2016 Long-Term Care Compliance Catalog

2016 Long-Term Care Compliance Catalog
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2016 Long-Term
YOUR NEXT NEW
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Care Compliance
Catalog
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Shop this catalog to find solutions for
the Top 10 Most Cited Deficiencies!
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Your Trusted Partner for Maintaining Compliance!
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
Healthcare providers are faced with the challenge of maintaining compliance
and delivering quality care while containing costs. From infection control to reducing the
use of unnecessary drugs, Briggs Healthcare has products to assist your facility with meeting regulatory compliance
requirements. Briggs developed this catalog to help you become familiar with the most frequently cited deficiencies
and provide products and services to help you maintain compliance!
Survey Guide for Long-Term Care
•Updateable
•Updates show the changes highlighted in red so they are easily identifiable
•Flexible package options are available, including FutureSafe™ with autorenewal updates every year
•Electronic file on CD for portability and to quickly search content
•Updates sent out as they occur
•Complete replacement for existing survey guide
Item #
1766
1767
1766RNW
Item #
1766A Description
PremiumPlusOne Package
PlusThree Package
Survey Guide Yearly Renewal Package
Price Per Each
$96.85
$193.75
$50.95
Description
FutureSafe™ Package
Price Per Each
$96.85
Ea Add’l Yr
$50.95
Four Easy Ways to Order
Web
Phone
Order online:
www.BriggsCorp.com
24 hours a day, 7 days a week
Phone Toll-Free
1.800.247.2343
Office hours: 7 a.m. to 6 p.m.
weekdays Central Time
Mail
Mail your purchase order to:
Briggs Healthcare®
P.O. Box 1698
Des Moines, IA 50306-1698
Fax
Fax Toll-Free
1.800.222.1996
The Briggs Healthcare®
FAX line is available 24 hours
a day, 7 days a week
Visa, MasterCard and American Express Accepted
TABLE OF CONTENTS
F241 | Dignity and Respect of
Individuality . . . . . . . . . . . . . . . . . . . . . . 27-28
F329 | Drug Regimen is Free from
Unnecessary Drugs . . . . . . . . . . . . . . . . . 16-19
F279 | Develop Comprehensive
Care Plans . . . . . . . . . . . . . . . . . . . . . . . . 23-26
F371 | Food Procurement, Store/Prepare/
Serve – Sanitary . . . . . . . . . . . . . . . . . . . . . . . 7
F282 | Services Provided by Qualified
Persons/Per Care Plan . . . . . . . . . . . . . . . . . . 33
F431 | Drug Records, Label/Store Drugs
& Biologicals . . . . . . . . . . . . . . . . . . . . . . 20-22
F309 | Provide Care/Services for
Highest Well-Being . . . . . . . . . . . . . . . . 12-15
F441 | Infection Control, Prevent
Spread, Linens . . . . . . . . . . . . . . . . . . . . . . 1-6
F323 | Free of Accident Hazards/
Supervision/Devices . . . . . . . . . . . . . . . . . 8-11
F514 | Resident Records –
Complete/Accurate/Accessible . . . . . . . . 29-32
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
F441 - Infection Control, Prevent Spread, Linens
F441 | Infection Control, Prevent Spread, Linens
Facilities must establish and maintain an infection control program designed to provide a safe, sanitary, and
comfortable environment and to help prevent the development and transmission of disease and infection.
2014 Ranking – #1 Most Cited | Also #1 for First 6 Months of 2015
To
NOSOCOMIAL
Yes
No
Other
Reporting Period
Eye
ISOLATED
X-RAY
DATE ORGANISM ANTIBIOTIC Yes/Date
No
Date Reported To Infection Control/Quality Assurance Committee
DescriptionPrice Per Pad (100/pd)
Infection Report
$13.70
INFECTION CONTROL LOG
Item #
CFS13-1
Month/Year:
CULTURE
No
Yes/Date
•Establish an ongoing system to identify and report
resident infections
•Printed 2 sides different
•3-hole side punched
REDATE
CULTURED RESOLVED
DATE
Infection Report
INFECTION CONTROL LOG
Shop these products to find compliance solutions!
UNIT TOTAL
HEALTHCARE ASSOCIATED
CFS 13-2 Rev. 5/00 © 1992 BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
EYE
TOTALS
EAR
ADMIT ONSET
DATE DATE
UTI
SKIN
RESIDENT
RESP
Urinary Tract Infection
RESIDENT – REPEAT INFECTIONS WITHIN 30 DAYS
RESIDENT
WOUND
GI
OTHER
TOTAL
ORGANISMS IDENTIFIED
ORGANISMS
INCIDENCES
ORGANISMS
Staphylococcus Aureus
Legionella (Legionnaires)
Clostridium Difficile
Neisseria Salmonella
Staphylococcus A
Escheri Coli
Staphylococcus B
Enterococcus
• MRSA (Methicillin Resistant)
Klebsiella
• VISA (Vancomycin Intermediate)
Candida
• VRSA (Vancomycin Resistant)
Proteus
INCIDENCES
ORGANISMS
INCIDENCES
Pseudomonas
Aspergillus
Tuberculosis
Streptococcus
Group A
Group B
CFS13-1
IDENTIFIED SOURCES OF INFECTION
•Establish an ongoing surveillance system for
identifying and monitoring resident infections
•Printed 1 side
•3-hole top punched (11” edge)
Item #
CFS13-2
INFECTION
RELATED DX
SITE
TOTALS
DescriptionPrice Per Pad (100/pd)
Monthly Resident Infection Analysis
$16.60
Infection Control Log
COMMUNITY ACQUIRED
Skin
Item #
1163P UNIT
Total Number Of Infections:
• Identify patterns and trends of infections
•Printed 2 sides different
•5-hole punched top and side
Facility #:
IDENTIFIED INFECTIONS PER UNIT
A Healthcare Associated Infection (HAI) is not present or incubating at time of admission. If the incubation time is unknown and the infection develops
after 72 hours of admission (or per facility policy), it is considered a HAI. Infections with signs and symptoms noted upon admission are usually
considered Community Acquired Infections.
Facility:
Monthly Resident Infection Analysis
Upper Respiratory Infection
MONTHLY FACILITY INFECTION ANALYSIS
Facility:
SizePrice Per Pad (100/pd)
11” x 8-1/2”
$11.40
UNIT
RESP
UTI
EYE
RESP
UTI
EYE
EAR
SKIN
WOUND
GI
OTHER
TOTAL
GI
OTHER
TOTAL
TOTALS
REQUIRED ISOLATION MEASURES
TYPE
EAR
SKIN
WOUND
Droplet
Airborne
Contact
TOTALS
IDENTIFIED TRENDS/ACTION PLAN
INFECTION CONTROL LOG
Facility:
Date Reported To Infection Control/Quality Assurance Committee
_________________________________________________________________________________________________________
Total Number Of Infections:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Skin
Urinary Tract Infection
Upper Respiratory Infection
Eye
Reporting Period
Medical Director
Date
Director of Nursing
Date
__________________________________________________
__________________________________________________
Infection Control Nurse
Quality Control Nurse
Date
Form 1163P Rev. 4/13 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
To
Other
ISOLATED
CULTURE
INFECTION
X-RAY
ADMIT ONSET SITE
RESIDENT
__________________________________________________
RELATED DX Yes/Date
DATE ORGANISM ANTIBIOTIC Yes/Date
DATE __________________________________________________
DATE
No
No
NOSOCOMIAL
Yes
No
REDATE
CULTURED RESOLVED
DATE
Date
MONTHLY FACILITY INFECTION ANALYSIS
1163P
CFS 13-2 Rev. 5/00 © 1992 BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
INFECTION CONTROL LOG
CFS13-2
CLICK HERE TO DOWNLOAD the
2016 Infection Prevention Catalog
and visit www.BriggsCorp.com for our complete
Infection Prevention product offering!
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
1
F441 - Infection Control, Prevent Spread, Linens
HIGH RISK FOR COMPLICATIONS FROM INFLUENZA
• Children: < 5 years / increases for < 2 years • Pregnant women • Care Center residents
• Adults: 65 or older • American Indian and Alaskan Native populations
Chronic Medical Conditions:
• Respiratory: Asthma, COPD, Cystic Fibrosis
• Cardiac: Congenital Heart Disease, CHF, Coronary Artery Disease
• Endocrine: Diabetes, Morbidly Obese
• Renal: Kidney Failure
• Liver Disorders
• Metabolic: Inherited and Mitochondrial
• Blood: Sickle Cell Disease
• Weakened Immune: HIV, AIDS, Cancer, Chronic Steroid Usage, Organ Transplant
CLINICAL INFLUENZA SYMPTOMS
• Chills/Fever
• Cough
• Muscle or body aches
• Sore throat
• Headache
• Runny or stuffy nose
• Fatigue (tiredness)
• N/V (children)
POSSIBLE VACCINE SIDE EFFECTS
Severe: Allergic reaction is possible, but very rare
Mild: Usually short term, 1-2 days
• Soreness, redness, or edema at injection site
• Hoarseness, sore, red or itchy eyes; cough
• Fever • Aches • Headache • Itching • Fatigue
VACCINE INFORMATION STATEMENT (VIS) PROVIDED TO RESIDENT
❑ Inactivated Influenza VIS Edition Date:______ /______ /______ (Statement: www.cdc.gov/flu)
❑ I have received the information about Influenza disease, and have been educated on the benefits and risks associated
with the Influenza Vaccine. I hereby give permission and request the Flu Vaccine be administered to me or the person
named for whom I am authorized to sign.
_____________________________________________________________
______ /______ /______
Resident/Legal Representative
Date Signed
_____________________________________________________________
______ /______ /______
Witness Signature/Title
Date Signed
REASON FOR VACCINE DECLINE (Medical or Personal Reasons)
❑ I have received the information about Influenza disease, and have been educated on the benefits and risks associated
with the Influenza Vaccine. I hereby decline my permission to receive the Influenza Vaccine for the following
reason(s): ________________________________________________________________________________________
A. Medication Contraindication(s): Check all that apply (Physician needs to be informed of Medical Conditions)
❑ Allergy to eggs or egg products
❑ Previous Hx of severe reaction to Influenza Vaccine
❑ Allergy to Thimerisol (preservative in vaccines) or any vaccine component
❑ History of Guillain-Barre Syndrome (within 6 weeks after previous vaccine)
❑ Febrile Illness at this time (Temp > 101.5° F or 38.6° C)
❑ Other medical conditions (specify)____________________________________________________________________
B. Personal Reason(s): Check all that apply (Physician needs to be informed of Personal Reason)
❑ Perceived vaccine ineffectiveness
❑ Fear of needles/injections
❑ Perceived vaccine will “give me the flu”
❑ Fear of side effects
❑ Other personal reasons (specify)_____________________________________________________________________
_____________________________________________________________
Pneumococcal Conjugate
Vaccine (PCV13) and Influenza
Immunization Informed Consents
ST R S
BELLE
SE
INFLUENZA IMMUNIZATION INFORMED CONSENT
Influenza is a contagious respiratory illness caused by flu viruses. The illness can be mild to severe, and at times can lead to
death. This acute disease comes on suddenly, with self-limiting symptoms (resembling a severe “common cold”) within 2-7
days of onset.
• 8.5” x 11”
• Printed
2 sides different
• 5-hole
punched top and side
Item #
7122P
Description
Price Per Pad (100/pd)
Pneumococcal Conjugate Vaccine (PCV13)
Informed Consent
$15.85
7123P-15 Influenza Immunization Informed Consent
$15.85
______ /______ /______
Resident/Legal Representative
Date Signed
_____________________________________________________________
______ /______ /______
Witness Signature/Title
Date Signed
NAME–Last
First
Middle
INFLUENZA IMMUNIZATION
INFORMED CONSENT
Form 7123P-10 Rev. 11/12 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
MR #
PRINTED IN U.S.A.
Tuberculosis Surveillance Summary Record
TUBERCULOSIS SURVEILLANCE SUMMARY RECORD
DATE OF
BIRTH
X-RAY
Day
Year
Month
Day
Year
INITIAL SKIN
TEST:
❑ Positive
Month
Day
Year
Month
Day
Year
Month
Day
Day
Month
Day
Location:
Day
Year
Month
Day
Year
❑ Positive
❑ Negative
❑ Positive
❑ Negative
Month
DIAGNOSIS
Day
Year
Date:
❑ Active TB
ACTIVE
TB
Day
Year
❑ TB Infection w/o Disease
Major Site of Disease
❑ Pulmonary
Year
❑ Other-Specify
Lot #:
Year
Size:
mm
Was Therapy Recommended? ❑ Yes ❑ No
RN Signature
HEALTH
DEPARTMENT
REPORTING
Case Reported to Health Department?
❑ Yes ❑ No
Date of Report:
Month
Day
Year
Contact
Done?
