AHRQ’s Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention
Functional Specifications
3. Specifications for Each Pressure Ulcer Prevention Report (continued)
3.7. Resident Clinical, Functional, and Intervention Profile Report
3.7.1. Report Description
This report displays 4 weeks of clinical data for a single resident that is captured from electronic CNA daily charting, physician orders, and lab result values.
3.7.2. Dependencies and Clinical Assumptions
3.7.2.1. This report assumes the EMR vendor can display data for multiple weeks using multiple data sources.
Week Ending | |||||
---|---|---|---|---|---|
4/6/14 | 4/13/14 | 4/20/14 | 4/27/14 | ||
Vital Signs | Number of pressure ulcers | 0 | 1 | 2 | 2 |
Temperature | 99.2 | ||||
Pulse | 82 | 88 | 90 | 100 | |
Respirations | 20 | 20 | 20 | 20 | |
Blood pressure | 102/58 | 110/60 | 102/58 | 120/88 | |
O2 saturation | 96 | 97 | 98 | 88 | |
Weight | Weight in pounds | 149.2 | 144 | ||
Weight date | 3/26/14 | 4/23/14 | |||
Nutrition / Vitamins & Supplements | Diet | Pureed | Pureed | Pureed | Clear liquids |
Tube feeding | No | No | No | No | |
Supplements | No | Ensure | Ensure | Ensure | |
Multivitamin | No | No | No | Yes | |
Vitamin C | No | Yes | Yes | Yes | |
Arginaid | No | No | No | No | |
Zinc | No | No | No | No | |
Protein | No | No | Yes | Yes | |
Weekly average meal intake - percent | |||||
Breakfast | 88 | 78 | 62 | 75 | |
Lunch | 79 | 74 | 25 | 25 | |
Dinner | 65 | 55 | 45 | 35 | |
Nutritional supplement – percent | |||||
Breakfast | 25 | 50 | 25 | 25 | |
Lunch | 25 | 25 | 25 | 25 | |
Dinner | 0 | 25 | 0 | 0 | |
Bowel | Habits | Continent | Continent | Incontinent | Incontinent |
Loose stool | No | No | Yes | Yes | |
Incontinence | |||||
# shifts / week | 0 | 0 | 12 | 18 | |
Daily incontinence | X | ||||
3 days without BM | X | X | |||
Bladder | Habits | Incontinent | Incontinent | Incontinent | Incontinent |
Catheter | Condom | No | No | Foley | |
Ostomy | No | No | No | No | |
Incontinence | |||||
# shifts / week | 9 | 12 | 12 | 14 | |
Daily incontinence | No | No | Yes | Yes | |
Did not void # shifts / week | 0 | 0 | 0 | 1 | |
Restorative | Bowel | No | No | No | No |
Bladder | No | No | Yes | Yes | |
Eating | No | No | No | No | |
Mobility | No | No | No | No | |
Self-Performance / Support Provided2 | Bed mobility | EA/1 | EA/1 | EA/1 | EA/2 |
Transfer | EA/1 | EA/1 | EA/1 | EA/2 | |
Locomotion | EA/1 | EA/1 | EA/1 | EA/2 | |
Dressing | LA/set up | EA/1 | EA/1 | EA/1 | |
Eating | LA/set up | EA/1 | EA/1 | EA/1 | |
Personal hygiene | LA/set up | EA/1 | EA/1 | EA/1 | |
Toileting | EA/1 | EA/1 | EA/1 | EA/2 | |
Labs1 | Pre-Albumin (19.5-35.8 mg/dL) | 33.0 | 21.6 | ||
Albumin (3.4-5.4 g/dL) | 3.4 | 3.6 | 5.8* | 6.2* | |
Sodium (135-145 mEq/L) | 128* | 122* | 114* | 120* | |
Potassium (3.5-5.2 mEq/L) | 4.0 | 4.3 | 4.4 | 4.3 | |
Creatinine (0.7-1.3 mg/dL) | 0.6* | 0.7 | 1.0 | 1.8* | |
BUN (6.0-20.0 mg/dL) | 6.0 | 6.2 | 6.0 | 6.1 | |
Transferrin (20-50%) | 20 | 25 | 35 | 35 | |
Bed Surfaces | Air fluidized surface | X | X | X | X |
Dynamic/alternating pressure | |||||
Low air loss | |||||
Replacement mattress | |||||
Chair Surfaces | Fluid filled or gel cushions | X | X | X | X |
Foam cushions | |||||
Combination cushions | |||||
Other | Heel boots | X | X | X | X |
3.7.4. Valid Input, Calculations, and Displays
3.7.4.1. If multiple data sources are listed, then the facility determines the best source to use for their organization.
