CLINICAL TOOLS

1 CLINICAL . TOOLS . AND. FORMS. 1/8" Margin all around. The Printer will trim too the margin area. FOR LONG-TERM CARE. BARBARA ACELLO, MS, RN. 1 6/15/15 2:07 PM. CLINICAL . TOOLS . AND. FORMS. FOR LONG-TERM CARE. BARBARA ACELLO, MS, RN. CLINICAL TOOLS and Forms for Long-Term Care is published by HCPro, a division of BLR. Copyright 2015 HCPro All rights reserved. Printed in the United States of America. 5 4 3 2 1. ISBN: 978-1-55645-476-9. No part of this publication may be reproduced, in any form or by any means, without prior writ- ten consent of HCPro or the Copyright Clearance Center (978-750-8400). Please notify us imme- diately 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. Barbara Acello, Author Olivia MacDonald, Managing Editor Erin Callahan, Senior Director, Product Elizabeth Petersen, Vice President Matt Sharpe, Production Supervisor Vincent Skyers, Design Services Director Vicki McMahan, Sr.

2 Graphic Designer Michael McCalip, Sheryl Boutin, Amanda Southworth, Sue Robinson, Jason Gregory, Layout/Graphic Design Reggie Cunningham, 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 100 Winners Circle, Suite 300. Brentwood, TN 37027. Telephone: 800-650-6787 or 781-639-1872. Fax: 800-785-9212. Email: Visit HCPro online at and CLINICAL .. 1. Inter-Facility Infection Control Transfer form .. 3. Admission and Preadmission Screening of Individuals With VRE or MRSA1.. 5. Admission/Readmission Checklist .. 7. Resident Personal Belongings Inventory.. 12. Discharge Education Tool.. 15. Discharge Plan .. 18. Wound Assessment Tool.. 20. Motorized/Power Wheelchair Assessment form .. 21. Delegation of Nursing Task to Unlicensed Staff.

3 25. DHandoff Assessment to Next Level of Care .. 28. Neurological Flow Sheet.. 29. Workload Management System for Nursing General Worksheet.. 32. Fall Risk Assessment.. 36. Fall Prevention Assessment .. 37. Fall Prevention Plan of Care .. 38. Assisted Living Resident Assessment form .. 39. Comprehensive Admission Skin Assessment .. 42. Supportive Documentation for MDS.. 43. Epworth Sleepiness Scale.. 50. Glasgow Coma Scale .. 51. Safe Smoking Risk Assessment.. 52. Nursing Assessment.. 53. Interdisciplinary Progress Note Template.. 59. ABCD Stroke Scale .. 60. Infection Control Environmental Rounds Checklist.. 63. CDC Environmental Checklist for Monitoring Terminal Cleaning .. 67. 2015 HCPro CLINICAL TOOLS and Forms for Long-Term Care iii Contents Quality Assessment/Improvement Tool.. 69. Daily/Weekly Checklist.. 71. Hydrotherapy Equipment Log form .. 72. Master Signature Log.. 73. Mechanical Lift Prevention Maintenance Checklist.

4 74. Safe Resident Handling Preparation Checklist.. 76. Mechanical Lift Competency Check .. 79. Sit to Stand Lift Competency Check .. 81. Mock Survey Observation form .. 82. Walking Rounds Resident Audit form .. 93. Door Alarm Checklist.. 97. Charge Nurse Cleaning Schedule.. 98. Chart Review Tool for Monitoring Quality Indicators: Effective Pain Management in Nursing.. 101. Daily AED & Crash Cart Checklist.. 103. Code Blue Event Debriefing/Critique.. 106. Emergency Crash Cart Checklist .. 108. Emergency Drug Kit Contents .. 110. Emergency Telephone Numbers.. 115. Signature Crash Cart Checklist .. 117. Diabetic Flow Sheet.. 118. Insulin and Blood Glucose Monitoring Orders.. 119. IV Flow Sheet .. 121. IV Nursing Notes.. 123. Tube Feeding Record.. 124. Order Sheet for Enteral Feeding .. 127. Fall Assessment Tool.. 128. Fall Management Program.. 130. Fall Prevention Assessment .. 131. Fall Prevention Plan of Care.

5 132. Post Fall 72-Hour Monitoring Report.. 134. PFall Documentation Guide/Temporary Care Plan.. 137. Centralized Immunization Record System .. 138. Individual Resident Infection Worksheet .. 139. Sepsis Screening Tool.. 140. Weekly Infection Control Plan.. 141. Pandemic Influenza Planning Checklist.. 142. iv CLINICAL TOOLS and Forms for Long-Term Care 2015 HCPro Contents Facility Summary Infection Worksheet .. 150. Preadmission Medicare Eligibility Worksheet .. 151. Medication Agreement.. 153. Medication Management form .. 155. Resident Assessment.. 156. Warfarin (Coumadin) Flow Sheet.. 157. Care Conference Attendance .. 158. CAPD Flow Sheet.. 159. Nursing Assistant Care Sheet .. 161. Nursing Assistant Plan of Care .. 163. Restorative Nursing Assistant Plan of Care .. 166. Restorative Audit of Nursing Staff Directly Responsible for Patient Care .. 169. Nursing Assistant Resident Care Documentation Worksheet.

