Quick Tips for Clinical Reports

On-Time Quality Improvement for Long-Term Care

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.

I. Completeness Report

Use: Monitor certified nurse assistants (CNA) form completeness and consistency by nursing station.

Form Completion: Questions Answered

  1. Are all required sections of the form >90%:
    • Meal Intake.
    • Bowels.
    • Bladder.
    • Behaviors.
  2. What are the completeness trends over the past 4 weeks for required sections of the form? Are rates stable? Better? Worse?
  3. For sections below 90%, are low rates shift-related or staff-specific?
  4. Are there differences across shifts? For example, is documentation consistent for all meals?
  5. Are completeness rates consistent with review of physical form? Are rates related to quality of handwriting?

Form Consistency: Questions Answered

  1. Are there documentation inconsistencies?
  2. Are form inconsistencies specific to one or more sections of the form?
  3. Are form inconsistencies occurring on all shifts? One shift? Two shifts?
  4. What are the form errors? Are errors associated with all 4 required sections of the form or isolated to one or two problem areas?
  5. Are the errors associated with specific team members?
  6. 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).

Questions Answered

  1. 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)?
  2. Is report information consistent with resident clinical picture?
  3. 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?
  4. Does the resident also have a pressure ulcer?
  5. When was last dietary consult?

III. Behavior Report

Use: Monitor behavior trends by nursing unit and behaviors by resident by nursing station.

Questions Answered

  1. What are the most frequent behaviors observed on the unit? Does this match staff perception?
  2. Are there residents with >10 behavior incidences for a single shift for the report week?
  3. Do report results match resident clinical picture?
  4. How many behaviors were observed during the report week for a specific resident?

IV. Trigger Summary Report

Use:

  1. Monitor number of pressure ulcer triggers by resident; compare current to previous report week.
  2. Monitor pressure ulcer trigger trends by nursing unit.

Questions Answered

  1. What are unit trends for PU triggers? Are they stable? Getting worse? Better?
  2. Are there improvements in target areas?
  3. Are there improvements in areas of new program development?
Page last reviewed June 2007
Internet Citation: Quick Tips for Clinical Reports: On-Time Quality Improvement for Long-Term Care . June 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/qualityimprov/puquicktips.html