Report Column | Data Source | Valid Input & Display |
---|---|---|
Vital Signs | ||
Number of pressure ulcers | Wound Assessment | Count number of unique pressure ulcers and display count. |
Temperature | Vital Signs | Display temperature in Fahrenheit or Celsius, per facility standard. Display xxx.x or xx.x. No leading zeroes. |
Pulse | Vital Signs | Display pulse value as xx or xxx. No leading zeroes. |
Respirations | Vital Signs | Display respiration value as xx. |
Blood pressure | Vital Signs | Display blood pressure value as systolic blood pressure / diastolic blood pressure xxx/xxx, no leading zeroes. |
O2 saturation | EMR vendor determines source, if available | Display oxygen saturation as percentage value as xx. |
Weight | ||
Weekly weight in pounds | Vital Signs or Weight documentation | Display weight value in pounds unless facility uses other metric and display pounds as xxx.x. No leading zeroes. |
Weight date | Vital Signs or Weight Documentation | Display weight date of lowest weekly weight value. See Weight Summary Report for description and instructions to determine weekly weights. |
Nutrition/Vitamins & Supplements | ||
Diet | Physician Orders | Display diet name. |
Tube feeding | Physician Orders | If there is a physician order for tube feeding, then display as yes or no. |
Supplements | Physician Orders | If there is a physician order for a nutritional supplement, then display the name of the supplement ordered; if no order, then display "no." |
Multivitamin | Physician Orders | If there is a physician order for Multivitamins, then display "yes"; if no order, then display "no." |
Vitamin C | Physician Orders | If there is a physician order for Vitamin C, then display "yes"; if no order, then display "no." |
Arginaid | Physician Orders | If there is a physician order for Arginaid, then display "yes"; if no order, then display "no." |
Zinc | Physician Orders | If there is a physician order for Zinc, then display "yes"; if no order, then display "no." |
Protein | Physician Orders or Dietitian Referral | If there is a physician order or if the dietitian prescribes Protein to supplement the diet order, then display "yes"; if not prescribed, then display "no." |
Weekly average meal intake – percent Breakfast |
Use calculations in Nutrition Report for computing average meal intake values | Display average meal intake percentage as xx. |
Lunch | Display average meal intake percentage as xx. | |
Dinner | Display average meal intake percentage as xx. | |
Nutritional supplement – percent Breakfast |
Use calculations in Nutrition Report for computing average meal intake values | Display average supplement intake percentage as xx. |
Lunch | Display average supplement intake percentage as xx. | |
Dinner | Display average supplement intake percentage as xx. | |
Bowel | ||
Habits | CNA documentation of bowel habits | If any bowel incontinence documented during the report week, then display "incontinent"; otherwise, display "continent." |
Loose stool | CNA documentation of bowel habits or nurse documentation | If any loose stool documented during the report week, then display "yes"; otherwise, display "no." |
Incontinence | CNA documentation of bowel habits | |
# shifts / week | CNA documentation of bowel habits | Count the number of shifts bowel incontinence recorded during the report week and display count as xx; maximum value = 21 if 8 hour shifts or 3 shifts per day; maximum value = 14 if 12 hour shifts or 2 shifts per day. Refer to facility schedule. |
Daily incontinence | CNA documentation of bowel habits | If bowel incontinence documented at least one shift each day during the report week, then display "yes"; otherwise, display "no." |
3 days without BM | CNA documentation of bowel habits | If "no bowel movement" selected for 9 consecutive shifts during report week and facility shifts = 8 hours, then display X. If 6 consecutive shifts during report week and facility shifts = 12 hours, then display X. |
Bladder | ||
Habits | CNA documentation of bladder habits | If any bladder incontinence documented during the report week, then display "incontinent"; otherwise, display "continent." |
Catheter | Physician Orders or CNA documentation of bladder habits | If Foley or external catheter used during the report week, then display X. |
Ostomy | Physician orders or CNA documentation of bladder habits | If Ostomy used during the report week, then display X. |
Incontinence | CNA documentation of bladder habits | |
