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
NEW ORDERS FOR LAB DRAW CARRIED OUT
ANTICOAGULANT RISK NOTIFICATION
PHYSICIAN ORDERS CARRIED OUT
POST FALL RISK ASSESSMENT
POST FALL PAIN ASSESSMENT
POST FALL REHAB ASSESSMENT
POST FALL RESTRAINT ASSESSMENT
WEEKLY SUMMARY REFLECTIVE OF FALL
IDT MEETING WITH ROOT CAUSE ANALYSIS
NURSING AND SSD BEHAVIOR DOCUMENTATION
MEDICATION ORDER COMPLETE
VALID DIAGNOSIS, INDICATION AND TARGET BEHAVIOR
CARE PLANS INCLUDE TARGET BEHAVIORS
MAR CONSISTENT WITH CURRENT MD ORDER
MAR REFLECT CURRENT BEHAVIOR AND SIDE EFFECT MONITORING
IDT DISCUSSION OF RISK AND BENEFITS
WEEKLY SUMMARIES REFLECT BEHAVIOR
MONTHLY BEHAVIOR SUMMARIES
PHYSICIAN'S PROGRESS NOTES
COMPLETE LICENSE NURSE COC DOCUMENTATION
PHYSICIAN'S ORDERS CARRIED OUT
COC COMMUNICATED IN 24 HOUR REPORT
DIAGNOSTIC ORDERS COMPLETED
DIAGNOSTIC RESULTS REPORTED TO MD
WEEKLY SUMMARY REFLECT THE COC
ANCILLARY DEPARTMENT REFERRALS
ACUTE CARE HOSPITAL ADMISSION
PHYSICIAN DOCUMENTATION OF TERMINAL DIAGNOSIS
ADVANCE DIRECTIVE, POLST OR PIC ON FILE
SOCIAL WORKER DOCUMENTATION
DOCUMENTATION OF COMMUNICATION BETWEEN SNF AND HOSPICE
FACILITY CARE PLANS CONSISTENT WITH HOSPICE CARE PLANS
COLLABORATION BETWEEN FACILITY AND HOSPICE
DOCUMENTATION AND ASSESSMENT PRIOR TO TRANSFER
ADVANCED DIRECTIVE FOLLOWED
ORDER TO TRANSFER TO THE ACUTE CARE HOSPITAL
INTER-FACILITY TRANSFER FORM COMPLETE
SNF NURSE GAVE REPORT TO ER
TIMELY MD/RP NOTIFICATIONS
FOLLOW UP CALL TO ACUTE CARE HOSPITAL
INVENTORY COMPLETE AND BELONGINGS SECURED
MEDICATIONS, MARS AND TARS REMOVED
MEDICAL RECORD REMOVED/DISCHARGED FROM EMR
PACEMAKER DATE OF IMPLANTATION
CARDIOLOGIST CONTACT INFORMATION
DIALYSIS ACCESS SITE DOCUMENTATION
NURSING AND DIETARY COORDINATION
EMOTIONAL WELL BEING ASSESSMENT
FLUID STATUS DOCUMENTATION
BLOOD PRESSURE NOTIFICATION
ACCESS SITE/GRAFT SITE DOCUMENTATION
BEHAVIORAL CHANGE DOCUMENTATION
NEPHROLOGIST CONTACT INFORMATION
TRANSPORTATION INFORMATION
DIALYSIS COMMUNICATION FORMS
DIALYSIS UNIT COMMUNICATION ASSESSMENT
DIALYSIS UNIT COMMUNICATION ASSESSMENT
DIALYSIS COMMUNICATION ASSESSMENT
POST DIALYSIS COMMUNICATION
QUARTERLY IDT DOCUMENTATION
FACILITY HISTORY AND PHYSICAL
BOWEL AND BLADDER ASSESSMENTS
DAILY NURSING DOCUMENTATION
SOCIAL SERVICE CARE PLANS
SOCIAL SERVICE PROGRESS NOTES
RECERTIFICATION FORM COMPLETE
DAILY SKILLED DOCUMENTATION
CERTIFICATION FORM COMPLETE
RESIDENT MEDICAL CONDITION
SMOKING EVALUATION COMPLETE
FLUCTUATING ATTENTION SPAN
SMOKING MATERIALS STORAGE
ASSIGN
