AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention
Functional Specifications
1.0. Functional Specs for Pressure Ulcer Prevention
2.0. Pressure Ulcer Prevention Reports
3.0. Specifications for Each Pressure Ulcer Prevention Report
3.1. Nutrition Risk Reports: High Risk and Medium Risk
3.2. Intervention History for Nutrition Risk Reports: High Risk and Medium Risk
3.3. Weight Summary Report
3.4. Trigger Summary Report: Resident Level
3.5. Trigger Summary Report: Unit Level
3.6. Risk Change Report (formerly Priority Report)
3.7. Resident Clinical, Functional, and Intervention Profile Report
3.8. Completeness Report
1.0. Functional Specs for Pressure Ulcer Prevention
This document describes the functional and high-level system requirements for each clinical report included in On-Time Pressure Ulcer Prevention. It is intended to provide enough information for EMR vendor programmers to produce technical specifications, develop the reports as designed, and incorporate reports into the vendor's EMR product. Data sources and rules specific to each report are included.
On-Time reports are designed to be added to the existing reporting feature of EMR products and to use existing EMR data elements as data sources for reports. This eliminates the need for EMR vendors to develop new software features, modify existing software, or make any changes to system design in order to add On-Time to their system. On-Time, once added to the EMR product, does not interfere with routine use of the product by end users.
Data elements and data sources are described for each report and the vendor or facility representative determines the availability of data elements required for each report by conducting a brief gap analysis. The vendor will add data elements as needed or make recommendations to the nursing home clinical representative for EMR development if substitute data elements are available and appropriate to accomplish the same report results and maintain the integrity of report design and meaning.
1.1. EMR Vendor Prerequisites
The following EMR capabilities are necessary to provide the required data elements for On-Time reports:
- Certified nursing assistant (CNA) daily documentation of meal intake, bowel and bladder habits, and activities of daily living (ADLs) such as bed mobility, transfer, locomotion, dressing, personal hygiene, toileting, and bathing.
- Documentation of resident weights and vital signs such as temperature, pulse, respirations, and blood pressure.
- Physician order entry.
- Nurse weekly documentation of wound assessments (preferred).
If any data are not available, then reports will be missing some data.
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