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ASSIGN
ADMISSION

001

FACE SHEET COMPLETE AND ACCURATE

 
 
 
 
 
 
 
 
 
 
 
 

002

CAPACITY DETERMINED

 
 
 
 
 
 
 
 
 
 
 
 

003

CONSENT TO TREAT - SIGNED

 
 
 
 
 
 
 
 
 
 
 
 

004

RISK LETTERS SIGNED

 
 
 
 
 
 
 
 
 
 
 
 

005

CONSENTS - PSYCHOACTIVE MEDS AND DEVICES

 
 
 
 
 
 
 
 
 
 
 
 

006

POLST COMPLETE

 
 
 
 
 
 
 
 
 
 
 
 

007

PASRR

 
 
 
 
 
 
 
 
 
 
 
 

008

FACILITY HISTORY AND PHYSICAL

 
 
 
 
 
 
 
 
 
 
 
 

009

HOSPITAL DISCHARGE SUMMARY

 
 
 
 
 
 
 
 
 
 
 
 

010

DIAGNOSES AND PROBLEM LIST

 
 
 
 
 
 
 
 
 
 
 
 

011

HOSPITAL DISCHARGE ORDERS

 
 
 
 
 
 
 
 
 
 
 
 

012

PHYSICIAN'S ORDERS ACCURATELY TRANSCRIBED - MARS, TARS & IV's

 
 
 
 
 
 
 
 
 
 
 
 

013

STANDARD NURSING ASSESSMENTS

 
 
 
 
 
 
 
 
 
 
 
 

014

SKIN/BODY ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

015

NURSING ASSESSMENT COMPLETED TIMELY

 
 
 
 
 
 
 
 
 
 
 
 

016

NURSING ADMISSION NOTE

 
 
 
 
 
 
 
 
 
 
 
 

017

HIGH RISK ASSESSMENT CARE PLANS

 
 
 
 
 
 
 
 
 
 
 
 

018

SHORT TERM CARE PLANS

 
 
 
 
 
 
 
 
 
 
 
 

019

BASELINE CARE PLANS

 
 
 
 
 
 
 
 
 
 
 
 

020

SETTING EXPECTATIONS WITH RESIDENT AND FAMILY

 
 
 
 
 
 
 
 
 
 
 
 

021

IDT DOCUMENTED RISKS WITH RESIDENT AND FAMILY

 
 
 
 
 
 
 
 
 
 
 
 

022

ADMINISTRATOR MEETING WITH RESIDENT AND FAMILY

 
 
 
 
 
 
 
 
 
 
 
 
UNEXPECTED EXPIRATION

023

NURSING COC DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

024

COC NOTIFICATIONS

 
 
 
 
 
 
 
 
 
 
 
 

025

POLST / PIC FOLLOWED

 
 
 
 
 
 
 
 
 
 
 
 

026

MORTICIAN DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

027

TIMELY PHYSICIAN VISITS

 
 
 
 
 
 
 
 
 
 
 
 

028

MEDICATION, MAR, TAR REMOVAL

 
 
 
 
 
 
 
 
 
 
 
 

029

MEDICAL RECORD REMOVAL

 
 
 
 
 
 
 
 
 
 
 
 

030

INVENTORY RECONCILATION

 
 
 
 
 
 
 
 
 
 
 
 

031

PERSONAL BELONGINGS SECURED

 
 
 
 
 
 
 
 
 
 
 
 

032

DNS CHART REVIEW

 
 
 
 
 
 
 
 
 
 
 
 
PRESSURE ULCER

033

SKIN/BODY ASSESSMENT COMPLETED WITHIN 2 HOURS OF ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

034

BRADEN / NORTON COMPLETED

 
 
 
 
 
 
 
 
 
 
 
 

035

WOUND PHOTOS UPON ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

036

PHYSICIAN'S ORDERS COINCIDE WITH ANATATOMICAL SITES

 
 
 
 
 
 
 
 
 
 
 
 

037

CARE PLANS PER WOUND SITE

 
 
 
 
 
 
 
 
 
 
 
 

038

AT RISK SKIN CARE PLAN UPON ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

039

FOLEY CATHETER USE

 
 
 
 
 
 
 
 
 
 
 
 

040

FOLEY CATHETER CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

041

FOLEY CATHETER USE NOTIFICATIONS

 
 
 
 
 
 
 
 
 
 
 
 

042

NEW WOUND COMMUNICATED TO MD, RESIDENT, RP

 
 
 
 
 
 
 
 
 
 
