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a divisionof B
LR
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.
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.
This book contains 100 of the most commonly utilized forms in long-term care facilities, including:
• Clinical assessment forms• Survey readiness assessments• Documentation forms• MDS tools• Regulatory forms• Accountability reports• Quality Assessment and Performance Improvement (QAPI) forms
10
0 Essential Form
s for Long-Term C
are
Carol Marshall, MAKate Brewer, PT, MBA, GCS, RAC-CT
Julie Ann Kemman, BBAHeather Stewart, RHIT
Marshall B
rewer K
emm
an Stew
art
100 Essential Forms
for Long-Term Care
Carol Marshall, MAKate Brewer, PT, MBA, GCS, RAC-CT
Julie Ann Kemman, BBAHeather 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, AuthorKate Brewer, PT, MBA, GCS, RAC-CT, AuthorHeather Stewart, RHIT, AuthorJulie Ann Kemman, BBA, AuthorOlivia MacDonald, Managing EditorAdrienne Trivers, Product ManagerErin Callahan, Senior Director, ProductElizabeth Petersen, Vice PresidentMatt Sharpe, Production SupervisorVincent Skyers, Design ManagerVicki McMahan, Sr. Graphic DesignerJason Gregory, Layout/Graphic DesignKelly 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:
HCPro75 Sylvan Street, Suite A-101Danvers, MA 01923Telephone: 800-650-6787 or 781-639-1872Fax: 800-639-8511E-mail: [email protected]
Visit HCPro online at: www.hcpro.com and www.hcmarketplace.com
©2014 HCPro iii
Contents
About the Authors ....................................................................................viiSection 1: Audit Forms ................................................................................ 1Form 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
100 Essential Forms for Long-Term Care
iv ©2014 HCPro
Section 2: Documentation Forms .............................................................. 81Form 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 ........................................................... 165Guidelines 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
Contents
©2014 HCPro v
Section 4: Regulatory Forms ................................................................... 183Form 4.1: Gantt chart for regulatory planning .............................................................................185
Form 4.2: Standing meeting/committee guidelines ......................................................................188
Form 4.3: Root cause analysis worksheet ....................................................................................192
Form 4.4: State department of health survey preparation .............................................................195
Form 4.5: Frequently used ICD-9 codes in LTC: Mapping guide to ICD-10 .....................................197
Form 4.6: Transition to ICD-10 guide ..........................................................................................200
Form 4.7: ICD-10 preparation survey: Knowledge base ................................................................202
Form 4.8: Preparation for ICD-10: Self-evaluation for coders ........................................................204
Section 5: Performance Improvement Forms ........................................... 207QAPI forms ...............................................................................................................................209
Form 5.1: QAPI form ................................................................................................................. 210
Form 5.2: QAPI form: Pain management sample ......................................................................... 211
Form 5.3: QAPI form: Fall reduction sample ...............................................................................213
Form 5.4: QAPI form: Transfers to hospital sample ......................................................................215
Form 5.5: QAPI form: Psychoactive drug use monitoring sample ..................................................217
Form 5.6: QAPI form: Restraint reduction sample ........................................................................219
Form 5.7: QAPI form: Infection control and surveillance sample ..................................................220
Form 5.8: Pain management data collection form for PIP .............................................................222
Form 5.9: Interdisciplinary action committee (IAC) form .............................................................224
Form 5.10: Performance improvement project assignment tool .....................................................225
Section 6: Credentialing and Communication Forms ............................... 227Credentialing and privileging physicians and nurse practitioners: Procedures ...............................228
Form 6.1: Request for application intake form: General appointment ...........................................231
Form 6.2: Request for application intake form: Temporary appointment .......................................232
Form 6.3: Credentialing cover letter: Initial appointment .............................................................233
Form 6.4: Credentialing cover letter: Reappointment ...................................................................234
Form 6.5: Credentialing checklist: Initial appointment .................................................................235
Form 6.6: Credentialing checklist: Temporary appointment ..........................................................236
Form 6.7: Credentialing checklist: Reappointment .......................................................................237
Form 6.8: Licensure verification .................................................................................................238
Form 6.9: Credentialing phone verification form .........................................................................239
Form 6.10: Reappointment evaluation ........................................................................................240
Form 6.11: Temporary appointment form ....................................................................................242
Form 6.12: Professional exchange report ....................................................................................243
Form 6.13: Therapy and nursing communication form ................................................................245
100 Essential Forms for Long-Term Care
vi ©2014 HCPro
Section 7: Additional Documentation Request Forms .............................. 247Form 7.1: Additional documentation request (ADR) ....................................................................249
Form 7.2: Internal ADR tracking log ...........................................................................................251
Form 7.3: ADR appeal documentation checklist ..........................................................................253
Form 7.4: Part A denial tracking/appeal request log ....................................................................255
Form 7.5: Part B denial tracking/appeal request log ....................................................................258
Form 7.6: RAC/ZPIC/CERT audit tracking log .............................................................................261
Forms and tools can be accessed with the purchase of this product.
