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BARBARA ACELLO, MS, RN

CLINICAL TOOLS

AND

FORMSFOR LONG-TERM CARE

29417_CTFLTC_spiral_Cover.indd 1 6/15/15 2:07 PM


CLINICAL TOOLS

AND


Clinical Tools and Forms for Long-Term Care is published by HCPro, a division of BLR.

Copyright © 2015 HCPro

All rights reserved. Printed in the United States of America. 5 4 3 2 1

ISBN: 978-1-55645-476-9

No part of this publication may be reproduced, in any form or by any means, without prior writ-ten consent of HCPro or the Copyright Clearance Center (978-750-8400). Please notify us imme-diately 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.

Barbara Acello, AuthorOlivia MacDonald, Managing EditorErin Callahan, Senior Director, ProductElizabeth Petersen, Vice PresidentMatt Sharpe, Production SupervisorVincent Skyers, Design Services DirectorVicki McMahan, Sr. Graphic DesignerMichael McCalip, Sheryl Boutin, Amanda Southworth, Sue Robinson, Jason Gregory, Layout/Graphic DesignReggie Cunningham, Cover Designer

Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions.

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© 2015 HCPro Clinical Tools and Forms for Long-Term Care iii

¢ Clinical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Inter-Facility Infection Control Transfer Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Admission and Preadmission Screening of Individuals With VRE or MRSA1 . . . . . . . . . . . . . . 5Admission/Readmission Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Resident Personal Belongings Inventory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Discharge Education Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Discharge Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Wound Assessment Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Motorized/Power Wheelchair Assessment Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Delegation of Nursing Task to Unlicensed Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25DHandoff Assessment to Next Level of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Neurological Flow Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Workload Management System for Nursing—General Worksheet . . . . . . . . . . . . . . . . . . 32Fall Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Fall Prevention Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Fall Prevention Plan of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Assisted Living Resident Assessment Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Comprehensive Admission Skin Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Supportive Documentation for MDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Epworth Sleepiness Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Glasgow Coma Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Safe Smoking Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Nursing Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Interdisciplinary Progress Note Template . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59ABCD Stroke Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Infection Control Environmental Rounds Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63CDC Environmental Checklist for Monitoring Terminal Cleaning . . . . . . . . . . . . . . . . . . . . 67

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Quality Assessment/Improvement Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Daily/Weekly Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71Hydrotherapy Equipment Log Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72Master Signature Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73Mechanical Lift Prevention Maintenance Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74Safe Resident Handling Preparation Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76Mechanical Lift Competency Check . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79Sit to Stand Lift Competency Check . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Mock Survey Observation Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82Walking Rounds Resident Audit Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93Door Alarm Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97Charge Nurse Cleaning Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98Chart Review Tool for Monitoring Quality Indicators: Effective Pain Management in Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101Daily AED & Crash Cart Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103Code Blue Event Debriefing/Critique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106Emergency Crash Cart Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108Emergency Drug Kit Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110Emergency Telephone Numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115Signature Crash Cart Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117Diabetic Flow Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118Insulin and Blood Glucose Monitoring Orders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119IV Flow Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121IV Nursing Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123Tube Feeding Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124Order Sheet for Enteral Feeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127Fall Assessment Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128Fall Management Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130Fall Prevention Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131Fall Prevention Plan of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132Post Fall 72-Hour Monitoring Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134PFall Documentation Guide/Temporary Care Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137Centralized Immunization Record System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138Individual Resident Infection Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139Sepsis Screening Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140Weekly Infection Control Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141Pandemic Influenza Planning Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142

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© 2015 HCPro Clinical Tools and Forms for Long-Term Care v

Facility Summary Infection Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150Preadmission Medicare Eligibility Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151Medication Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153Medication Management Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155Resident Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156Warfarin (Coumadin) Flow Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157Care Conference Attendance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158CAPD Flow Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159Nursing Assistant Care Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161Nursing Assistant Plan of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163Restorative Nursing Assistant Plan of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166Restorative Audit of Nursing Staff Directly Responsible for Patient Care . . . . . . . . . . . . . 169Nursing Assistant Resident Care Documentation Worksheet . . . . . . . . . . . . . . . . . . . . . 171Nursing Assistant Assignment Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172Nurse/CNA Communication Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173Nursing Assistant Communication Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174Dehydration Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176Dehydration Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177Bedside Fluid Intake and Output Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179Dehydration Risk Appraisal Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180Three-Day Calorie/Protein Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181Documentation of Meal Intake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182Numeric Pain Scale 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

