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On-Time Quality Improvement for Long-Term Care

Sample Reports

The On-Time program is funded by the Agency for Healthcare Research and Quality (AHRQ), with support from the California Healthcare Foundation, to improve long-term care by turning daily documentation into useful information that enhances clinical care planning. These are samples of clinical reports used by front-line teams on a weekly basis to monitor resident status and prompt for changes in the care plan.

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Completeness Report / Nutrition Report / Behavior Report / Pressure Ulcer Trigger Summary Report / Priority Reports


Completeness Report

I. Documentation Completeness: All Shifts

Documentation Item 7/10/2006 7/17/2006 7/24/2006 7/31/2006
Meal Intake 90.2 84.9 83.7 88.3
Bowels 65.8 61.9 63.3 72.7
Bladder 60.1 63.1 60.4 70.3
Behaviors 72.0 74.8 76.5 81.7

II. Summary for Week of 7/31

Total Residents 30
# residents missing ≥75% nutritional intake data  0
# residents missing ≥75% of bowel data  0
# residents missing ≥75% of bladder data  0
# residents missing ≥75% of behavior data  0

III. Documentation Completeness: Night Shift

Documentation Item 7/10/2006 7/17/2006 7/24/2006 7/31/2006
Bowels 39.7 41.6 45.2 62.9
Bladder 40.6 58.0 46.5 68.1
Behaviors 46.0 69.0 65.0 77.6

IV. Documentation Completeness: Day Shift

Documentation Item 7/10/2006 7/17/2006 7/24/2006 7/31/2006
Breakfast 88.8 84.1 82.0 85.2
Lunch 92.0 86.9 82.9 85.2
Bowels 87.5 76.3 73.3 75.7
Bladder 68.3 62.9 61.3 67.1
Behaviors 87.9 83.3 82.9 81.0

V. Documentation Completeness: Evening Shift

Documentation Item 7/10/2006 7/17/2006 7/24/2006 7/31/2006
Dinner 89.7 83.7 86.2 94.3
Bowels 70.1 67.8 71.4 79.5
Bladder 71.4 68.6 73.3 75.7
Behaviors 82.1 72.2 81.6 86.7

VI. Form Consistency Errors

Name Resident ID Section Description
Sample Resident 1 0001119 08/01 (E) bladder Catheter but Incontinent Urine Count not 0
Sample Resident 2 0038900 08/02 (E) bladder Catheter but Incontinent Urine Count not 0
Sample Resident 3 0082800 08/02 (N) bladder Catheter but Incontinent Urine Count not 0
Sample Resident 4 0001117 08/03 (E) behaviors No Behaviors Observed and Frequent Crying both checked
Sample Resident 45 0047100 08/03 (E) behaviors No Behaviors Observed and Abusive Language both checked

VII. Resident Summary Details: Sample

Name Resident ID Section % Complete
______________________ X Behaviors 85.7
______________________ X Bladder 71.4
______________________ X Bowels 66.7
______________________ X Meals 95.2
______________________ X Behaviors 76.2
______________________ X Bladder 71.4
  X Bowels 76.2
  X Meals 90.5
______________________ X behaviors 85.7
______________________ X Bladder 71.4
______________________ X Bowels 81.0
______________________ X Behaviors 71.4
______________________ X Bladder 66.7

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Nutrition Report

High Risk (Decreased Meal Intake and Weight Loss)

Resident Name Resident
ID		 Decreased
Intake		 Avg Meal
Intake %
Wk.
07/10/06		 Avg Meal
Intake %
Wk.
07/17/06		 Avg Meal
Intake Wk.
% 07/24/06		 Avg Meal
Intake %
Wk.
07/31/06		 Wt.
Change
lbs.		 History
Resolved PU		 Most
Recent
Ulcer
Assess
Date		 # PUs
Sample Resident 1 0001119 7/31/2006 73 51 61 52 -2.3   - -
Sample Resident 2 0038900 7/31/2006 0 7 33 36 -6.2   7/19/2006 1