©2014 HCPro vii
ABOUT THE AUTHORS
Carol Marshall, MA, is a risk management specialist based in Fort Worth, Texas. For the past 18
years, she has trained managers and staff members in long-term care facilities across the country
about the benefits of exceptional customer service and risk management. She has offered
training programs at numerous state conferences, professional groups, and individual facilities.
Kate Brewer, PT, MBA, GCS, RAC-CT, is the president of Greenfield Rehabilitation Agency, a
company that provides physical, occupational, and speech-language pathology services in skilled
nursing facilities. Having spent over 15 years in long-term care, Brewer has extensive experience
in various processes and approaches to regulatory compliance from a Medicare and survey
perspective. Her areas of expertise include therapy documentation and compliance with Medicare
regulations, coordinating the MDS process to ensure optimal reimbursement and compliance,
and bridging the gap between the different professions that work together in long-term care.
Julie Ann Kemman, BBA, president of Health Care Professional Consulting Services, Inc.,
has over 20 years of experience working within the long-term care community. She holds a
bachelor’s degree in business administration from Northwood University. Julie has held multiple
corporate regional positions for a large nursing home chain and has been the cornerstone in staff
training, compliance monitoring, and management. Health Care Professional Consulting Services,
Incorporated, was started in July 2005 and provides skilled nursing organizations, assisted living,
home health agencies, and outpatient rehabilitation providers a variety of consulting services,
including billing, collections, training, policy writing, and software implementation.
Heather Stewart, RHIT, is a knowledgeable health information management consultant
with more than 16 years of experience in the long-term care industry. Stewart has an
extensive background in healthcare compliance, medical coding, and electronic health record
implementation.
©2014 HCPro 1
S e c t i o n 1
Audit Forms
1. Quality auditing form: Nursing documentation
2. Triple-check form
3. Resident care status survey tool
4. Preadmission screen
5. Dysphagia audit
6. Psychotropic audit
7. Urinary catheter reminder order
8. Urinary catheter checklist
9. Medical staff documentation audit
10. Safety rounds audit
11. Kitchen/dietary audit
12. Discharge record documentation audit
13. Skilled nursing facility self-audit
14. MDS chart audit tool
15. Compliance audit worksheet
16. CAA completion audit tool
17. Quarterly Medicare compliance guide
18. Policy and procedure: Medicare Part A triple-check process
19. Policy and procedure: Medicare Part B triple-check process
20. Assessment itinerary announced site visit
100 Essential Forms for Long-Term Care
2 ©2014 HCPro
21. Sample checklist for unannounced audit
22. Resident review worksheet
23. Quality of life assessment resident interview
24. Quality of life assessment family interview
25. Quality of life assessment group interview
26. Statement of deficencies and plan of correction
©2014 HCPro 3
Form 1.1
Quality auditing form: Nursing documentation
Purpose: To perform a quick audit to ensure compliance with nursing documentation standards for
skilled care.
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.
100 Essential Forms for Long-Term Care
4 ©2014 HCPro
Form 1.1
Quality auditing form: Nursing documentation
Date of audit: ___________ Auditor (signature/title): ____________________
Resident name: __________________________________ Room/Unit #: ____________
Admissions date: _______________________________________________________________
Indicators/areas of focus Yes No Comments
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. re-cords (MAR) signed.
5. Immunizations document-ed properly/done.
6. Weights charted monthly per order.
7. Does the documentation demonstrate skilled ob-servation and monitoring.
• Assessment
• Progress notes
• Other
Section 1 Audit Forms
©2014 HCPro 5
Form 1.1
Quality auditing form: Nursing documentation
Indicators/areas of focus Yes No Comments
8. Is care plan accurate and up to date? Measurable goals? Relevant problems? Specific problems or potential problems identified and planned interventions identified? Indication of daily or more frequent monitoring of vital signs, lung sounds, bowel sounds, skin condition, nutritional status, hydration, mental status, and mobility as it relates to instability or possible changes in condition to help identify if changes in nursing care are indicated.