 
 

043

NEW WOUND CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

044

DAILY WOUND DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

045

SKIN SHEET FOR EACH SITE

 
 
 
 
 
 
 
 
 
 
 
 

046

RD ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

047

RD RECOMMENDATIONS CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

048

PAIN ASSESSMENT PRE AND POST TREATMENT

 
 
 
 
 
 
 
 
 
 
 
 

049

RECOMMENDED EQUIPMENT IN PLACE

 
 
 
 
 
 
 
 
 
 
 
 

050

IDT MEETING WITH RESIDENT AND/OR RP

 
 
 
 
 
 
 
 
 
 
 
 

051

NOTIFICATION OF WOUND STATUS

 
 
 
 
 
 
 
 
 
 
 
 

052

WEEKLY IDT MEETING

 
 
 
 
 
 
 
 
 
 
 
 

053

WOUND PHYSICIAN CONSULTATION

 
 
 
 
 
 
 
 
 
 
 
 

054

PHYSICIAN PROGRESS NOTES

 
 
 
 
 
 
 
 
 
 
 
 

055

PHYSICIAN RECOMMENDATIONS CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

056

WOUND NURSE CONSULTATION

 
 
 
 
 
 
 
 
 
 
 
 

057

WOUND NURSE CONSULTANT RECOMMENDATIONS CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

058

WEEKLY SUMMARIES DEPICT CURRENT WOUND STATUS

 
 
 
 
 
 
 
 
 
 
 
 

059

NON COMPLIANCE NOTIFICATIONS AND CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

060

NON COMPLIANT EDUCATION

 
 
 
 
 
 
 
 
 
 
 
 
NON-PRESSURE ULCER

061

SKIN/BODY ASSESSMENT COMPLETED WITHIN 2 HOURS OF ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

062

BRADEN / NORTON COMPLETED

 
 
 
 
 
 
 
 
 
 
 
 

063

WOUND PHOTOS UPON ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

064

PHYSICIAN'S ORDERS COINCIDE WITH ANATOMICAL SITES

 
 
 
 
 
 
 
 
 
 
 
 

065

CARE PLANS PER WOUND SITE

 
 
 
 
 
 
 
 
 
 
 
 

066

AT RISK SKIN CARE PLAN UPON ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

067

FOLEY CATHETER USE

 
 
 
 
 
 
 
 
 
 
 
 

068

FOLEY CATHETER CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

069

FOLEY CATHETER USE NOTIFICATIONS

 
 
 
 
 
 
 
 
 
 
 
 

070

NEW WOUND COMMUNICATED TO MD, RESIDENT, RP

 
 
 
 
 
 
 
 
 
 
 
 

071

NEW WOUND CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

072

NON PRESSURE ULCER AUDIT

 
 
 
 
 
 
 
 
 
 
 
 

073

SKIN SHEET FOR EACH SITE

 
 
 
 
 
 
 
 
 
 
 
 

074

RD ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

075

RD RECOMMENDATIONS CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

076

PAIN ASSESSMENT PRE AND POST TREATMENT

 
 
 
 
 
 
 
 
 
 
 
 

077

RECOMMENDED EQUIPMENT IN PLACE

 
 
 
 
 
 
 
 
 
 
 
 

078

IDT MEETING WITH RESIDENT AND/OR RP

 
 
 
 
 
 
 
 
 
 
 
 

079

NOTIFICATION OF WOUND STATUS

 
 
 
 
 
 
 
 
 
 
 
 

080

WEEKLY IDT MEETING

 
 
 
 
 
 
 
 
 
 
 
 

081

WOUND PHYSICIAN CONSULTATION

 
 
 
 
 
 
 
 
 
 
 
 

082

PHYSICIAN RECOMMENDATIONS CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

083

WOUND NURSE CONSULTATION

 
 
 
 
 
 
 
 
 
 
 
 

084

WOUND NURSE CONSULTATION RECOMMENDATIONS CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

085

WEEKLY SUMMARIES DEPICT CURRENT WOUND STATUS

 
 
 
 
 
 
 
 
 
 
 
 

086

NON COMPLIANCE NOTIFICATION

 
 
 
 
 
 
 
 
 
 
 
 
WEIGHT CHANGE

087

NUTRITIONAL ASSESSMENTS

 
 
 
 
 
 
 
 
 
 
 
 

088

WEIGHT UPON ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

089

WEEKLY WEIGHTS X 4 WEEKS

 
 
 
 
 
 
 
 
 
 
 
 

