Long-Term Care Forms. Custom and State-Specific Forms Available! Activities. Administration. Advance Directives/Consents. Admissions.

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1 Custom and State-Specific Forms Available! For more information please contact: Tim Caver at or Sherry Anderson at Long-Term Care Forms Activities Activity Evaluation... CFS4-2HH Activity Progress Notes... CFS4-9HH Daily Record of Participation.... CFS4-8 Group Volunteer Application P Individual Participation Record... CFS4-6 One-To-One Program/Individual Job Assignment Plan... CFS4-5 Overall Activity Plan.... CFS4-4HH Shared Activities Worksheet Therapeutic Recreation/Activity Evaluation HH Volunteer Application P Volunteer Hours P Administration Business Associate Agreement Census Report... CFS2-3 Daily Nursing Staff Posting E Disclosure Log E Employee In-Service/Education Attendance Record E In-Service Training Report E Request To Review Resident Council Minutes... CFS1-2E Admissions Accumulative Diagnosis Record P Alzheimer s Disease Disclosure P-12 Cancer Disclosure P-12 Cerebrovascular Accident (Stroke) Disclosure P-12 Chronic Renal Failure Disclosure P-12 Congestive Heart Failure Disclosure P-12 Depression Disclosure P Diabetes Mellitus Disclosure P-12 Emphysema Disclosure P Hold Harmless Agreement /2P Hypertension Disclosure P Inventory of Personal Effects...CFS1-12/2PS Inventory of Personal Effects Notice of Privacy/Acknowledgement Receipt Notice of Transfer or Discharge...CFS2-1/3P Osteoporosis Disclosure P-12 Parkinson s Disease Disclosure P Post Discharge Plan of Care...CFS2-2/2P Pressure Ulcers Disclosure P-12 Privacy Act Statement HC Records Record of Admission...CFS5-1/3P Record of Death Release of Responsibility For Discharge P Release of Responsibility For Leave of Absence Resident Data Sheet E Resident Refusal of Treatment /2P Resident Transfer Form /2 Resident Transfer Form... CFS2-4 Advance Directives/Consents Advance Directives/Medical TX Acknowledgement Receipt... CFS1-10 Authorization To Release Patient Information Consent To Photograph /2P Herpes Zoster/Zoster Vaccine Informed Consent E Influenza Immunization Informed Consent P-15E Notification & Consent... CFS1-4HH Physical Restraint Consent... CFS3-4 Pneumococcal (PCV13)(PPSV23) Informed Consent E Psychoactive Medication Informed Consent... CFS3-8 Psychoactive Medication Therapy Informed Consent E Resident Rights November CFS Resident Rights November R-16 Tetanus/Diphtheria (Td) Vaccine Informed Consent E Assessments Bed Rail/Assist Bar Evaluation E Behavior Intervention Evaluation Checklist P Call Fax BriggsHealthcare.com 1

2 Behavior Intervention Monitoring E Behavior Management Plan P Behavior Symptoms Checklist P Bladder Incontinence Evaluation... CFS6-10HF Bowel Retraining Assessment.... CFS6-8HF Braden Scale - For Predicting Pressure Sore Risk E Brief Interview For Mental Status E CAM - Cognitive And Behavior E Diabetic Foot Assessment P Edema Measurement Flowsheet... CFS6-23E Fall Risk Discipline Trigger Fall Risk Evaluation... CFS6-17E Fecal/Bowel Incontinence Assessment P Geriatric Depression Scale P Indwelling Catheter Assessment P Mood (PHQ-9) Collection Tool E Neurological Record E Non-Pressure Skin Conditions Report E Norton Plus Pressure Ulcer Scale E Nurses Summary Seven Day Look Back P Nursing Evaluation/Data Collection.... CFS5-3HH-10 Pain Evaluation E Pain Rating Scale - Languages PHQ-9 Staff Collection Tool E Physical Restraint Elimination Evaluation... CFS3-2E Pre-Psychoactive Medication Assessment HH Pre-Restraining Evaluation... CFS3-1HF Pressure Ulcer Risk Evaluation... CFS6-4E Psychoactive Medication Quarterly Evaluation.. CFS3-10E Short Portable Mental Status Questionnaire Skin Condition Record/Non-Pressure Ulcer E Smoking Safety Evaluation E Urinary Incontinence Assessment P-13 Wander Data Collection Tool E-15 Weekly Pressure Ulcer Record... CFS6-6E Wound/Skin Healing Record E Wound/Skin Record.... CFS6-5E Beneficiary Notices Advance Beneficiary Notice of Non-Coverage.. CMS-R-131E Advance Beneficiary Notice of Non-Coverage (Spanish)... CMS-R-131E-S Detailed Explanation of Non-Coverage.... CMS Detailed Explanation of Non-Coverage (Spanish)... CMS S Notice of Medicare Non-Coverage (Spanish)... CMS S Skilled Nursing Facility Advance Beneficiary Notice... CMS-10055E CNA Records Nurse Aide s Information Sheet Nurse Assistant Care Record - AM Shift.... CFS6-3AHH Nurse Assistant Care Record - Night Shift... CFS6-3CHH Nurse Assistant Care Record - PM Shift... CFS6-3BHH Plan of Care Kardex P Plan of Care Kardex E Restraint Release Record... CFS3-3HH Turn/Reposition Record.... CFS6-7 Consults Oral/Dental Record... CFS11-1HF Report of Consultation...852E Report of Consultation...263E Dementia Activity Interest Summary /2P Cornell Scale for Depression in Dementia Family Questionnaire E Functional Assessment - Alzheimer s Disease E Missing Resident Identification Physical Restraint Reduction Evaluation E Resident Summary HH-10 Resident Weekly Care Log P Resident/Family Conference Notes E Safety Check Log P Special Care Unit Consent /2P Special Care Unit Criteria Review P Dietary Diet History/Food Preference list p Diet Order & Communication Diet Preference List...505E Food Temperature Record... CFS8-1 Malnutrition Risk Assessment... CFS6-20E Nutritional Assessment of Tube Fed Resident.. CFS5-8HF Nutritional Care Recommendations P Nutritional Enteral Assessment... CFS5-9E Nutritional Evaluation/History & Data Collection... CFS5-5HF Nutritional Progress Notes.... CFS5-7E Nutritional Status Review E Refrigerator/Freezer Temperature Log P Temperature/Sanitizer Log Form Flow Sheets ADL Flow Record HH-15 Call Fax BriggsHealthcare.com 2