Medium Risk (Decreased Meal Intake or Weight Loss)

Resident
Name		 Resident
ID		 Decreased
Intake		 Avg Meal
Intake %
Wk.
07/10/06		 Avg Meal
Intake %
Wk.
07/17/06		 Avg Meal
Intake Wk.
% 07/24/06		 Avg Meal
Intake %
Wk.
07/31/06		 Wt.
Change
lbs.		 History
Resolved PU		 Most
Recent
Ulcer
Assess
Date		 # PUs
Sample Resident 1 0000000 07/31/2006 32 34 40 42 -   - -
Sample Resident 2 1111111 07/31/2006 76 76 - 71 -   - -
Sample Resident 3 0001119 08/02/2006 49 36 44 54 -   - -
Sample Resident 4 0038900 08/01/2006 74 78 - 64 -   - -
Sample Resident 5 0082800 07/31/2006 56 23 43 43 -   - -
Sample Resident 6 0001117 07/31/2006 41 23 28 47 -   - -
Sample Resident 7 0047100 08/04/2006 73 71 71 62 -   - -

Weight Summary

Resident
Name		 Resident
ID		 Wt. 180
Days Prior		 Wt. 90
Days Prior		 Wt. For Wk.
07/10/06		 Wt For Wk.
07/17/06		 Wt. For Wk.
07/24/06		 Wt. For Wk.
07/31/06		 Wt.
Change lbs.		 Date 5-10% Wt.
Loss ≤ 30 Days		 Date
> 10% Wt. Loss
≤ 180 Days
Sample Resident 1 0000000 - - 139 - 139 140 1 - -
Sample Resident 2 1111111 - - - - - - - - -
Sample Resident 3 0001119 - - 159 159 - - 0 - -
Sample Resident 4 0038900 - - - - - - - - -

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Behavior Report

Number of Residents with Behaviors by Shift: Unit Snapshot

Shift Frequent
Crying		 Yell/
Scream		 Kicking/
Hitting		 Pinch/
Scratch/
Spit		 Biting Wandering Abusive
Language		 Threatening
Behavior		 Resists
Care		 Repititive
Verbalization		 Repititive
Movement		 Sexually
Inappropriate
Behavior
D 2 (6%) 4
(13%)		 1 ( 3%) 0 ( 0%) 0
(0%)		 4 (13%) 2 ( 6%) 2 ( 6%) 2
( 6%)		 4
(13%)		 2 (6%) 0 (0%)
E 1 (3%) 4
(13%)		 1 ( 3%) 0 ( 0%) 0
(0%)		 4 (13%) 2 ( 6%) 1 ( 3%) 5
( 17%)		 5
( 17%)		 1 (3%) 0 (0%)
N 3 (10%) 3
(10%)		 0 ( 0%) 0 ( 0%) 0
(0%)		 0 ( 0%) 1 ( 3%) 0 ( 0%) 3
( 10%)		 3
( 10%)		 2 (6%) 0 (0%)
All 5 (17%) 5
(17%)		 1 ( 3%) 0 ( 0%) 0
(0%)		 5 ( 17%) 2 ( 6%) 2 ( 6%) 6
( 20%)		 5
( 17%)		 3 (10%) 0 (0%)


Name Resident
ID		 Shift Frequent
Crying		 Yell/
Scream		 Kicking/
Hitting		 Pinch/
Scratch/
Spit		 Biting Wandering Abusive
Language		 Threatening
Behavior		 Resists
Care		 Repititive
Verbalization		 Repititive
Movement		 Sexually
Inappropriate
Behavior		 Total
# of
Behaviors
______________________ X D 0 0 0 0 0 0 0 0 0 1 1 0 2
______________________   E 0 0 0 0 0 0 0 0 0 3 3 0 6
______________________   N 0 0 0 0 0 0 0 0 0 0 0 0 0
______________________ X D 0 1 0 0 0 0 0 0 1 1 0 0 3
______________________   E 1 0 0 0 0 0 0 0 3 3 0 0 7
______________________   N 3 1 0 0 0 0 0 0 3 1 1 0 9
______________________ X D 0 6 0 0 0 0 5 0 0 0 0 0 11
    E 0 5 0 0 0 0 4 0 0 0 0 0 9
    N 0 7 0 0 0 0 6 0 0 0 0 0 13
______________________ X D 0 1 1 0 0 2 0 1 1 1 0 0 7
______________________   E 0 1 1 0 0 4 0 2 1 2 0 0 11
______________________   N 0 0 0 0 0 0 0 0 0 0 0 0 0

