Essential Forms. For Long-Term Care Documentation. Kathleen Martin, RN, MSN, MPA, LNHA

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Kathleen Martin, RN, MSN, MPA, LNHA

60

Essential

Forms

For Long-Term Care

Documentation

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C

o n t e n t s

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

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Co n t E n t s

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

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Co n t E n t s

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

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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

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Quality auditing form: Documentation

Form 1.1

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:

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Quality auditing form: Documentation

Form 1.1

Item/indicator Yes No Comment

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?

Date of audit: ___________ Auditor (signature/title): ____________________

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

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Quality auditing form: Documentation

Form 1.1

Indicators/areas of focus Yes No Comment

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?

Other:

Area: Comment: __________________________________________________ ___________________________________ Signature/title Date

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MDS auditing form: Documentation for reimbursement

Form 1.2

Purpose:

To audit key areas of the MDS for accurate documentation, ensuring proper reimbursement and compliance with Medicare regulations and guidelines.

Directions:

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 necessary.

Should be completed by:

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MDS auditing form: Documentation for reimbursement

Form 1.2

Medical record number: _________________________ Resident name: _________________________

Admissions date: ___________________ Discharge date: ________________________

UB-92 bill:

1. 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?

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MDS auditing form: Documentation for reimbursement

Form 1.2

17. 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:

_____________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

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Resident care status survey tool

Form 1.3

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. 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:

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Resident care status survey tool

Form 1.3

Indicators/areas of focus Yes No Follow-up/action Comments/NA

Resident name: __________________________________ Room/Unit #: ________________________________ Date: __________________________________________ Auditor: ____________________________________

A. Resident rooms

1. 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 feedings

1. 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 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?

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Resident care status survey tool

Form 1.3

Indicators/areas of focus Yes No Follow-up/action Comments/NA

Interview questions

Have 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? ______________

8. Protective/assistive devices applied correctly. 9. Curtains are closed during personal care. 10. Foley catheters are properly positioned, dated

and labeled, and covered.

11. Is resident properly positioned in wheel chair/ 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 positioned appropriate for meals/

eating.

4. Appropriate music is playing during meals.

E. Staff

1. All staff are wearing ID tags. 2. Staff knock before entering rooms. 3. Staff speak to residents in “customer

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Resident care status survey tool

Form 1.3

Do you receive what you like or order? ___________________________________________________________ ___________________________________________________________________________________________ ________________________________

___________________________________________________________________________________________ Are you offered snacks in the afternoon and evening? ________________________________________

Are you receiving your showers to your satisfaction? _________________ Do you know your shower 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:

___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ __________________________________________________ ___________________________________

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New admission documentation audit

Form 1.4

Purpose:

To ensure that all of required information is in newly admitted residents’ records.

Directions:

1. Complete this form for all new residents within 24 hours of admission (or as per facility policy). 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:

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New admission documentation audit

Form 1.4

Yes No Comments

1. Admission assessments completed, signed by RN?

2. Fall risk completed. If at risk, care analysis plan initiated?

3. Pressure ulcer risk is completed? If at risk, care plan initiated, pressure relieving devices ordered

4. Self administration of medications form completed?

5. Bowel and bladder assessment complete? 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 dyspahgia, chart marked as such? 14. Side-rail assessment completed?

Comments:

___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Resident name: __________________________________ Admission date: _____________________

Room/Unit #: _____________________________________

__________________________________________________ ___________________________________

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Dysphagia audit

Form 1.5

Purpose:

To provide a focused audit of dysphagia, 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:

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Dysphagia audit

Form 1.5

1. Water pitcher at bedside?

2. Medication administration record reflects daily temperature?

3. Care plan reflects dysphagia? 4. Proper ID band on resident?

Resident’s name: _________________________________________________ Room/Unit #: ________________ Auditor: ________________________________________________________ Date: ______________________

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

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Psychotropic audit

Form 1.6

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. 2. Place a check mark in the appropriate column and provide comments as needed.

Should be completed by:

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Psychotropic audit

Form 1.6

1. Psychiatry consultation on chart?

2. Consultation reflects psychiatric diagnosis for medication?

3. Care plan reflects nondrug interventions for management by all disciplines? 4. Fall risk is reflected in care plan?

5. Behavior note is present in the medical record by the 15th of the month?

6. Behavior note is inclusive of behaviors monitored on “behavior monitor log”? 7. Behavior monitor logs accurately account

for residents’ behavior and continued use of psychotropic medication?

8. If on PRN antianxiety, nondrug intervention form is in medication admin record? 9. Coded correctly on MDS?

Resident name: _________________________________________________ Room/Unit #: _______________ Auditor: ________________________________________________________ Date: _____________________ Specific medication: __________________________________________________________________________

__________________________________________________ ___________________________________

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Nursing audit: Urinary catheter use

Form 1.7

Purpose:

Regulatory agencies discourage the use of urinary catheters, as it is felt that residents should be toileted regularly and remain as independent as possible. Auditing catheter use helps ensure survey success and helps prevent associated infections.

Directions:

1. Complete the form for each resident, checking the appropriate box and adding comments as necessary. 2. Sign and date the form, then forward it to the person who instructed you to perform the audit.

Should be completed by:

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Nursing audit: urinary catheter use

Form 1.7

Yes No Comments/NA

1. Is urinary-bedside bag labeled and dated? 2. Is there evidence that the bag and set-up have

been changed as per procedure? 3. Is there evidence that the catheter care

is provided?