Numeric Pain Scale 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

Mood Pain Relief Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185Nurse Pain Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186Pain Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187Pain Screen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189Severity Relief Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191Verbal Pain Scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192Verbal Pain Scales 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193Verbal Pain Scales 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194Verbal Pain Scales 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195Verbal Pain Scales 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196Systems Check for Physician Calls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197Systems Check Prior to Physician Call . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199Restraints: Side Rail Utilization Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200

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New Admission Restraint Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203Resident Safety Flow Sheet 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204Resident Safety Flow Sheet 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205Is the Intervention a Physical Restraint? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206Resident Restraint Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208Skin Monitoring: Comprehensive CNA Shower Review . . . . . . . . . . . . . . . . . . . . . . . . 209Impaired Skin Integrity Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210Licensed Nurse Weekly Skin Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211Pressure Ulcer Flow Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212Pressure Ulcer Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213Pressure Ulcers: Communication With Physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215Pressure Ulcer Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219QA&A Pressure Ulcer Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220SBAR: Skin Care Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229Skin Breakdown Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231Skin Monitoring: Daily Skin Check . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232Skin Observation Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233Skin Tear Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235Skin Tear Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236Tissue Tolerance and Individualized Turning Schedule . . . . . . . . . . . . . . . . . . . . . . . . . 237Care Plan Approaches for Pressure Ulcer Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . 241Behavior Observation Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243Behavioral Pain Assessment for Cognitively Impaired Adults . . . . . . . . . . . . . . . . . . . . . 244Behavioral Scale for Cognitively Impaired Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245Brink/Yesavage Geriatric Depression Scale (Short Form) . . . . . . . . . . . . . . . . . . . . . . . 247Social Adjustment Rating Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248Suicide Precautions Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250Monthly Vital Sign Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251Vital Sign Flow Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252Weight Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253Elopement Patterning Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254Resident Safety Flow Sheet 1 (Wandering) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256Resident Safety Flow Sheet 2 (Wandering) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257Elopement Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258Long-Term Care and Other Residential Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

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© 2015 HCPro Clinical Tools and Forms for Long-Term Care vii

¢ Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261Master Discharge List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263Notice of Discharge/Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264Delegation Assignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267Assessment for Safe Resident Handling and Movement . . . . . . . . . . . . . . . . . . . . . . . . . . . .268

Daily Rounds Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271Daily Temperature Log—Medication Refrigeration . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273Daily Temperature Log—Specimen Refrigerator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275Nursing Assistant Cleaning Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277Nursing: Direct Care & Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281Systems Investigative Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286Bomb Threat Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288Call Signal Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290Fire Drill Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291Generator Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292Generator Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294Grievance/Complaint Follow-Up Tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295Grievance/Complaint Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296Grievance/Complaint Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297Incident, Accident, Unusual Occurrence Monitoring Log . . . . . . . . . . . . . . . . . . . . . . . . 299Laundry Equipment Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300Life Safety Code® Survey Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306Master Index of Admissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310Master Index of Admissions and Discharges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311Master Index of Discharges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312Monthly Dietary Preventive Maintenance Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313Monthly Exterior Maintenance Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315Monthly Life Safety and Preventive Maintenance Checklist . . . . . . . . . . . . . . . . . . . . . . 317QA&A Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318Dietary Infection Control Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321Monthly Beauty Shop Infection Control/Sanitation Log . . . . . . . . . . . . . . . . . . . . . . . . 325Water Temperature Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327Meal Rounds Dining Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330Certificate of Achievement Form (Restorative Nursing) . . . . . . . . . . . . . . . . . . . . . . . . . 334Certificate of Attendance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335Certificate of Achievement Form (Restorative Nursing) . . . . . . . . . . . . . . . . . . . . . . . . . 336

Contents

Clinical Tools and Forms for Long-Term Care © 2015 HCProviii

Daily AED & Crash Cart Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337Code Blue Event Debriefing/Critique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339Code Blue Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341Suggested Crash Cart Supply List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342Cardiopulmonary Resuscitation Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 344Employee Physical Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349Employee Incident Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351General Employee Orientation Inventory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352Sample Exit Interview Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 364Tuberculin and Immunization Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365Monthly Facility Infection Control Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366Individual Education Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367Record of In-Service Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368In-Service Record Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369In-Service Sign-In Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370Mechanical Lift Competency Check . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372Sit to Stand Lift Competency Check . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373Visiting Pet Registration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374Daily Nurses’ Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375Intensive Monitoring Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376Change of Condition Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377Hourly Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378Nursing Assistant Assignment Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379Nursing Assistant Care Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38124-Hour Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385Release of Responsibility for Leave of Absence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386Smoking Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387Behavior Record: General Log . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388Elopement Risk Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 390

