Forms for Long Term CareLong Term Care Forms

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October, 2016 Edition for MDS v1.15.1

Current with all RAI Manual Updates, Surveyor Guidelines and Federal Regulatory Changes

127 Forms in the book and on CD:

Assessments, Audits, Monitoring and Flow Sheets, and more

 Table of Contents

Skilled Charting Guidelines Cardiac Care

Skilled Charting Guideline for Tube Feeding

Urinary Catheter Audit

Long term care nursing documentation can be very time consuming. Having the right nursing form for the job at hand makes the task easier and quicker. The right form will have all of the essential information, but no more, and be organized logically for the task.

The form templates in this manual cover all the basic needs of long term care data collection, assessment, monitoring, and tracking. All the forms in the book are included on the CD-ROM, and can easily be made facility and resident specific with a word processor. Having the master forms on CD enables the user to change them as the facility policies evolve. It also assures clean copy.

Forms have been updated to ensure compliance with the change to MDS 3.0 and with all of the federal regulations and guidelines updated during the past year.

The 20 Care Area Assessment Modules in this book are easy-to-use checklists of triggers, and include many other very pertinent MDS 3.0 items to help make the care-planning decision clearer.

The applicable MDS 3.0 sections are listed on the left side of the form, and flow alphabetically in MDS order for fast reference. Ample space is at the bottom of the form for Care Area Assessment Summary documentation notes.

The Skilled Charting Guidelines provide clear instructions for the supporting documentation required for Medicare reimbursement, and can also assist in determining what conditions may be considered skilled care. They are often placed in front of the nurses’ notes in the resident’s chart to clarify what must be charted on the Medicare resident.

Forms for Long Term Care will benefit:

Charge Nurses

MDS Coordinators

Directors of Nursing

Restorative Nurses

Quality Assurance departments

Social Services departments