Kathleen Martin, RN, MSN, MPA, LNHA
60 Essential
FormsFor Long-Term Care
Documentation
�60 Es s E n t i a l Fo r m s F o r lo n g-tE r m Ca r E Do C u m E n t a t i o n
Contents
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
Form 2.10: Pain assessment for those with communication barriers/dementia . . . . . . . . . . . . . . 63
Form 2.11: Pain management tracking form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Co n t E n t s
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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
Form 5.3: CQI and PI form: Fall reduction sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Form 5.4: CQI and PI form: Transfers to hospital sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Co n t E n t s
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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
Form 6.11: Temporary appointment form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
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 • Form 1.10: Kitchen/dietary audit
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Quality auditing form: DocumentationForm 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: This form should be completed by a nurse and returned to the director of nursing or facility administrator.
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Quality auditing form: DocumentationForm 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: DocumentationForm 1.1
Indicators/areas of focus CommentNoYes
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 reimbursementForm 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: An MDS coordinator or an RN familiar with the MDS.
�60 Es s E n t i a l Fo r m s F o r lo n g-tE r m Ca r E Do C u m E n t a t i o n
MDS auditing form: Documentation for reimbursement Form 1.2
Item/indicator Yes No Comment
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?
4. Other?
� 60 Es s E n t i a l Fo r m s F o r lo n g-tE r m Ca r E Do C u m E n t a t i o n
MDS auditing form: Documentation for reimbursementForm 1.2
Item/indicator Yes No Comment
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 toolForm 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: An LPN or RN should complete this form.
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Resident care status survey toolForm 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?
7. ID bracelet is intact/correct?
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Resident care status survey toolForm 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
friendly” manner.
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Resident care status survey toolForm 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:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________ ___________________________________ Signature/title Date
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New admission documentation auditForm 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: A nurse manager or his/her designee should complete this form.
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New admission documentation auditForm 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 #: _____________________________________
Source: Steven Missaggia, RNC, DN.
__________________________________________________ ___________________________________ Signature/title Date
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Dysphagia auditForm 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: Any staff nurse can complete this form.
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Dysphagia auditForm 1.5
Yes No Comments
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:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Source: Steven Missaggia, RNC, DN.
__________________________________________________ ___________________________________ Signature/title Date
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Psychotropic auditForm 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: Any staff nurse can complete this form.
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Psychotropic auditForm 1.6
Source: Steven Missaggia, RNC, DN.
Yes No Comments
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: __________________________________________________________________________
__________________________________________________ ___________________________________ Signature/title Date
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Nursing audit: Urinary catheter useForm 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: This may be assigned to any clinical staff member by the director of nursing.
20 60 Es s E n t i a l Fo r m s F o r lo n g-tE r m Ca r E Do C u m E n t a t i o n
Nursing audit: urinary catheter useForm 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:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Source: Steven Missaggia, RNC, DN.
__________________________________________________ ___________________________________ Signature/title Date
2160 Es s E n t i a l Fo r m s F o r lo n g-tE r m Ca r E Do C u m E n t a t i o n
Medical staff documentation auditForm 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: This may be assigned to any clinical staff member by the director of nursing.
22 60 Es s E n t i a l Fo r m s F o r lo n g-tE r m Ca r E Do C u m E n t a t i o n
Medical staff documentation auditForm 1.8
Resident: __________________________________________________________________________________
Physician name: ____________________________________________________________________________
Auditor: _________________________________________________ Date: ____________________________
Plan of correction:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Yes No Comments
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.)?
Source: Steven Missaggia, RNC, DN.
__________________________________________________ ___________________________________ Signature/title Date
2�60 Es s E n t i a l Fo r m s F o r lo n g-tE r m Ca r E Do C u m E n t a t i o n
Safety rounds auditForm 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.
2� 60 Es s E n t i a l Fo r m s F o r lo n g-tE r m Ca r E Do C u m E n t a t i o n
Safety rounds auditForm 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?
2�60 Es s E n t i a l Fo r m s F o r lo n g-tE r m Ca r E Do C u m E n t a t i o n
Safety rounds auditForm 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?
__________________________________________________ ___________________________________ Signature/title Date
2� 60 Es s E n t i a l Fo r m s F o r lo n g-tE r m Ca r E Do C u m E n t a t i o n
Kitchen/dietary auditForm 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: This form should be completed by the food service director/manager or one of his/her designees.
2�60 Es s E n t i a l Fo r m s F o r lo n g-tE r m Ca r E Do C u m E n t a t i o n
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,
correct water temperature, immersion time?
2� 60 Es s E n t i a l Fo r m s F o r lo n g-tE r m Ca r E Do C u m E n t a t i o n
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 auditForm 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:
__________________________________________________ ___________________________________ Signature/title Date
Name
Title
Organization
Street Address
City State ZIP
Telephone Fax
E-mail Address
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