¢ Legal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391Vial of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393Example DNR Checklist: Who May Implement a DNR Order . . . . . . . . . . . . . . . . . . . . 395Federal Resident Self-Determination Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396DNR Order Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 403Do Not Resuscitate Order . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 404Do Not Resuscitate Request . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405

Contents

© 2015 HCPro Clinical Tools and Forms for Long-Term Care ix

Physician Orders for Life-Sustaining Treatment (POLST) . . . . . . . . . . . . . . . . . . . . . . . . . 406Beauty and Barber Services Agreement 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408Beauty and Barber Services Agreement 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410Beauty and Barber Services Agreement 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412SNF/LTCF Outpatient Dialysis Services Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . 414SAffidavit to Accompany Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421Medicare Reconsideration Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422Medicare Redetermination Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423Request for Part A Medicare Hearing by an Administrative Law Judge . . . . . . . . . . . . . . 424Transfer of Appeal Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425Authorization for Release of Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427 Authorization for Use or Disclosure of Protected Health Information . . . . . . . . . . . . . . . . 428Vaccine Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431Consent for Use of Picture and/or Voice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 434 Consent to Use Psychoactive Medications Chemical Restraints . . . . . . . . . . . . . . . . . . . . 435Smoking Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437

¢ Restorative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439ADL Flow Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441Seven-Day Resident Self Ability Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .443

Seven-Day Restorative Nursing Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444Activities of Daily Living Daily Flow Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445ADL Data Tracking Tool by Shift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447ADL Flow Sheet, Format 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449 Initial Incontinence Evaluation Voiding Pattern Assessment . . . . . . . . . . . . . . . . . . . . . . 450Admission Bladder Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451 Assessment for Bowel and Bladder Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 452 Assessment for Bowel and Bladder Management Programs . . . . . . . . . . . . . . . . . . . . . . 454 Assessment for Bowel and Bladder Management (Elimination History) . . . . . . . . . . . . . . 455Assessment for Bowel and Bladder Management (Incontinence Management History) Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 456Nursing Assistant Resident Observations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 458Restorative Nursing Flow Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459Nursing Restorative Program Individual Program Plan of Care . . . . . . . . . . . . . . . . . . . . 460ROM Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461Restorative Dining Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462Restorative Exercise Program Courtesy of Our Island Home . . . . . . . . . . . . . . . . . . . . . . 464

Contents

Clinical Tools and Forms for Long-Term Care © 2015 HCProx

Restorative Nursing Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465Restorative Nursing Assistant Plan of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466Restorative Nursing Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 468Restorative Nursing Transfer and Referral Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 470Restorative Nursing Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471Bathing Task Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472Bed Mobility Task Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473Dressing and Undressing Task Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 474Feeding Task Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476Hand Washing Task Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477Showering Task Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478Task Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480Toothbrushing Task Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 482Wheelchair Task Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483

Clinical

Admission, Transfer, Discharge

© 2015 HCPro Clinical Tools and Forms for Long-Term Care 3

¢ Inter-Facility Infection Control Transfer Form

Resident name: Room #:

This form must be filled out for transfer to accepting facility with information communicated prior to or with transfer

Please attach copies of latest culture reports with susceptibilities if available

Sending healthcare facility:

Patient/Resident last name First name Date of birth Medical record number

/ /

Name/Address of sending Facility Sending unit Sending facility phone

Sending facility contacts Name Phone Email

Case manager/Admin/SW

Infection prevention

Is the patient currently in isolation? ❏❏ No ❏❏ Yes

Type of Isolation (check all that apply) ❏❏ Contact ❏❏ Droplet ❏❏ Airborne ❏❏ Other:

Does patient currently have an infection, colonization OR a history of positive culture of a multidrug-resistant organism (MDRO) or other organism of epidemiological significance?

