100 Essential Forms for Long-Term Care -...

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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



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

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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


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


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.


4 ©2014 HCPro

Form 1.1


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



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.


6 ©2014 HCPro

Form 1.1



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.


©2014 HCPro 7

Form 1.1


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.


©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


10 ©2014 HCPro

Form 1.2

Triple-check form


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


©2014 HCPro 11

Form 1.2

Triple-check form


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.


©2014 HCPro 13

Form 1.3


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.


14 ©2014 HCPro

Form 1.3



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.


©2014 HCPro 15

Form 1.3



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? ______________


16 ©2014 HCPro

Form 1.3


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:__________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________


©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.


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.


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:


©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.


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


©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


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



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