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Pressure Ulcer Trigger Summary Report

Number of Residents and the Percentage of the Unit Within Each Trigger by Week

Pressure Ulcer Triggers Week 1 Week 2 Week 3 Week 4
  2006-07-10 2006-07-17 2006-07-24 2006-07-31
Wt. Loss 5-10% in ≤ 30 Days - - - -
Wt. Loss > 10% in ≤ 180 Days - - - -
2 Meals ≤ 50% in 1 Day  6 (18%)  8 (23%)  8 (23%)  8 (22%)
Weekly Meal Intake Average < 50%  4 (12%)  7 (20%)  5 (14%)  4 (11%)
Daily Urine Incontinence 10 (30%) 16 (47%) 13 (38%) 15 (41%)
> 3 Days Bowel Incontinence. 13 (39%) 18 (52%) 12 (35%) 15 (41%)
Catherized 10 (30%) 16 (47%) 8 (23%) 12 (33%)
History of Resolved Ulcer - - - -
Current Pressure Ulcer - - - -

Pressure Ulcer Trigger Summary by Resident for Current Week

Name Resident
ID		 Wt. Loss 5-10% in
≤ 30 Days		 Wt. Loss
> 10% in
≤ 180 Days		 2 Meals < 50% in 1 Day Weekly Meal Intake Average < 50% Daily Urine
Incontinence.		 > 3 Days Bowel Incontinence Catheter History of
Resolved
Ulcer		 Current
Pressure
Ulcer		 # of Triggers
Last Week		 # of
Triggers
This Week
______________________ X     X X X X       3 4
______________________ X         X X X     2 3
______________________ X     X     X X     5 3
______________________ X         X X X     0 3
______________________ X         X X X     2 3
______________________ X     X     X X     0 3
  X     X X     X     3 3
______________________ X         X X       1 2
______________________ X     X       X     1 2
______________________ X           X X     3 2

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Priority Reports

Priority Report

Name Resident
ID		 Decreased
Meal +
Wt. Loss		 Wt. Loss
≥5% Last
30 Days		 Incontinence
Increase		 Different
Behaviors
≥ 31		 Worsening
Ulcer		 New
Ulcer		 Open
Area
Resident Name 0001122       3*      
Resident Name 0079601     X       X
Resident Name 0052124     X 4*      
Resident Name 0001637     X        
Resident Name 0003242     X 4      
Resident Name 0039624     X   X    
Resident Name 0065677             X
Resident Name 0002146     X   X X X

1Definition
Behaviors ≥ 3: If 2 or more different behaviors present for the report week that did not present during previous week
AND total number of behaviors ≥ 3, display total number of behaviors with asterisk next to number (asterisk indicates 2
or more additional, different behaviors from previous report week).
Examples
If < 3 different behaviors THEN leave behaviors column blank
If ≥ 3 different behaviors for current week THEN display total # behaviors
If ≥ 3 different behaviors for current week AND increase in total # of different behaviors from previous week by
≥ 2 THEN display # behaviors for current week and asterisk next to number

Residents with Red Areas

Name Resident Id Red Area
Resident Name 0001119 X
Resident Name 0038900 X
Resident Name 0082800 X
Resident Name 0001117 X
Resident Name 0047100 X

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Current as of November 2008

Internet Citation:

On-Time Quality Improvement for Long-Term Care: Sample Reports. November 2008. Rockville, MD; Agency for Healthcare Research and Quality. http://www.ahrq.gov/research/ltc/pusamplerep.htm

 
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