Facility Self-Assessment (Mock Survey) Tool - Nursing Home Help

CHART AUDIT TOOL
FOCUS REVIEW RELATED TO:
Change of condition of
Focus Documentation (Medicare/Hospice/Dialysis) Incident
Admission
Discharge
Date:
Patient: Rm#: Admit Date:
Area of review
Resident Physical Assessment
positioning:
preventative devices:
catheter positioning:
ADL care:
dated equipment:
call light:
water in reach:
personal care items:
Consents
restraints:
advance directives:
non-compliance:
H & P
signed:
timely:
Physicians Orders
DNR:
TB testing:
certification:
timely:
Telephone Orders
written correctly:
return timely:
transcribed:
Nursing Assessment / Summary
complete:
timely:
accurate:
Nurses Notes
family / Dr. notified:
accurate descriptive:
follow-up evident:
vital signs:
MDS 3.0
MDS
accurate/CAA:
date:
Quality
updated:
date timely:
complete:
Met
Not
Met N/A Comments
5.75