6 171. Nursing Assistant Assignment Sheet .. 172. Nurse/CNA Communication Log.. 173. Nursing Assistant Communication Log .. 174. Dehydration Checklist.. 176. Dehydration Risk Assessment.. 177. Bedside Fluid Intake and Output Worksheet .. 179. Dehydration Risk Appraisal Checklist.. 180. Three-Day Calorie/Protein Summary .. 181. Documentation of Meal Intake.. 182. Numeric Pain Scale 1.. 183. Numeric Pain Scale 2.. 184. Mood Pain Relief Scale .. 185. Nurse Pain Assessment.. 186. Pain Assessment .. 187. Pain Screen.. 189. Severity Relief Scale.. 191. Verbal Pain Scales.. 192. Verbal Pain Scales 2 .. 193. Verbal Pain Scales 3 .. 194. Verbal Pain Scales 4 .. 195. Verbal Pain Scales 5 .. 196. Systems Check for Physician Calls.. 197. Systems Check Prior to Physician Call.. 199. Restraints: Side Rail Utilization Assessment .. 200. 2015 HCPro CLINICAL TOOLS and Forms for Long-Term Care v Contents New Admission Restraint Assessment.

7 203. Resident Safety Flow Sheet 1.. 204. Resident Safety Flow Sheet 2.. 205. Is the Intervention a Physical Restraint?.. 206. Resident Restraint Record.. 208. Skin Monitoring: Comprehensive CNA Shower Review .. 209. Impaired Skin Integrity Audit.. 210. Licensed Nurse Weekly Skin Assessment .. 211. Pressure Ulcer Flow Sheet.. 212. Pressure Ulcer Assessment.. 213. Pressure Ulcers: Communication With Physician .. 215. Pressure Ulcer Record .. 219. QA&A Pressure Ulcer Audit .. 220. SBAR: Skin Care Instructions.. 229. Skin Breakdown Guide.. 231. Skin Monitoring: Daily Skin Check.. 232. Skin Observation Protocol.. 233. Skin Tear Risk Assessment.. 235. Skin Tear Audit.. 236. Tissue Tolerance and Individualized Turning Schedule .. 237. Care Plan Approaches for Pressure Ulcer Prevention .. 241. Behavior Observation Scale .. 243. Behavioral Pain Assessment for Cognitively Impaired Adults .. 244. Behavioral Scale for Cognitively Impaired Adults.

8 245. Brink/Yesavage Geriatric Depression Scale (Short form ) .. 247. Social Adjustment Rating Scale.. 248. Suicide Precautions Audit.. 250. Monthly Vital Sign Record.. 251. Vital Sign Flow Record.. 252. Weight Record .. 253. Elopement Patterning Tool.. 254. Resident Safety Flow Sheet 1 (Wandering).. 256. Resident Safety Flow Sheet 2 (Wandering).. 257. Elopement Risk Assessment.. 258. Long-Term Care and Other Residential Facilities .. 259. vi CLINICAL TOOLS and Forms for Long-Term Care 2015 HCPro Contents Documentation .. 261. Master Discharge List.. 263. Notice of Discharge/Transfer .. 264. Delegation Assignment.. 267. Assessment for Safe Resident Handling and Movement .. 268. Daily Rounds Worksheet.. 271. Daily Temperature Log Medication Refrigeration.. 273. Daily Temperature Log Specimen Refrigerator.. 275. Nursing Assistant Cleaning Schedule.. 277. Nursing: Direct Care & Environment.. 281. Systems Investigative Audit.

9 283. Audit.. 286. Bomb Threat Checklist .. 288. Call Signal Checklist .. 290. Fire Drill Schedule.. 291. Generator Checklist.. 292. Generator Log.. 294. Grievance/Complaint Follow-Up Tool .. 295. Grievance/Complaint Log .. 296. Grievance/Complaint Report .. 297. Incident, Accident, Unusual Occurrence Monitoring Log.. 299. Laundry Equipment Log.. 300. Life Safety Code Survey Checklist .. 306. Master Index of Admissions .. 310. Master Index of Admissions and Discharges.. 311. Master Index of Discharges.. 312. Monthly Dietary Preventive Maintenance Log .. 313. Monthly Exterior Maintenance Checklist .. 315. Monthly Life Safety and Preventive Maintenance Checklist .. 317. QA&A Audit.. 318. Dietary Infection Control Checklist.. 321. Monthly Beauty Shop Infection Control/Sanitation Log .. 325. Water Temperature Log .. 327. Meal Rounds Dining Room.. 330. Certificate of Achievement form (Restorative Nursing).

10 334. Certificate of Attendance .. 335. Certificate of Achievement form (Restorative Nursing) .. 336. 2015 HCPro CLINICAL TOOLS and Forms for Long-Term Care vii Contents Daily AED & Crash Cart Checklist.. 337. Code Blue Event Debriefing/Critique.. 339. Code Blue Documentation.. 341. Suggested Crash Cart Supply List.. 342. Cardiopulmonary Resuscitation Report.. 344. Employee Physical form .. 349. Employee Incident Report.. 351. General Employee Orientation Inventory .. 352. Sample Exit Interview Questions .. 364. Tuberculin and Immunization Record .. 365. Monthly Facility Infection Control Report .. 366. Individual Education Record .. 367. Record of In-Service Training.. 368. In-Service Record Sheet .. 369. In-Service Sign-In Sheet.. 370. Mechanical Lift Competency Check .. 372. Sit to Stand Lift Competency Check .. 373. Visiting Pet Registration .. 374. Daily Nurses' Notes.. 375. Intensive Monitoring Log.