Quantitative Monitoring

Admit/Return first 24 hours

• Consent to Treatment signed on admission
• Transfer Form or Order to Admit Received.
• Admission orders transcribed accurately from transfer form.’
• All orders required per facility policy are verified or clarified by the attending physician notified.
• If transfer form not signed by physician, orders are verified by telephone or fax order.
• A diagnosis or reason is identified for admission i.e., diagnosis supports the medical necessity of admission and the billing requirements, each medication, ancillary service, and treatment with billable supplies that are ordered. (Diagnosis in text of order, on diagnosis list, or through supporting physician documentation).
• Orders are transcribed accurately to MAR and TAR.
• All medication orders include the name of the med, dose, frequency, route, and if appropriate the duration.  PRN orders should include reasons for administration. 
• Admission orders are signed and noted by a nurse as appropriate in accordance with facility procedure.
• An initial nursing assessment/admission note  is completed to include i.e., time of admission, how resident was admitted,  condition of resident, assessment of major body systems, skin, pain
• Care plan is initiated  including primary reason for admission or immediate needs, diet and nursing care.
• Initial Medicare Certification is completed if applicable.
• Allergies are identified and checked for consistency among all the documents.
• Discharge plan is initiated if  applicable (i.e. as required by Joint Commission Accreditation)

Physician Orders: 

• Legible
• Follow standards of practice
• Abbreviations on approved list
• Orders not in conflict
• Labs ordered for appropriate screening of specific drugs

Admit/Return

24 – 48 hours

• Face sheet or demographic information on record.
• Admit – Consent to Treat signed on admission
• H&P and Discharge summary requested from hospital if applicable if not sent with resident. 
• If H&P not completed prior to admission, an exam is scheduled per state requirements.  Resident capacity identified.
• Advanced directive acknowledgement is completed. A copy of the directive is in the record if applicable, physician orders coincide with resident directives.
• Inventory of personal effects is completed if applicable.
• Nursing Assessments completed or updated and others assessments required per facility policy are completed immediately upon admission are complete, timely and authenticated. (No missed sections or questions on the assessment without explanation).  Note:  A Nursing Assessment may be started on admission and completed within 24 hours.
• Admission vital signs, height, and weight are documented.
• Admission paperwork such as consents, consent to treat, privacy statement acknowledgement, bill of rights acknowledgement, etc. Are completed per facility policy.
• PASARR documentation on record or review scheduled.
• Admission PPD read or TB test ordered.  If not, documentation indicates if contraindicated or previously completed within an acceptable timeframe.
• Although it is not recommended to accept an order for restraints on admission, if physical restraints are ordered upon admission the order should include the type of physical restraint/device, the reason for use, the frequency of use and the restrictions for use.  Complete an initial assessment the use of the restraint and a determination made for the time of re-review.  Informed consent has been obtained from the resident or their representative.
• Diagnosis list/other method of diagnosis identification have been started and accurate ICD codes assigned consistent with reason for admission/Medicare.
• Labs, x-rays, consultation visits, etc.  that were ordered upon admission have been scheduled.
• Assessments and monitoring records were initiated or completed per facility policy:  Common assessments include skin risk, fall risk, bowel & bladder monitoring, intake and output records, self-administration of meds, pain assessments, interdisciplinary assessments (dietary, activities, social service, chaplain), teaching/resident education plans, oral/dental assessment, restorative nursing assessments.
• If therapy has been ordered, the plan of treatment/evaluation has been initiated no later than 48 hours.  Physician orders have been clarified to include the specific therapy plan. Diagnoses used for therapy used are identified and consistent with reason for admission/Medicare, etc.

• Primary reason for admission, is identified at the time of admission, with initial care plan that reflects those conditions, alerts and risk factors are clear with monitoring at the time of admission

Admit/Return 14-21 days

• The assessments listed in the 24-48 hour audit that were not initiated in that time frame should be audited during the 14-21 day audit. This can be accomplished by a self- completion manual document and/or tracked in the eHR with reports provided
• Items that were not complete on the admit and 24-48 hour audits are checked.
• 14 day Medicare Recertification has been completed if applicable.
• The 2nd step of the PPD/TB test was administered and read (if applicable).
• The MDSs (both OBRA/regulatory and PPS if applicable).  See the MDS audit criteria for specifics.
• Care plan is complete by day 21 (should be available for use by day 21)

RAI Process

The RAI process should be audited by someone independent of the process to assure compliance with completion and timeliness timeframes.  Recommend auditing each MDS (OBRA/Regulatory and PPS).

