpose:

To perform a quick audit to ensure compliance with nursing documentation standards; for use with concurrent records/resident status.

Directions:

1. Place a check mark in the appropriate column.

2. Make comments in the provided space.

3. Edit the form for your own use and facility needs.

Should be completed by:

This form should be completed by a nurse and returned to the director of nursing or facility administrator.

60 Essential Forms for Long-Term Care Documentation

Form 1.1

Quality auditing form: Documentation

Date of audit: ___________

Auditor (signature/title): ____________________

Resident name: __________________________________ Room/Unit #: ______________________________ Admissions date: ______________________________________________________________________________

Item/indicator

Yes No

Medical record: 1. Admission assessment is fully completed,

signed by RN (co-sign). 2. All other assessments done: pain, fall, skin, etc. 3. Treatment admin. records signed for? 4. Medication admin. records (MAR) signed? 5. Immunizations documented properly/done? 6. Weights charted monthly and/or per order? 7. Does the documentation support the MDS?

? Assessments? ? Progress notes? ? Other? 8. Does documentation support Medicare requirements? 9. Is care plan accurate and up to date? Measurable goals? Relevant problems? 10. Proper evaluation dates and follow-ups? 11. Proper signatures on care plan? 12. Care planning reflects MDS and other assessments? 13. Evidence of teaching? Special needs: Thickened liquids/dysphagia: 14. Proper notation by the door (if permitted by state); proper protocol followed? 15. Water at bedside? Fall risks: 16. Fall risk evident? 17. Care planned?

Comment

60 Essential Forms for Long-Term Care Documentation

Form 1.1

Quality auditing form: Documentation

Indicators/areas of focus Wounds: 18. Wound care protocol followed/proper forms completed? 19. Care planned? Pain management: 20. Protocol/forms followed? (assessment and outcome) 21. Care planned? 22. MAR completed? 23. Initial and ongoing pain assessments done? Equipment in room: 24. Respiratory, feeding pump equipment labeled/tagged? 25. IVs dated, labeled? 26. Wound dressings, IV site dated and signed? Resident appearance: 27. Properly positioned? WC, bed? 28. Appears clean, appropriate dress? 29. Any complaints/concerns?

Yes No

Comment

Other:

Area: Comment:

__________________________________________________

Signature/title

___________________________________

Date

60 Essential Forms for Long-Term Care Documentation

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