AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention

Facilitator Training—Additional Exercises (continued)

Completeness Report

Exercise #1: Report Information: Entire Facility

Sample Completeness Report: Entire Facility
Documentation Section 5/4/14 5/11/14 5/18/14 5/25/14
Meal Intake 92.2 93.1 90.4 92.0
Bowels 67.6 74.9 66.2 58.3
Bladder 54.8 61.7 78.2 86.9
Behaviors 53.1 69.9 87.1 91.0

Discussion Questions

  1. Which documentation category in current week has:
    • The highest completeness rate? The lowest?
  2. Viewing the trends over the last 4 weeks, which category has:
    • Shown no improvement over 4 weeks?
    • The most fluctuation week to week?
  3. What questions would you ask the team about:
    • Trend in Behavior completeness rates?
    • Changes in Bladder completeness rates?

Answers:

  1. Highest completeness rate: Meal intake
    Lowest completeness rate: Bowels
  2. Shown no improvement: Bowels
    Most fluctuation: Behaviors
  3. Trend in Behavior completeness rate: Did they make any changes to the way they record behaviors? Have there been any recent in-services or trainings that have raised awareness of behaviors?
    Trend in changes in Bladder completeness rates: What have they been doing to improve their completion rates so significantly?

Return to Additional Exercises Contents

Exercise #2: Report Information by Shift

Day Shift

Documentation Section 5/29/13 6/5/13 6/12/13 6/19/13
Meal Intake Breakfast 88.2 97.2 99.1 99.4
Meal Intake Lunch 98.4 96.2 92.2 96.6
Bowels 87.6 84.9 96.2 98.3
Bladder 54.8 61.7 78.2 86.9
Behaviors 53.1 69.9 87.1 91.0

Evening Shift

Documentation Section 5/29/13 6/5/13 6/12/13 6/19/13
Meal Intake Dinner 90.0 92.0 80.0 80.0
Bowels 97.6 94.9 96.2 98.3
Bladder 54.8 61.7 78.2 86.9
Behaviors 53.1 69.9 87.1 91.0

Night Shift

Documentation Section 5/29/13 6/5/13 6/12/13 6/19/13
Bowels 67.6 64.9 66.2 58.3
Bladder 54.8 61.7 78.2 86.9
Behaviors 53.1 69.9 87.1 91.0

Discussion Questions

  1. What can you say about documentation completeness in the current week?
  2. What trends are worth noting:
    • Which shift has the most consistent rates?
    • Which shift has the most fluctuation in rates?
  3. What areas of documentation need some followup investigation? Why?

Answers:

  1. Only one category is below 75%—Bowels on night shift
  2. Shift with most consistent rates—Day shift
    Shift with the most fluctuation in rates—Evening
  3. Areas of documentation in need of followup: Bowels on night shift because they are still below 75 percent in completeness. Also, all three shifts have the exact same percent completeness for Behaviors, which makes it look like evening and night shifts are copying day shift entries.

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Return to Pressure Ulcer Prevention

Page last reviewed April 2016
Page originally created March 2013
Internet Citation: AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention. Content last reviewed April 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/ontime/pruprev/addexercises5.html