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Table 4.3. Sample Trigger Summary Tracking Form

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

Trigger Summary Report Review

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Unit Information

1

# Residents on unit

      

2

# Residents on unit with NEW pressure ulcers (all stages)

      

3

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

      

Residents Who Trigger

4

# Residents with ≥4 triggers

      

5

# Residents with ≥3 triggers

      

6

# Resident with increase in triggers by ≥2 from previous week

      

Residents Who Are Also

7

# High risk on Nutrition Report

      

8

# Tube fed

      

13

# Admitted within past 7 days

      

14

# Admitted within past 30 days

      

Interventions

15

# Referral: Dietitian

      

16

# Referral: Wound nurse/team

      

17

# Referral: Speech

      

18

# Referral: Rehab

      

19

# Referral: Psych

      

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Page last reviewed January 2011
Internet Citation: Table 4.3. Sample Trigger Summary Tracking Form: 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/qimanltab4-3.html