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ASSIGN
ADMISSION

001

NURSING

FACE SHEET COMPLETE AND ACCURATE

 
 
 
 
 
 
 
 
 
 
 
 

002

NURSING

CAPACITY DETERMINED

 
 
 
 
 
 
 
 
 
 
 
 

003

NURSING

CONSENT TO TREAT - SIGNED

 
 
 
 
 
 
 
 
 
 
 
 

004

NURSING

RISK LETTERS SIGNED

 
 
 
 
 
 
 
 
 
 
 
 

005

NURSING

CONSENTS - PSYCHOACTIVE MEDS AND DEVICES

 
 
 
 
 
 
 
 
 
 
 
 

006

NURSING

POLST COMPLETE

 
 
 
 
 
 
 
 
 
 
 
 

007

NURSING

PASRR

 
 
 
 
 
 
 
 
 
 
 
 

008

NURSING

FACILITY HISTORY AND PHYSICAL

 
 
 
 
 
 
 
 
 
 
 
 

009

NURSING

HOSPITAL DISCHARGE SUMMARY

 
 
 
 
 
 
 
 
 
 
 
 

010

NURSING

DIAGNOSES AND PROBLEM LIST

 
 
 
 
 
 
 
 
 
 
 
 

011

NURSING

HOSPITAL DISCHARGE ORDERS

 
 
 
 
 
 
 
 
 
 
 
 

012

NURSING

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

 
 
 
 
 
 
 
 
 
 
 
 

013

NURSING

STANDARD NURSING ASSESSMENTS

 
 
 
 
 
 
 
 
 
 
 
 

014

NURSING

SKIN/BODY ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

015

NURSING

NURSING ASSESSMENT COMPLETED TIMELY

 
 
 
 
 
 
 
 
 
 
 
 

016

NURSING

NURSING ADMISSION NOTE

 
 
 
 
 
 
 
 
 
 
 
 

017

NURSING

HIGH RISK ASSESSMENT CARE PLANS

 
 
 
 
 
 
 
 
 
 
 
 

018

NURSING

SHORT TERM CARE PLANS

 
 
 
 
 
 
 
 
 
 
 
 

019

NURSING

BASELINE CARE PLANS

 
 
 
 
 
 
 
 
 
 
 
 

020

NURSING

SETTING EXPECTATIONS WITH RESIDENT AND FAMILY

 
 
 
 
 
 
 
 
 
 
 
 

021

NURSING

IDT DOCUMENTED RISKS WITH RESIDENT AND FAMILY

 
 
 
 
 
 
 
 
 
 
 
 

022

NURSING

ADMINISTRATOR MEETING WITH RESIDENT AND FAMILY

 
 
 
 
 
 
 
 
 
 
 
 
UNEXPECTED EXPIRATION

023

NURSING

NURSING COC DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

024

NURSING

COC NOTIFICATIONS

 
 
 
 
 
 
 
 
 
 
 
 

025

NURSING

POLST / PIC FOLLOWED

 
 
 
 
 
 
 
 
 
 
 
 

026

NURSING

MORTICIAN DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

027

NURSING

TIMELY PHYSICIAN VISITS

 
 
 
 
 
 
 
 
 
 
 
 

028

NURSING

MEDICATION, MAR, TAR REMOVAL

 
 
 
 
 
 
 
 
 
 
 
 

029

NURSING

MEDICAL RECORD REMOVAL

 
 
 
 
 
 
 
 
 
 
 
 

030

NURSING

INVENTORY RECONCILATION

 
 
 
 
 
 
 
 
 
 
 
 

031

NURSING

PERSONAL BELONGINGS SECURED

 
 
 
 
 
 
 
 
 
 
 
 

032

NURSING

DNS CHART REVIEW

 
 
 
 
 
 
 
 
 
 
 
 
PRESSURE ULCER

033

NURSING

SKIN/BODY ASSESSMENT COMPLETED WITHIN 2 HOURS OF ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

034

NURSING

BRADEN / NORTON COMPLETED

 
 
 
 
 
 
 
 
 
 
 
 

035

NURSING

WOUND PHOTOS UPON ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

036

NURSING

PHYSICIAN'S ORDERS COINCIDE WITH ANATATOMICAL SITES

 
 