HEPATITIS
BInvestigation
VIRUS
VACCINE CONSENT/DECLINATION
PERIODIC SKIN TESTS
Date
❑ Worsening
Month
Date:
Month
Date Read:
Size/mm RN Signature
❑ Stable
Date:
Source
Year
Date Given:
Month
❑ Abnormal
Date Collected:
Lot #:
Size:
mm
Was Therapy Recommended? ❑ Yes ❑ No
RN Signature
Date
❑ Cavitary
❑ Infection
Microscopy:
BACTERIOLOGY
FOR
M. TUBERCULOSIS Culture:
Date Given:
Date Read:
SECOND SKIN
TEST:
(In approximately
1 week if initial
test is negative)
If Abnormal:
❑ Negative
Date:
Location:
Year
❑ Normal
❑ TB Disease
BASELINE TESTING
Result:
Day
Result:
❑ Non-Cavitary
HISTORY OF
PREVIOUS TB
TREATMENTS
SOCIAL SECURITY
OR I.D. NUMBER
PRIOR MANTOUX
HISTORY
Date:
Month
Month
• Record
dates/results of periodic TB tests
• Space
for documenting type/result of test, recommended
treatment (if any) and date of report to the Health
Department (if required)
• Use
back to document periodic x-ray screening and
bacteriology testing
• Printed
2 sides different
• 5-hole
punched top or side
ALTERNATIVE TESTING
IDENTIFICATION INFORMATION
NAME
(Last, first,
middle initial)
DATE OF
ADMISSION/
EMPLOYMENT
❑ Yes
Size/mm RN Signature
CHEMOTHERAPY
(For infection
or disease)
❑ No
BLOODBORNE PATHOGENS
Drugs Recommended:
I have received information and understand that my profession increases risks of
exposure to bloodborne pathogens including hepatitis B virus (HBV). This exposure
includes blood, body
and other potentially infectious material and surfaces. The
Date fluids,
Drugs Started:
facility’s exposure control programMonthhasDaybeen Year
explained to me, and I understand the
Date Drugs Stopped:
process to follow should
an exposure incident occur.
Month
Day
HIV TEST
(Voluntary)
Date:
Month
Day
Year
Date VIS Provided:
If Not Done,
Give(Vaccine
Reason: Information Statement)
VIS
www.cdc.gov/vaccines
HEPATITIS B VACCINE CONSENT
I consent
toAdditional
administration
of theonhepatitis
Record
X-Rays and Bacteriology
the Reverse. B vaccine. I have been informed of the
method of administration,TUBERCULOSIS
the risks, complications,
and expected benefits of the vaccine.
SURVEILLANCE
Form 2121HH Rev. 6/06 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
SUMMARY RECORD
❑ Continued on Reverse
X
Signature of the Employee
2121HH
Date
Print Employee’s Name
HEPATITIS B VACCINE DECLINATION
Occupational Safety & Health Administration, Standard Number 1910.1030 App. A
I understand that due to my occupational exposure to blood or other potentially
infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I
have been given the opportunity to be vaccinated with hepatitis B vaccine, at no
charge to myself. However, I decline hepatitis B vaccination at this time. I understand
SOURCE INDIVIDUAL EXPLANATION
CONSENT
OR DECLINATION
TOat risk of acquiring hepatitis B, a
that OF
by AND
declining
this vaccine,
I continue to be
HUMAN IMMUNODEFICIENCY VIRUS serious
(HIV), HEPATITIS
B in
VIRUS
(HBV) IAND
HEPATITIS
C occupational exposure to blood or
disease. If
the future
continue
to have
VIRUS (HCV) TESTING FOLLOWING
EMPLOYEE
EXPOSURE.
other potentially
infectious
materials and I want to be vaccinated with hepatitis B
vaccine, I can receive the vaccination series at no charge to me.
CONFIDENTIAL
Facility
EXPLANATION
X
Signature of the Employee
A member of our facility staff was accidentally exposed to your blood or body fluid. In order
to comply with recommendations of the Centers for Disease Control and needlestick protocol,
we are requesting your consent to Print
testEmployee’s
your Name
blood for the antibody to the human
immunodeficiency virus (HIV), the hepatitis B virus (HBV) and hepatitis C virus (HCV). This test is
Form 2115R Rev. 11/12
designed to show whether or not you yourself have been exposed to HIV, HBV or HCV. It will not
show whether or not you actually have AIDS or hepatitis (or an AIDS/HBV/HCV related illness).
Your consent will enable our facility to provide the necessary care and assist in the
proper medical management of the exposed employee. It is important that you understand
the following:
1. We cannot test for HIV without your consent.
2. You will not be charged for this test.
3. This signed consent form and the test results will be kept
confidential and will NOT be placed in your medical record.
4. Should the test results be positive, you will be notified by your
doctor for counseling and appropriate medical advice.
CONSENT/DECLINATION
I have been informed about the implications and limitations of the test for the antibody
to HIV, HBV and HCV. I have been able to ask questions about the test. Those questions
were answered to my satisfaction. I understand the benefits and risks of the test.
❑ I hereby decline to have my blood
tested for the HIV/HBV/HCV antibody
Resident’s Signature
Date
Print Name of Resident
If Resident Unable to Sign, Signature of Authorized Individual
Print Name Here
Date
Witness
Print Name Here
Date
Form 2116 Rev. 3/00 © 1992 BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
2116
2
Price Per Pad (100/pd)
$13.70
$13.70
HBV Vaccine Consent/Declination
and HBV Vaccination Record
• Provides
reliable proof the HBV vaccine was offered
to employees and residents by requiring a signature
verifying consent or refusal
• Back
side allows you to record vaccinations actually
administered
Item #
2115R
Description
Price Per Pad (100/pd)
HBV Vaccine Consent/Declination and Record
$13.40
Date
Source Individual Consent
© 1992 BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
❑ I hereby consent to have my blood
tested for the HIV/HBV/HCV antibody
Description
Side Punched
Top Punched
Year
I am aware of Reason:
the symptoms, hazards, and transmission modes associated with
Supervised
the hepatitis B virus;
and By:
a vaccine is available to me at no additional cost. I also have
If Drugs Not Started,
Reason: will be administered according to CDC recommendations.
been informed theGive
vaccine
VIS Edition Date:
Item #
2121HH
2121HF 2115R
• Explains
to the resident/patient in very simple terms
that by consenting to HIV/HBV/HCV infection testing
the facility/agency may protect and aid in the medical
management of their employees
• Discusses
the confidentiality of the matter and
explains that the resident (source individual) will not
be charged
• 8-1/2”
x 11”
• White
paper, black and red ink
• Printed
1 side
Item #
2116
Description
Source Individual Consent Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
Price Per Pack (100/pk)
$13.00
F441 - Infection Control, Prevent Spread, Linens
VPF Vinyl Powder Free Exam Gloves
• 100% latex free
• Very soft and flexible to fit snugly and comfortably
• Strong and durable for superior protection
Item #
70-232
70-235
70-236
70-238
ST R
B E LLE
SE
Super Sani-Cloth®
High Alcohol 55%
Germicidal Cloths
•Cleans, disinfects and
deodorizes hard,
non-porous surfaces
•Kills a broader range
of bacteria and viruses,
including RSV and TB in
1 minute; HBV and HIV-1
in 2 minutes; MRSA, VRE,
Staphylococcus aureus,
Pseudomonas aeruginosa,
E. coli, Klebsiella
pneumoniae, Adenovirus
Type 5, Rhinovirus
Vaccinia virus, Influenza A2/Hong Kong, and
Herpes Simplex Type 5 in 5 minutes
•Contains 55% alcohol to achieve faster kill times
•EPA-registered; meets CDC and OSHA guidelines
•Unique deep well lid provides adequate
space to store and access
Item #
82-55172
Style
Canister
Size
6” x 6-3/4”
Qty
1 ea
Description
Small
Medium
Large
X-Large Qty
100/bx
100/bx
100/bx
100/bx
Price
$4.10
$4.10
$4.10
$4.10
DermaRite® Gelrite®
Hand Sanitizers
•Contains Vitamin E
•Fast-acting broad-spectrum
antimicrobial activity
•Soothing, rich emollients
help keep hands soft, even
after repeated use
•No sticky or tacky residue
Item #
Description Qty
11-SCS4 Flip Top, 4-oz. 1 ea 11-SCS17 Pump, 16-oz. 1 ea Price
$0.85
$3.80
11-SCS17
11-SCS4
Price
$10.20
NEW! Earloop Procedure Mask
These procedure masks are made from lightweight,
breathable material and have a BFE of >97%.
Item #
15-M50P
Description
Earloop Procodure Mask
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
Qty
50/bx
Price
$9.70
3
F441 - Infection Control, Prevent Spread, Linens
ST R
B E LLE
SE
Safetec® Universal Precaution
Compliance Kit (OSHA 1910.1030)
Each kit contains:
• Pair of vinyl gloves
• Protective apron
• Twist tie
• Scoop/scraper
• SaniZide Plus® Germicidal wipe
• p.a.w.s.® Antimicrobial hand wipe
•
•
•
•
•
Red biohazard bag
Identification tag
10 g. Red Z® Solidifier
Instructions
Combo mask/safety shield
*Suggested shelf life for kit is 3 years
Item #
11-17100
ST R
B E LLE
SE
SharpStar
In-Room­ Sharps
Disposal System
®
•Automatically stops
in the ”full” position
indicating when the
container reaches
capacity
•Restricts access to
container contents
•Provides safe closure
for final disposal
•Economical horizontal drop
•Lock is integrated into door and all wall enclosures
are keyed the same
•Mailbox lid
•Saves valuable counter space
Item #
68-8556H
Description
Disposal System
Container Only
Item #
Color
68-85121 Clear
68-85131
Transparent Red
Qty
Price
1 ea
$76.60
Size
Price
5-qt.$5.30
5-qt.
$5.90
CLICK HERE
TO DOWNLOAD
the 2016 Infection
Prevention Catalog
4
Description
Universal Precaution Kit (poly bag)
Qty
1 ea
Price
$16.00
All Barrier
Precaution Gown
•Entire gown made with
fluid resistant barrier fabric
constructed from
99% high density continuous
filament texturized polyester
yarns and 1% conductive
carbon yarn
• Two sets of tie closures
• White knit cuffs
•48-1/2” length,
60-1/2” sweep
Item #
40-8190524
Color
Yellow
Qty
1 ea
Price
$30.80
Ultra-Tuff™ Infectious
Waste Disposal Bags
•Designed specifically for
small waste collection
•Constructed with low-density polyethylene resin
•Fold-over security flap
•Biohazard label meets OSHA and state-suggested
regulations
Item #
61-5042
Size
11” x 14”
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
Qty
50/ca
Price
$9.20
F441 - Infection Control, Prevent Spread, Linens
Infection Prevention Labels & Signs
Clearly warn, inform and promote your Infection
Prevention policies.
ISOLATION
L-9104N
Permanent Adhesive
Item #
Description
L-9104N
Tape
2” x 6” Tape
500” Roll
Fl. Red on White
1” Core
8-1/2” x 8-1/2”
10/Pack
48
Item #
Description
$13.60 $12.10 $11.50$10.80
L-9214
Laminnated Sign
1
Price Per Roll
12
24
L-9214
Red on White
1
Price Per Pack
5
10
$12.45
$9.55
Help your organization comply with
handwashing guidelines and regulations.
Remind staff of the importance of handwashing
and proper technique. Apply to doors and walls
in and out of the lavatory areas.
1
$8.95
ST R S
BELLE
SE
Handwashing Labels and Signs
$9.20
20
Price Per Pack
5
10
20
Item #
Qty
L-9209
Sign, 10/pk
$12.45 $9.55 $9.20 8.95
L-9026
Label, 25/pk
$10.75 $9.50 $8.75 $8.40
L-9209
8-1/2” x 8-1/2”
Laminated Sign Black on Yellow
L-3034
Fl. Red
4-1/2” x 4-1/2”
Removable Adhesive
2” x 3”
500/bx
Biohazard
Labels
Visit www.BriggsCorp.com for our complete
offering of Standard Precaution Laminated Signs!
L-9026 Fl. Yellow
L-3032 2” x 3”
500/bx
Price Per Box
5
10
20
Item #
Qty
L-3032
500/bx
$30.30 $25.30 $23.55 $21.75
L-3034
500/bx
$30.30 $25.30 $23.55 $21.75
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
1
Fl. Red
5
F441 - Infection Control, Prevent Spread, Linens
NEW! Infection Control: How to
Implement an Effective Approach for
Long-Term Care
Among skilled nursing facilities, infection control
violations make up one of the most common survey
deficiencies. This book gives frontline staff the tools and
guidance to remain compliant with the government’s
infection control policies. Acting as a one-stop reference,
this resource offers staff quick and convenient access
to procedures, policies, and forms. This comprehensive
manual includes the following:
• CMS’ regulations to F441, infection control
•The most up-to-date government regulations in an
easy-to-apply format
• Staff training in-services
•Sample policies, procedures and forms to help facilities
stay compliant
2016, HCPro
Item #
4981
UPDATED
Description
Infection Control: How to Implement an Effective
Approach for Long-Term Care
Price Per Each
$130.00
Infection Prevention Inservice Training Programs
These inservices are designed to provide periodic infection
prevention training and orientation for your staff. These programs
provide a comprehensive overview of the subject matter and give
pertinent, detailed information which has been written so that it is
easy to understand.
