FACE SHEET COMPLETE AND ACCURATE
CONSENT TO TREAT - SIGNED
CONSENTS - PSYCHOACTIVE MEDS AND DEVICES
FACILITY HISTORY AND PHYSICAL
HOSPITAL DISCHARGE SUMMARY
DIAGNOSES AND PROBLEM LIST
HOSPITAL DISCHARGE ORDERS
PHYSICIAN'S ORDERS ACCURATELY TRANSCRIBED - MARS, TARS & IV's
STANDARD NURSING ASSESSMENTS
NURSING ASSESSMENT COMPLETED TIMELY
HIGH RISK ASSESSMENT CARE PLANS
SETTING EXPECTATIONS WITH RESIDENT AND FAMILY
IDT DOCUMENTED RISKS WITH RESIDENT AND FAMILY
ADMINISTRATOR MEETING WITH RESIDENT AND FAMILY
NURSING COC DOCUMENTATION
MEDICATION, MAR, TAR REMOVAL
PERSONAL BELONGINGS SECURED
SKIN/BODY ASSESSMENT COMPLETED WITHIN 2 HOURS OF ADMISSION
BRADEN / NORTON COMPLETED
WOUND PHOTOS UPON ADMISSION
PHYSICIAN'S ORDERS COINCIDE WITH ANATATOMICAL SITES
CARE PLANS PER WOUND SITE
AT RISK SKIN CARE PLAN UPON ADMISSION
FOLEY CATHETER USE NOTIFICATIONS
NEW WOUND COMMUNICATED TO MD, RESIDENT, RP
DAILY WOUND DOCUMENTATION
RD RECOMMENDATIONS CARRIED OUT
PAIN ASSESSMENT PRE AND POST TREATMENT
RECOMMENDED EQUIPMENT IN PLACE
IDT MEETING WITH RESIDENT AND/OR RP
NOTIFICATION OF WOUND STATUS
WOUND PHYSICIAN CONSULTATION
PHYSICIAN RECOMMENDATIONS CARRIED OUT
WOUND NURSE CONSULTANT RECOMMENDATIONS CARRIED OUT
WEEKLY SUMMARIES DEPICT CURRENT WOUND STATUS
NON COMPLIANCE NOTIFICATIONS AND CARE PLAN
SKIN/BODY ASSESSMENT COMPLETED WITHIN 2 HOURS OF ADMISSION
BRADEN / NORTON COMPLETED
WOUND PHOTOS UPON ADMISSION
PHYSICIAN'S ORDERS COINCIDE WITH ANATOMICAL SITES
CARE PLANS PER WOUND SITE
AT RISK SKIN CARE PLAN UPON ADMISSION
FOLEY CATHETER USE NOTIFICATIONS
NEW WOUND COMMUNICATED TO MD, RESIDENT, RP
RD RECOMMENDATIONS CARRIED OUT
PAIN ASSESSMENT PRE AND POST TREATMENT
RECOMMENDED EQUIPMENT IN PLACE
IDT MEETING WITH RESIDENT AND/OR RP
NOTIFICATION OF WOUND STATUS
WOUND PHYSICIAN CONSULTATION
PHYSICIAN RECOMMENDATIONS CARRIED OUT
WOUND NURSE CONSULTATION RECOMMENDATIONS CARRIED OUT
WEEKLY SUMMARIES DEPICT CURRENT WOUND STATUS
NON COMPLIANCE NOTIFICATION
RD ASSESSMENT FOR WEIGHT CHANGE
RD RECOMMENDATIONS CARRIED OUT
AT RISK CARE PLAN UPON ADMISSION
NURSING DOCUMENTATION REFLECTS INTAKE
COC NURSING DOCUMENTATION INITIATED
RESIDENT / RP NOTIFICATION
CARE CONFERENCE CONDUCTED
PHYSICIAN'S ORDERS CARRIED OUT
NON COMPLIANCE NOTIFICATIONS
POLST / ADVANCED DIRECTIVE REVIEWED AND FOLLOWED
WEEKLY SUMMARIES ACCURATELY REFLECT WEIGHT CHANGE
MD NOTIFICATION OF LABS AND DIAGNOSTICS
LICENSED NURSE AND CNA DOCUMENTATION CONSISTENT
PSYCHIATRY OR PSYCHOLOGY CONSULTATION
SPEECH THERAPY EVALUATION
NON COMPLIANCE ASSESSMENT
NURSING NOTES REFLECT NONCOMPLIANCE
WEEKLY SUMMARIES REFLECT NONCOMPLIANCE
CARE CONFERENCE CONDUCTED
ROUTINE BEHAVIOR MONITORING
ADMINISTRATOR DOCUMENTATION
SOCIAL SERVICE DOCUMENTATION
PSYCHIATRY / PSYCHOLOGY REFERRAL
CAPACITY STATEMENT CONSISTENT WITH POLST / PIC
CARE CONFERENCE CONDUCTED
NURSING NOTES REFLECT CARE TO ADDRESS CONCERNS
CARE PLAN AND FAMILY DYNAMICS
ADMINISTRATOR/AIT MEETING WITH RESIDENT AND/OR RP
DIRECTOR OF NURSING MEETING WITH RESIDENT AND/OR RP
ELOPEMENT RISK ASSESSMENT
WEEKLY SUMMARIES REFLECT BEHAVIOR
CARE CONFERENCE CONDUCTED
ADMINISTRATOR / SSD DOCUMENTATION
PSYCHIATRIC / PSYCHOLOGY REFERRAL
MD NOTIFICATION OF LAB RESULTS
NURSING DOCUMENTATION OF LAB RESULTS
INSULIN ADMINISTRATION AS ORDERED
ROTATION OF INJECTION SITES
WEEKLY SUMMARIES REFLECT INTAKE
DIABETIC NUTRITION CARE PLAN
DIABETIC RISK FACTORS DISCUSSED
DIAGNOSIS ON DIAGNOSIS LIST
PT/INR COMPLETED AS ORDERED
MD NOTIFICATION OF LAB RESULTS
ASSIGN