3 ADL Flow Record HH-15 Diabetic Monitoring Flowsheet.... CFS6-22HH Late Loss ADL Flow Sheet Neurological Assessment Flowsheet... CFS6-19 Pain Management Flow Sheet... CFS6-38HH Vital Signs and Weight Record.... CFS6-21HH History and Physical History and Physical Medical History and Admission Examination E Infection Control HBV Vaccine Consent/Declination R Infection Control Log.... CFS13-2E Monthly Facility Infection Analysis E Monthly Schedule For TB Testing E Source Individual Consent/Declination Intake and Output Bladder Schedule... CFS6-11 BM Elimination Record Bowel & Bladder Retraining Program /25 Bowel Schedule... CFS6-9 Comprehensive Intake-Output Record HH Food Intake Record Lab and Special Reports Anticoagulant Therapy Flow Sheet E Blood Glucose Equipment Check Form E Test/Immunization Record E-15 Tuberculosis Surveillance Summary Record E MDS/Care Plan Activities CAA E ADL CAA E Behavioral SX CAA E Care Plan Conference Summary.... CFS5-13E Cognitive Loss CAA E Communication CAA E Comprehensive Plan of Care E Dehydration/Fluid Maintenance CAA E Delirium CAA E Dental Care CAA E Fall CAA E Feeding Tube CAA E Functional Abilities and Goals (Section GG) Admission/Start of SNF PPS Part A Stay E Functional Abilities and Goals (Section GG) Discharge/End of SNF PPS Part A Stay E Initial Interdisciplinary Evaluation HH-10 Insert Page P Interdisciplinary Care Plan... CFS5-12E Interdisciplinary Discharge Summary.... CFS5-17 Interim Plan of Care E MDS 3.0 Nursing Home and Swing Bed OMRA (NO/SO) Item Set, v E-17 MDS 3.0 Nursing Home and Swing Bed Tracking (NT/ST) Item Set. v E-17 MDS 3.0 Nursing Home Comprehensive (NC) Item Set. v E-17 MDS 3.0 Nursing Home Discharge (ND) Item Set, v E-17 MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Item Set, v E-17 MD5 3.0 Nursing Home PPS (NP) Item Set/ Nursing Home Quarterly (NO) Item Set, v E-17 MDS Section C: Brief Interview for Mental Status (BIMS) E-15 MDS Section D: Mood Interview E-15 MDS Section F: Preferences for Customary Routine & Activities Interview E-15 MDS Section J: Pain Assessment Interview E-15 Mood Status CAA E Nutritional Status CAA E Overall Resident Profile... CFS5-10E Pain CAA E Physical Restraints CAA E PPS Assessment Log... CFS6-36E Pressure Ulcer(s) CAA E Psychosocial Well-Being CAA E Psychotropic Medication Use CAA E Resident Status and Care Plan Return to Community Referral CAA E Temporary Problem List... CFS5-14E Urinary Incont/Catheter CAA P Visual Function CAA E Medications and Treatments AIMS Scale... CFS3-7E Antianxiety Monitoring HH-12 Antidepressant Monitoring HH-12 Antipsychotic Monitoring HH-12 Hypnotic/Sedative Monitoring HH-12 Controlled Drug Administration Record.... CFS12-3HH Disruptive.... CFS3-5 Drug Destruction Log E Call Fax BriggsHealthcare.com 3