Colonization or history

Check if Yes

Active infection on Treatment

Check if Yes

Methicillin-resistant Staphylococcus aureus (MRSA)

Vancomycin-resistant Enterococcus (VRE)

Clostridium difficile

Acinetobacter, multidrug-resistant*

E coli, Klebsiella, Proteus etc. w/Extended Spectrum B-Lactamase (ESBL)*

Carbapenemase resistant Enterobacteriaceae (CRE)*

Other:

Clinical

Clinical Tools and Forms for Long-Term Care © 2015 HCPro4

Does the patient/resident currently have any of the following?

❏❏ Cough or requires Suctioning ❏❏ Central line/PICC (Approx. date inserted / / )

❏❏ Diarrhea ❏❏ hemodialysis catheter

❏❏ Vomiting ❏❏ Urinary catheter (Approx. date inserted / / )

❏❏ Incontinent of urine or stool ❏❏ Suprapubic catheter

❏❏ Open wounds or wounds requiring dressing change

❏❏ PEG or gastronomy tube

❏❏ Drainage (source) ❏❏ Tracheostomy

Is the patient/resident currently on antibiotics? No Yes:

Antibiotic and dose Treatment for: Start date Anticipated stop date

Vaccine Date administered (If known)

Lot and Brand (If known)

Year administered (If exact date not known)

Does patient self-report receiving vaccine?

Influenza (seasonal) ❏❏ Yes ❏❏ No

Pneumococcal ❏❏ Yes ❏❏ No

Other: ❏❏ Yes ❏❏ No

Printed name of person completing form

Signature Date If information communicated prior to transfer: Name and phone of individual at receiving facility

¢ Inter-Facility Infection Control Transfer Form (cont .)



¢ Admission and Preadmission Screening of Individuals With VRE or MRSA1


Residents who are colonized with VRE or MRSA should not be denied entry to the facility strictly because of the presence of the VRE or MRSA pathogens. Use this form for preadmission screening and making recommendations.

Screening Information

Does the resident have a history of current or prior VRE or MRSA infection or colonization?

❏❏ Yes ❏❏ No

Results of C&S from the most recent hospitalization: Site: Organism:

If the resident is currently positive for VRE or MRSA, do labs represent colonization or active infection?

❏❏ Colonization ❏❏ Infection

Is a private room necessary for resident’s care? ❏❏ Yes ❏❏ No

Can the resident be admitted to a room with another resident with the same infection? (MRSA may be cohorted with any strain; VRE is cohorted if both residents share the same strain)


Are transmission-based precautions necessary for resident care? If yes, specify type:


Is dedicated equipment (B/P cuff, stethoscope, glucometer, etc.) necessary for resident care? If yes, specify:


If the resident is currently positive for VRE or MRSA, can the infected material be easily contained?


If the resident is currently positive for VRE or MRSA, does he/she have the cognitive ability to follow instructions for personal hygiene to prevent transmission in common areas of the facility?


If resident has past history of VRE, have subsequent stool cultures (x3) and infection site cultures (where appropriate) been negative for VRE?


If resident has past history of MRSA, have all wounds been cultured and have nasal cultures been done?


If yes, what is the status?

Comments of nurse assessor:

Recommendations of nurse assessor: ❏❏ Admit ❏❏ Do not admit

Clinical


Medical director comments:

Medical director recommendations: ❏❏ Admit ❏❏ Do not admit

Administrator comments:

Administrator admission decision ❏❏ Admit ❏❏ Do not admit

Signatures:

Nurse assessor:

Medical director:

Administrator:

Date:

1

1 Modified from: American Medical Directors’ Association. (2006). Issues related to admission and pre-admission screening of individuals with VRE or MRSA. Clinical Corner. AMDA online. www.amda.com/clinical/infectioncontrol/admissionissues.htm

¢ Admission and Preadmission Screening of Individuals With VRE or MRSA1 (cont .)



¢ Admission/Readmission Checklist

Resident nam e: Date: Room #:

Item Initials Date Comments

Resident ID band

HIPAA consents signed for name, photos, etc.

Note restrictions:

Bed (and/or door frame) labeled per policy

Showed resident how to use call signal

Admission nursing history complete

Complete skin check

Immunization history completed; consents signed

Personal inventory

Belongings labeled

Dentures marked

Jewelry described; release to keep at bedside signed or sent home/locked in safe

Note description of jewelry if release signed. If not, note disposition.