 
 
 
 
 
 
 
 
 
 

037

NURSING

CARE PLANS PER WOUND SITE

 
 
 
 
 
 
 
 
 
 
 
 

038

NURSING

AT RISK SKIN CARE PLAN UPON ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

039

NURSING

FOLEY CATHETER USE

 
 
 
 
 
 
 
 
 
 
 
 

040

NURSING

FOLEY CATHETER CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

041

NURSING

FOLEY CATHETER USE NOTIFICATIONS

 
 
 
 
 
 
 
 
 
 
 
 

042

NURSING

NEW WOUND COMMUNICATED TO MD, RESIDENT, RP

 
 
 
 
 
 
 
 
 
 
 
 

043

NURSING

NEW WOUND CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

044

NURSING

DAILY WOUND DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

045

NURSING

SKIN SHEET FOR EACH SITE

 
 
 
 
 
 
 
 
 
 
 
 

046

NURSING

RD ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

047

NURSING

RD RECOMMENDATIONS CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

048

NURSING

PAIN ASSESSMENT PRE AND POST TREATMENT

 
 
 
 
 
 
 
 
 
 
 
 

049

NURSING

RECOMMENDED EQUIPMENT IN PLACE

 
 
 
 
 
 
 
 
 
 
 
 

050

NURSING

IDT MEETING WITH RESIDENT AND/OR RP

 
 
 
 
 
 
 
 
 
 
 
 

051

NURSING

NOTIFICATION OF WOUND STATUS

 
 
 
 
 
 
 
 
 
 
 
 

052

NURSING

WEEKLY IDT MEETING

 
 
 
 
 
 
 
 
 
 
 
 

053

NURSING

WOUND PHYSICIAN CONSULTATION

 
 
 
 
 
 
 
 
 
 
 
 

054

NURSING

PHYSICIAN PROGRESS NOTES

 
 
 
 
 
 
 
 
 
 
 
 

055

NURSING

PHYSICIAN RECOMMENDATIONS CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

056

NURSING

WOUND NURSE CONSULTATION

 
 
 
 
 
 
 
 
 
 
 
 

057

NURSING

WOUND NURSE CONSULTANT RECOMMENDATIONS CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

058

NURSING

WEEKLY SUMMARIES DEPICT CURRENT WOUND STATUS

 
 
 
 
 
 
 
 
 
 
 
 

059

NURSING

NON COMPLIANCE NOTIFICATIONS AND CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

060

NURSING

NON COMPLIANT EDUCATION

 
 
 
 
 
 
 
 
 
 
 
 
NON-PRESSURE ULCER

061

NURSING

SKIN/BODY ASSESSMENT COMPLETED WITHIN 2 HOURS OF ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

062

NURSING

BRADEN / NORTON COMPLETED

 
 
 
 
 
 
 
 
 
 
 
 

063

NURSING

WOUND PHOTOS UPON ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

064

NURSING

PHYSICIAN'S ORDERS COINCIDE WITH ANATOMICAL SITES

 
 
 
 
 
 
 
 
 
 
 
 

065

NURSING

CARE PLANS PER WOUND SITE

 
 
 
 
 
 
 
 
 
 
 
 

066

NURSING

AT RISK SKIN CARE PLAN UPON ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

067

NURSING

FOLEY CATHETER USE

 
 
 
 
 
 
 
 
 
 
 
 

068

NURSING

FOLEY CATHETER CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

069

NURSING

FOLEY CATHETER USE NOTIFICATIONS

 
 
 
 
 
 
 
 
 
 
 
 

070

NURSING

NEW WOUND COMMUNICATED TO MD, RESIDENT, RP

 
 
 
 
 
 
 
 
 
 
 
 

071

NURSING

NEW WOUND CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

072

NURSING

NON PRESSURE ULCER AUDIT

 
 
 
 
 
 
 
 
 
 
 
 

073

NURSING

SKIN SHEET FOR EACH SITE

 
 
 
 
 
 
 
 
 
 
 
 

074

NURSING

RD ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

075

NURSING

RD RECOMMENDATIONS CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

076

NURSING

PAIN ASSESSMENT PRE AND POST TREATMENT

 
 
 
 
 
 
 
 