Each program is delivered on a CD-ROM and includes:
•An introduction that states the program’s goals and objectives
and guidelines for presenting the program
•A brief competency assessment which can be used to evaluate
your staff for retention of the program content
• PowerPoint training Presentation
• An answer key for the competency assessment
• A presenter’s program evaluation
•A certificate of completion for participants upon successful
completion of the program
Reviewed for accuracy and updated May, 2015
2015, Briggs Healthcare
This is a series of eight (8) inservices – available titles include:
4901CD Clostridium Difficile in Long Term Care 4905CD
4906CD
4902CD Emerging Infectious Diseases
4903CD Housekeeping - Infection Prevention 4907CD
4908CD
4904CD Multi-Drug Resistant Organisms:
Ambulatory Care
Item #
See Above
Multi-Drug Resistant Organisms: Long Term Care
Multi-Drug Resistant Organisms: Acute Care
Norovirus Gastroenteritis - Management of Outbreaks
Tuberculosis
Description
Price Per Each
Infection Prevention Inservice Training Programs $99.00
For complete offering of Infection Prevention Training Resources for Long-Term Care,
visit www.BriggsCorp.com today!
6
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
F371 | Food Procurement, Store/Prepare/Serve – Sanitary
Facilities must obtain food for resident consumption from sources approved or considered satisfactory by
Federal, State or Local Authorities; and Follow proper sanitation and food handling practices to prevent the
outbreak of foodborne illness. Safe food handling for the prevention of foodborne illnesses begins when
food is received from the vendor and continues throughout the facility's food handling process.
2014 Ranking – #2 Most Cited | Also #2 for First 6 Months of 2015
Shop these products to find compliance solutions!
ST E R
B E LL
SE
Thermoworks Fridge-Freezer
Thermometer
L-1834
15/16” x 2-1/4”
White
•
•
•
•
•
250/bx
Leftover Label
Cold-temp adhesive sticks in refrigerator
and freezer
Item #
Qty
L-1834
250/bx
1
Item #
15-800150
Price Per Box
2
4
Range: -40 to 86°F (-40 to 30°C)
Sensor: Bimetal
Accuracy: +/-3°F from 0 to 70°F
Units: 1°F or °C, divisions
Size: 2” (50mm) diameter
10
Description
Fridge/Freezer Thermometer Qty
1 ea
Price
$3.95
20
$11.85$10.40$9.95$9.00$8.30
3142P
REFRIGERATOR/FREEZER TEMPERATURE LOG
Refrigerator/Freezer
Temperature Log
Month/Year________________________
DIRECTIONS: Record temperatures of all refrigeration/freezer units and initial.
REFRIGERATOR
DATE
FREEZER
INITIALS
WALK-IN UNIT #1 UNIT #2 UNIT #3 UNIT #4 WALK-IN UNIT #1 UNIT #2 UNIT #3 UNIT #4
AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM
AM
PM
1
2
• Record refrigerator and freezer
temperatures to ensure all foods
are appropriately stored
• Printed 1 side
• 5-hole punched top and side
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Item #
3142P Description Price Per Pad (100/pd)
Refrigerator/Freezer
Temperature Log
$11.60
17
18
3139P
19
20
21
22
TEMPERATURE/SANITIZER LOG
23
Month/Year________________________
24
Temperature/Sanitizer Log
Allows the Dietary Department
to ensure proper sanitiation and
cleaning of all dietary serviceware
by monitoring and recording the
temperature and test strip results for
the dishwasher and/or the pots and
pans sink.
DIRECTIONS: Record temperature and test strip results for the dishwasher and/or the pots & pans sink.
25
BREAKFAST
DATE Wash
26
Rinse
LUNCH
Strip Sink PPM Initials
Wash
DINNER
Strip Sink PPM Initials
Wash
Rinse
Strip Sink PPM Initials
2
28
3
29
4
30
Customizable CD-Rom Included!
5
31
6 (800) 247-2343 www.BriggsCorp.com
Form 3142P © BRIGGS, Des Moines, IA 50306
8/03
Rinse
1
27
Unauthorized copying or use violates copyright law.
REFRIGERATOR/FREEZER TEMPERATURE LOG
PRINTED IN U.S.A.
7
8
9
10
11
Dining and Dietary Services
Policy and Procedure
12
13
14
15
16
17
18
19
20
Item #
3139P 21
Description Price Per Pad (100/pd)
Temperature/Sanitizer Log $11.60
22
23
24
25
26
Food Temperature Record
•Record
food temperatures at
the beginning of meal service to
ensure proper food temperatures
for residents
•Printed 1 side
•3-hole top punched (11” edge)
Item #
CFS8-1
Description Price Per Pad (100/pd)
Food Temperature Record
$11.60
27
28
FOOD TEMPERATURE RECORD
Week of
through
INSTRUCTIONS: Record food temperatures and identify the cook at the beginning of each meal service. The Dietary Manager will review by checking (✔) ACC if acceptable; UN if
unacceptable. He/She will then review problem areas or food types with the cook so that appropriate temperatures are attained. See Serving Temperature Standards below.
DATE ➡
BREAKFAST
Milk
Eggs
Fruit/Juice
Cereal
Meat/Entree: Regular
Ground
Puree
Beverage
COOK ➡
LUNCH
Milk
Meat/Mn. Dish: Regular
Ground
Puree
Starch
Vegetable: Regular
Puree
Salad: Regular
Puree
Dessert: Regular
Puree
Beverage
COOK ➡
DINNER
Milk
Meat/Mn. Dish: Regular
Ground
Puree
Starch
Vegetable: Regular
Puree
Salad: Regular
Puree
Dessert: Regular
Puree
Soup
Beverage
COOK ➡
29
TEMP
30 ACC UN
TEMP
ACC UN
TEMP
ACC UN
TEMP
ACC UN
TEMP
ACC UN
TEMP
ACC UN
TEMP
ACC UN
31
TEMPERATURE/SANITIZER LOG
Form 3139P © BRIGGS, Des Moines, IA 50306 (800) 247-2343 www.BriggsCorp.com
8/03
Unauthorized copying or use violates copyright law.
PRINTED IN U.S.A.
TEMP
ACC UN
TEMP
ACC UN
TEMP
ACC UN
TEMP
ACC UN
TEMP
ACC UN
TEMP
ACC UN
TEMP
ACC UN
TEMP
ACC UN
TEMP
ACC UN
TEMP
ACC UN
TEMP
ACC UN
TEMP
ACC UN
TEMP
ACC UN
TEMP
ACC UN
SERVING TEMPERATURE STANDARDS (F°)
Solids (meat /vegetables) 160°
CFS 8-1 Rev. 10/07 © 1992 BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
Soft Food (mashed potatoes/oatmeal) 150°
Liquids (soup/gravy) 170°
Chilled foods/beverages at or below 41°
FOOD TEMPERATURE RECORD
A great time-saver, includes step-by-step
guidelines to ensure that regulatory,
nutritional, dietary needs are met for
optimal health of individuals in your care.
This best selling manual includes more
than 65 sample forms and covers a wide
range of topics including Meal Service to
Alternative Nutrition Intervention.
2013, Hardcover, Becky Dorner
& Associates
Item #
8363 Description
Price Per Each
Dining and Dietary Services
Policy and Procedure $179.95
CFS8-1
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
7
F323 | Free of Accident Hazards/Supervision/Devices
The facility must ensure that – (1) The resident environment remains as free from accident hazards as is
possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents.
2014 Ranking – #3 Most Cited | Also #3 for First 6 Months of 2015
Shop these products to find compliance solutions!
FALL RISK EVALUATION
LEVEL OF
CONSCIOUSNESS/
MENTAL STATUS
B.
HISTORY OF
FALLS
(Past 3 months)
C.
AMBULATION/
ELIMINATION
STATUS
D.
E.
F.
VISION STATUS
GAIT/BALANCE
SYSTOLIC
BLOOD PRESSURE
G.
MEDICATIONS
SCORE RESIDENT STATUS/CONDITION
0
2
4
0
2
4
0
2
4
0
2
4
ALERT - (oriented x 3) OR COMATOSE
2
0
1
1
1
1
1
1
0
2
4
N/A - not able to perform function
PREDISPOSING
DISEASES
2
3
4
INTERMITTENT CONFUSION
Fall Risk Evaluation
NO FALLS in past 3 months
1 - 2 FALLS in past 3 months
3 OR MORE FALLS in past 3 months
AMBULATORY/CONTINENT
•Evaluate 8 parameters of functional status to
determine resident fall risk
CHAIR BOUND - Assist with elimination
AMBULATORY/INCONTINENT
ADEQUATE (with or without glasses)
POOR (with or without glasses)
• Printed 2 sides same
Gait/Balance normal
Balance problem while standing
• 5-hole punched
Balance problem while walking
Decreased muscular coordination
Change in gait pattern when walking through doorway
Gait Problems: Jerking, unstable when making turns, unsteady gait, shuffling gait
Item #
CFS6-17HH
CFS6-17HF
Requires use of assistive devices (i.e., cane, w/c, walker, furniture)
NO NOTED DROP between lying and standing
Drop LESS THAN 20 mm Hg between lying and standing
Drop MORE THAN 20 mm Hg between lying and standing
Antipsychotics, Antianxiety Agents, Antidepressants, Hypnotics,
Cardiovascular Medications, Diuretics, Narcotic Analgesics, Neuroleptics,
Other Medications That Cause Lethargy or Confusion
NONE of these medications taken currently or within last 7 days
DescriptionPrice Per Pad (100/pd)
Side Punched
$13.05
Top Punched
$13.05
TAKES 1 - 2 of these medications currently and/or within last 7 days
TAKES 3 - 4 of these medications currently and/or within last 7 days
If resident has had a change in medication and/or change in dosage
in the past 5 days = score 1 additional point.
Circulatory/Heart, Neuromuscular/Functional, Orthopedic, Perceptual,
Psychiatric/Cognitive, Infection, Pain/Headache, Fatigue/Weakness/Weight
Loss, Vitamin D Deficiency, History of Falls
0
2
4
TOTAL SCORE
NONE PRESENT
1 - 2 PRESENT
3 OR MORE PRESENT
Total score of 10 or above represents HIGH RISK
SIGNATURE / TITLE / DATE
SIGNATURE / TITLE / DATE
1
2
NAME–Last
1
DISORIENTED x 3 at all times
LEGALLY BLIND
To evaluate the resident’s Gait/Balance, have him/her stand on both feet
without holding onto anything; walk straight forward; walk through a doorway;
and make a turn. If N/A, do not (✓) any other boxes.
0
2
4
1
H.
▼
DATE
PARAMETER
A.
ST R
B E LLE
SE
INSTRUCTIONS: Evaluate the resident status in the eight clinical condition parameters listed below (A-H) by assigning the corresponding
score which best describes the resident in the appropriate evaluation column. Add the column of numbers to obtain the Total Score. If
the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be
initiated immediately and documented on the care plan.
3
4
First
Middle
Attending Physician
Record No.
Room/Bed
FALL RISK EVALUATION
CFS 6-17HH Rev. 8/10 © 1992 BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
❑ Continued on Reverse
FALL RISK ASSESSMENT
ASSESSMENT DATE
PARAMETER
•Assess 8 parameters of functional status to determine
resident fall risk
•Printed 2 sides same
•5-hole punched side
Item #
3634HH
DescriptionPrice Per Pad (100/pd)
Fall Risk Assessment SC
$13.05
SCORE RESIDENT STATUS/CONDITION
ORIENTED x 3 (time, place, person)
0
DISORIENTED x 1
1
DISORIENTED x 2
2
DISORIENTED x 3
4
WANDERS
4
B.
HISTORY OF
NO FALLS in past 3 months
0
FALLS
1 - 2 FALLS in past 3 months
2
(Past 3 months)
3 OR MORE FALLS in past 3 months
4
C.
AMBULATION/
REGULARLY CONTINENT
0
ELIMINATION
REQUIRES REGULAR ASSIST WITH ELIMINATION
2
STATUS
REGULARLY INCONTINENT
4
D.
VISION STATUS
ADEQUATE (with or without glasses)
0
POOR (with or without glasses)
2
LEGALLY BLIND
4
E.
GAIT/BALANCE/
0 Gait/Balance normal
AMBULATION
1 Balance problem while standing/walking
Indicate
appropriate
1 Decreased muscular coordination/jerking movements
point value
1 Change in gait pattern when walking (i.e., shuffling)
for each item
that applies.
1 Requires use of assistive devices (i.e., cane, w/c, walker, furniture)
F.
SYSTOLIC
0 NO NOTED DROP between lying and standing
BLOOD PRESSURE
2 Drop LESS THAN 20 mm Hg between lying and standing
BED RAIL/ASSIST BAR EVALUATION
4 Drop MORE THAN 20 mm Hg between lying and standing
❑ Admission___ ❑ Re-admission___ ❑ Quarterly___ ❑ Annual___
❑ Significant Change___
❑ Other_______________
Respond below
based on the following types of medications: Anesthetics,
G.
MEDICATIONS
A.
Fall Risk Assessment
▼
INSTRUCTIONS: Upon admission and quarterly (at a minimum) thereafter, assess the resident status in the eight clinical condition
parameters listed below (A-H) by assigning the corresponding score which best describes the resident in the appropriate assessment
column. Add the column of numbers to obtain the Total Score. If the total score is 10 or greater, the resident should be considered
at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan.
