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.

2 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 ..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 .

3 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 , , , ).

4 89 form : Sample monthly report: Director of nursing .. 90 form : Sample monthly report: Assistant director of nursing .. 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 .

5 113 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 ..122 form : CQI and PI form : Infection control and surveillance sample..123 form : Pain management data collection form for performance improvement program.

6 124 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.

7 140 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.

8 To perform a quick audit to ensure compliance with nursing documentation standards; for use with concurrent records/resident : 1. 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.

9 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? 10. Proper evaluation dates and follow-ups?11. Proper signatures on care plan?

10 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.