 
 
 
 

077

NURSING

RECOMMENDED EQUIPMENT IN PLACE

 
 
 
 
 
 
 
 
 
 
 
 

078

NURSING

IDT MEETING WITH RESIDENT AND/OR RP

 
 
 
 
 
 
 
 
 
 
 
 

079

NURSING

NOTIFICATION OF WOUND STATUS

 
 
 
 
 
 
 
 
 
 
 
 

080

NURSING

WEEKLY IDT MEETING

 
 
 
 
 
 
 
 
 
 
 
 

081

NURSING

WOUND PHYSICIAN CONSULTATION

 
 
 
 
 
 
 
 
 
 
 
 

082

NURSING

PHYSICIAN RECOMMENDATIONS CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

083

NURSING

WOUND NURSE CONSULTATION

 
 
 
 
 
 
 
 
 
 
 
 

084

NURSING

WOUND NURSE CONSULTATION RECOMMENDATIONS CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

085

NURSING

WEEKLY SUMMARIES DEPICT CURRENT WOUND STATUS

 
 
 
 
 
 
 
 
 
 
 
 

086

NURSING

NON COMPLIANCE NOTIFICATION

 
 
 
 
 
 
 
 
 
 
 
 
WEIGHT CHANGE

087

DIETARY

NUTRITIONAL ASSESSMENTS

 
 
 
 
 
 
 
 
 
 
 
 

088

DIETARY

WEIGHT UPON ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

089

DIETARY

WEEKLY WEIGHTS X 4 WEEKS

 
 
 
 
 
 
 
 
 
 
 
 

090

DIETARY

RD ASSESSMENT FOR WEIGHT CHANGE

 
 
 
 
 
 
 
 
 
 
 
 

091

DIETARY

RD RECOMMENDATIONS CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

092

DIETARY

AT RISK CARE PLAN UPON ADMISSION

 
 
 
 
 
 
 
 
 
 
 
 

093

DIETARY

EPISODIC CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

094

DIETARY

NURSING DOCUMENTATION REFLECTS INTAKE

 
 
 
 
 
 
 
 
 
 
 
 

095

DIETARY

COC NURSING DOCUMENTATION INITIATED

 
 
 
 
 
 
 
 
 
 
 
 

096

DIETARY

MD NOTIFICATION

 
 
 
 
 
 
 
 
 
 
 
 

097

DIETARY

RESIDENT / RP NOTIFICATION

 
 
 
 
 
 
 
 
 
 
 
 

098

DIETARY

CARE CONFERENCE CONDUCTED

 
 
 
 
 
 
 
 
 
 
 
 

099

DIETARY

MD DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

100

DIETARY

WEEKLY IDT MEETING

 
 
 
 
 
 
 
 
 
 
 
 

101

DIETARY

RISK NOTIFICATION FORM

 
 
 
 
 
 
 
 
 
 
 
 

102

DIETARY

PHYSICIAN'S ORDERS CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

103

DIETARY

NON COMPLIANCE NOTIFICATIONS

 
 
 
 
 
 
 
 
 
 
 
 

104

DIETARY

POLST / ADVANCED DIRECTIVE REVIEWED AND FOLLOWED

 
 
 
 
 
 
 
 
 
 
 
 

105

DIETARY

WEEKLY SUMMARIES ACCURATELY REFLECT WEIGHT CHANGE

 
 
 
 
 
 
 
 
 
 
 
 

106

DIETARY

MD NOTIFICATION OF LABS AND DIAGNOSTICS

 
 
 
 
 
 
 
 
 
 
 
 

107

DIETARY

LICENSED NURSE AND CNA DOCUMENTATION CONSISTENT

 
 
 
 
 
 
 
 
 
 
 
 

108

DIETARY

PSYCHIATRY OR PSYCHOLOGY CONSULTATION

 
 
 
 
 
 
 
 
 
 
 
 

109

DIETARY

ORAL EXAM

 
 
 
 
 
 
 
 
 
 
 
 

110

DIETARY

SPEECH THERAPY EVALUATION

 
 
 
 
 
 
 
 
 
 
 
 

111

DIETARY

PAIN ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

112

DIETARY

MEDICATION REVIEW

 
 
 
 
 
 