1
2
3
4
MENTAL STATUS
Antihistamines, Antihypertensives, Antiseizure, Benzodiazepines, Cathartics,
INSTRUCTIONS: For each evaluation type (Admission, Annual, etc.) identify the corresponding
number
in the space
provided
Diuretics,
Hypoglycemics,
Narcotics,
Psychoactives, Sedatives/Hypnotics.
on the right (i.e. Admission 1 ). Check (✓) Yes or No for each evaluation factor. If Yes, summarize on Side Two. Complete the
of these
taken currently or within last 7 days
0 atNONE
Summary of Findings corresponding to each evaluation number using the Intervention Codes
the top
of themedications
page.
❑ Assist Bar
2
❑ Bed Rail: ❑ Half ❑ Quarter ❑ Full
TAKES
currently and/or within last 7 days
1 1 - 22 of these
3 medications
4
TAKES 3 - 4 of these medications currently and/or within last 7 days
4
Date
EVALUATION FACTORS
If resident has had a change in medication and/or change in dosage
1
1. Has resident expressed a desire to have bed rails/assist bar while in bed for their own
in the past 5 days = score 1 additional point.
❑ Yes ❑ Yes ❑ Yes ❑ Yes
safety and/or comfort? If yes, explain _________________________________________
Respond❑below
H.
PREDISPOSING
No based
❑ No on❑the
Nofollowing
❑ Nopredisposing conditions: Hypotension,
Vertigo, CVA, Parkinson’s disease, Loss of limb(s), Seizures, Arthritis,
DISEASES
_______________________________________________________________________
Osteoporosis, Fractures, Multiple Sclerosis.
NONE PRESENT
2. Does the resident have fluctuations in levels of consciousness or a cognitive deficit? 0If
❑ Yes ❑ Yes ❑ Yes
1❑
- 2Yes
PRESENT
yes, explain _____________________________________________________________
2
❑ No ❑ No ❑ No ❑ No
_______________________________________________________________________
3 OR MORE PRESENT
4
Bed Rail/Assist Bar Evaluation
•
•
•
•
Determine appropriateness of bed rail/assist bar usage
Form allows for 4 separate evaluations
Printed 2 sides different
5-hole punched
Item #
3714HH-10
3714HF-10
DescriptionPrice Per Pad (100/pd)
Side Punched
$14.85
Top Punched
$14.85
above
10 represents HIGH RISK
TOTAL SCORE
3. Does the resident have any visual deficits? If yes, explain _________________________
❑ Yes Total
❑ Yesscore
❑ Yes
❑ Yes
_______________________________________________________________________
❑ No ❑ No ❑ No ❑ No ASSESS
ASSESS
SIGNATURE/TITLE/DATE
SIGNATURE/TITLE/DATE
5. Is the resident able to get out of bed safely?
6. Does the resident have a history of falls?
2
NAME–Last
First
❑ Yes
❑ No
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No Middle
❑ No
❑ Yes
❑ No
Attending Physician
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No
❑ Yes
❑ No
Form 3634HH Rev. 12/03 © 1997 BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No
❑ Yes
❑ No
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No
❑ Yes
❑ No
9. Does the bed rails/assist bar help the resident rise from a supine position to a sitting /
standing position?
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No
❑ Yes
❑ No
10. Does the resident have a history of postural hypotension?
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No
❑ Yes
❑ No
11. Is there a possibility the resident will climb over the bed rails/assist bar?
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No
❑ Yes
❑ No
12. Is there evidence (reason to believe) the resident has (or may have) a desire or reason
to get out of bed? If yes, explain _____________________________________________
_______________________________________________________________________
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No
❑ Yes
❑ No
13. Does the resident receive any medications that would require safety precautions? Is yes,
explain _________________________________________________________________
_______________________________________________________________________
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No
❑ Yes
❑ No
14. Is there a risk to the resident if bed rails/assist bar are used? If yes, explain___________
_______________________________________________________________________
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No
❑ Yes
❑ No
15. Do the bed rails/assist bar alternatives /interventions create more risks than bed rails/
assist bar use? If yes, explain _______________________________________________
_______________________________________________________________________
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No
❑ Yes
❑ No
Form 3714HH-10 Rev. 5/13 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
Middle
Attending Physician
Record No.
4
Record No.
Room/Bed
FALL RISK ASSESSMENT
❑ Continued on Reverse
8. Does the resident use the bed rails/assist bar for positioning or support?
First
3
❑ Yes ❑ Yes ❑ Yes
❑ No ❑ No ❑ No
7. Is the resident having problems with balance or poor trunk control? If yes, explain
_______________________________________________________________________
_______________________________________________________________________
NAME–Last
8
1
4. Is the resident able to get in/out of bed?
3634HH
Room/Bed
BED RAIL /ASSIST BAR EVALUATION
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
❑ Continued on Reverse
3714HH-10
F323 – Free of Accident Hazards/Supervision/Devices
Wander Data Collection Tool
•Assists in determining whether resident presents a risk
for elopement
•Includes intervention initiated and room for summary/
conclusions and/or recommendations
• Printed 2 sides different
• 5-hole punched
Item #
3711HH-14
3711HF-14
DescriptionPrice Per Pad (100/pd)
Side Punched
$14.85
Top Punched $14.85
3711HH-10
WANDER DATA COLLECTION TOOL
❑ Admission___ ❑ Re-admission___ ❑ Quarterly___ ❑ Annual___ ❑ Significant Change___ ❑ Other_______________
INSTRUCTIONS: For each evaluation type (Admission, Annual, etc.) identify the corresponding number in the space
provided on the right (i.e. Admission 1 ). Check (✓) Yes or No for each evaluation factor. If Yes, summarize on Side Two.
Complete the Summary of Findings corresponding to each evaluation number using the Intervention Codes at the top
of the page.
1
2
3
4
Has the resident wandered? Did the resident wander at home, in previous living
settings, family/significant others voiced concerns?
❑ Yes
❑ No
❑ Yes
❑ No
❑ Yes
❑ No
❑ Yes
❑ No
Does the wandering place the resident at significant risk of getting to a
potentially dangerous place (stairs, outside the facility)?
❑ Yes
❑ No
❑ Yes
❑ No
❑ Yes
❑ No
❑ Yes
❑ No
EVALUATION FACTORS
Date
5900P
SMOKING SAFETY EVALUATION
❑ Yes
❑ Yes
❑ Yes
❑ Yes
INSTRUCTIONS:
Does the wandering significantly intrude on the privacy or activities
of others? For residents requesting to smoke, complete for admission, significant change, quarterly, annually and when fire
safety is compromised for❑resident
or❑other
❑ Noeach area and check (✓) all that apply. Complete with summary and
❑ No Evaluate
No residents.
No
utilize for follow-up evaluations.
1
RESIDENT ABILITY/OBSERVATIONS
Yes
Is the resident cognitively impaired with poor decision-makingMemory:
skills (i.e. Short
poor Term: ❑❑Intact
decisions, cues, intermittent confusion, inattention, disorganized thinking)?
No
Long Term: ❑❑Intact
Judgement:
❑ Yes
❑ Yes
❑ Problematic
❑ No
❑ No
❑ Problematic
SUMMARY OF EVALUATION
❑ Yes ❑ Unsupervised ❑ Supervised ❑ Assistance to Safely Hold
❑ No
❑ Uses Smoking Apron
Smoking Materials: ❑ Resident Stores ❑ Facility Stores
Mental Status: ❑ Alert ❑ Altered
Decision Ability: ❑ Consistent ❑ Inconsistent
Is the resident a new admission or re-admission (within past 30
days) and not
Mobility:
accepting the new situation?
(Range of Motion)
Yes
Upper❑Body:
No
Lower❑Body:
❑ Yes
❑ Limitations
Yes
❑
❑ No
❑ Limitations
No
❑
❑ Yes
❑ No
Limits
❑ No
❑ No
Limits
Manual Dexterity: ❑ Grasps/Holds ❑ Weak Grasp/Drops Items
Mobility Devices: ❑ Yes ❑ No
❑ Yes
❑ Yes
❑ Yes
Does the resident have any visual, auditory or communicationReflexes:
deficits? ❑ Quick Response ❑ Diminished Response
❑ No
❑ No
❑ No
COMMUNICATION
Speech: ❑ Clear, Understood ❑ Unclear, Not Understood
Comprehension of Speech: ❑ Yes ❑ No
Does the resident ambulate independently, with or without the use of assistive
❑ Yes
Vision: ❑ Adequate ❑ Impaired
devices (include wheelchair)?
❑ No
Hearing: ❑ Adequate ❑ Impaired
❑ Yes
❑ Yes
Education – Policies/Procedures:
❑ Resident ❑ Family ❑ Resident Representative
Verification of Evaluation Results:
❑ Resident ❑ Family ❑ Resident Representative
❑ Yes Plan of Care: ❑ Initiated ❑ Revised
❑ No Referrals: ❑ Yes ❑ No
Comments: ______________________________________________
❑ Yes _______________________________________________________
Corrective Lenses: ❑ Yes ❑ No
❑ No
❑ No Aids:❑❑No
Hearing
Yes ❑ No
_______________________________________________________
_______________________________________________________
DIRECT OBSERVATION
Smokes only in designated area
❑ Yes ❑ No
_______________________________________________________
❑ Yes
❑ Yes
Does the resident verbally express the desire to go home or packed belongings
❑ Yes
❑ Yes
Safely lightsPOST-FALL
smoking material
❑ Yes ❑ No _______________________________________________________
INTERDISCIPLINARY
to leave?
❑ No
❑ No
❑ No
❑ No ASSESSMENT
Smoking Safety Evaluation
•Used to evaluate the ability of a resident to smoke in
a safe manner
•Convenient check-off-style format
• 8½” x 11”
• 5-hole punched top and side
• White paper, black ink, printed front and back
Item #
5900P
DescriptionPrice Per Pad (100/pd)
Smoking Safely Evaluation
$13.05
Holds smoking materials safely
❑ Yes ❑ No _______________________________________________________
Disposes of ashes in ashtray
❑ Yes ❑ No
_______________________________________________________
Date of current fall: __________________________ Date of last fall: __________________________
Responds quickly to fallen ashes
No
❑ Yes❑ Yes ❑❑Yes
❑ Yes
❑ Yes
Does the resident receive any medication that increases the restlessness or
Use: Removes tubing/not
brought into
No _______________________________________________________
Number of falls last 30 days: 30 days_______Oxygen
90 days_______
180
days_______
agitation?
❑ No❑ Yes ❑❑ No
❑ No
❑ No
smoking area
_______________________________________________________
Description of fall: _______________________________________________________________________________________
Follows smoking guidelines per policy
❑ Yes ❑ No
Is this a new behavior or has thee been any changes in their functional
Able to call status/
for emergency assistance
❑ Yes ❑ No ________________________________________ ____ /____ /____
_______________________________________________________________________________________________________
❑ Yes
❑ Yes
❑ Yes
❑ Yes
routing (i.e. new medication, pain, acute illness/infection, personal
tragedy,
new
Date
Returns
smoking
materials to storage
❑ Yes ❑ No Signature /Title
❑ No
❑ No
❑ No
❑ No
active diagnosis,
upsetting information)?
_______________________________________________________________________________________________________
RESIDENT ABILITY/OBSERVATIONS
2
SUMMARY OF EVALUATION
Memory: Short Term: ❑ Intact ❑ Problematic
❑ Unsupervised ❑ Supervised ❑ Assistance to Safely Hold
_______________________________________________________________________________________________________
Long Term: ❑❑Intact
❑ Yes ❑ Uses Smoking Apron
❑ Yes
❑ Yes
Yes ❑ Problematic
Is the resident_______________________________________________________________________________________________________
seeking to find spouse/family?
Judgement: Mental Status:
❑ Alert ❑❑No
Altered ❑ No
❑ No Smoking Materials: ❑ Resident Stores ❑ Facility Stores
❑ No
Decision Ability: ❑ Consistent ❑ Inconsistent
_______________________________________________________________________________________________________
Education – Policies/Procedures:
Mobility:
(Range of Motion)
Upper Body:
Lower Body:
❑ No Limits
❑ No Limits
❑ Limitations
❑ Limitations
❑ Resident ❑ Family ❑ Resident Representative
_______________________________________________________________________________________________________
❑ Yes Verification of Evaluation Results:
Does the resident’s
former lifestyle/profession affect the current behavior/
❑ Yes
❑ Yes
❑ Yes
Manual Dexterity: ❑ Grasps/Holds
❑
Items
wandering (i.e. night watchman, mailman, etc.)?
❑ No ❑ Resident ❑ Family ❑ Resident Representative
❑ No
❑ Weak
No Grasp/Drops
❑ No
Yes ❑ No
Injury: ❑ No injury ❑ First aid ❑ Transfer Mobility
to acuteDevices:
care ❑ ❑Death
NAME–Last
Plan of Care: ❑ Initiated ❑ Revised
Reflexes: ❑ Quick Response ❑ Diminished Response
First
Middle
Attending Physician
Room/Bed
Record No.
