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
- Which documentation category in current week has:
- The highest completeness rate? The lowest?
- Viewing the trends over the last 4 weeks, which category has:
- Shown no improvement over 4 weeks?
- The most fluctuation week to week?
- What questions would you ask the team about:
- Trend in Behavior completeness rates?
- Changes in Bladder completeness rates?
Answers:
- Highest completeness rate: Meal intake
Lowest completeness rate: Bowels - Shown no improvement: Bowels
Most fluctuation: Behaviors - 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?
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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
- What can you say about documentation completeness in the current week?
- What trends are worth noting:
- Which shift has the most consistent rates?
- Which shift has the most fluctuation in rates?
- What areas of documentation need some followup investigation? Why?
Answers:
- Only one category is below 75%—Bowels on night shift
- Shift with most consistent rates—Day shift
Shift with the most fluctuation in rates—Evening - 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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