Your shortcut to accurate assessment and compliant documentation
The quick and easy way to document quality resident care!
The Long-Term Care Clinical Assessment and Documentation Cheat Sheets is the ultimate blueprint for how to provide resident-centered care for any symptom or condition. Available on CD, this electronic-only resource provides nurses with a thorough list of what to check and what to document during every shift, based on the specific circumstances of a given resident. Best of all, the new electronic format of this content enables long-term care clinicians to easily search for the condition they need to treat and access the appropriate checklist within seconds.
Each checklist can be downloaded and printed to fit directly into the resident’s record to ensure thorough, focused, and regular assessments and documentation. Long-Term Care Clinical Assessment and Documentation Cheat Sheets is the most convenient way to guarantee your residents receive the proper care and your facility maintains compliant documentation.
Long-Term Care Clinical Assessment and Documentation Cheat Sheets will help you:
- Save time finding the correct guidelines for a resident’s condition with the searchable, electronic checklists
- Maintain complete and accurate clinical records for each resident to authenticate that physician orders were followed and residents were provided with the highest quality of care
- Ensure consistency of care across each nurse’s shift by including the relevant checklist in each resident record
- Assess and document resident status, including cardiovascular, hematologic, and neurological conditions with more than 190 guidelines, tools, and cheat sheets
- Avoid survey citations, lost reimbursement, and legal implications arising from improper documentation
- Minimize nurses’ stress by providing them with reliable guidance and data for each resident, in an easy-to-use format that fits seamlessly in their everyday work flow
- Electronic, searchable checklists, which enable you to upload the information to the resident’s EHR or print to file in their paper record!
- Special chapter covering the most frequent diagnoses for hospital readmissions and strategies for how to prevent them.
Download the Table of Contents
The comprehensive table of contents can be found by clicking here and downloading a 12-page PDF of every checklist contained within Long-Term Care Clinical Assessment and Documentation Cheat Sheets
About the Author
Barbara Acello, MS, RN, is an independent nurse consultant and educator. She has worked in long-term care for more than 30 years. In addition to owning and operating a school for nursing assistants, she helped write and develop mandatory state curricula for nurse aides and EMTs.