Nursing Documentation Forms

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Hello Everyone!

I would like to find colleagues who would like to share their nursing forms. I have PLENTY to share if anyone is interested. I plan on working with the staff to do some paperwork reduction in the near future and am interested in what others have found that works to meet all of the JCAHO requirements. I would greatly appreciate any replies.

Thanks!

KimRN41514

Daytonite, BSN, RN

4 Articles; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

what are you looking for? when i worked in a nursing home i created fax forms for us. we faxed all kinds of stuff to doctors and rather than waste time writing these messages up i created fill in the blank type forms for stuff we were constantly faxing (lab results, requests for medications). i had a memo template for writing cnas up. i had a report sheet. i also had a number of care plans that the nurses just needed to fill in pertinent information that applied to the patient. many of these, however, were lost when a technician failed to save the data on the hard drive of my computer before he erased it. it would not be difficult to re-create them.

here is the report sheet: report sheet.doc

NRSKarenRN, BSN, RN

11 Articles; 17,554 Posts

Specializes in Vents, Telemetry, Home Care, Home infusion. Has 46 years experience.

look at medqic, quality improvement organization, to see what info they have, visit their tools link.

example:

sbar nursing home package

sbar (situation, background, assessment, recommendation) is a device that can be used to improve communication within the nursing home setting. the sbar nursing home package includes two versions of a physician communication sbar tool, an sbar tool for pain, a flyer, a pocket card, phone stickers, references, sample scenarios and more.

several other tools listed ..

KimRN41514

37 Posts

Thank you for replying. I Like the report sheet. I'm interested in seeing other admission history forms and things like that too. We have a good care plan/interdisciplinary education form as well as many protocols- skin care, chest pain, pneumonia, chf. sbar. Staff is really complaining about the volume of paperwork to complete an admission.

JoycMarr

59 Posts

Has 10 years experience.

I would be willing to share, but most of our forms are now on computer (we are trying to go paperless) so I don't know how much help I could be to you. We have been doing admission history paperless for quite a while now.

ame222

29 Posts

Specializes in ER, CCU, Geri.

Can anyone share their schedules / forms for recommended labs for medication monitoring and how often they are being done. What forms / tracking procedure do you use to assure these are being completed. Who orders your initial labs and who follows up on further labs to be ordered? How do you audit your ordered labs on new admissions--then the follow-up labs. Any forms you could share? Does anyone have a form they could share on lab tracking: When labs are drawn, verifying all results are recieved. What procedures do you use to assure all lab slips are made? What procedures do you use to assure routine drraws are being ordered and done? I am open to any suggestions and would like any forms you are willing to share. Thankyou for your help.:)


ame222

29 Posts

Specializes in ER, CCU, Geri.

From ame222:

Can anyone share their schedules / forms for recommended labs for medication monitoring and how often they are being done. What forms / tracking procedure do you use to assure these are being completed. Who orders your initial labs and who follows up on further labs to be ordered? How do you audit your ordered labs on new admissions--then the follow-up labs. Any forms you could share? Does anyone have a form they could share on lab tracking: When labs are drawn, verifying all results are recieved. What procedures do you use to assure all lab slips are made? What procedures do you use to assure routine drraws are being ordered and done? I am open to any suggestions and would like any forms you are willing to share. Thankyou for your help.:)


Hello Everyone!

I would like to find colleagues who would like to share their nursing forms. I have PLENTY to share if anyone is interested. I plan on working with the staff to do some paperwork reduction in the near future and am interested in what others have found that works to meet all of the JCAHO requirements. I would greatly appreciate any replies.

Thanks!

KimRN41514

ame222

29 Posts

Specializes in ER, CCU, Geri.

FYI: This is for long term care nursing:

From ame222:

Can anyone share their schedules / forms for recommended labs for medication monitoring and how often they are being done. What forms / tracking procedure do you use to assure these are being completed. Who orders your initial labs and who follows up on further labs to be ordered? How do you audit your ordered labs on new admissions--then the follow-up labs. Any forms you could share? Does anyone have a form they could share on lab tracking: When labs are drawn, verifying all results are recieved. What procedures do you use to assure all lab slips are made? What procedures do you use to assure routine drraws are being ordered and done? I am open to any suggestions and would like any forms you are willing to share. Thankyou for your help.:)


Hello Everyone!

I would like to find colleagues who would like to share their nursing forms. I have PLENTY to share if anyone is interested. I plan on working with the staff to do some paperwork reduction in the near future and am interested in what others have found that works to meet all of the JCAHO requirements. I would greatly appreciate any replies.

Thanks!

KimRN41514

I would love to see your forms.. I love the idea of ready forms for faxing for scripts, renewals, notes to the physicians etc.. Mainly right now, i would love to come up with a simple, to the point yet comprehensive new order tracking form.. Some of our nurses seem to have a problem with getting new orders on the mar etc.

thank you

PeaceonearthRN

126 Posts

Specializes in cardiac, psychiatric emergency, rehab.

Does anyone have a form/workbook template they used to monitor medical case managment in long term residential care

that can be converted into a report? I would appreciate any feedback. A lot of the links for Quality Improvement are disabled.

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