9. Proper evaluation dates and follow-ups.
10. Proper signatures on care plan.
11. Care planning reflects MDS and other assess-ments.
12. Evidence of teaching, training, and outcomes clearly noted.
Special Needs
Thickened liquids/dysphagia
13. Proper notation by the door (if permitted by state); proper protocol followed.
14. Water at bedside.
Fall risks
15. Fall risk evident.
16. Care planned.
100 Essential Forms for Long-Term Care
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Form 1.1
Quality auditing form: Nursing documentation
Indicators/areas of focus Yes No Comments
Wounds
17. Wound care protocol followed/proper forms completed.
18. Care planned.
Pain management
19. Protocol/forms followed (assessment and out-come).
20. Care planned.
21. MAR completed.
22. Initial and ongoing pain assessments done.
Equipment in room
23. Respiratory, feeding pump equipment labeled/tagged.
24. IVs dated, labeled.
25. Wound dressings, IV site dated and signed.
Resident appearance
26. Properly positioned. WC, bed.
27. Appears clean, appropri-ate dress.
28. Any complaints/con-cerns.
Section 1 Audit Forms
©2014 HCPro 7
Form 1.1
Quality auditing form: Nursing documentation
Other:
Area:
Comment:
Signature/title Date
8 ©2014 HCPro
Form 1.2
Triple-check form
Purpose: To perform a quick audit to ensure compliance with nursing documentation standards for
skilled care.
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, therapist, and business office staff and be filed in the
resident’s business file.
Section 1 Audit Forms
©2014 HCPro 9
Form 1.2
Triple-check form
Resident’s name: ___________________________________________________________
Reason for triple-check:
q Randomly selected q Multiple admissions in the same month
q ICD code falls in high utilization frequency q Interrupted stay
q New admission q Denial of payment q Short stay q Client left AMA q Off-cycle MDS
q Death in facility q Other: ______________
Instructions: Place a check mark under each date column when information is confirmed as accurate.
Compliance Standard Source Document Date 1: Date 2: Date 3: Date 4:
Beneficiary Data
Beneficiary’s name is correct
Government issued identification;
HETS file
Birthdate is correct Government issued identification;
HETS file
Sex is correct Government issued identification;
HETS file
Status correct
Payment status confirmed
Medical payment identification number confirmed
Secondary insurance is verified
Medicare number is correct and verified
Beneficiary’s identification number is accurate
Professional and Facility IdentifiersNPI number is correct
Facility number is correct
UB04 DataBill type is correct
Dates of service are correct
100 Essential Forms for Long-Term Care
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Form 1.2
Triple-check form
Compliance Standard Source Document Date 1: Date 2: Date 3: Date 4:
Most current admission date matches UB04 and record
Hospital stay dates match UB04 and record
HIPPS (MDS Section Z) codes match UB04
For Rehab RUG, therapy charges are correct
Significant change and all OMRAs are billed accurate-ly
ARDs corresponds to MDS and UB04
ARD falls within allowable billing time frame
ARD established within the observation window (upon opening assessment)
Number of days billed for each MDS is correct
Number of dates billed cor-responds to medical record
Pharmacy charges are for legend meds used during dates of service
Laboratory charges are for legend services and dates of services
Documentation supports medical necessity
MDS Sections G and O are supported in the record
MDS Sections G and O are supported in the record
Diagnoses are documented in the record
Diagnoses codes are appro-priately coded
Treatment diagnoses are present in the record
Section 1 Audit Forms
©2014 HCPro 11
Form 1.2
Triple-check form
Compliance Standard Source Document Date 1: Date 2: Date 3: Date 4:
Certifications and re-certifi-cations are accurate and in the record
Admission orders are signed and current
Plan of care is accurate and complete and documenta-tion supports administra-tion of designated care
Repeat admissions include discharge documentation from prior stay
Room charges and dates are the same
LOA dates and numbers of days are accurate
I certify that I have confirmed the accuracy of documentation reviewed as part of the triple-check.
______________________________________________Administrator Date: _____________
_________________________________________Business Office Manager Date: _____________
_____________________________________________ Rehab Director Date: _____________
___________________________________________MDS Coordinator Date: _____________
12 ©2014 HCPro
Form 1.3
Resident care status survey tool
Purpose: To help your facility prepare for surveys; to monitor resident care.
