-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/exercises.html
December 01, 2017 - Is this a documentation issue or was something going on with the resident?
Resident J. … Nurse weekly documentation
Physician orders
MDS assessment
None of the above
What value … True
False
Meal documentation for a resident must be at least 75% complete for the resident to … True
False
A resident will not display on the Nutrition Reports if meal documentation for the … ( Choose all that apply. )
NPO
Refused meal
Unavailable for meal or LOA
Missing documentation
-
www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/highlight05.pdf
September 08, 2015 - Practices in both States grappled
with clinical documentation
limitations and worse-than-expected … Before systems or practices could
measure improvement, they first had to
improve documentation and … convey the
importance of improved documentation
to all relevant staff. … Physicians who
paid proper clinical attention to a matter
were displeased when documentation
did not … Finally, staff
articulated what they need to sustain
improvement—EHRs that facilitate
documentation
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/functional-specs.html
December 01, 2017 - Nurse documentation of wound assessments each week. … The following CNA documentation elements must have 75 percent of the documentation completed to perform … for specific CNA documentation sections. … CNA Documentation Completeness Rules
Any Report Column That Includes
Determine Documentation … Resident bladder documentation
For each resident, count the number of shifts a bladder entry was
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruhealing/functional-specifications.docx
February 10, 2014 - The following CNA documentation elements must have 75 percent of the documentation completed to perform … for specific CNA documentation sections. … CNA Documentation Completeness Rules
Any Report Column That Includes
Determine Documentation Completeness … Resident bowel documentation
1. … Resident bladder documentation
1.
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-232-section-6-table-9.pdf
June 02, 2025 - Section 6, Tables 7-9
Table 9: Documentation of Heart Rate for Children with Severe Sepsis or Septic
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/2023-ASC-Database-Report-I.pdf
January 01, 2023 - Item Results on Near-Miss Documentation – 2023 SOPS ASC Database................25
Table 6-4. … Example of Computing Percent Positive for Near-Miss Documentation and
Overall Patient Safety Rating … Item Results Average Percentage Response on Near-Miss Documentation -
2023 SOPS ASC Database ...... … documentation. … Table 6-3 presents statistics for near-miss documentation.
-
www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/asc/2023-ASC-Database-Report-I-rev.pdf
January 01, 2023 - Item Results on Near-Miss Documentation – 2023 SOPS ASC Database................25
Table 6-4. … Example of Computing Percent Positive for Near-Miss Documentation and
Overall Patient Safety Rating … Item Results Average Percentage Response on Near-Miss Documentation -
2023 SOPS ASC Database ...... … documentation. … Table 6-3 presents statistics for near-miss documentation.
-
www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/techdocrpt-appe.pdf
January 01, 2019 - Health Systems, 2016, Technical Documentation-Appendix E
Comparative Health System Performance Initiative … Health Systems, 2016, Technical
Documentation
Prepared for:
Agency for Healthcare Research and Quality … Health Systems, 2016, Technical Documentation
Appendix E.
-
www.ahrq.gov/sites/default/files/wysiwyg/chsp/compendium/techdocrpt-appb.pdf
January 01, 2019 - Health Systems, 2016, Technical Documentation-Appendix B
Comparative Health System Performance Initiative … Health Systems, 2016, Technical
Documentation
Prepared for:
Agency for Healthcare Research and Quality … Health Systems, 2016, Technical Documentation
Appendix B.
-
www.ahrq.gov/cahps/about-cahps/index.html
June 01, 2025 - overview of CAHPS surveys: Understanding CAHPS Surveys (PDF, 117 KB) All CAHPS surveys and related documentation … Glossary— The CAHPS glossary explains terminology that is frequently used in documentation about CAHPS
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-241-bmi-communication-full-report.pdf
February 01, 2020 - Clinical or Other Rationale Supporting the Focus of the Measure
(optional)
Provide documentation of … Agreement was assessed for three measure variables:
documentation of communication of weight status, … documentation of height, and documentation
of weight (necessary to calculate BMI). … Agreement for documentation of height and
documentation of weight were both 100 percent, with Kappa … A higher percentage
of documentation of BMI percentile indicates better performance.