• Basic tracking form complete and signed. 
• All questions on the MDS are appropriately answered.
• The Assessment Reference Date (ARD) is determined before the assessment is initiated.
• A2300 Assessment Reference date within the proper range.
• Z0400 date and dates of staff completing the MDS are not prior to the A2300 date.  Staff dates cannot be after the Z0500b date.
• Staff signatures include their title, sections completed and date completed.
• When a computer print-out of the MDS is placed in the chart, the signature dates should reflect the date the staff actually completed the sections of the MDS, not the print-out date.  If a hand-written version of the MDS is used as an input tool, it is retained in the thin chart.
• Triggered CAAs are identified in section V.
• For triggered CAAs, assessment documentation is shown in the location of information column.
• Date in V0200B2 is no later than day 14 after the start of the assessment period.  (Admission no later than day 14, quarterly no more than 92 days between R2b dates, and annual no more than 366 days from last annual V0200B2 date).
• Date in V0200C2 is no more than 7 days after V0200B2.
• CAA documentation/assessments are completed prior to V0200B2.
• If a CAA is identified to be care planned, the issue is addressed on the resident’s plan of care.

Significant Change

• If possible significant change note indicates monitoring to determine need for Full MDS or reason for no new MDS
• Significant change assessment completed within 14 days after significant change in status is noted.
• Basic tracking form completed, signed, dated
• Care Plan Updated

Readmissions

• Discharge Assessment and Reentry Assessment are completed within 7 days of the event.
• Previous Section A copied and left on prior record, original brought forward to readmission record
• New MDS if significant change is noted upon readmission, if no significant change, same MDS continues
• Significant change Permanent – Full MDS completed within 14 days.
• Previous 15 months MDS copied and brought forward (or may be maintained electronically)

Abbreviated Assessment 

• Used only for PPS/MDS Assessment
• If PPS assessment box is not checked (Section A0310B), abbreviated assessment is not used.

MDS Corrections 

• Significant error, correction form completed
• Section X of the MDS is completed
• CAA Triggers recalculated
• Incorrect MDS manually corrected/corrections dated, signed.
• Care Plan updated to reflect changes
• Corrected MDS documents are called to the attention of the business office to assure that adjustment bills are completed if necessary

• The supporting documentation in the medical record is consistent with the MDS scoring.

• The CAA note/documentation addresses the following:  nature of the condition, complications and risk factors that affect the decision to proceed to care planning, factors that must be considered in developing individualized care plan interventions, need for referrals, whether a new care plan, care plan revision, or continuation of current care plan is necessary to address the problem identified

• Verify latest version of MDS software updated per maintenance contract, staff trained

MDS Validation Reports

• The validation report is reviewed after each submission and appropriate follow-up is conducted to address errors.

Concurrent or Quarterly

• Admission Record/Face Sheet: Check if any changes have been made on the face sheet page or any areas are inaccurate.  Reprint a new face sheet if there are changes or inaccuracies.
• Diagnosis List Updated And Coded: Check if new diagnoses have been written on the diagnosis list. Check physicians orders, progress notes, referrals, etc. to see if the physician has documented any new diagnoses.  Code new diagnoses, input into the computer, and print a new list.
• RAI Process:  See RAI Audit Criteria
• Care Plan Current and Complete: Care conference held within 7 days of the MDS (either quarterly or full). All those in attendance signed the attendance record. Care plan is either updated or rewritten or reprinted if there are too many changes and it is difficult to read/use.
• Nursing Assessment and Monitoring: Assessments completed per policy. All entries are signed and dated.  Monitoring records are completed and authenticated – no open holes or breaks in documentation.
• Restorative Program (if applicable):  actual treatment time is documented for rehab nursing service delivery record, an assessment has been completed.  Progress notes reflect residents status and progress.  The care plan reflects restorative program and goals.
• Nursing Documentation:  Nurses notes are signed and dated changes in condition  i.e., incidents/falls, new behavioral manifestation, new skin condition, condition requiring antibiotics;  to include a description of the condition, update of the CP if indicated and documented follow up,  ongoing observations re: conditions identified on the CP,  and supporting documentation for Medicare coverage completed. Weekly/monthly summary or case mix charting completed as applicable.
• Physician Orders – Renewals:  Physician has signed and dated the renewals in the specified timeframe (?)  Orders did not expire before being resigned. Nursing noted orders upon return per facility policy.
• Telephone and Fax Orders:  All telephone orders are complete, signed and dated. All original telephone orders have been returned within the appropriate time frame. All orders given by a physician has a corresponding signed order (TO, fax order, signed physician referral, etc.).
• Physical Restraints:  If ordered, current assessment completed, informed consent documented, order matches device in use. Documentation includes alternatives tried before restraint used.
• Psychotropic, Antipsychotic, Antidepressant, Hypnotic medication Monitoring:  If ordered, monitoring assessments completed, signed and authenticated.  Side effect monitoring completed.  Dose reduction documentation or justification on record. 
• Physician Visits: Visits are made timely. Progress notes written or dictated notes sent back and filed.  Notes are authenticated and dated.  Required NP/PA and physician visits alternate. 
• Physician referrals are complete and noted by the nurse receiving.  Orders on physician referral have been verified with the attending if appropriate and transcribed accurately.
• Documentation of consults for dental, vision, podiatry, audiology/hearing aid, and psychological services are in record when applicable.  Physician progress notes reference diagnosis/condition that support medical necessity of admission, principal care/services; and support the evaluation and management current procedural terminology code (CPT).  Consults are related to a diagnosis/condition for referral, report includes recommendations that are followed up.
• Vital Sign Records: Vitals completed and recorded in a timeframe consistent with facility policy and state regulation where applicable. 
• Weights recorded monthly or per facility policy/state regulation where applicable. Changes in weight (5% in 30 days/10% in 6 mo.) noted in record for possible significant change assessment.  Referrals are made to dietary and physician.  Action follow up.  CP reviewed/updated, progress review follow up on weight also evaluate consistent increase/decrease.
• Medication and Treatment Record:  Look for open holes on the MAR/TARs before end of each shift.  PRN records signed, reason and result documented.  Other flowsheets are complete. If deficiencies found, self monitoring established. Staff is scheduled to complete their documentation and provide self-monitoring systems.