Directions: 1. Place a check mark in the appropriate column; be sure to note follow-up/comments. Make
comments in the provided space.
2. Using the questions listed at the bottom of the form, interview the resident about his/her
perceived quality of care.
3. After the form is complete, forward it to the director of nursing.
Should be completed by: An LPN or RN should complete this form.
Section 1 Audit Forms
©2014 HCPro 13
Form 1.3
Resident care status survey tool
Resident name: ____________________________ Room/Unit #: ___________________
Date: ________________________________________ Auditor: _______________________
Indicators/areas of focus Yes No Follow-up Comments/NA
A. Resident rooms
1. Over-bed tables, night stands, and dressers are clean and free of clutter.
2. Water is within reach, with swal-lowing precautions noted appropriately, if applicable.
3. Call light within reach/is working.
4. Closet clean and orderly:
a. No medications at bedside.
b. No treatment supplies on bed-side table.
5. Side rails are in prescribed position.
6. Floor is free and clear of any clutter or linens.
7. Appropriate signage is present if precau-tions or “Oxygen in use” sign is posted before entering resident’s room (as applicable).
B. Tube Feedings
1. Pump, appliances, and supplies are clean.
100 Essential Forms for Long-Term Care
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Form 1.3
Resident care status survey tool
Indicators/areas of focus Yes No Follow-up Comments/NA
2. Type, rate, volume and duration of feeding is clearly identified and con-sistent with recom-mendations.
3. Resident is properly positioned per care plan.
4. Mouth care is evident; including teeth, gums and tongue.
C. Resident-specific care
1. 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.
7. Identification band is present if used per facility policy.
8. Assistive devices applied correctly. Within resident reach if indepen-dent. Splints or braces applied cor-rectly, if applicable.
9. Curtains/door are closed during per-sonal care.
10. Foley catheters are properly positioned, dated and labeled, and covered.
Section 1 Audit Forms
©2014 HCPro 15
Form 1.3
Resident care status survey tool
Indicators/areas of focus Yes No Follow-up Comments/NA
11. Is resident prop-erly positioned in wheelchair/bed.
12. Are IVs/dressings, other tubings dated and initialed.
D. Nutrition
1. Before meal, hands are washed.
2. Bibs are on for meals and removed after.
3. Resident is posi-tioned appropriate for meals/eating.
4. Appropriate music is playing during meals, in common areas, and in pa-tient rooms.
E. Staff1. All staff are wearing
name tags in the proper position.
2. Staff knock before entering rooms.
3. Staff speak to resi-dents in “custom-er-friendly” manner.
Interview questionsHave you attended activities today, or have you in the past? ______________
What kind? __________________________________________________________________
Are you encouraged to attend? _________________
Do you experience any barriers to attending activities?___________________________________
If you have any pain, has it been managed to your satisfaction? (May elaborate on this):
____________________________________________________________________________________________________________________________________________________________________________
Meal selection: Do you enjoy your meals generally? ______________
100 Essential Forms for Long-Term Care
16 ©2014 HCPro
Form 1.3
Resident care status survey tool
Do you receive what you like or order? __________________________________________________________________________________________________________________________________________
Are you offered snacks in the afternoon and evening? _______________________________________
Are you receiving your bathing to your satisfaction? _________________
Do you know your bathing schedule? ___________________
Do you know the name of your caregivers on most days?_____________________________
Do nursing staff respond to you in a timely manner?__________________
(Differentiate between nurses and CNAs)
Are nursing staff attentive to your needs? ____________________
Are medications on time?______________
Are nursing staff generally courteous and kind in their speaking tone/manner? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Elaborate on any area here:__________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________
Signature/title Date
©2014 HCPro 17
Form 1.4
Preadmission screen
Purpose: To ensure that the admission is able to be covered under Medicare.
Directions: 1. Complete this form prior to admission.
2. Place a check mark in the appropriate column.
3. This form may be monitored to meet your facility’s specific needs.
Should be completed by: A nurse manager or his/her designee should complete this form.