History and physical

Discharge summary

Transfer form

Advance directive

Consent-CPR/DNR

Consent-rails and restraints

Consent-smoking

Clinical



Fall risk assessment

Skin risk assessment

Other assessment (specify)

Other assessment (specify)

Care plan initiated

Diet ordered

Admission Lab ordered

Give first step Mantoux; schedule reading

Chest x-ray ordered

Therapy consults requested, if indicated

Admission nursing note Document date and time of admission, from where, transportation, room number, overall condition, mental status, summary of primary diagnosis, skin condition, complete vital signs, allergies, notifications.

Schedule for nursing notes/vitals q shift x 72h

Height/weight obtained

Schedule appointments

Add to bath schedule

Initiate intake and output monitoring, if indicated

Admission orders

Diagnosis Medications; include diagnosis for each

PRN Define PRN orders (for what, when); diagnosis for each

Diet Diet order

Activities Activities per plan of care

Rehab potential Rehab potential/prognosis

¢ Admission/Readmission Checklist (cont .)





Therapy Therapy evaluations, if indicated; treat per plan of care

Mantoux Two-step Mantoux testing or chest X-Ray

Pass May go on therapeutic pass with medications PRN, or as indicated

POD prn Podiatrist, optometrist, dentist PRN

Foley Foley catheter-size and orders to change; obtain order to remove, if indicated

Tube feeding Tube feeding type, size; orders to change for plugging or accidental dislodgment, if indicated; x-ray for placement check

Tube feeding solution, type of administration, time, amount, number of calories per day

Obtain orders for free water on all tube feeders, including 30 to 50 ml before and after each medication

Obtain orders for tube placement checks, residual checks

Measure and document length of tube

List HOB elevation, other special care on care plan

Obtain a physician’s order if the continuous tube feeding must be suspended for any reason; for example, a daily shower. (Or obtain an order to run continuous feeding 23 hours a day to allow for ADL care)

Weight and vitals Specify frequency of weight and vital signs on physician order sheet

Communicable disease Note resident is free from communicable disease

Informed of condition Note that resident or legal representative have been apprised of resident’s condition

Fingerstick blood sugar If resident is diabetic, note frequency for blood sugar testing. Specify physician notification for blood sugar above 300 and below 70, or according to policy.

Medication monitoring If resident is on Coumadin (warfarin), note frequency for INR and protime testing


Clinical



Inquire about specific laboratory testing related to medications (e.g., digoxin, anti-seizure medications, lithium, etc.)

Ancillary orders Obtain routine orders per facility policy (laxative, medication for pain/fever, skin tear treatment, etc.)

Treatment orders Obtain specific treatment orders (area, frequency, stop order or until healed)

Oxygen If resident is using oxygen, note liter flow, method, and frequency

Restraints, including siderails

Type, time, reason, release.

Physician contacted; Orders verified

Allergies documented on MAR, chart cover, and as indicated

ADL Sheet started

Pharmaceuticals ordered

MAR started

Treatment record started

Other, according to facility policy:

Adm ission/Readmission Checklist

Item Date Obtained Initials Comments

History and physical

CBC

Hemoglobin

Hematocrit

Chemistry

Glucose

BUN




Item Date Obtained Initials Comments

Creatinine

Urinalysis

Stool for occult blood

PPD step 1

PPD step 2

Chest x-ray

Vision exam

Hearing exam

Dental exam

Immunizations - Pneumovax (5 years)

Immunizations - Influenza

Immunizations - DT (10 years)

Other Assessment (Specify)

Other Assessment (Specify)


Clinical


¢ Resident Personal Belongings Inventory

Resident name: Room #: Instructions: Provider or resident manager completes upon admission. The Provider/Resident manager

and the resident or the resident’s guardian or agent sign. File in the resident’s record. Records and information concerning each person in care shall be maintained in such a manner as to preserve confidentiality.

Name of resident’s guardian Date of admission

Contact lenses Dentures

Eye glasses Hearing aid

Jewelry Watch

Money/checkbook/credit cards Other

Clothing list

Number Item Description

Bathrobe

Belt

Blouse

Brassiere

Coat

Dress

Girdle/spanx, or similar undergarment

Gloves

Handkerchief

Hat

House coat

Necktie



Clothing list


Nightgown

Pajamas

Pants

Shirts

Shoes

Skirts

Slippers

Slips

Socks

Stockings

Suit

Suspenders

Sweater

Undershirt

Underpants/panties/shorts

Underwear - long

Vests

Other:

Miscellaneous


Brush

Cane or crutches

Clock

Luggage

Radio

¢ Resident Personal Belongings Inventory (cont .)