All flowsheets and MAR/TARs have resident name, MR#, month and year identified on every page.

• Pharmacist review conducted monthly.
• Medication disposal/destruction records are complete. Documentation signed and dated.
• Labs:  All orders for labs (routine and stat) have a corresponding lab report in chart.  Labs are noted and dated by nursing.  Lab results are communicated to physician.
• Social Service Documentation:  Each quarter a progress note or assessment form is completed at the time of care conference noting changes to be made to the care plan.  Updates are completed on the Social History.  Entries on all documentation are signed and dated.
• Dietary/Nutrition Documentation:  Each quarter a progress note or assessment form is completed at the time of care conference noting changes to be made to the care plan.  Intake monitoring records are completed as appropriate.  All entries are signed and dated.
• Activity Documentation: Each quarter a progress note or assessment form is completed at the time of care conference noting changes to be made to the care plan.  All entries are signed and dated.
•  Rehabilitation Documentation (PT, OT, SLP): Documentation for each therapy is filed together (all PT doc. together, etc.)  For residents currently treated, service delivery record are completed, treatment time documented, signed and dated, progress notes are written at least every seven days, the physician plan of care/evaluation/cert/recert has been completed and signed by the therapist and physician.  A current physician order is on record matching the current treatment plan.

• Care Plan Content: All CAAs indicated to proceed to the care plan are addressed on the care plan.  Goals are measurable and objective.
• Care Plan and interventions that match the needs of the resident are initiated on admission for the primary reason/s for admission and those high risk areas based on the assessment findings.
• Charting reflects the care plan
• Restorative Program: Progress notes reflect residents status and progress.  The care plan reflects restorative program and goals.

• Med/Tx records; if documentation incomplete, the passing of medication/treatment process is an issue. Implement self-monitoring. Develop policies and procedures/tools to accomplish the self monitoring.  Pharmacy Committee monitors progress from Pharmacist review.
• The lab results are followed up with the physician to assure orders applicable to the lab results
• Social Services  notes reflect evaluation of behavioral issues; follow up on Hx, input from family, visits with resident and social intervention on care plan. 

• Dietary/Nutrition percentage evaluated, labs followed up, weights considered, skin condition considered, care plan reflects current resident status. 

• Activity documentation reflects resident’s interest from assessment, participation alternation trials if not involved, recognizes behavioral manifestations and plan activities accordingly. 

• Chart Thinned:  The chart is thinned per thinning schedule  Forms are repaired Chart is cleaned and organized

• Chart has a file order that indicates location of records, i.e., an automated document.

Resident Transferred to ER or Acute

• Gather all loose forms,  collect the medical record and place in a location that is secure and unavailable for current charting.
• Review the record for completeness of the final transfer note/inter-facility transfer report, current status of the resident at the time of transfer, follow up as needed.
• Check for signatures, time, completeness of the medical record and all loose forms, i.e., ADL sheets, medication/treatment records, therapy records, etc.
• Note: A new record may or may not be initiated on return from the acute hospital.  If the resident returns from the Emergency Room the same record will be continued.

• Assure the record is intact.
• Secure the record in a location that is not available to staff who are taking care of current residents.
• Identify how the electronic record is “checked out” when the resident is out to the ER or short term admission to an acute hospital.