_______________________________________________________________________________________
describe:
If injury,
Referrals: ❑ Yes ❑ No
COMMUNICATION
Speech: ❑ Clear, Understood ❑ Unclear, Not Understood
_______________________________________________________________________________________________________
Comments: ______________________________________________
Comprehension of Speech:
❑ Yes ❑
No COLLECTION TOOL
WANDER
DATA
_______________________________________________________
_______________________________________________________________________________________________________
Vision: ❑ Adequate ❑ Impaired Corrective Lenses: ❑ Yes ❑ No
Form 3711HH-10 9/10 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
Hearing: ❑ Adequate ❑ Impaired
Hearing Aids: ❑ Yes ❑ No
Orthostatic BP (if applicable): Lying______________ Sitting______________ Standing______________
DIRECT OBSERVATION
_______________________________________________________
_______________________________________________________
Diagnosis: ______________________________________________________________________________________________
Smokes only in designated area
❑ Yes ❑ No _______________________________________________________
Safely lights smoking material
❑ Yes ❑ No
Holds smoking materials safely
❑ Yes ❑ No _______________________________________________________
Cardiovascular condition: _________________________________________________________________________
Disposes of ashes in ashtray
❑ Yes ❑ No
_______________________________________________________
Responds quickly to fallen ashes
❑ Yes ❑ No
_______________________________________________________
_______________________________________________________________________________________________________
New medical condition: __________________________________________________________________________
_______________________________________________________
Oxygen Use: Removes tubing/not brought into
❑ Yes ❑ No
smoking area
_______________________________________________________
Mental status:_________________________________________________________________________________
Follows smoking guidelines per policy
❑ Yes ❑ No
Medications/Side effects:_________________________________________________________________________
Able to call for emergency assistance
❑ Yes ❑ No ________________________________________ ____ /____ /____
Date
Returns smoking materials to storage
❑ Yes ❑ No Signature /Title
_______________________________________________________________________________________________________
NAME–Last
First
Middle
Attending Physician
_______________________________________________________________________________________________________
Form 5900P 1/13 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
LOG
Recent medicationRESIDENT
changes: ❑ Yes FALL
❑ No TRACKING
❑ Added ❑ Discontinued
SMOKING SAFETY EVALUATION
PRINTED IN U.S.A.
DIRECTIONS: Each
time a resident experiences a fall, enter the date and time of the fall at the top of theDose:_______________________
column. In that same
Medication:____________________________________________________________
column, check (✓) all of the items listed that may have contributed to that fall. Be sure to include items listed on the reverse.
Summarize findings,
make any conclusions drawn on related plans on the reverse, sign and
all entries.
Frequency:________________________________________________
Datedate
of change:__________________________
Date
Sensory deficits:________________________________________________________________________________________
Time
Location of Fall
Gait balance deficits:____________________________________________________________________________________
R = Room, B = Bathroom, H = Hall
DR = Dining Room, O = Other
Item #
1161P
DescriptionPrice Per Pad (100/pd)
Interdisciplinary Post-Fall Assessment
$13.05
Orthopedic
NAME–Last
Fatigue/Weakness/
Weight Loss
Neuromuscular/
Functional
Form 1161P Rev. 3/13
Infection
First
Visit www.BriggsCorp.com
to find additional Care Area Assessments!
❑ Continued on Reverse
Supporting Documentation
Basis/reason for checking the item, including the location,
date and source (if applicable) of that information
✓ History of Falling (J1700, J1800, J1900)
EXTERNAL RISK FACTORS
❑
❑
❑
Pacemaker
Cane/Crutch
Walker
❑
❑
❑
❑
❑
❑
❑
Meriwalker
Restraints
Antipsychotics
Antianxiety Agents
Antidepressants
Diuretic
Cardiovascular
❑
Narcotic Analgesics
Neuroleptics
Change in Med
❑
❑
ENVIRONMENTAL HAZARDS
Poor Lighting
Glare
Patterned Carpet/Rug
❑
❑
❑
❑
Poorly Arranged
Furniture
Slippery Floors
New Admit/Move
Obstructed Walkway
Uneven Surfaces
❑
❑
Poor Fitting or Slippery
Shoes
NAME–Last
Previous falls
Time of day, exact hour of the fall(s)
Location of the fall(s), such as bedroom, bathroom,
hallway, stairs, outside, etc.
Related to specific medication
Proximity to most recent meal
Responding to bowel or bladder urgency
Doing usual/unusual activity
Standing still or walking
Reaching up or reaching down
Use/Inappropriate use of mobility aid(s) (i.e. walker, cane,
wheelchair)
Identify the conclusions about the root cause(s),
contributing factors related to previous falls
✓ Physical Performance Limitations: Balance, Gait, Strength, Muscle Endurance (G0300A - G0300E)
9+ Medications
First
Middle
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
Difficulty maintaining sitting balance
Need to rock body or push off on arms of chair when
standing up from chair
Ambulates in room without assistive device
Difficulty maintaining standing position
Impaired balance during transitions (G0300A - G0300E)
Gait problem, such as unsteady gait, even with mobility aid
or personal assistance, slow gait, takes small steps, takes
rapid steps, or lurching gait
One leg appears shorter than the other
Musculoskeletal
problem, such asRecord
kyphosis,
weak
hip
Attending Physician
No.
Room/Bed
flexors from extended bed rest, or shortening of a leg
✓ Medications
Form 3091 Rev. 8/10 © BRIGGS, Des Moines, IA (800) 247-2343
RESIDENT FALL TRACKING LOG
PRINTED IN U.S.A.
❑
❑
❑
❑
❑
3091
❑
❑
MDS 3.0 Care Area Assessments
Item #
DescriptionPrice Per Pack (25/pk)
1911PFall $12.00
1914P
Dehydration/Fluid Maintenance
$12.00
Room/Bed
POST-FALL ASSESSMENT
This Report Has Been Generated As Part Of The Facilities Quality Assessment And
Assurance Process And Constitutes Confidential Quality Assurance Committee Records. Ref. CFR 4438.75(0)
❑
❑
•Establishes a logical flow for assessing multiple
problems, complications and risk factors
• Provides the location of supporting documentation
•Directs the staff to appropriate care plans
Record No.
INTERDISCIPLINARY
Review of Indicators
of Fall Risk
PRINTED IN U.S.A.
Vitamin D Deficiency
MEDICATION
DescriptionPrice Per Pad (100/pd)
Resident Fall Tracking Log
$13.70
Attending Physician
11. FALL(S) CARE AREA ASSESSMENT (CAA)
History of Falls
Resident Fall Tracking Log
Item #
3091 Middle
© BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
Hypnotics
•Used to track falls of individual resident
•Printed 2 sides different
•3-hole side punched
1161P
Pain/Headache
CONDITIONS / DIAGNOSIS
•Used to assess residents who have fallen
•Printed 2 sides different
•5-hole punched top and side
Pattern of current fall: Time of day:________________________
INTERNAL RISK FACTORS
Activity: ❑ Ambulation
❑ W/C or gerichair
❑ Independent
❑ Bed
❑ Staff assisted
❑ Toilet/Shower chair
Psychiatric/Cognitive
❑ Transfer
❑ Other: _________________________________________
❑ Unwitnessed ❑ Witnessed
______________________________________________
Perceptual
Circulatory/Heart
APPLIANCE/DEVICE
Interdisciplinary Post-Fall Assessment
Room/Bed
Record No.
_______________________________________________________________________________________________________
❑ Continued on Reverse
Antipsychotics (N0410A)
Antianxiety agents (N0410B)
Antidepressants (N0410C)
Hypnotics (N0410D)
Cardiovascular medications (from medication
administration record)
Diuretics (N0410G) (from medication administration record)
Narcotic analgesics (from medication administration
record)
Neuroleptics (from medication administration record)
Other medications that cause lethargy or confusion (from
medication administration record)
NAME–Last
1191P
First
Middle
Form 1911P Rev. 5/12 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
Attending Physician
Record No.
Room/Bed
FALL(S) RISK CARE AREA ASSESSMENT
Does Your
Software
Provider Have
Briggs® Inside?
Visit www.BriggsCorp.com/BriggsInside
to find out more!
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
9
F323 – Free of Accident Hazards/Supervision/Devices
Falls in Older People: Prevention & Management, 4th Edition
A thorough guide to preventing and managing falls in hospitals and long-term care settings.
This guide explores the internal and external causes of falls, analyzes their consequences,
provides clinical assessments for actual falls as well as risks for falling, and promotes an
interdisciplinary approach to falls management. Jam-packed with practical strategies,
assessment tools, and management practices, Falls in Older People includes all the
medical, rehabilitative, and environmental strategies needed in any care setting to protect
the safety and health of at-risk older adults.
2012, Softbound, Health Professions Press
Item #
8943
Description
Falls in Older People: Prevention & Management, 4th Edition Price Per Each
$39.99
Transfer and Ambulation Skills – DVD
Nursing assistants must master the skills needed for transfer and ambulation to assist persons with impaired
mobility to walk, move to wheelchairs, toilets and beds. This Nursing Assistant Series program provides clear
descriptions and demonstrations using proper techniques for:
• Pivot Transfer from Bed to Wheelchair and back
• Pivot Transfer from Wheelchair to Toilet and back
• Two-person Lift from bed to Wheelchair
2013, Medcom
Item #
7723DV
•
•
•
•
Three-person Lift from Bed to Gurney
Transfer from Mechanical Lift
Assisting with Ambulation
Preventing Injury during a Fall
Description
Transfer & Ambulation Skills -DVD
Price Per Each
$149.00
NEW! Posey Bariatric Gait Belt
Used correctly, gait and transfer belts reduce the risk of injury
to the patient/resident and the caregiver resulting from a loss
of balance or an uncontrolled fall.
• Easily applied quick-release nylon buckles
• Made of sturdy cotton
• 2” wide webbing
• Machine washable
• Weight capacity: 279 Lbs.
• Fits waist sizes: Up to 72” (183 cm)
Item #
15-6528QL Color
Navy Price Per Each
$14.00
Clearly Communicate Fall
Risk to Staff with Briggs
Chart Labels!
L-2183 15/16” x 2-1/4” Fl. Orange 250/bx
L-2109 15/16” x 2-1/4” Fl. Red
500/bx
Labels
These labels feature removable adhesive. Not shown actual size.
Item #
Price Per Box
Qty124
10
20
L-2071
250/bx $16.35 $14.80 $13.35 $12.45 $11.70
L-2183
250/bx $11.85 $10.40 $9.95 $9.00 $8.30
L-2109
500/bx $19.55 $18.55 $17.80 $16.70 $15.40
10
L-2071
1-5/8” x 3”
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
Fl. Yellow
250/bx
F323 – Free of Accident Hazards/Supervision/Devices
Magnetic Care Signs
Improve Safety by Signaling Fall Risk at the Door or Bedside
• Highly visible red and white plastic signs
•Magnetic backing adheres to metal door frames, cabinets and bedframes
without sticky adhesive residue
• Available in 2 sizes: 5”H x 3”W and 9”H x 2”W
• Blank area can be customized with a water-based marker
• Minimum order of 5 signs (can be any combination)
Item #
6510DS 6509DS
Size (H x W)
5” x 3”
9” x 2” 6510DS
Sign Title Attention High Fall Risk
Attention High Fall Risk
Price Per Each
$6.25
$6.25
Visit www.BriggsCorp.com for our
complete offering of Magnetic Signs!
6509DS
ST R
B E LLE
SE
Ultra Lightweight Aluminum Rollator
Hip Protector Set – Men’s/Women’s
•Straight padded backrest
•Adjustable handle height: 32” – 36”
in 1” increments
•Secure bicycle-style,
loop-lock handbrakes
with ergonomic
handgrips
• Folds for storage and
transportation
• 2-position storage basket
• Wire basket size:
16” x 8-3/4” x 5-3/4”
• Distance between
handles: 18”
• Wheel size: 6”
• Overall width: 24”
•Flip-up cushion seat size:
14” x 13”; seat height: 22”
• Weight: 15 lbs.
• Weight capacity: 300 lbs.
Item #
HealthSmart™
501-1012-2100HS
DMI
501-1012-0700
501-1012-4100
Frame Color
• Comfortable fit. The secret is in “the curve”
• Lightweight, wearable around-the-clock
• Effectiveness supported by extensive studies
•2 undergarments per package
Qty
Price
Royal Blue
1 ea
$107.07
Burgundy
Titanium
1 ea
1 ea
$110.08
$111.49
®
Price
$60.00
Size
Men’s Women’sMen’s
w/pads
w/pads
without pads
Small
Medium
Large
X-Large
XX-Large
XXX-Large
14-CHMS14-CHWS
14-CHMM14-CHWM
14-CHML 14-CHWL
14-CHMXL 14-CHWXL
14-CHMXXL14-CHWXXL
14-CHMXXXL14-CHWXXXL
Item #
14-CHPAD
$60.00
Description
Protector Pads
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
$33.00
$33.00
Women’s
without pads
14-CHMSUG 14-CHWSUG
14-CHMMUG 14-CHWMUG
4-CHMLUG
14-CHWLUG
14-CHMXLUG 14-CHWXLUG
14-CHMXXLUG 14-CHWXXLUG
14-CHMXXXLUG 14-CHWXXXLUG
Qty
2/pk
Price
$29.00
11
F441 - Infection
Control,
Prevent Spread,
Linens
F309
| Provide
Care/Services
Each resident must receive and the facility must provide
the necessary care and services to attain or maintain the
highest practicable physical, mental, and psychosocial
well-being, in accordance with the comprehensive
assessment and plan of care.
for Highest Well-Being
The facility must ensure that the resident obtains
optimal improvement or does not deteriorate
within the limits of a resident’s right to refuse
treatment, and within the limits of recognized
pathology and the normal aging process.
