60 Essential Forms - hcmarketplace.com

1 Kathleen Martin, RN, MSN, MPA, LNHA60 EssentialFormsFor long -Term CareDocumentation 6 0 Es sE n t i a l Fo r m s F o r lo n g- tE r m Ca rE Do C u mE n t a t i o nContentsPreface .. viSection one: Audit Forms ..1 form : Quality auditing form : Documentation.. 3 form : MDS auditing form : Documentation for reimbursement .. 6 form : Resident care status survey tool.. 9 form : New admission documentation audit .. 13 form : Dysphagia audit .. 15 form : Psychotropic audit .. 17 form : Nursing audit: Urinary catheter use .. 19 form : Medical staff documentation audit.. 21 form : Safety rounds audit.. 23 form : Kitchen/dietary audit .. 26 Section two: Documentation Forms .. 29 form : Admission data base assessment.. 31 form : Nursing care flow-sheet .. 39 form : Monthly psychoactive summary ..44 form : Restraint elimination/reduction assessment..47 form : Restraint needs assessment ..49 form : Interdisciplinary health education form .

2 52 form : Fall risk assessment ..56 form : 48-hour post-fall monitoring form ..58 form : Incident/accident form .. 61 form : Pain assessment for those with communication barriers/dementia..63 form : Pain management tracking form ..65Co n tE n t s 6 0 Es sE n t i a l Fo r m s F o r lo n g- tE r m Ca rE Do C u mE n t a t i o nForm : Pain management assessment ..66 form : ADL/restorative nursing flow sheet..69 form : ADL data collection form ..72 form : Cognitive/mood/behavioral data collection flow sheet ..74 form : Restorative nursing flow sheet ..76 form : Wandering assessment..78 form : Product evaluation form ..81 form : Transfer checklist (sub-acute to LTC units) .. 83 form : Infection control tracking form ..85 Section three: Accountability reports .. 87 Guidelines for monthly reports ( Forms , , , ).. 89 form : Sample monthly report: Director of nursing .. 90 form : Sample monthly report: Assistant director of nursing.

3 92 form : Sample monthly report: Non-nursing manager..93 form : Sample monthly report: Maintenance director ..94 form : Task management sheet..95 form : Utilization review/discharge meeting worksheet..97 Section four: Regulatory Forms ..99 form : Gantt chart for regulatory planning .. 101 form : Standing meeting/committee guidelines..104 form : Root-cause analysis worksheet .. 108 form : State department of health survey preparation..110 Section five: Performance improvement Forms ..113 CQI and PI form : Directions ..116 form : CQI and PI form ..117 form : CQI and PI form : Pain management sample ..118 form : CQI and PI form : Fall reduction sample..119 form : CQI and PI form : Transfers to hospital sample ..120Co n tE n t s 6 0 Es sE n t i a l Fo r m s F o r lo n g- tE r m Ca rE Do C u mE n t a t i o nForm : CQI and PI form : Psychoactive drug use monitoring sample..121 form : CQI and PI form : Restraint reduction sample.

4 122 form : CQI and PI form : Infection control and surveillance sample..123 form : Pain management data collection form for performance improvement program..124 form : Interdisciplinary action committee (IAC) form ..126 Section six: Other Forms ..129 Credentialing and privileging physicians and nurse practitioners: Procedures ..131 form : Request for application intake form : General appointment..134 form : Request for application intake form : Temporary appointment ..135 form : Credentialing cover letter: Initial appointment..136 form : Credentialing cover letter: Reappointment ..137 form : Credentialing checklist: Initial appointment ..138 form : Credentialing checklist: Temporary appointment..139 form : Credentialing checklist: Reappointment ..140 form : License verification..141 form : Credentials phone verification form ..142 form : Reappointment evaluation ..143 form : Temporary appointment form .. 145S E C T I O N O N EAudit Forms form : Quality auditing form : Documentation form : MDS auditing form : Documentation for reimbursement form : Resident care status survey tool form : New admission documentation audit form : Dysphagia audit form : Psychotropic audit form : Nursing audit: Urinary catheter use form : Medical staff documentation audit form : Safety rounds audit form : Kitchen/dietary audit 6 0 Es sE n t i a l Fo r m s F o r lo n g- tE r m Ca rE Do C u mE n t a t i o nQuality auditing form : DocumentationForm : To perform a quick audit to ensure compliance with nursing documentation standards; for use with concurrent records/resident : 1.