 
 
 
 
 
 
NONCOMPLIANCE

113

NURSING

NON COMPLIANCE ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

114

NURSING

CARE PLANS

 
 
 
 
 
 
 
 
 
 
 
 

115

NURSING

LIFESTYLE ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

116

NURSING

NURSING NOTES REFLECT NONCOMPLIANCE

 
 
 
 
 
 
 
 
 
 
 
 

117

NURSING

WEEKLY SUMMARIES REFLECT NONCOMPLIANCE

 
 
 
 
 
 
 
 
 
 
 
 

118

NURSING

IDT DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

119

NURSING

CARE CONFERENCE CONDUCTED

 
 
 
 
 
 
 
 
 
 
 
 

120

NURSING

ROUTINE BEHAVIOR MONITORING

 
 
 
 
 
 
 
 
 
 
 
 

121

NURSING

PHYSICIAN DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

122

NURSING

ADMINISTRATOR DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

123

NURSING

SOCIAL SERVICE DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

124

NURSING

CNA DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

125

NURSING

PSYCHIATRY / PSYCHOLOGY REFERRAL

 
 
 
 
 
 
 
 
 
 
 
 

126

NURSING

OMBUDSMAN

 
 
 
 
 
 
 
 
 
 
 
 
DISSATISFIED CUSTOMER

127

NURSING

CAPACITY DETERMINATION

 
 
 
 
 
 
 
 
 
 
 
 

128

NURSING

CAPACITY STATEMENT CONSISTENT WITH POLST / PIC

 
 
 
 
 
 
 
 
 
 
 
 

129

NURSING

FACE SHEET ACCURATE

 
 
 
 
 
 
 
 
 
 
 
 

130

NURSING

CONSENT TO TREAT

 
 
 
 
 
 
 
 
 
 
 
 

131

NURSING

ARBITRATION AGREEMENT

 
 
 
 
 
 
 
 
 
 
 
 

132

NURSING

IDT MEETING

 
 
 
 
 
 
 
 
 
 
 
 

133

NURSING

IDT/MD/OMBUDSMAN

 
 
 
 
 
 
 
 
 
 
 
 

134

NURSING

CARE CONFERENCE CONDUCTED

 
 
 
 
 
 
 
 
 
 
 
 

135

NURSING

NURSING NOTES REFLECT CARE TO ADDRESS CONCERNS

 
 
 
 
 
 
 
 
 
 
 
 

136

NURSING

DISCHARGE PLAN OF CARE

 
 
 
 
 
 
 
 
 
 
 
 

137

NURSING

CARE PLAN AND FAMILY DYNAMICS

 
 
 
 
 
 
 
 
 
 
 
 

138

NURSING

SSD DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

139

NURSING

PHYSICIAN DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

140

NURSING

ACTIVITY DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

141

NURSING

OMBUDSMAN INVOLVEMENT

 
 
 
 
 
 
 
 
 
 
 
 

142

NURSING

ADMINISTRATOR/AIT MEETING WITH RESIDENT AND/OR RP

 
 
 
 
 
 
 
 
 
 
 
 

143

NURSING

DIRECTOR OF NURSING MEETING WITH RESIDENT AND/OR RP

 
 
 
 
 
 
 
 
 
 
 
 

144

NURSING

SERVICE RECOVERY

 
 
 
 
 
 
 
 
 
 
 
 
ELOPEMENT

145

NURSING

ELOPEMENT RISK ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

146

NURSING

CONSENT TO TREAT

 
 
 
 
 
 
 
 
 
 
 
 

147

NURSING

CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

148

NURSING

MONITORING WHEREABOUTS

 
 
 
 
 
 
 
 
 
 
 
 

149

NURSING

WANDERGUARD SYSTEM

 
 
 
 
 
 
 
 
 
 
 
 

150

NURSING

AMA DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

151

NURSING

ELOPEMENT BRACELETS

 
 
 
 
 
 
 
 
 
 
 
 

152

NURSING

WEEKLY SUMMARIES REFLECT BEHAVIOR

 
 
 
 
 
 
 
 
 
 
 
 

153

NURSING

CARE CONFERENCE CONDUCTED

 
 
 
 
 
 
 
 
 
 
 
 