2014 Ranking – #4 Most Cited | Also #4 for First 6 Months of 2015
Shop these products to find compliance solutions!
Pain Management Flowsheet
PAIN MANAGEMENT FLOWSHEET
•Form allows for easy monitoring of the resident’s pain
•11” x 8-1/2”, printed 2 sides different
• 5-hole punched
INSTRUCTIONS: Choose pain scale A, B, C, or D. For each medication given, enter medication name/date, dose/time, pain rating score (from scales below), related
behaviors and vital signs. Once the prescribed length of time has passed, enter the Pain Rating After Intervention. Note any related COMMENTS. Additional comments
may be entered on reverse. Initial and date all comments. Identify initials with signature on reverse. Record vital signs on Vital Signs Record as needed.
Pain cause, origin and radiation of pain:
TIME /
DATE
SCALE
USED
(A,B,C or D)
PAIN
RATING
MEDICATION/
DOSE
ALTERNATIVE Tx (i.e. heat,
cold, relaxation, TENS, other)
PAIN RATING
AFTER
INTERVENTION
RESIDENT
BEHAVIORS
INITIALS
COMMENTS
CFS6-38HH
Item #
CFS6-38HH
CFS6-38HF
DescriptionPrice Per Pad (100/pd)
Side Punched
$13.05
Top Punched
$13.05
PAIN INTENSITY SCALES
SCALE A
Ask the resident, “Please rate your worst pian, with 0 being no pain
and 10 as the worst pain you can imagine.”
Wong-Baker FACES Pain Rating Scale
Ask the resident, “Please rate your worst pian, with 0 being no pain
and 10 as the worst pain you can imagine.”
SCALE B
Other Pain Rating Scales
Medical Professional: Ask patient to mark scale
to indicate degree of pain felt at that moment.
0
No Hurt
2
Hurts
Little Bit
4
6
Hurts
LIttle More
Hurts
Even More
8
10
Hurts
Whole Lot
Hurts
Worst
No
Pain
Medical Professionals Please Note:
Explain to the person that each face is for a person who feels happy because he
has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very
happy because he doesn’t hurt at all. Face 2 hurts just a little bit. Face 4 hurts a
little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as
much as you can imagine, although you don’t have to be crying to feel this bad.
Ask the person to choose the face that best describes how he is feeling.
0
1
No
Pain
2
3
First
4
5
Moderate
Pain
Very Severe
Pain
Worst
Pain
6
7
8
9
10
Worst
Possible
Pain
0
2
1
SCORE
Normal
Occasional labored breathing.
Short period of hyperventilation.
Noisy labored breathing.
Long period of hyperventilation.
Cheyne-Stokes respirations
Negative
Vocalization
None
Occasional moan or groan.
Low level speech with a
negative or disapproving quality.
Repeated troubled calling out. Loud
moaning or groaning. Crying.
Facial
Expression
Smiling, or
inexpressive
Sad, Frightened, Frowning
Facial grimacing
Body
Language
Relaxed
Tense, Distressed
pacing, Fidgeting
Rigid. Fists clenched. Knees pulled up.
Pulling or pushing away. Striking out.
Consolability
No need
to console
Distracted or reassured
by voice or touch
Unable to console,
distract or reassure.
Development and Psychometric Evaluation of the Pain Assessment in Advanced Dementia (PAINAD)
Scale; Victoria Warden, RN, Ann C. Hurley, RN, DNSc, FAAN, and Ladislav Volicer, MD, PhD, FANN.
TOTAL
ADVANCE DIRECTIVES/MEDICAL TREATMENT DECISIONS
ACKNOWLEDGMENT
OF RECEIPT
PAIN MANAGEMENT FLOWSHEET
Middle
CFS 6-38HH Rev. 8/10 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
Severe
Pain
Moderate
Pain
SCALE C
From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L. Schwartz P.:
Wong’s Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by
Mosby, Inc. Reprinted by permission.
NAME–Last
Mild
Pain
PAINAD: Score each row and total
SCALE D
Breathing
Independent of
Vocalization
Attending Physician
Record No.
Room/Bed
❑ Continued on Reverse
RESIDENT UNDERSTANDING ACKNOWLEDGMENT–ADVANCE DIRECTIVE/MEDICAL
TREATMENT DECISIONS
PRINTED IN U.S.A.
This is to acknowledge that I have been informed in writing in a language that I understand of my rights
and all rules and regulations to make decisions concerning medical care, including the right to accept
or refuse medical or surgical treatment and the right to formulate and to issue advance directives to
be followed should I become decisionally incapable. I understand it is my responsibility to provide to
the facility copies of all pertinent documentation which verify advance directives formulated and/or
issued by me for placement in my medical record.
X
Resident or appropriate resident’s representative
Date
If resident representative signed, complete the following:
CFS1-10/2PS
Print name
Relationship to resident
(1) Witness
Date
(2) Witness (Second witness signature required if acknowledged by resident “mark”.)
Date
Interpreter (if applicable)
RECEIVED FROM RESIDENT
DATE
INITIALS
PLACED IN CHART
DATE
INITIALS
LOCATION OF DOCUMENTATION
PAIN ASSESSMENT MONITOR
Financial Durable Power
of Attorney
PAIN ASSESSMENT
CODES
=
=
=
=
G
M
R
C
I
A
T
V
O
N
Continuous
Intermittent
Occasionally
Frequently
Side Effects
Proxy
N
= Nausea
V
= Vomiting
S
= Sleepy
CF = Confusion
C
= Constipation
UR = Urinary retention
MSD = Motor sensory
deficit
HA = Headache
J
= Itching/rash
R
= Resp. depression
P
= Pain
O
= Other
NO = None
Rx = Medication
R = Repositioning
MT = Music therapy
I = Ice
H = Heat
V = Visitors
D = Diversion/Guided
Imagery
T = Tens unit
M = Massage
Withhold Medications
S = Spiritual (prayer)
O
=
Other
Autopsy Request
= Grimacing
= Moaning
Do Not Resuscitate
= Restless
Living Will
= Crying
= Irritability
Organ Donation
= Anger
= TenseIntravenous Feedings
= Change in vital signs
= OtherTube Feedings
= None
No Hospitalization Request
PAIN
LOCATION
Other (specify)
#1 _______________
#2_______________ #3 _______________
#4 _______________
Pain quality
INITIALS
Pain duration
Request Concerning
Life-Prolonging Procedures
SIGNATURE/TITLE
What triggers pain?
Non-verbal behaviors
NAME–Last
INITIALS
First
Middle
SIGNATURE/TITLE
INITIALS
Attending Physician
SIGNATURE/TITLE
Room/Bed
Record No.
On this_______day of__________________, ______, I,____________________________,
Pain intensity before PCT (0-10)
Month
Year
Resident or Legal Guardian, as appropriate
Pain intensity after PCT (0-10)
CFS 1-10/2PSthe following care in the event that the attending physician determines that
request
ADVANCE DIRECTIVES/
Patient’s goal for pain relief (0-10)
my __________________________________________’s condition (beACKNOWLEDGMENT
it injury, disease or
OF RECEIPT
Family’s goal for pain relief (0-10)
illness) is terminal, incurable and irreversible, and that death is imminent:
Rev. 8/03 © 1992 BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
MEDICAL TREATMENT DECISIONS
Name of Resident, if being completed by legal guardian
Current pain control therapies (PCT)
Comments/Plans (e.g. for relief of side effects, improving pain management, pain barriers, family beliefs, concerns)
Cardiopulmonary resuscitation (CPR)
_________________________________________________________________________________________________________
❑ Yes
❑ No
_________________________________________________________________________________________________________
Use of respirators or ventilators
Wong-Baker FACES Pain Rating Scale
❑ Yes
❑ No
Blood transfusion
Medical Professionals Please Note:
❑ Yes
❑ No
Explain to the person that each face is for a person who feels happy because he has
no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very happy
because he doesn’t hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little more.
Face 3 hurts even more. Face 4 hurts a whole lot. Face 5 hurts as much as you can
imagine, although you don’t have to be crying to feel this bad. Ask the person to
choose the face that best describes how he is feeling.
❑ Yes
❑ No
❑ Yes
❑ No
Administration of medications other
0
1
2
3
4
5
Moderate
Pain
6
7
8
9
10
Worst
Imaginable Pain
infection, provide comfort or
**From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong’s Essentials of
Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission.
alleviate pain.
Clinician_______________________________________________________________________
Part 1 – Clinical Record
Transfer
an acute
Part
2 – Care to
Coordination
Other
PATIENT NAME–Last, First, Middle Initial
3459/2P
PRINTED IN U.S.A.
care hospital
ID#
PAIN ASSESSMENT MONITOR
Form 3459/2P Rev. 9/02 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
Date_____________________
DescriptionPrice Per Pack (100/pk)
Pain Assessment Monitor
$34.70
Request Concerning Life-Prolonging
Procedures
than those necessary to prevent
No
Pain
DescriptionPrice Per Pack (100/pk)
Advance Directives
$32.45
•Facilitate the monitoring of pain assessment and pain
management for individual patients
• 2-part set
• White original, canary copy
• Printed 1 side
• 5-hole punched top and side
Item #
3459/2P
You must indicate Yes or No for each listed procedure.
Yes means to do procedure, No means DO NOT do procedure.
Side effects of PCT
Item #
CFS1-10/2PS Pain Assessment Monitor
➝
C
I
O
F
A = Ache/dull
N = Nagging
H = Heavy/crushing
S = Sharp/stabbing
Th = Throbbing
R = Radiating
B = Burning
T = Tingling
C = Cramping
O = Other
Pain Control Therapies /
Treatments (PCT)
Guardian
Non-Verbal
Behaviors
Pain Duration
•Includes expanded Advance Directive/Treatment
Decision List
•Part 1: 8-1/2” x 11”, Part 2: 8-1/2” x 5”
•2-part set
• White original, pink copy
• 5-hole punched top and side
Date
FACILITY ACKNOWLEDGMENT OF RECEIPT–RESIDENT ADVANCE DIRECTIVES
RESIDENT SUPPLIED VERIFICATION
Medical Durable Power of Attorney
Pain Quality
Advance Directives/Medical Treatment
Decisions, Acknowledgement of
Receipt
I fully understand the impact and potential consequences of this document and wish to emphasize my
desire to have the procedures performed or withheld (as indicated above) if death is imminent.
Witness Signature
Date
Signature of Resident or Legal Guardian
Date
Witness Signature
Date
Physician Signature
Date
•Request to decline life-prolonging procedures
• 2-part set
• Yellow copy
Item #
3122/2
ATTENDING PHYSICIAN’S COMMENTS:
DescriptionPrice Per Pack (100/pk)
Life-Prolonging Procedures Request
$32.60
Form 3122/2 Rev. 4/03 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
3122/2
12
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
F309 – Provide Care/Services for Highest Well-Being
Pain Rating Scale Card
• Uses the Wong-Baker FACES Rating Scale
•For residents who are non-communicative
•Instructions on back
• Pocket-sized, laminated manila cardstock
FUNCTIONAL ASSESSMENT
FOR PERSONS WITH ALZHEIMER’S DISEASE
Move In /
Annual
Date
1st
Qtr.
Date
2nd
Qtr.
Date
3rd
Qtr.
Date
Full use of language skills.
0
0
0
0
Repeats things; mild word-finding problems; is reticent in conversation; difficulty
following conversation with more than 2 people.
1
1
1
1
LANGUAGE SKILLS
Item #
1846
1846
INSTRUCTIONS: Circle the highest number in each section that reflects the skills or behavior of the patient at this time in at
least one way. All descriptions for that number don’t have to apply. Underline any description that does apply. Do not circle
more than one number in a given section. Add the scores for all three pages together to obtain a total score.
NURSING SCREEN FOR MEAL ASSISTANCE
Unable to follow 1 step directions; severe vocabulary limitations; uses gibberish
5
5
5
5
or word salad; parrots words.
Answer only for residents who do not eat in the dining room.
Does this resident
6 receive nourishment
6
6by another6means? ❑ Yes ❑ No
Is mute and unresponsive.
If yes, write the method:___________________________________________________________________________________
Does this resident eat in his/her room or another location besides the dining room? ❑ Yes ❑ No
SOCIAL SKILLS
If yes, write the reason the resident does not eat in the dining room:________________________________________________
Takes initiative; assists readily and appropriately.
0
0
0
0
Answer only for residents who do eat in the dining room.
May self isolate and socially withdraw, but will participate/follow appropriately with
This resident: 1
1
1
1
encouragement.
Remembers mealtimes? ❑ Yes ❑ No
Remembers location of dining room? ❑ Yes ❑ No
Most social skills intact, but may be less empathetic; tactless at times; anxious or Is able to independently get to the dining room?2 ❑ Yes ❑ No
2
2
2
insecure behavior.
If no, check the type of help needed? ❑ Wheelchair ❑ CNA assistance ❑ Other: _______________________________
Remains
at
the
table
until
finished
with
meal?
❑ Yes ❑ No Is able to open packaged items: ❑ Yes ❑ No
Needs help to participate in selective activities; is sometimes belligerent, defensive
3
Is able to cut3 food? ❑ 3Yes ❑ No 3 Uses fingers
to handle food? ❑ Yes ❑ No
and/or suspicious.
Assistance needed to get to and from the dining room? ❑ Yes ❑ No
Passive group participant; occasional intrusive, uninhibited behavior in group activities.