4 Enteral Feeding Record... CFS6-16HH Evaluation for Self-Administration of Medications... CFS1-14HF Hemodialysis Communication P IV Medication Sheet HH Medication Disposition Log E Medication Reconciliation Form P Medication Record E Medication Record.... CFS6-27E Medication Record Addendum...CFS6-27E-ADD PRN Medication Record Self-Medication Administration Record... CFS1-13P Treatment Record... CFS6-29HH Nurse s Notes Interdisciplinary Progress Notes...CFS6-31 E Nurse s Notes... CFS6-32E Nurse s Notes...484E Nurses Progress Note... CFS5-20HH-10 Skilled Daily Nurses Notes E Pharmacy Controlled Drugs - Count Record.... CFS12-4 Medication Pass Evaluation.... CFS12-1E Monthly Drug Regimen Review... CFS12-5E Physician Action Report.... CFS12-7E Physical Environment Deep Cleaning List... CFS14-5 Emergency Generator Monthly Test Log Housekeeping Log... CFS14-8 Laundry QA Checklist.... CFS14-3 Preadmission Room Inspection Check... CFS14-2 Preventative Maintenance Log - Resident Room... CFS14-14 Repair Requisition...169E Weekly Generator Test Log Physician Orders Admission Orders... CFS5-2E Physician Discharge Summary... CFS5-16HH Physician s Progress Notes... CFS9-1HH Physician s Telephone Orders... CFS9-3E Physician s Telephone Orders E Request for Gradual Dose Reduction... CFS3-9R SNF Certification/Recertification SE Pre-Admission Medicare Secondary Payer Worksheet E Quality Assurance 24 Hr/Change of Condition Report E Action Plan... CFS14-20E Dehydration Risk Tracking Log E Diabetic Audit E Discharge Audit Elopement Risk Tracking Log E Employee Incident/Accident Report /3 Grievance QA Log... CFS14-1E Grievance/Complaint Report... CFS1-11 Hydration Investigative Protocol Incident Report /2R Incident Report QA & A Monthly Summary E Incident Report QA/CQI Log E Incident/Accident Report.... CFS6-18 Infection Report... CFS13-1 Interdisciplinary Post-Fall Assessment Investigation Follow-Up Lab Audit E Long-Term Care Admission Checklist E MDS 3.0 Focused Survey Worksheet E MDS Accuracy Review Tool Medical Record Audit E Medication Error Report... CFS6-30 PEPPER Medicare Part A Clinical Review E PEPPER Medicare Part A Financial Review E Physician s Visit Log.... CFS9-2E Quality Assurance Action Plan/ Follow-Up Log... CFS14-21E Resident Abuse Incident Report.... CFS3-11/2 Resident Fall Tracking Log E Safety/Infection Control QA Checklist... CFS14-9E Skin/Wound QI Log E Triple Check E Weekly Medicare Meeting Report E Weekly Pressure Ulcer QI Log E Weekly Weight Variance QI Log E Weight Variance QI Log E Restorative Nursing Bladder Retraining Program P CNA Care Plan Reference Sheet CNA Care Plan Reference Sheet Range of Motion Record... CFS6-12E Restorative Care Flow Record.... CFS6-13HH Call Fax BriggsHealthcare.com 4

5 Restorative Care Flow Record P Restorative Dining Program Flow Sheet P Restorative Feeding Evaluation... CFS6-14E Restorative Needs ID Form P Restorative Nurses Meeting-Signature Page E Restorative Nursing Care Plan & Progress Notes E Restorative Nursing Meeting-Individual Resident Programs E Restorative Nursing Program Flow Record P Restorative Nursing Program RCNA Tracking Form. 3770E Restorative Nursing Progress Notes E Restorative Nursing Progress Notes E Restorative Nursing Transfer Form P Screening for Meal Time Assistance/ Restorative Dining Needs P Unit Restorative Program Tracking Form E-12 Voiding Diary P-13 Voiding Diary P-13 Walk to Dine Program Flow Sheet P Social Services Denial of Amendment Discharge Plan...616E Discharge Plan/Discharge Plan Review... CFS5-15HH Initial Psychosocial Evaluation & Social History HF Initial Social Service History.... CFS4-10HH New Roommate Notification.... CFS1-15 Notification of Room Change... CFS1-9R/2TP Request for Amendment of Information Resident/Family Education Record E Resident/Family Educational Assessment P Social Service Progress Notes.... CFS4-13E Social Services Evaluation... CFS4-12HH Therapy Certification/Recertification for Part B Rehabilitation Services P Dysphagia Medical Work Up P Home Assessment Tool Occupational Therapy Progress Status E OT Daily Service & Treatment Grid P Physical Therapy Progress Status E PT Daily Service & Treatment Grid SLP Daily Service & Treatment Grid P Speech Therapy Progress Status E Call Fax BriggsHealthcare.com