100 Essential Forms for Long-Term Care
18 ©2014 HCPro
Form 1.4
Preadmission screen
Resident name: __________________________________ Admission date: _____________________
Room/Unit #: _____________________________________
Yes No Comments
1. Admission assessments completed, signed by RN.
2. Fall risk completed. If at risk, care anal-ysis plan initiated.
3. Pressure ulcer risk is completed? If at risk, care plan initiated, pressure reliev-ing devices ordered?
4. Self-administration of medications form completed.
5. Bowel and bladder assessment completed.
6. Immunizations documented?
7. Learning/teaching assessment completed.
8. Medicare certification initiated.
9. Interim care plan initiated.
10. Weight/height documented.
11. If diabetic, chart marked as such.
12. If resident has do-not-resuscitate order, chart marked as such.
13. If resident has dysphagia, chart marked as such.
14. Side-rail assessment completed.
Comments:
Signature/title: Date:
©2014 HCPro 19
Form 1.5
Dysphagia audit
Purpose: To provide a focused audit for residents with swallowing problems, which tends to be
problematic in long-term care facilities.
Directions: 1. This form should be completed weekly for any resident on thickened liquids/NPO.
2. Place a check mark in the appropriate column and provide comments as needed.
Should be completed by: Any staff nurse can complete this form.
100 Essential Forms for Long-Term Care
20 ©2014 HCPro
Form 1.5
Dysphagia audit
Resident’s name: ______________________________________ Room/Unit #: _________
Auditor: ______________________________________________ Date: _________________
Yes No Comments
1. Water pitcher at bedside?
2. Medication administration record proper administration (whole, crushed, what type of liquid)?
3. Care plan reflects dysphagia diagnosis and precautions needed?
4. Is facility-specific designation present (wristband, identification communica-tion for caregivers to be aware of
precautions)?
5. If recommendations for safety with food and liquids prescribed by SLP, informa-tion is present and accessible for care-givers to ensure patient safety?
Note: All deficiencies are to be corrected and reported to the nurse manager. Form should be forwarded to director of nursing.
Comments:
Signature/title Date
©2014 HCPro 21
Form 1.6
Psychotropic audit
Purpose: To provide a focused audit of psychotropic drug use, ensuring that regulations are met and
quality care is provided.
Directions: 1. This form should be completed for every resident taking a psychotropic medication, long-
acting benzodiazepines, anxiolytics, and or hypnotics.
2. Place a check mark in the appropriate column and provide comments as needed.
3. Identify the residents who should be audited by reviewing Section N0140 of the MDS.
Should be completed by: Any staff nurse can complete this form.
100 Essential Forms for Long-Term Care
22 ©2014 HCPro
Form 1.6
Psychotropic audit
Resident name: _____________________________________________ Room/Unit #: _______
Auditor: ___________________________________________________ Date: ______________
Specific medication: _____________________________________________________________
Yes No Comments
1. Is a medical diagnosis present to support the use of the medications?
2. Do the care plan and assessments in-clude therapeutic goals and monitoring plan for medication?
3. Is there an assessment for gradual dose reduction unless clinically contraindicated?
4. Is there documented observation of the resident’s function over time and vari-ous shifts?
5. Is it correctly coded on the MDS?
6. Is the impact of the medication on the resident’s function documented? This may include side effects which include but are not limited to:
a. Unsteady gait
b. Tardives dyskinesia
c. Parkinson-like symptoms
d. Frequent falls
e. Refusing to eat
f. Difficulty swallowing
g. Dry mouth
h. Depression
i. Suicidal ideations
j. Social isolations
k. Blurred vision
l. Diarrhea
m. Fatigue
n. Insomnia
o. Loss of appetite
p. Weight loss
Section 1 Audit Forms
©2014 HCPro 23
Form 1.6
Psychotropic audit
Yes No Comments
q. Muscle cramps
r. Nausea/vomiting
s. Behavioral changes
7. If on a hypnotic, are sleep enhancing measures in place, including:a. Limiting caffeineb. Decreasing noise as ablec. Altering lighting levelsd. Consistent bedtime routinee. Maximizing daytime activity and
social activities
8. If on antipsychotic:a. Behaviors are observed and docu-
mentedb. Staff interactions to behaviors are
documented in response to behaviors
Signature/title Date
75 Sylvan Street | Suite A-101Danvers, MA 01923www.hcmarketplace.com
EFLTC100
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.
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.
This book contains 100 of the most commonly utilized forms in long-term care fa-cilities, including:
• Clinical assessment forms• Survey readiness assessments• Documentation forms• MDS tools• Regulatory forms• Accountability reports• Quality Assessment and Performance Improvement (QAPI) forms
Carol Marshall, MAKate Brewer, PT, MBA, GCS, RAC-CT
Julie Ann Kemman, BBAHeather Stewart, RHIT
26551_100 Essential Forms_spiral.indd 2 10/10/14 2:53 PM