Admission assessment is fully completed, signed by RN (co-sign).
All other assessments done: pain, fall, skin, etc.
Treatment admin. records signed for.
Medication admin. records (MAR) signed.
Immunizations documented properly/done.
Weights charted monthly per order.
Does the documentation demonstrate:
• Skilled observation and monitoring
• Progress notes
What else do the documentation demonstrate:
Is the care plan:
Accurate and up to date?
Specific problems or potential problems identified and planned interventions identified?
Indication of daily or more frequent monitoring of vital signs, lung sounds, bowel sounds, skin condition, nutritional status, hydration, mental status, and mobility as it relates to instability or possible changes in condition to help identify if changes in nursing care are indicated.
Proper evaluation dates and follow-ups.
Proper signatures on care plan.
Care planning reflects MDS and other assessments.
Evidence of teaching, training, and outcomes clearly noted.
Proper notation by the door (if permitted by state); proper protocol followed.
Water at bedside.
Fall risk evident.
Wound care protocol followed/proper forms completed.
Protocol/forms followed (assessment and outcome).
Initial and ongoing pain assessments done.
Equipment in room
Respiratory, feeding pump equipment labeled/tagged.
IVs dated, labeled.
Wound dressings, IV site dated and signed.
Properly positioned. WC, bed.
Appears clean, appropriate dress.