Clinical


Miscellaneous


Television (model and serial number)

Walker

Wheelchair (model and serial number)

Other:

Statement: I have read and agree that this is an accurate list of my belongings .

Provider’s/Resident manager’s signature: Date:

Resident’s or guardian’s signature: Date:

¢ Resident Personal Belongings Inventory (cont .)



¢ Discharge Education Tool


Medical record #

Name: Phone number:

Admission date: Discharge date: Days in the facility:

Primary care doctor: Phone number:

Consultant doctor: Phone number:

Other doctor: Specialty:



Diagnosis

I had to stay in the facility because:

The medical word for this condition is:

I also have these medical conditions:

Tests

While I was in the facility I had these tests: which showed:

Medical record #

Clinical


Treatment

While I was in the facility I was treated with: The purpose of this treatment was:

Follow-up appointments

After leaving the facility, I will follow up with my doctors.(initials)

Primary care doctor: Phone number:

Date: , , 20 Time: : m

Specialist Doctor: Phone number:

Date: , , 20 Time: : m

Follow-up tests

After leaving the facility, I will show up for my tests.(initials)

Tests Location Date Time

, , 20 m

m

m

Medical record #

¢ Discharge Education Tool (cont .)



Call your primary care doctor for the following:

Warning signs

1) 4)

2) 5)

3) 6)

Lifestyle changes

After leaving the facility, I will make these changes in my activity and diet.(initials)

Activity: , because

Diet: , because

Smoking:❏❏ Non-smoker❏❏ Smoker- plan for quitting:

Follow-up phone call date: , , 20 Time: : m

Patient signature:

Doctor or nurse case manager signature: Date: / / 20

MedicationsWhen I go home, I will be taking the medicines on my prescription form. I will stop the medicines I took before I came to the facility.

(initials) (If applicable)

I understand the medicines I will continue taking and new medicines I will take.(initials)

I understand why and when I need to take each medicine.(initials)

I understand which side effects to watch for.(initials)

Please bring all of your medicines to your follow-up appointments .

¢ Discharge Education Tool (cont .)

Clinical


¢ Discharge Plan


§483.15(g)(1) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Discharge planning services include helping to place a resident on a waiting list for community congregate living, arranging intake for home care services for residents returning home, and assisting with transfer arrangements to other facilities.

Dear Doctor: Please complete the (tentative) discharge plan on your resident, within seven days and return it to us by: . Thank you!

Discharge plan Yes No

Resident will be discharging to:

a. Own home or home of a relative

b. Intermediate care facility

c. Sheltered or residential care facility

d. Other, specify:

e. Prolonged or permanent placement in this facility anticipated

If resident is discharging to home, he or she will need:

Personal care

Nursing services

Housekeeping assistance

Adaptive equipment or medical supplies

Assistance with psychosocial or emotional adjustment

Dietitian

Physical therapy

Occupational therapy

Speech therapy

Respiratory therapy

Community resources or services (specify):

Financial assistance



Discharge plan Yes No

Other, specify:

Other, specify:

None of the above

I will be making discharge plans and providing related services to this patient.

I would appreciate facility staff assistance with discharge planning.

Physician signature Date:

¢ Discharge Plan (cont .)

Clinical


¢ Wound Assessment Tool

Resident Name: Room #:

Pressure Other

Location:

Date: Initial assessment

Length (cm)

Width (cm)

Depth (cm)

Stage

Undermining/tunneling (cm)

Wound base

Ulcer margins

Exudate

Odor

Peri-wound skin

Pain

Pressure reduction interventions1. Pressure-reducing mattress2. W/C cushion3. Specialty bed4. Other

Debridement (yes/no, type)

PUSH Tool score

Improved, same, deteriorated

Treatment appropriate (yes/no)

Last change in treatment (date)

MD notified of change (date)

Family notified of change (date)

Nurse’s initials

Nurse signature/title


CLINICAL TOOLS

AND


100 Winners Circle, Suite 300Brentwood, TN 37027www.hcmarketplace.com

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