# shifts / week | CNA documentation of bladder habits | Count the number of shifts bladder incontinence recorded during the report week and display count as xx; maximum value = 21 if 8 hour shifts or 3 shifts per day; maximum value = 14 if 12 hour shifts or 2 shifts per day. Refer to facility schedule. |
Daily incontinence | CNA documentation of bladder habits | If bladder incontinence documented at least one shift each day during the report week then display "yes"; otherwise, display "no." |
Did not void # shifts / week | CNA documentation of bladder habits | Count the number of shifts "did not void" selected and display count; display as xx. |
Restorative | ||
Bowel | Physician Orders or Nurse Orders or nurse notes or restorative notes | If restorative program for bowel in place during the report week, then display. "yes"; otherwise, display "no." |
Bladder | Physician Orders or Nurse Orders or nurse notes or restorative notes | If restorative program for bladder in place during the report week, then display "yes"; otherwise, display "no." |
Eating | Physician Orders or Nurse Orders or nurse notes or restorative notes | If restorative program for eating in place during the report week, then display "yes"; otherwise, display "no." |
Mobility | Physician Orders or Nurse Orders or nurse notes or restorative notes | If restorative program for mobility in place during the report week, then display "yes"; otherwise, display "no." |
Self Performance/Support Provided | ||
Bed Mobility | CNA documentation of ADL | Use the following responses for self-performance and support provided for bed mobility, transfer, locomotion, dressing, eating, personal hygiene, and toileting:
|
Transfer | CNA documentation of ADL | See instructions for Bed Mobility. |
Locomotion | CNA documentation of ADL | See instructions for Bed Mobility. |
Dressing | CNA documentation of ADL | See instructions for Bed Mobility. |
Eating | CNA documentation of ADL | See instructions for Bed Mobility. |
Personal Hygiene | CNA documentation of ADL | See instructions for Bed Mobility. |
Toileting | CNA documentation of ADL | See instructions for Bed Mobility. |
Labs | ||
Pre-Albumin (19.5-35.8 mg/dL | Lab Results | If the EMR vendor stores lab values, then display value closest and prior to report ending date for the report week. Provide indicator for out-of-range values; above average and below average indicator. Display Pre-Albumin value as xx.x mg/dL. |
Albumin (3.4-5.4 g/dL) | Lab Results | Display Albumin value as x.x. |
Sodium (135-145 mEq/L) | Lab Results | Display Sodium value as xxx. |
Potassium (3.5-5.2 MEq/L) | Lab Results | Display Potassium value as x.x. |
Creatinine (0.7-1.3 mg/dL) | Lab Results | Display Creatinine value as x.x. |
BUN (6-20 mg/dL) | Lab Results | Display BUN value as x.x. |
Transferrin (20-50%) | Lab Results | Display Transferrin percentage value as xx. |
Bed Surfaces | ||
Air fluidized surface | Physician Orders | If there is a physician order for air fluidized surface, then display "X"; otherwise, leave blank. If physician order not required, then facility determines source. |
Dynamic/alternating pressure | Physician Orders | If there is a physician order for dynamic/alternating pressure surface, then display "X"; otherwise, leave blank. If physician order is not required, then facility determines source. |
Low air loss | Physician Orders | If there is a physician order for low air loss bed surface, then display "X"; otherwise, leave blank. If physician order is not required, then facility determines source. |
Replacement mattress | Physician Orders | If there is a physician order for replacement mattress, then display "X"; otherwise, leave blank. If physician order is not required, then facility determines source. |
Chair Surfaces | ||
Fluid filled or gel cushions | Physician Orders | If there is a physician order for fluid filled or gel cushions then display "X"; otherwise, leave blank. If physician order is not required, then facility determines source. |
Foam cushions | Physician Orders | If there is a physician order for foam cushions, then display "X"; otherwise, leave blank. If physician order is not required, then facility determines source. |
Combination cushions | Physician Orders | If there is a physician order for combination cushions, then display "X"; otherwise, leave blank. If physician order is not required, then facility determines source. |
Other | ||
Heel boots | Physician Orders | If there is a physician order for heel boots, then display "X"; otherwise, leave blank. If physician order is not required, then facility determines source. |
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