4 assistance
4 is needed?
4 ________________________________________________________________________
4
If yes, what
•Assess functional level of a resident over an entire year
and quickly compare functional status from quarter to
quarter
• 4-page booklet-style form, including suggested use
• 5-hole side punched
Add to the
to CNAs
verbally and in writing.
5 Care Plan5 and communicate
5
5
_____________________________________________________________
Date: ____________________
Nurse Signature/Title:
6
6
6
6
Lack of response to environmental stimuli.
NURSING SCREEN FOR OT AND / OR SPEECH
ATTENTION, MEMORY AND COGNITIVE FUNCTIONING
This resident: 0
0
0
0
Is able to open packaged items: ❑ Yes ❑ No Is able to cut food? ❑ Yes ❑ No Uses fingers to handle food? ❑ Yes ❑ No
Frequent episodes of forgetfulness, occasional confusion, usually able to cover them
Is able to eat without spilling? ❑ Yes ❑ No
Is able to drink without spilling? ❑ Yes ❑ No
well; gets lost easily; some difficulty doing familiar tasks; difficulty with planning, Is able to hold
1 utensils?1 ❑ Yes ❑1 No Is able
1 to scoop food effectively onto utensil? ❑ Yes ❑ No
decision making; prefers the familiar, resists change.
Has chewing problems? ❑ Yes ❑ No
Refuses to eat certain food consistencies? ❑ Yes ❑ No
Noticeable short-term memory deficit; difficulty with calculation; unable to handle Chokes? ❑ Yes ❑ No Pockets food? ❑ Yes ❑ No Has swallowing problems? ❑ Yes ❑ No
2 pain or 2discomfort?2 ❑ Yes ❑2 No Has thick, copious mucus in oral or nasal cavity? ❑ Yes ❑ No
finances; unable to self medicate safely; neglect of self and personal space; lacks Has swallowing
insight or in denial.
Has vocal changes during/after meals? ❑ Yes ❑ No
Has abnormal head and body positioning? ❑ Yes ❑ No
Has a gastric tube? ❑ Yes ❑ No
Eats from one side or quadrant of plate? ❑ Yes ❑ No
Lack of safety awareness; hides things; loses things; hoards; rummages;
Has frequent3 coughing before,
during
demonstrates change in ability to show/handle feelings; fear of being alone;
3
3 and after3meals? ❑ Yes ❑ No Has history of aspiration pneumonia? ❑ Yes ❑ No
Has history of pneumonia of unknown cause? ❑ Yes ❑ No
Has difficulty getting food to mouth? ❑ Yes ❑ No
sundowning; attempts to leave premises.
Is unable to keep food in mouth? ❑ Yes ❑ No
Has persistent drooling? ❑ Yes ❑ No
Distractible; severe short-term memory deficit; long-term memory somewhat impaired;
Has upper extremity tremors? ❑ Yes ❑ No
Has visual deficits? ❑ Yes ❑ No
fixations; possessive with belongings; territorial; sleep disturbances; has catastrophic
4
4
4
4
Can remain focused on the meal? ❑ Yes ❑ No
reactions; unprovoked aggression; resists care; misidentifies objects/use.
Other? ❑ Yes ❑ No If yes, name:________________________________________________________________________
No longer able to reminisce; attention can be engaged only sporadically and briefly;
5 Devices 5– Check the5 assistive 5devices that could benefit this resident:
Adaptive Eating
noticeable spatial-perceptual deficits.
❑ Sippy cup ❑ Double handhold glass and cup ❑ Rubber matting under plate ❑ Straw ❑ Nose cup ❑ Scoop plate
Is oblivious to surroundings.
6 ❑ Hand6 wrap utensil
6 holder ❑
6 Heavy weighted utensils ❑ Foam handle utensil ❑ Wrist weight
❑ Plate guard
❑ Other:_______________________________________________________________________________________________
SCORE PAGE 1
Is this resident a candidate for OT or Speech? ❑ Yes ❑ No
NAME–Last
First
Middle
Attending Physician
Record No.
❑ Speech Date:_________________
Referrals made: ❑ OT Date:_________________
Is this resident a candidate for Restorative Dining following therapy? ❑ Yes ❑ No Comments:___________________________
❑ Yes ❑ No Comments:____________________________________
Is
this
resident
a
candidate
for
assistive
feeding
devices?
Form 3650HH Bonnie M. Haley, printed with permission by Briggs Corporation, Des Moines, IA 50306
Pre-dementia level of independence, functioning.
To order, phone 1-800-247-2343 www.BriggsCorp.com
R1103
PRINTED IN U.S.A.
Item #
3650HH
FUNCTIONAL ASSESSMENT
_____________________________________________________________
Date: ____________________
NursePERSONS
Signature/Title:
FOR
WITH
ALZHEIMER’S DISEASE
ADMISSION CRITERIA FOR RESTORATIVE DINING:
1. Has the potential for increasing eating skills
2. Has the potential to eat and swallow as safely as possible
3. Requires skills practice to reinforce skills and techniques learned
in therapy
3650HH
NAME–Last
First
Middle
Record No.
Room/Bed
SCREENING FOR MEAL TIME ASSISTANCE
AND RESTORATIVE DINING NEEDS
Form 3854P 7/13 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
3854P
Resident
Identifier
Section J
Date
Health Conditions
J0100. Pain Management – Complete for all residents, regardless of current pain level
At any time in the last 5 days, has the resident:
Enter Code
A.
Enter Code
B.
Enter Code
C.
Received scheduled pain medication regimen?
0. No
1. Yes
Resident
Identifier
Date
Received PRN
pain medications OR was offered and declined?
0. No
1. Yes
Received non-medication intervention for pain?
C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
0. No
Attempt to conduct interview with all residents
1. Yes
Enter Code
0. No (resident is rarely/never understood)
Resident g Skip to and complete C0700-C1000, Staff Assessment for Mental Status
Identifier
1. Yes g Continue to C0200, Repetition of Three Words
Cognitive Patterns
Section C
J0200. Should Pain Assessment Interview be Conducted?
Section D
Brief
Interviewunderstood)
for Mental
(BIMS)
Skip to and
completeD0100.
J0800, Indicators
Pain or Possible
No (resident
is rarely/never
g Status
Shouldof
Resident
MoodPain
Interview be Conducted? – Attempt to conduct interview with all residents
Yes g Continue
J0300, Pain Presence
C0200.to Repetition
of Three Words CAA
Enter Code
0. No (resident is rarely/never understood) g Skip to and complete D0500-D0600, Staff Assessment of Resident Mood
(PHQ-9-OV)
Ask resident: “I am going to say three words for you to remember. Please
repeat the words after I have said all three.
The words are: sock, blue, and bed. Now tell me the three words.”
1. Yes g Continue to D0200, Resident Mood Interview (PHQ-9©)
Pain Assessment Interview
Enter Code
Number of words repeated after first attempt
Resident
Identifier
Date
0. None 1 2
J0300. Pain Presence
D0200. Resident Mood Interview (PHQ-9©) CAA
1 2
1. One
Enter Code Ask resident: “Have you had pain or hurting at any time in the last 5 days?”
1 2
2. Two
Say to resident: “Over the last 2 weeks , have you been bothered by any of the following problems?”
0. No g Skip to J1100, Shortness
of Breath
1 2
3. Three
symptom
is present,
enter
1 (yes) intocolumn
1, Symptom
Presence.
1. Yes g Continue to
J0400,
Pain Frequency
F0300.
Should
interview
Daily and Activity Preferences be Conducted? – Attempt to interview all residents able to
After
the resident’s
first attempt, repeat theIf words
using
cues (“sock,
something
wear;
blue,
a color; bed,
a piece offor
furniture”).
yes
in column
1, then ask the resident: communicate.
“About how often
have you
bothered
by this?”
If resident
is been
unable
to complete,
attempt to complete interview with family member or significant other
9. Unable to answer
Skip
to J0800,
Indicators
of more
Pain Ifor
Possible
Pain
Yougmay
repeat
the words
up to two
times.
Read and show the resident a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
CAA
Enter Code
0. No (resident is rarely/never understood and family/significant other not available) g Skip to and complete F0800, Staff
J0400. Pain Frequency C0300.
Temporal Orientation (orientation to year,
month, and
day) CAA
1. Symptom
Presence
2. Symptom
Frequency
Assessment
of Daily and Activity Preferences
over
the
last 52)days?”
Enter Code Ask resident: “How much of the time have you experienced pain or0.hurting
2.
No (enter
0 in
column
NeverContinue
or 1 dayto F0400, Interview for Daily Preferences 1.
Ask resident:
“Please tell me what year it is right now.”
1. 0. Yes
g
19 2 01.01 14.01
Symptom
Symptom
1. AlmostEnter
constantly
1. Yes (enter 0-3 in column 2)
1. 2-6 days (several days)
Code
A.
Able to report correct year
Presence
Frequency
2. Frequently 19 2 01.010. 14.01Missed by > 5 years or no answer 9. 1 No2response (leave column 2 blank)
2. 7-11 days (half or more of the days) 30.01
3. 12-14
days Preferences
(nearly every day) 30.01
3. Occasionally
1. Missed by 2-5 years 1 2
i Enter Scores in Boxes i
F0400. Interview
for Daily
2. Missed by 1 year 1 2
4. Rarely
Show resident the response options and say: “While you are in this facility...”
3. Correct 1 2
7 10
8
A.
Little interest or pleasure in doing things 30.01
9. Unable to answer
i Enter Codes in Boxes
J0500. Pain Effect on Function Ask resident: “What month are we in right now?”
8
B.
Feeling down, depressed, or hopeless 30.01
B.pastAble
to report
correct
month
Enter
Code the
A. how important is it to you to choose what clothes to wear?
Enter Code A.
Ask resident:
“Over
5 days,
has pain
made
it hard for
you
to sleep at night?”
0. Missed by > 1 month or no answer 1 2
0. No
1. Missed by 6 days to 1 month C.1 2Trouble falling or staying asleep, or sleeping too much
8
1. Yes 19
B. how important is it to you to take care of your personal belongings or things?
2. Accurate within 5 days 1 2
9. Unable to answer
Coding:
C. how important is it to you to choose between a8 tub bath, shower, bed bath, or
D.
Feeling tired or having little energy
Ask resident: “What day of the week is today?”
1. Very important
Enter Code B.
Ask resident:
“Over the
pastAble
5 days,
have you limited your day-to-day activities because of pain?”
sponge bath?
Enter Code
C.
to report correct day of the week
2. Somewhat important
0. No
0. Incorrect or no answer 1 2 E.
8
Poor appetite or overeating
3. Not very important
D. how important is it to you to have snacks available between meals?
1. Yes 19
1. Correct 1 2
4. Not important at all
0.
1.
Section F
9.
• Used to determine the need for meal time assistance
and other restorative dining needs
• Nursing screen for meal assistance
• Nursing screen for OT and/or Speech
• Prints front only
Date
Mood
Attempt to conduct interview with all residents. If resident is comatose, skip to J1100, Shortness of Breath (dyspnea)
Enter Code
DescriptionPrice Per Pack (100/pk)
Functional Assessment – Alzheimer’s$31.40
Screening for Meal Time Assistance and Restorative Dining Needs
DISCHARGE CRITERIA FOR RESTORATIVE DINING:
1. Met individual program goals
2. Not met program goals; no progress after a set time
3. Refusing to cooperate with the program
4. No longer able to do the program
Attending Physician
Price Per Each
$5.40
Functional Assessment for Persons with
Alzheimer’s Disease
SCREENING FOR MEAL TIME ASSISTANCE
Talks around words he/she cannot remember (circumlocution); easily led in
AND
RESTORATIVE
DINING NEEDS
2
2
2
2
conversation; has difficulty following multiple step directions or abstract concepts;
tells white lies (confabulation).
Most skilled nursing facilities require a therapy screen on resident admission. This practice identifies residents who could benefit by
therapy for improvement in eating skills and problems that interfere with eating and swallowing. Residents who quality for a Restorative
Unable to sustain train of thought; rambles; marked vocabulary loss; some
3
3 therapy3first. One of the main goals of a RD program is to provide more practice time for a
Dining (RD) program
almost3 always require
difficulty with reading, writing.
resident to reinforce what was taught in therapy. See criteria for RD admission and discharge below. The criteria helps staff understand
Less aware of mistakes; poor syntax; shows perseveration (word/phrase
why all residents needing assistance with eating or who are unable to feed themselves are not candidates for RD.
repetition); word substitutions; begins to revert to primary language; difficulty
4
4
4
4
Check (✓) Yes or No items as applicable, fill in the blanks as indicated.
following 1x1 conversation.
Continuous pacing; flat affect.
Size
2-1/2” x 6”
Preferences for Customary Routine and Activities
Item #
3854P Description Price Per Pad 100/pd
Screening for Meal Time Assistance and
Restorative Dining Needs $11.15
Unable to answer
5. you
Important,
but can’t
do or
8
are a failure
or have
letno
yourself or your family
F.
Feeling bad about yourself – or that
C0400. Recall CAA
E. down
how important is it to you to choose your own bedtime?
choice
J0600. Pain Intensity – Administer ONLY ONE of the following pain intensity questions (A or B) CAA
Ask resident: “Let's go back to an earlier question. What were those three words that I asked
you
to repeat?”
response
or non-responsive
9. No
Enter Rating
A.