5 Place a check mark in the appropriate Make comments in the provided space. 3. Edit the form for your own use and facility be completed by: This form should be completed by a nurse and returned to the director of nursing or facility administrator. 6 0 Es sE n t i a l Fo r m s F o r lo n g- tE r m Ca rE Do C u mE n t a t i o nQuality auditing form : DocumentationForm Yes No CommentMedical record:1. Admission assessment is fully completed, signed by RN (co-sign).2. All other assessments done: pain, fall, skin, 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?

6 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? Date of audit: _____ Auditor (signature/title): _____Resident name: _____ Room/Unit #: _____Admissions date: _____ 6 0 Es sE n t i a l Fo r m s F o r lo n g- tE r m Ca rE Do C u mE n t a t i o nQuality auditing form : DocumentationForm of focusCommentNoYesWounds: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?

7 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?Other:Area: Comment: _____ _____ Signature/title Date 6 0 Es sE n t i a l Fo r m s F o r lo n g- tE r m Ca rE Do C u mE n t a t i o nMDS auditing form : Documentation for reimbursementForm : To audit key areas of the MDS for accurate documentation, ensuring proper reimbursement and compliance with Medicare regulations and : 1. UB-92 is helpful in auditing for MDS accuracy, as the bill must match with the MDS to ensure proper reimbursement. 2. Place a check mark in the appropriate column and add comments as be completed by: An MDS coordinator or an RN familiar with the MDS. 6 0 Es sE n t i a l Fo r m s F o r lo n g- tE r m Ca rE Do C u mE n t a t i o nMDS auditing form : Documentation for reimbursement form Yes No CommentMedical record number: _____ Resident name: _____Admissions date: _____ Discharge date: _____UB-92 bill:1.

8 Days billed correctly? Match resource utilization group (RUG)?2. Diagnosis codes? Accurate?MDS: 3. MDS reflects the RUG areas billed?4. UB-92 reflects the MDS?5. Consistent claim data? 6. Illogical RUG jumps? (example: A jump from a CC to RB level may be indicative of a mistake) MDS: Key areas: 7. Section E: Mood/depression: Capturing when can?8. Section G: ADLs?9. ARD? Best date? Lookback date consistent?10. Does ARD match UB-92 service date ?11. Section T: Left blank or inaccurate, under/over-estimated?12. MDS: Reason for assessment: modifier codes?13. Rehab log: Sections K and P: Consistent/true/matching times?14. Section K/P (IV): Indicated?15. Tube feed/supplies on UB-92 if applicable?Chart/documentation:16. Documentation supports the MDS? 1. Assessments? 2. Progress nurses notes? 3. Rehab notes? 4. Other? 6 0 Es sE n t i a l Fo r m s F o r lo n g- tE r m Ca rE Do C u mE n t a t i o nMDS auditing form : Documentation for reimbursementForm Yes No Comment17.

9 Documentation supports Medicare requirements?18. care plan accurate and up to date?19. Proper evaluation dates and follow-ups?20. Proper signatures on care plan?21. care planning reflects MDS and assessments?Other: _____ _____ 6 0 Es sE n t i a l Fo r m s F o r lo n g- tE r m Ca rE Do C u mE n t a t i o nResident care status survey toolForm : To help your facility prepare for surveys; to monitor resident : 1. Place a check mark in the appropriate column; be sure to note follow-up/comments. 2. Using the questions listed at the bottom of the form , interview the resident about his/her perceived quality of After the form is complete, forward it to the director of be completed by: An LPN or RN should complete this 0 Es sE n t i a l Fo r m s F o r lo n g- tE r m Ca rE Do C u mE n t a t i o nResident care status survey toolForm of focus Yes No Follow-up/action Comments/NAResident name: _____ Room/Unit #: _____Date: _____ Auditor: _____A.

10 Resident rooms1. Over-bed tables are clean and free of clutter?2. Water is within reach? Cup is dated as per policy/practice?3. Call bell within reach/is working?4. Bedside cabinet clean and orderly: a. No medications at bedside? b. No treatment supplies on bedside table?5. Side rails are in prescribed position?6. Supplies not designated for resident are not found in the rooms?7. Soiled linen/personal clothing not placed on floor?8. Oxygen sign is posted before entering resident s room (as applicable)?B. Tube feedings1. Pump is clean, free of dust and dried debris?2. Tubing is dated and changed as per policy?3. G-tube solution bottle is dated, labeled per policy?4. Head of bed is elevated 30-45 degrees?5. Mouth care is evident?C. Resident-specific care1. Appearance is neat and clean?2. Resident is properly dressed?3. Correct footwear is on?4. Nails are clean and trimmed?5. Hair is neat and clean?6. Men are shaved?