154

NURSING

CNA DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

155

NURSING

ADMINISTRATOR / SSD DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

156

NURSING

ACTIVITY PLAN

 
 
 
 
 
 
 
 
 
 
 
 

157

NURSING

DISCHARGE PLAN OF CARE

 
 
 
 
 
 
 
 
 
 
 
 

158

NURSING

PHYSICIAN DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

159

NURSING

PSYCHIATRIC / PSYCHOLOGY REFERRAL

 
 
 
 
 
 
 
 
 
 
 
 

160

NURSING

OMBUDSMAN INVOLVEMENT

 
 
 
 
 
 
 
 
 
 
 
 
DIABETIC

161

NURSING

DIET ORDER

 
 
 
 
 
 
 
 
 
 
 
 

162

NURSING

DIABETIC HS SNACK ORDER

 
 
 
 
 
 
 
 
 
 
 
 

163

NURSING

BLOOD SUGAR ORDERS

 
 
 
 
 
 
 
 
 
 
 
 

164

NURSING

FSBS PARAMETERS

 
 
 
 
 
 
 
 
 
 
 
 

165

NURSING

ROUTINE LAB ORDERS

 
 
 
 
 
 
 
 
 
 
 
 

166

NURSING

MD NOTIFICATION

 
 
 
 
 
 
 
 
 
 
 
 

167

NURSING

LAB RESULTS

 
 
 
 
 
 
 
 
 
 
 
 

168

NURSING

MD NOTIFICATION OF LAB RESULTS

 
 
 
 
 
 
 
 
 
 
 
 

169

NURSING

NURSING DOCUMENTATION OF LAB RESULTS

 
 
 
 
 
 
 
 
 
 
 
 

170

NURSING

INSULIN ADMINISTRATION AS ORDERED

 
 
 
 
 
 
 
 
 
 
 
 

171

NURSING

ROTATION OF INJECTION SITES

 
 
 
 
 
 
 
 
 
 
 
 

172

NURSING

WEEKLY SUMMARIES REFLECT INTAKE

 
 
 
 
 
 
 
 
 
 
 
 

173

NURSING

QUARTERLY DIETARY NOTES

 
 
 
 
 
 
 
 
 
 
 
 

174

NURSING

CNA DOCUMENTATION

 
 
 
 
 
 
 
 
 
 
 
 

175

NURSING

DIABETIC NUTRITION CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

176

NURSING

DIABETIC RISK FACTORS DISCUSSED

 
 
 
 
 
 
 
 
 
 
 
 
ANTICOAGULANT

177

NURSING

DIAGNOSIS FOR MEDICATION

 
 
 
 
 
 
 
 
 
 
 
 

178

NURSING

DIAGNOSIS ON DIAGNOSIS LIST

 
 
 
 
 
 
 
 
 
 
 
 

179

NURSING

ORDER INCLUDES DIAGNOSIS

 
 
 
 
 
 
 
 
 
 
 
 

180

NURSING

PT/INR ORDERS

 
 
 
 
 
 
 
 
 
 
 
 

181

NURSING

PT/INR COMPLETED AS ORDERED

 
 
 
 
 
 
 
 
 
 
 
 

182

NURSING

PT/INR RESULTS ON FILE

 
 
 
 
 
 
 
 
 
 
 
 

183

NURSING

MD NOTIFICATION OF LAB RESULTS

 
 
 
 
 
 
 
 
 
 
 
 

184

NURSING

DOSE CHANGE

 
 
 
 
 
 
 
 
 
 
 
 

185

NURSING

DOSE CHANGE CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

186

NURSING

NEW ORDERS FOR LAB DRAW CARRIED OUT

 
 
 
 
 
 
 
 
 
 
 
 

187

NURSING

ANTICOAGULANT CARE PLAN

 
 
 
 
 
 
 
 
 
 
 
 

188

NURSING

ANTICOAGULANT RISK NOTIFICATION

 
 
 
 
 
 
 
 
 
 
 
 
FALL INCIDENT

189

NURSING

FALL RISK ASSESSMENT

 
 
 
 
 
 
 
 
 
 
 
 

190

NURSING

FALL CARE PLANS

 
 
 
 
 
 
 
 
 
 
 
 

191

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