Discharge Analysis

• Chart in placed in discharge chart order per facility policy.
• All Forms have Name/MR#:
• Discharge Plan of Care or Discharge Instructions or Transfer Form: All sections are completed. Signed and dated by appropriate discipline(s) Resident received a copy of discharge plan/instructions which has been written in layman’s terms.
• Recap of stay documented for planned discharged.
• Physician Discharge Summary completed if required by State law.  Physician discharge summary may reference the Interdisciplinary Discharge Summary and Plan of Care; signed by the physician and includes the final diagnosis and prognosis initiated by facility staff.  Physician completed, signed and returned within 30 days of discharge unless other timeframe required by State law.
• Discharge Order:  Discharge order obtained on day of discharge Order included discharge destination, if meds sent when transferring to another facility include statement in order.  Order upon death states to release the body or documentation of physician notification on record.  Discharge order has been signed, dated and returned by the physician
• Orders: Renewals / TO's:  All renewals have been returned and signed All TO's have been returned and signed.  Facility policy should define how to handle orders that have not been returned.
• Discharge documentation:  There is documentation of events leading to discharge or death:   Nurse wrote a note at the time of discharge.  The note leading to discharge/death includes assessment, observations, intervention and detailed documentation of nursing process that lead to death/discharge (as applicable).
• Disposition of Personal Belongings:  Inventory of Personal Belongings completed on discharge; or documentation of belongings sent with resident or picked up by the family documented in notes.
• DC Diagnoses coded and indexed per facility policy.
• MDS Discharge Tracking form completed within 7 days of discharge.

DEATH ONLY:

• Nurses notes reflect physician notification
• Nurses notes reflect family notification
• Mortician Receipt completed.

• Qualitatively and for time saving reasons, consider filing manual discharge record in the same order as the inhouse record.  For automated records, identify  via a slip sheet in the manual record those “record in transition” see the eHR for “specific documentation and specify

Privacy and Security

• Is PHI protected?
• Are destruction processes being followed?
• Is the health record signout process used?
• Are the residents provided with the Notice of Privacy practices on admission?
• Are resident privacy practices available upon request?
• Are computer system precautions in place to prevent inappropriate sharing of PHI?
• Have all employees completed HIPAA training?
• Have all volunteers completed HIPAA training?
• Automated records are available only to staff identified top have access by thePrivacy & Security grid.

Acute Problems/24 Hour Board

(completed daily)

Review the 24 hour log, Nursing identify new orders via computer, alert log or other system reflective of the computer system. For each resident and problem identified check to see if corresponding documentation was completed such as nurses note, monitoring record, physician, family, resident notifications, CP upgrade, etc.

Not only verify that the documentation was done, but also analyze what was documented based on the condition.  Does a note contain information applicable to the problem, should other issues been addressed referrals needed  should the documentation have included an assessment or plan?  Was plan updated as applicable?

Weights

Implement an on-going monitoring system when weights are recorded to note significant weight loss changes or there is a trend over time.

If a significant weight loss or trend has occurred review the documentation content to determine if the assessment and plan are complete and appropriate and if referrals were approved.

Physician Visits

Monitoring system to assure that physician visits are made and documented every 30 days for the first three visits and then every 60 days thereafter.  Assure dictation is returned if applicable. 

Content of the progress note addresses or supports resident issues.

Physician Orders

Reviewed and signed by the physician within specified time frame (30 or 60 days).

Diagnosis can be associated with orders; Check for duplication of medications or treatments in treating a diagnosis.

MAR/TAR

Documentation completed at time of administration or within 24 hours if documentation omission occurs.

Reason and results are documented for PRN administration. Self-monitoring identifies who assumed the med/tx documentation if manual, (sign on and off).  eHR includes an edit/alert system to remind nurses to complete entries.

Physical Restraints

Assessment completed and reviewed/updated at least quarterly.  Consent obtained from resident or responsible party.  Physician order obtained.

Reason for restraint is appropriate to justify use.

Skin/Pressure Sore

Assessment completed and reviewed/updated weekly until healed.

Documentation shows improvement or modification of plan if no improvement and follows the criteria for survey guidance on this subject.

Psychotropic, Antipsychotic, and Hypnotic Medication Use

Assessment completed and reviewed/updated at least every 6 months.  Physician order obtained.  Consent obtained from resident o responsible party.

Diagnosis associated with medication is listed in the federal regulations as appropriate.  Continued justification for administration of medication is documented.  Annual dose reduction considerations are documented.

Lab Result Monitoring

Results of physician orders for all labs are in the medical record.

Documentation reflects that abnormal lab results are communicated with physician.