NURSING DOCUMENTATION AUDIT TOOL

The following report has been generated as part of the facility’s quality assessment, quality assurance process and constitutes confidential quality assurance committee records, Ref. 42 CFR, 438.75(o).

AREA OF REVIEW  Resident Name:
(check, highlight, etc) Date of Admission: / Follow Up Required and By Whom / Date Complete
On Admission, within 8 hours
  • Admission / Re-admission Data Collection complete including
  • Braden
  • Fall Risk
  • Smoking Assessment
  • Elopement Risk
  • Pain
  • Vital Signs
  • Height
  • Weight
  • Range of Motion
  • MAR correct to orders
  • TAR correct to orders
  • ADL Record correct to capabilities
  • Resident Information Sheet correct to capabilities
  • Psychotropic Consent (state specific)
  • Depression Screen
  • Code Status
  • Interim Plan of Care complete (based upon assessments above)
  • Admission noted on 24 hr report

On Admission, based upon assessment
  • 3 Day B & B Review
  • Pain Intervention Flow Sheet
  • Skin grid – Pressure
  • Skin Grid – Other
  • Elopement Risk Alert
  • Self Administration of Medication Review
  • Side Rail screen
  • Restraint Data Collection & Evaluation
  • Behavior Monitoring Tools
  • Warfarin flow sheet
  • Blood sugar flow sheet

Daily, based upon policy and need
  • Skilled note every shift to skilled and resident need
  • Non skilled note based upon resident need
  • POC updated as condition changes
  • ADL Record complete
  • MAR complete
  • TAR complete
  • Nursing Assistant daily skin check
  • 24 hour chart check for new orders
  • As Indicated
  • Pain Intervention Flow Sheet
  • Elimination Pattern
  • Restorative Care Flow record
  • Behavior Monitoring Flow Sheet
  • Depression Monitoring

Occurrence
  • Issues noted on 24 hour report
  • Documentation reflects resident issues
  • Physician notification of lab values
  • Physician notification of change of condition
  • Family notification of change of condition
  • POC updated based upon COC

Day 3
  • Care Review
  • Family and resident invited
  • POC Updated

Weekly
  • Weekly skin sweep complete
  • Skin Grid – Pressure
  • Skin Grid – Other
  • Braden scale for the first 4 weeks
  • Restorative care documentation
  • Weekly Nursing summary per policy / state

Monthly
  • Resident Summary per policy / state
  • Recap of orders accurate
  • New MAR reflect current orders
  • New TAR reflect current orders
  • New Behavior Monitoring record
  • Vital Signs obtained
  • Weight obtained / review
  • POC updated

Quarterly
  • Review, Update complete per policy
  • Fall Risk
  • Restraint Screen
  • Side Rail Screen
  • Braden Scale
  • Elopement Risk
  • Pain Evaluation
  • As Indicated
  • Behavior Data Collection
  • Bladder IncontinenceEvaluation
  • Bowel Incontinence Evaluation
  • Smoking Safety Screen
  • Range of Motion Data Collection
  • Self Administration Review

MDS
  • Completed 5 day MDS
  • Updated POC
  • Completed 14 Day MDS
  • Updated POC (7 days)
  • Quarterly MDS
  • Updated POC
  • Change of condition MDS
  • Updated POC

Discharge
  • Note of status
  • Resolution of Care Plan Goals
  • Resident Family Education Record
  • Interdisciplinary Discharge Summary
  • Discharge Information

Care Management Notations
  • Weekly review for skilled
  • Monthly review for high risk issues
  • Quarterly review if long term care, no risk items