-
www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/aspirin-narrative.pdf
December 31, 2018 - an active diagnosis of ischemic vascular
disease (IVD) during the measurement period, and who had documentation … Exclusions
None
Denominator
The eligible population
Numerator
The number of patients who have documentation
-
www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/affinity-details-coping-staff-challenges.pdf
September 16, 2020 - to additional responsibilities among staff, it may be useful to allow staff time to complete their
documentation … responsibilities among staff, Stacey strives to
ensure that everyone has enough time to complete their documentation … Although this was one
more task for staff, it has actually streamlined documentation in the long run … Meanwhile, due to
the additional documentation burden, she has reduced staff-patient ratios.
-
www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-201-fullreport.pdf
March 01, 2019 - regardless of severity, who are prescribed and dispensed a new medication delivery
device and have documentation … For the purposes of this measure, education in proper use is defined as
documentation of verbal instruction … Clinical or Other Rationale Supporting the Focus of the Measure
(optional)
Provide documentation of … A total of 28 (24.1 percent) children
had documentation of either the child or caregiver(s) receiving … Review of clinical documentation was required to
ensure that the numerator was appropriately captured
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/asc/ascwebinar/tinsleyslides.pdf
September 01, 2015 - Meeting with physicians quarterly to emphasize this
as a priority for leadership
64
64
Near-Miss Documentation … Surgery/Procedure Room
Changes Implemented
Communication Openness
Change Implemented
Near-Miss Documentation
-
www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/guide3.html
October 01, 2017 - Ask: Does your facility have standardized prevention procedures and documentation for medical devices … Ask: How do you review or audit documentation now? … The failure to have clear admission documentation led to an increase in the documentation of hospital-acquired … Having a colleague evaluate the assessment provides immediate feedback and lowers documentation errors … Computer documentation that ties assessment directly to the care plan saves time.
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/handouts2.html
December 01, 2017 - MDS Assessment Documentation
X
4. Nurse Shift Change Report
X
5. … MDS Assessment Documentation
X
4. Risk Management Meetings
X Quarterly
5. … MDS Assessment Documentation
X
4. Rehab Department Internal Review
X
5. … MDS Assessment Documentation
X
5. Nurse Shift Change Report
X
6. … review of resident records and aids MDS assessment documentation.
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4a_combo_psi03-pressureulcer-bestpractices.pdf
January 01, 2012 - Recommended Practice Details of Recommended Practice
Skin Assessment at Admission and
Daily, With Documentation … sacral skin, heels and skin adjacent to
external devices.5 Include in the medical record
complete documentation … Recommended Practice: Skin Assessment at Admission and Daily, With Documentation of
Lesions
• Determine … prominences and skin adjacent to external devices.1,5-9
o Include a visual cue on each admission documentation … Introduction: Essential First Steps
Recommended Practice: Skin Assessment at Admission and Daily, With Documentation
-
www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/care/resources/ontime/pruprev/saworksheet.html
December 01, 2017 - Documentation requirements
___
___
d. … ___ Medical record
___ Nursing assistant documentation
___ Skin assessment form
___ Other (specify … Documentation—meal and fluid intake
CNAs
g. … Documentation—positioning
CNAs
Section 4: Investigations/Root Cause Analysis of Pressure
-
www.ahrq.gov/patient-safety/settings/hospital/resource/qitool/index.html
March 01, 2017 - Toolkit
Updated content to partially address the transition from ICD-9 to ICD-10, including updated documentation … Includes: software instructions to calculate the QI rates and tips for coding and documentation. … Documentation and Coding for AHRQ Quality Indicators
Includes strategies for addressing documentation