AHRQ's Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention
Functional Specifications
3. Specifications for Each Pressure Ulcer Prevention Report (continued)
3.8. Completeness Report
3.8.1. Report Description
The Completeness Report is a check of CNA documentation to determine how much of the data needed for report calculations may be missing. It is not included as a required report because of the advances long-term care/postacute care (LTPAC) EMR vendors have made in the last decade in providing a mechanism for users to monitor CNA documentation completion; Therefore, the report is now an optional report for implementers.
On-Time Reports are generated from four sections of CNA documentation: Meal Intake, Bowels, Bladder, and Behaviors.
3.8.2. Dependencies and Clinical Assumptions
3.8.2.1. CNAs are charting daily notes in electronic format for meal intake, bowel, bladder, and behavior documentation.
3.8.3. Report Example
Documentation Section |
5/29/13 |
6/5/13 |
6/12/13 |
6/19/13 |
Meal Intake |
90.7 |
86.1 |
85.3 |
85.3 |
Bowels |
67.7 |
74.9 |
66.2 |
68.3 |
Bowels |
67.6 |
74.9 |
66.2 |
58.3 |
Bladder |
54.8 |
61.7 |
78.2 |
86.9 |
Behaviors |
53.1 |
69.9 |
87.1 |
91.0 |
3.8.4. Valid Input, Calculations, and Displays
Report Column |
Data Source |
Valid Input & Display |
Meal Intake |
CNA documentation of meal intake |
Includes: All residents on a unit during each week.
- For each resident, count the number of times a meal intake entry was made for the current week. (Note: A week is defined as static week starting every Monday through Sunday.)
- Divide the count by the total number of meals possible for the current week (i.e., if a resident was not on unit for specific days during the week, the possible number of meals should be reduced).
- Report the value as a percentage (allow one decimal point).
- If the completeness for a resident is ≥75%, set meal intake completeness flag to true. (This will be used to identify which residents appear on subsequent reports.)
- Compute an overall meal intake completeness average for the unit.
|
Bowels |
CNA documentation of bowel habits |
Includes: All residents on a unit during each week.
- For each resident, count the number of shifts a bowel entry was made for the current week. (Note: A week is defined as static week starting every Monday through Sunday.)
- Divide the count by the total number of shifts possible for the current week (i.e., if a resident was not on unit for specific days during the week, the possible number of shifts should be reduced).
- Report the value as a percentage (allow one decimal point).
- If the completeness for a resident is ≥75%, set bowel completeness flag to true. (This will be used to identify which residents appear on subsequent reports.)
- Compute an overall bowel completeness average for the unit.
|
Bladder |
CNA documentation of bladder habits |
Includes: All residents on a unit during each week.
- For each resident, count the number of shifts a bladder entry was made for the current week. (Note: A week is defined as static week starting every Monday through Sunday.)
- Divide the count by the total number of shifts possible for the current week (i.e., if a resident was not on unit for specific days during the week, the possible number of shifts should be reduced).
- Report the value as a percentage (allow one decimal point).
- If the completeness for a resident is ≥75%, set bladder completeness flag to true. (This will be used to identify which residents appear on subsequent reports.)
- Compute an overall bladder completeness average for the unit.
|
Behaviors |
CNA documentation of behaviors |
Includes: All residents on a unit during each week.
- For each resident, count the number of shifts a behaviors entry was made for the current week. (Note: a week is defined as static week starting every Monday through Sunday.)
- Divide the count by the total number of shifts possible for the current week (i.e., if a resident was not on unit for specific days during the week, the possible number of shifts should be reduced).
- Report the value as a percentage (allow one decimal point).
- If the completeness for a resident is ≥75%, set behaviors completeness flag to true. (This will be used to identify which residents appear on subsequent reports.)
- Compute an overall behaviors completeness average for the unit.
|
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