4. Is catheter tubing secured at a level below resident’s bladder?

5. Is tubing and drainage bag free from touching floor?

6. Is a dignity-bag cover in use by the 15th of the month?

7. Is there an MD order/diagnosis present? Reason for catheter use?

8. Is a measuring container present with name labeled on it?

Resident name: _________________________________________________ Room/Unit #: _______________ Auditor: ________________________________________________________ Date: _____________________

Plan of correction:

_______________________________________________________________________________

__________________________________________________ ___________________________________ Signature/title Date

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Medical staff documentation audit

Form 1.8

Purpose:

Physicians have to comply with several documentation standards and prescribed policies related to medical record compliance. It is advantageous to audit such records to ensure that the record is complete for general information purposes, to monitor the physicians, and to monitor credentialing and privileging procedures.

Directions:

1. Complete the form for each resident, placing a check in the appropriate box.

2. Sign and date the form, then forward it to the person who instructed you to perform the audit.

Should be completed by:

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Medical staff documentation audit

Form 1.8 Resident: __________________________________________________________________________________ Physician name: ____________________________________________________________________________ Auditor: _________________________________________________ Date: ____________________________

Plan of correction:

_______________________________________________________________________________

1. Written medical evaluation and summary of current medical diagnosis is complete? 2. Physician’s orders are available at time of

admission of resident (within 24 hours)? 3. An initial history and physical is done in a

timely manner (within 48 hours, including weekends)?

4. Required periodic visits (30 days) are done and reflected in the resident’s medical record (i.e., progress notes)?

5. Progress notes reflect admission? 6. Verbal or phone orders are dated and

countersigned within the required period? 7. All consults are countersigned by attending

phy-sician (pharmacy, podiatry, psychiatry, etc.)?

__________________________________________________ ___________________________________

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Safety rounds audit

Form 1.9

Purpose:

This form is designed to assist the nursing, housekeeping, and maintenance departments survey the facility’s environment for hazards and ensure that regulatory compliance guidelines are in place.

Directions:

For each item, place a check box in the appropriate column and add comments as necessary. When the form is complete, forward it to the director of nursing or other supervisor.

Should be completed by:

The facility administrator determines who should complete this form. Nursing management can also use this form regularly to survey their units.

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Safety rounds audit

Form 1.9

Area/indicator Yes/ No/ N/A Action/ satisfactory unsatisfactory comment

1. Items blocking fire exits? 2. Carts covered?

3. Carts/equipment on one side of halls/hall way clear?

4. Equipment properly tagged/dated/checked? 5. Walls in satisfactory to good condition

(indicate area)? 6. MSDS books on units?

7. Evidence of ice chests disinfected? 8. Suction machine in dining room(s) working, covered? Extension cord present? Gloves present?

9. Medical waste containers empty/ appropriate level?

10. Treatment carts locked?

Rooms/location

11. Access to bed area without clutter, etc.? 12. Floors dry, clean?

13. Emergency call bell/light working in bathroom?

14. Call light in working order? 15. Call bell in reach of resident? 16. Ceiling tiles in place? 17. Leaks in sinks, ceiling tiles? 18. Trash cans empty/appropriate level

(indicate area)? 19. TV working properly?

20. Staff performing proper body mechanics when observed?

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Safety rounds audit

Form 1.9

Area/indicator Yes/ No/ N/A Action/ satisfactory unsatisfactory comment

21. Equipment (oxygen, humidifier, tube feeding pumps, etc) in room labeled as per policy; clean?

22. Personal protective equipment used properly?

23. Isolation equipment provided outside isolation rooms?

24. Comfort of room (hot/cold)?

Kitchen

25. Hair nets used by all?

26. Gloves, aprons on personnel as appropriate?

__________________________________________________ ___________________________________

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Kitchen/dietary audit

Form 1.10

Purpose:

To periodically review the kitchen and dietary department for compliance with federal standards. This is purposely designed to be brief, addressing the critical areas of a typical kitchen survey.

Directions:

Place a check mark in the appropriate column. At the conclusion of the audit, develop a plan of correction, if necessary. Sign and date the form and deliver to the facility administrator.

Should be completed by:

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Kitchen/dietary audit

Form 1.10

Yes/OK No N/A Comments

Facility: _________________________________ Director: ________________________________________

Food Storage:

1. Are refrigerator and freezer shelves/floors clean, free of mold and debris, etc.?

2. Is the freezer temp 0°F or below/and refrigera-tor 41°F or below (2–3° variance is ok)? 3. Are refrigerated foods covered, dated, labeled,

and shelved to allow air circulation? 4. Is dry storage maintained in a manner to

prevent pest infestation?

Food preparation:

5. Are frozen raw meats and poultry thawed in refrigerator?

6. Are food contact surfaces and utensils cleaned to prevent cross contamination?

Sanitation:

7. Are hot foods maintained at 140°F or above at steam table?

8. Are cold foods maintained at 41°F or below when served?

9. Are food trays clean?

10. Are foods covered until served? Protected on transportation?

11. Employees wash hands?

12. Is dishwasher hot water wash 140°F and rinse cycle 180°F or chemical sanitation followed? 13. Manual dishwashing: three-compartment sink,

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Yes/OK No N/A Comments

Food temperature section

1. Hot food: (last tray on cart): ___________________ Temperature: _________________

Cold food: (last tray on cart): ___________________ Temperature: __________________

2. Hot food: (last tray on cart): ___________________ Temperature: _________________

Cold food: (last tray on cart): ___________________ Temperature: __________________

Kitchen/dietary audit

Form 1.10

14. Check under cabinets, stove, sink: all in order (no grease, storage, etc)? Is back-splash in good repair?

Dining:

15. Did meals arrive on time?

16. Protective garment placed on resident, hand washing observed for resident, properly seated?

17. All served at one table at once? 18. Is food intake monitored? Other:

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