Quick Tips for Clinical Reports
These Quick Tips describe the purpose and use of clinical reports. The On-Time program is funded by the Agency for Healthcare Research and Quality (AHRQ), with support from the California Healthcare Foundation, to improve long-term care by turning daily documentation into useful information that enhances clinical care planning.
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Use: Monitor certified nurse assistants (CNA) form completeness and consistency by nursing station.
Form Completion: Questions Answered
- Are all required sections of the form >90%:
- Meal Intake.
- What are the completeness trends over the past 4 weeks for required sections of the form? Are rates stable? Better? Worse?
- For sections below 90%, are low rates shift-related or staff-specific?
- Are there differences across shifts? For example, is documentation consistent for all meals?
- Are completeness rates consistent with review of physical form? Are rates related to quality of handwriting?
Form Consistency: Questions Answered
- Are there documentation inconsistencies?
- Are form inconsistencies specific to one or more sections of the form?
- Are form inconsistencies occurring on all shifts? One shift? Two shifts?
- What are the form errors? Are errors associated with all 4 required sections of the form or isolated to one or two problem areas?
- Are the errors associated with specific team members?
- How many residents have errors? What percent of total census?
II. Nutrition Report
Use: Identify and monitor residents with decreased meal intake and/or weight loss (indicators for high risk of pressure ulcer [PU] development).
- How many residents trigger for high risk (decreased meal intake of 2 meals @ <50% at least one time during report week AND weight loss for report week)? Medium risk (decreased meal intake OR weight loss)?
- Is report information consistent with resident clinical picture?
- For residents at high risk, is average meal intake <50%? If no, is there a downward trend in average meal intake over past 4 weeks?
- Does the resident also have a pressure ulcer?
- When was last dietary consult?
III. Behavior Report
Use: Monitor behavior trends by nursing unit and behaviors by resident by nursing station.
- What are the most frequent behaviors observed on the unit? Does this match staff perception?
- Are there residents with >10 behavior incidences for a single shift for the report week?
- Do report results match resident clinical picture?
- How many behaviors were observed during the report week for a specific resident?
IV. Trigger Summary Report
- Monitor number of pressure ulcer triggers by resident; compare current to previous report week.
- Monitor pressure ulcer trigger trends by nursing unit.
- What are unit trends for PU triggers? Are they stable? Getting worse? Better?
- Are there improvements in target areas?
- Are there improvements in areas of new program development?
Current as of June 2007
On-Time Quality Improvement for Long-Term Care: Quick Tips for Clinical Reports. June 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/ltc/puquicktips.htm