090

RD ASSESSMENT FOR WEIGHT CHANGE

 
 
 
 
 
 
 
 
 
 
 
 

091

RD RECOMMENDATIONS CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

092

AT RISK CARE PLAN UPON ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

093

EPISODIC CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

094

NURSING DOCUMENTATION REFLECTS INTAKE

 
 
 
 
 
 
 
 
 
 
 
 

095

COC NURSING DOCUMENTATION INITIATED

 
 
 
 
 
 
 
 
 
 
 
 

096

MD NOTIFICATION

 
 
 
 
 
 
 
 
 
 
 
 

097

RESIDENT / RP NOTIFICATION

 
 
 
 
 
 
 
 
 
 
 
 

098

CARE CONFERENCE CONDUCTED

 
 
 
 
 
 
 
 
 
 
 
 

099

MD DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

100

WEEKLY IDT MEETING

 
 
 
 
 
 
 
 
 
 
 
 

101

RISK NOTIFICATION FORM

 
 
 
 
 
 
 
 
 
 
 
 

102

PHYSICIAN'S ORDERS CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

103

NON COMPLIANCE NOTIFICATIONS

 
 
 
 
 
 
 
 
 
 
 
 

104

POLST / ADVANCED DIRECTIVE REVIEWED AND FOLLOWED

 
 
 
 
 
 
 
 
 
 
 
 

105

WEEKLY SUMMARIES ACCURATELY REFLECT WEIGHT CHANGE

 
 
 
 
 
 
 
 
 
 
 
 

106

MD NOTIFICATION OF LABS AND DIAGNOSTICS

 
 
 
 
 
 
 
 
 
 
 
 

107

LICENSED NURSE AND CNA DOCUMENTATION CONSISTENT

 
 
 
 
 
 
 
 
 
 
 
 

108

PSYCHIATRY OR PSYCHOLOGY CONSULTATION

 
 
 
 
 
 
 
 
 
 
 
 

109

ORAL EXAM

 
 
 
 
 
 
 
 
 
 
 
 

110

SPEECH THERAPY EVALUATION

 
 
 
 
 
 
 
 
 
 
 
 

111

PAIN ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

112

MEDICATION REVIEW

 
 
 
 
 
 
 
 
 
 
 
 
NONCOMPLIANCE

113

NON COMPLIANCE ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

114

CARE PLANS

 
 
 
 
 
 
 
 
 
 
 
 

115

LIFESTYLE ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

116

NURSING NOTES REFLECT NONCOMPLIANCE

 
 
 
 
 
 
 
 
 
 
 
 

117

WEEKLY SUMMARIES REFLECT NONCOMPLIANCE

 
 
 
 
 
 
 
 
 
 
 
 

118

IDT DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

119

CARE CONFERENCE CONDUCTED

 
 
 
 
 
 
 
 
 
 
 
 

120

ROUTINE BEHAVIOR MONITORING

 
 
 
 
 
 
 
 
 
 
 
 

121

PHYSICIAN DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

122

ADMINISTRATOR DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

123

SOCIAL SERVICE DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

124

CNA DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

125

PSYCHIATRY / PSYCHOLOGY REFERRAL

 
 
 
 
 
 
 
 
 
 
 
 

126

OMBUDSMAN

 
 
 
 
 
 
 
 
 
 
 
 
DISSATISFIED CUSTOMER

127

CAPACITY DETERMINATION

 
 
 
 
 
 
 
 
 
 
 
 

128

CAPACITY STATEMENT CONSISTENT WITH POLST / PIC

 
 
 
 
 
 
 
 
 
 
 
 

129

FACE SHEET ACCURATE

 
 
 
 
 
 
 
 
 
 
 
 

130

CONSENT TO TREAT

 
 
 
 
 
 
 
 
 
 
 
 

131

ARBITRATION AGREEMENT

 
 
 
 
 
 
 
 
 
 
 
 

132

IDT MEETING

 
 
 
 
 
 
 
 
 
 
 
 

133

IDT/MD/OMBUDSMAN

 
 
 
 
 
 
 
 
 
 
 
 

134

CARE CONFERENCE CONDUCTED

 
 
 
 
 
 
 
 
 
 
 
 

135

NURSING NOTES REFLECT CARE TO ADDRESS CONCERNS

 
 
 
 
 
 
 
 
 
 
 
 

136

DISCHARGE PLAN OF CARE

 
 
 
 
 
 
 
 
 
 
 
 

137

CARE PLAN AND FAMILY DYNAMICS

 
 
