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

Functional Specifications

3. Specifications for Each Pressure Ulcer Prevention Report (continued)

3.8. Completeness Report

3.8.1. Report Description

The Completeness Report is a check of CNA documentation to determine how much of the data needed for report calculations may be missing. It is not included as a required report because of the advances long-term care/postacute care (LTPAC) EMR vendors have made in the last decade in providing a mechanism for users to monitor CNA documentation completion; Therefore, the report is now an optional report for implementers.

On-Time Reports are generated from four sections of CNA documentation: Meal Intake, Bowels, Bladder, and Behaviors.

3.8.2. Dependencies and Clinical Assumptions

3.8.2.1.  CNAs are charting daily notes in electronic format for meal intake, bowel, bladder, and behavior documentation.

3.8.3. Report Example

Documentation Section 5/29/13 6/5/13 6/12/13 6/19/13
Meal Intake 90.7 86.1 85.3 85.3
Bowels 67.7 74.9 66.2 68.3
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

3.8.4. Valid Input, Calculations, and Displays

Report Column Data Source Valid Input & Display
Meal Intake CNA documentation of meal intake Includes: All residents on a unit during each week.

  • For each resident, count the number of times a meal intake entry was made for the current week. (Note: A week is defined as static week starting every Monday through Sunday.)
  • 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).
  • Report the value as a percentage (allow one decimal point).
  • If the completeness for a resident is ≥75%, set meal intake completeness flag to true. (This will be used to identify which residents appear on subsequent reports.)
  • Compute an overall meal intake completeness average for the unit.
Bowels CNA documentation of bowel habits Includes: All residents on a unit during each week.

  • For each resident, count the number of shifts a bowel entry was made for the current week. (Note: A week is defined as static week starting every Monday through Sunday.)
  • 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).
  • Report the value as a percentage (allow one decimal point).
  • If the completeness for a resident is ≥75%, set bowel completeness flag to true. (This will be used to identify which residents appear on subsequent reports.)
  • Compute an overall bowel completeness average for the unit.
Bladder CNA documentation of bladder habits Includes: All residents on a unit during each week.

  • For each resident, count the number of shifts a bladder entry was made for the current week. (Note: A week is defined as static week starting every Monday through Sunday.)
  • 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).
  • Report the value as a percentage (allow one decimal point).
  • If the completeness for a resident is ≥75%, set bladder completeness flag to true. (This will be used to identify which residents appear on subsequent reports.)
  • Compute an overall bladder completeness average for the unit.
Behaviors CNA documentation of behaviors Includes: All residents on a unit during each week.

  • For each resident, count the number of shifts a behaviors entry was made for the current week. (Note: a week is defined as static week starting every Monday through Sunday.)
  • 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).
  • Report the value as a percentage (allow one decimal point).
  • If the completeness for a resident is ≥75%, set behaviors completeness flag to true. (This will be used to identify which residents appear on subsequent reports.)
  • Compute an overall behaviors completeness average for the unit.

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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-functspecs3-8.html