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Table 3.3. Sample Tracking Form: High-Risk Residents

On-Time Quality Improvement Manual for Long-Term Care Facilities

Nutrition Report and CNA 5 minute standups

Date

Date

Date

Date

Date

Date

Unit Information

1

# Residents on unit

      

2

# Residents on unit with pressure ulcers (all stages): new ulcers

      

3

# Residents on unit with pressure ulcers (all stages): existing ulcers

      

4

Total time spent

      

High-Risk Results

5

# Residents who triggered

      

6

# Residents on hospice

      

High-Risk Interventions

7

# Diet changes

      

8

# Food preference changes

      

9

# Referral: Speech

      

10

# Referral: Rehab

      

11

# Referral: Psych

      

12

# Referral: Hospice

      

13

# Referral: Labs

      

14

# Referral: Gastro/ENT

      

15

# Referral: Other

      

* Tracking forms are available for high risk, medium risk, or combination high and medium risk.

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Page last reviewed January 2011
Internet Citation: Table 3.3. Sample Tracking Form: High-Risk Residents: On-Time Quality Improvement Manual for Long-Term Care Facilities. January 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/ontimeqimanual/qimanltab3-3.html