 
 
 
 
 
 
 
 
 
 

138

SSD DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

139

PHYSICIAN DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

140

ACTIVITY DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

141

OMBUDSMAN INVOLVEMENT

 
 
 
 
 
 
 
 
 
 
 
 

142

ADMINISTRATOR/AIT MEETING WITH RESIDENT AND/OR RP

 
 
 
 
 
 
 
 
 
 
 
 

143

DIRECTOR OF NURSING MEETING WITH RESIDENT AND/OR RP

 
 
 
 
 
 
 
 
 
 
 
 

144

SERVICE RECOVERY

 
 
 
 
 
 
 
 
 
 
 
 
ELOPEMENT

145

ELOPEMENT RISK ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

146

CONSENT TO TREAT

 
 
 
 
 
 
 
 
 
 
 
 

147

CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

148

MONITORING WHEREABOUTS

 
 
 
 
 
 
 
 
 
 
 
 

149

WANDERGUARD SYSTEM

 
 
 
 
 
 
 
 
 
 
 
 

150

AMA DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

151

ELOPEMENT BRACELETS

 
 
 
 
 
 
 
 
 
 
 
 

152

WEEKLY SUMMARIES REFLECT BEHAVIOR

 
 
 
 
 
 
 
 
 
 
 
 

153

CARE CONFERENCE CONDUCTED

 
 
 
 
 
 
 
 
 
 
 
 

154

CNA DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

155

ADMINISTRATOR / SSD DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

156

ACTIVITY PLAN

 
 
 
 
 
 
 
 
 
 
 
 

157

DISCHARGE PLAN OF CARE

 
 
 
 
 
 
 
 
 
 
 
 

158

PHYSICIAN DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

159

PSYCHIATRIC / PSYCHOLOGY REFERRAL

 
 
 
 
 
 
 
 
 
 
 
 

160

OMBUDSMAN INVOLVEMENT

 
 
 
 
 
 
 
 
 
 
 
 
DIABETIC

161

DIET ORDER

 
 
 
 
 
 
 
 
 
 
 
 

162

DIABETIC HS SNACK ORDER

 
 
 
 
 
 
 
 
 
 
 
 

163

BLOOD SUGAR ORDERS

 
 
 
 
 
 
 
 
 
 
 
 

164

FSBS PARAMETERS

 
 
 
 
 
 
 
 
 
 
 
 

165

ROUTINE LAB ORDERS

 
 
 
 
 
 
 
 
 
 
 
 

166

MD NOTIFICATION

 
 
 
 
 
 
 
 
 
 
 
 

167

LAB RESULTS

 
 
 
 
 
 
 
 
 
 
 
 

168

MD NOTIFICATION OF LAB RESULTS

 
 
 
 
 
 
 
 
 
 
 
 

169

NURSING DOCUMENTATION OF LAB RESULTS

 
 
 
 
 
 
 
 
 
 
 
 

170

INSULIN ADMINISTRATION AS ORDERED

 
 
 
 
 
 
 
 
 
 
 
 

171

ROTATION OF INJECTION SITES

 
 
 
 
 
 
 
 
 
 
 
 

172

WEEKLY SUMMARIES REFLECT INTAKE

 
 
 
 
 
 
 
 
 
 
 
 

173

QUARTERLY DIETARY NOTES

 
 
 
 
 
 
 
 
 
 
 
 

174

CNA DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

175

DIABETIC NUTRITION CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

176

DIABETIC RISK FACTORS DISCUSSED

 
 
 
 
 
 
 
 
 
 
 
 
ANTICOAGULANT

177

DIAGNOSIS FOR MEDICATION

 
 
 
 
 
 
 
 
 
 
 
 

178

DIAGNOSIS ON DIAGNOSIS LIST

 
 
 
 
 
 
 
 
 
 
 
 

179

ORDER INCLUDES DIAGNOSIS

 
 
 
 
 
 
 
 
 
 
 
 

180

PT/INR ORDERS

 
 
 
 
 
 
 
 
 
 
 
 

181

PT/INR COMPLETED AS ORDERED

 
 
 
 
 
 
 
 
 
 
 
 

182

PT/INR RESULTS ON FILE

 
 
 
 
 
 
 
 
 
 
 
 

183

MD NOTIFICATION OF LAB RESULTS

 
 
 
 
 
 
 
 
 
 
 
 

184

DOSE CHANGE

 
 
 
 
 
 
 
 
 
 
 
 

185

DOSE CHANGE CARRIED OUT