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

Functional Specifications (continued)

2.0. Pressure Ulcer Prevention Reports

The reports included in On-Time Pressure Ulcer Prevention and described in this document are listed in the table below.

On-Time Pressure Ulcer Prevention Reports 

# Report
1a Nutrition Risk Report: High Risk
1b Nutrition Risk Report: Medium Risk
2a Intervention History for Nutrition High Risk Report
2b Intervention History for Nutrition Medium Risk Report
3 Weight Summary Report
4a Trigger Summary Reports: Resident Level
4b Trigger Summary Report: Unit Level
5 Risk Change Report (Priority Report)
6 Resident Clinical, Functional, and Intervention Profile Report
7 Completeness Report

2.1. Report Titles

The functional specifications for all On-Time sections are available to any long-term care EMR vendors wanting to incorporate On-Time reports into their product; however, all reports must be labeled "On-Time" and developed as specified, to maintain the integrity of the reports for facilities participating in the On-Time Pressure Ulcer Prevention Program.

Nursing home facilities adopting any of the work with an On-Time facilitator who adheres to a structured implementation plan using detailed implementation and guidance materials that are also provided to nursing home participants. It is important for successful implementation of the program and end user adoption of the sections that users have easy access to the appropriate report when needed, the report is labeled and developed as described in the implementation materials and during facilitation, and the report can be used as intended in day-to-day work.

2.2. Report Headers

For all On-Time Reports, display the following information:

  • Include "On-Time" in the name of the report.
  • Include in the top left margin:
  • Nursing unit
  • Report ending date
  • Include "Source: Agency for Healthcare Research and Quality; 2014" in the bottom left margin.

2.3. General Report Rules

The following rules apply to all reports.

2.3.1. Exclusions

Exclude from report calculations and displays residents who do not have a minimum of 75 percent documentation completed for the following components of CNA documentation:

  • Meal intake.
  • Bowel.
  • Bladder.
  • ADL assistance needed and support provided for bed mobility, transfer, locomotion, dressing, personal hygiene, toileting, and bathing.

Display a dash (-) in report sections with insufficient documentation to compute values.

Note: If a resident has the required amount of documentation for meal intake and bowel but lacks the required 75 percent documentation for bladder and ADL documentation on a report that displays these categories, the report will display a dash (-) in the report sections with insufficient documentation to compute values. The dash (-) will alert the user that insufficient data were available for calculations and therefore improvement or decline in these areas from the prior week is unknown.

Additional exclusions follow:

  • Residents no longer being treated at the facility, which includes residents with discharge dates within 7 days prior to the report date.
  • Physician orders with discontinuation dates or expiration dates within 7 days prior to the report date and during calculation periods; includes medication profiles.
  • Resident diagnosis codes that are inactive or discontinued within 7 days prior to the report date and during calculation periods.

2.3.2. Reports With Data for Multiple Weeks

For reports that display data for multiple weeks, use a static week for 4 weeks prior to report date, 3 weeks prior to report date, and 2 weeks prior to report date for report calculations. The EMR vendor must use the static week parameters set forth by the facility (e.g., Sunday through Saturday, Monday through Sunday). Examples of static week parameters used in report definitions or calculations are illustrative and do not represent a requirement for the range of days to be used for the static report week.

It is important to use static weeks to maintain consistency in the values that display in prior report weeks. A static week uses fixed date ranges. Clinicians who reviewed the report 2 or 3 weeks prior likely acted on values that displayed. If dynamic weeks were used in trended reports, the values for prior weeks would change each time the report was generated, causing confusion for users.

In addition to the column title, display the last date of the static week in the column heading. For example, if the end user chooses to generate a Nutrition High Risk report with an end date of 3/22/14 (a Saturday), the column headings will display these dates:

Avg. Meal Intake %
3/1/14
Avg. Meal Intake %
3/8/14
Avg. Meal Intake %
3/15/14
Avg. Meal Intake %
3/22/14
       

If the end user chooses to generate a Nutrition High-Risk Report with an end date of 3/19/14 (a Wednesday), instead of 3/22/14 (a Saturday), the column headings will display the same dates because the last date of the static week displays in the column heading regardless of the report generation date within the report week. 

2.3.3. Filters

End users must be able to filter reports by nursing unit.

2.3.4. End Dates

End users must be able to specify a report "end date" to generate reports for specified periods.

2.3.5. Pressure Ulcer Identifiers

In some cases, an On-Time report will display information about a resident's pressure ulcers, which is captured from nursing documentation of a weekly wound assessment. For example, if a single resident has six pressure ulcers, then the system must assign a unique identifier to each one.

2.3.6. Documentation Completion Calculations

The following table describes a process that may be used to determine documentation completion percentages for specific documentation sections. The EMR vendor can use an existing mechanism to determine documentation completion by section, if available, and the rule meets the minimum requirement for 75 percent completion.

Any Report Column That Includes Determine Documentation Completeness
Resident Meal Intake Documentation (for breakfast, lunch, and dinner)
  1. For each resident, count the number of times a meal intake entry was made for the current week.
  2. Divide the count by the total number of meals possible for the current week (i.e., if a resident was not on unit for specific days during the week, the possible number of meals should be reduced).
  3. Report the value as a percentage (allow one decimal point).
  4. If the completeness for a resident is ≥75%, set a meal intake completeness flag to true. (This will be used to identify which residents appear on subsequent reports.)
Resident Bowel Documentation
  1. For each resident, count the number of shifts a bowel entry was made for the current week. (Example: a week is defined as a static week starting every Monday through Sunday.)
  2. Divide the count by the total number of shifts possible for the current week (i.e., if a resident was not on unit for specific days during the week, the possible number of shifts should be reduced).
  3. Report the value as a percentage (allow one decimal point).
  4. If the completeness for a resident is ≥75%, set a bowel completeness flag to true. (This will be used to identify which residents appear on subsequent reports.)
Resident Bladder Documentation
  1. For each resident, count the number of shifts a bladder entry was made for the current week. (Example: a week is defined as a static week starting every Monday through Sunday.)
  2. Divide the count by the total number of shifts possible for the current week (i.e., if a resident was not on unit for specific days during the week, the possible number of shifts should be reduced).
  3. Report the value as a percentage (allow one decimal point).
  4. If the completeness for a resident is ≥75%, set a bladder completeness flag to true. (This will be used to identify which residents appear on subsequent reports.)
ADLs: assistance needed and support provided For each ADL component, repeat steps 1-4 for the following:

  • Bed mobility
  • Transfer
  • Locomotion
  • Dressing
  • Personal hygiene
  • Toileting
  • Bathing

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Page last reviewed April 2016
Page originally created September 2014
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/pruprev-functspecs2.html