F. how important is it to you to have your family8or a close friend involved in
G.
Trouble
concentrating
on things,
such as
the newspaper or watching television
Numeric Rating Scale
(00-10)
If unable
to remember a word, give cue (something
to wear;
a color; a piece
of furniture)
forreading
that word.
discussions about your care?
Enter
Code rate
A. your
Able
to recall
Ask resident
“Please
worst
pain“sock”
over the last 5 days on a zero to ten scale, with zero being no pain and ten
1 2pain
0. No –(Show
could resident
not recall 00-10
H. scale)
Moving or speaking so slowly that other people could have noticed. Or the opposite – being so
as the worst pain you can imagine.”
G. how important is it to you to be able to use the8 phone in private?
2 restless
Yes,99
after
cueing (“something
wear”)
fidgety
you= have
=
05-10
= 01.01that
05-10
19 21 or
14.01 been moving around a lot more than usual
Enter two-digit response.1.Enter
if unable
to answer. to4-10
Enter Code
B.
Verbal Descriptor Scale
H. how important is it to you to8have a place to lock
8 your things to keep them safe?
I.
Thoughts that you would be better off dead, or of hurting yourself in some way
Enter
Code rate
B. the
Able
to recall
Ask resident:
“Please
intensity
of “blue”
your worst pain over the last 5 days .” (Show resident verbal scale)
0. No – could not recall 1 2
F0500. Interview for Activity Preferences CAA
1. Mild
D0300.
Total Severity Score CAA
1
2
2. Moderate 19 2 01.01 1.14.01 Yes, after cueing (“a color”)
Show resident the response options and say: “While you are in this facility...”
2. Yes, no cue required 1 2
3. Severe 19 2 01.01 14.01
Add scores for all frequency responses in Column 2, Symptom Frequency.
score
must be between 00 and 27.
EnterTotal
Codes
in Boxes
i
19 2 01.01 14.01
Enter Score
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more items). 00-27 = 8 3 10-27 = 30.01
4. Very severe,
C.
Able
to recall “bed”
Enter Codehorrible
A. how important is it to you to have books, newspapers, and magazines to read?
9. Unable to answer
0. No – could not recall 1 2
19
19
2
2.
Yes, no cue required
1.
= 7 3
1 2 Notification – Complete only if D0200I1 = 1 indicating possibility of resident self4 harm
Yes, after cueing (“a piece of furniture”)
D0350. Safety
1
2
4 or 5 = 10
3
01.01 2.Residents
moderate to severe
1 2pain (short stay)
Yes,who
noself-report
cue required
(longCode
stay)
14.01 Residents who self-report moderate to severe painEnter
Pain
Pain, 2 Items Trigger
B. self
how
important is it to you to listen to music you like? 4 = 7 3
Was responsible staff or provider
harm?
Coding: informed that there is a potential for resident
0. No
1. Very important
CAA
1. Yes
2. Somewhat important
C. how important is it to you to be around animals such as pets?
MDS 3.0 Nursing Home Comprehensive (NC)
2
1 2Not2very
5 important
00-15
= 3.
Add scores for questions C0200-C0400
and fill© in
total
score
(00-15)
Version
1.13.2reserved.
Effective
10/01/2015
20 of 40
Copyright
Pfizer
Inc.
All rights
Reproduced with permission.
Enter 99 if the resident was unable to complete the interview 13-15 = 14.01 4. Not important at all
D. how important is it to you to keep up with the news? 4 = 7 3
5. Important,
do or no
30.01 Residentsbut
7
Psychosocial Well-Being
whocan't
have depressive
symptoms
choice
8
Mood
State
14.01 Residents who self-report moderate to
9. No response or non-responsive
E. how important is it to you to do things with groups of people?
severe 8pain3 Mood State, 3 or More Items Trigger
C0500. Summary Score
Form 1873P-15 2015 BRIGGS, Des Moines, IA 50306 (800) 247-2343
www.BriggsCorp.com
Enter Score
1873P-15
1
1
2
5
2
2
Delirium
Delirium, 2 Items Trigger
Cognitive Loss/Dementia
ADL Function/Rehabilitation Potential,
2 Items Trigger
10
Activities
F.
Form 1870P-15 2015 BRIGGS, Des Moines, IA 50306 (800) 247-2343
MDS 3.0 Nursing Home Comprehensive (NC)
Version 1.13.2 Effective 10/01/2015
www.BriggsCorp.com
how important is it to you to do your favorite activities?
Form 1871P-15 2015 BRIGGS, Des Moines, IA 50306 (800) 247-2343
1871P-15
7
10
www.BriggsCorp.com
3
3
3
3
3
3
3
3
4 or 5 = 10
3
CAA
Indicate primary respondent for Daily and ActivityMDS
Preferences
(F0400 and F0500)
3.0 Nursing Home Comprehensive (NC)
1. Resident 7 3
Version 1.13.2 Effective 10/01/2015
9 of 40
2. Family or significant other (close friend or other representative)
9. Interview could not be completed by resident or family/significant other (“No response” to 3 or more items”)
Psychosocial Well-Being, 3 or More Items Trigger
Activities, 3 or More Items Trigger
Form 1872P-15 2015 BRIGGS, Des Moines, IA 50306 (800) 247-2343
MDS Interview
Forms
3
G. how important is it to you to go outside to get fresh air when the weather is
4 or 5 = 10 3
good? 4 = 7 3
H. how important is it to you to participate in religious services or practices?
4 = 7
1870P-15
4 = 7
4 or 5 = 10
3 or 4 = 7
4 or 5 = 10
3
3
4 or 5 = 10
7 of 40
F0600. Daily and Activity Preferences Primary Respondent
Enter Code
4 or 5 = 10
4 = 7
4 or 5 = 10
www.BriggsCorp.com
MDS 3.0 Nursing Home Comprehensive (NC)
Version 1.13.2 Effective 10/01/2015
13 of 40
1872P-15
• Black ink
• Padded in 25’s
• 5-hole punch top and side
MDS Cue Cards
Item #
1873P-15
Description Price Per Pad (25/pd)
Section J
$5.50
1870P-15
1871P-15
1872P-15
Section C
Section D
Section F
$5.50
$5.50
$5.50
•Pocket sized laminated cards
•Printed front/back
•Black Ink
Item #
1870
Description
MDS Cue Cards
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
Price Per Pack
$21.00
13
F309 – Provide Care/Services for Highest Well-Being
ST R
B E LLE
SE
Restorative Nursing Simplified Manual & CD
TM
With this manual, you will have the tools you need to provide
quality care and optimize reimbursement.
Additionally, Restorative Nursing Simplified™ provides customizable forms,
policies and procedures and a sample program to ensure your restorative
nursing program meets the well-being needs of each resident.
Your manual includes:
• Quality Assurance checklists
•CD-ROM
•Policies and procedures/
Job descriptions
• Care plans
•Definitions
Item #
7320
Restorative Nursing
Simplif ied
™
• Forms appendix
• Staff education/Clinical competencies
Developed by BJ Collard, founder of CTS, Inc.
Description
Restorative Nursing Simplified™ Manual & CD
Price Per Each
$122.35
The Long-Term Care Restorative Nursing Desk Reference
An all-inclusive desk reference that describes the clinical aspects of restorative
nursing in detail and provides a much-needed guide for nurses in a long-term
care facility. This resource makes it easy to find instant answers to questions
you may have about maintaining or developing your restorative program.
HCPro
Item #
4754
Description
The Long Term Care Restorative Nursing Desk Reference
Price Per Each
$150.00
Nursing Assistant’s Guide to Advanced Restorative Skills
Ensure that your nursing assistants provide top-notch restorative care with
this book written specifically for RNAs or nursing assistants. Provides detailed
nursing procedures that do not fall under therapy treatment and must be
provided by your nursing staff.
HCPro
Item #
4753 Description
Nursing Assistant’s Guide to Advanced Restorative Skills
Price Per Each
$150.00
Patient Education Booklet: Flu & Pneumonia
Designed to help the individual, family and caregivers understand the signs,
symptoms and complications of both flu and pneumonia.
Contents include:
•Understanding how the respiratory system works
•What is a respiratory infection?
•Recommended treatment
•Good health habits for prevention
•Facts about lower respiratory infections in older adults
Item #
8132
Description
Flu & Pneumonia
Price Per Each
$3.05
Visit www.BriggsCorp.com to see our entire offering of Patient Education Booklets!
14
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F309 – Provide Care/Services for Highest Well-Being
Dementia Care Handbooks for Long Term Care
Adhere to the Centers for Medicare & Medicaid Services (CMS) dementia
care initiative to reduce the use of antipsychotic medications in treating
residents with dementia. Your staff will benefit from the how-to
guidance that breaks down CMS’ initiative, and will learn how to provide
appropriate and beneficial care to residents.
These staff-specific handbooks will help long-term care staff understand
and address the challenging care needs of residents with dementia at
each stage of the disease’s progression. These handbooks provide:
• Staff-specific guidance for various roles and responsibilities
•Guidance on the use of non-pharmacological methods of reducing
dementia-related behaviors
•Strategies for educating staff to provide assistance and assurance to
residents’ family members
Sold 10 per pack; HCPro
Item #
4780
4781
4782
Description
Social Services Staff Nursing Staff
Dietary Staff
Price Per Pack
$105.00
$105.00
$105.00
Item #
4783
4784
4785
Description
Certified Nursing Assistants
Activities Staff
Therapy Staff
Price Per Pack
$105.00
$105.00
$105.00
Memory Care & Engagement Solutions
LifeBio captures life stories and provides a creative way to promote
social engagement while also meeting the memory care needs of
people living with mild cognitive impairment, Alzheimer’s Disease,
and related dementias.
Going beyond a standard assessment or social history, LifeBio’s
person-centered care process explores the people, times, and places
that make each individual unique. Knowing too little about what
is meaningful to each person can result in barriers to providing
personalized engagement and behavior management strategies
every day.
The reminiscence and life review activities in LifeBio will help you:
• Improve staff/resident/family relations
• Engage people with dementia
• Assist with cognitive orientation
• Increase life satisfaction
• Lower or prevent depression
• And more!
DID YOU KNOW?
The Mayo Clinic uses LifeBio with people
diagnosed with mild cognative impairment.
Visit www.BriggsCorp.com/LifeBio to learn more!
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15
F329 | Drug Regimen is Free from Unnecessary Drugs
The intent of this requirement is that each resident’s entire drug/medication regimen be
managed and monitored to achieve the following goals:
• The medication regimen helps promote or maintain the resident’s highest practicable mental, physical,
and psychosocial well-being, as identified by the resident and/or representative(s) in collaboration with the
attending physician and facility staff;
• Each resident receives only those medications, in doses and for the duration clinically indicated to treat the
resident’s assessed condition(s);
• Non-pharmacological interventions (such as behavioral interventions) are considered and used when indicated,
instead of, or in addition to, medication;
• Clinically significant adverse consequences are minimized; and
• The potential contribution of the medication regimen to an unanticipated decline or newly emerging or
worsening symptom is recognized and evaluated, and the regimen is modified when appropriate.
This guidance applies to all categories of medications including antipsychotic medications.
2014 Ranking – #4 Most Cited | Also #4 for First 6 Months of 2015
Shop these products to find compliance solutions!
ST E R
B E LL
SE
ABNORMAL INVOLUNTARY MOVEMENT SCALE (AIMS)
Psychoactive
Medication
Informed Consent
•Informs
MEDICATION INTERVENTION RECOMMENDED
A physician has prescribed the following psychoactive medication(s): (Drug, Dosage, Frequency)
_______________________________________________________________________________________
_______________________________________________________________________________________
resident of
their right to be free
from medication
interventions for
purposes of discipline
❑
or staff convenience,
❑
❑
and aids in identifying
less restrictive, nondrug approaches and
target behaviors for
which drug usage
may be recommended
•Provides for consent or
refusal as well as acknowledgement signatures
•2-part set with white original and pink copy
• 5-hole punched top and side
PURPOSE THE PSYCHOACTIVE MEDICATION IS INDICATED
Specific Condition/Dx.
Beneficial Effects Expected
(List Target Symptom/Behaviors)
Possible Side Effects/Risks
(Identify Source Used for Review)
PROPOSED COURSE OF THE MEDICATION(s)
ACKNOWLEDGMENT SIGNATURES
Resident or Resident Representative X
Signature
Signature and Title
First
Middle
CFS 3-8/2P Rev. 8/10 © 1992 BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
Description
Informed Consent for
Psychoactive Medication
Attending Physician
e.g., movements of forehead, eyebrows, periorbital
area, cheeks; include frowning, blinking, smiling, grimacing
2. LIPS AND PERIORAL AREA
e.g., puckering, pouting, smacking
Abnormal
Involuntary
Movement
Scale (AIMS)
3. JAW
e.g., biting, clenching, chewing, mouth opening, lateral
movement
Rate only increase in movement both in and out of
mouth, NOT inability to sustain movement.
Price Per Pack (100/pk)
Include choreic movements, (i.e., rapid, objectively
purposeless, irregular, spontaneous), athetoid movements (i.e., slow, irregular, complex, serpentine).
Do NOT include tremor (i.e., repetitive, regular, rhythmic)
e.g., lateral knee movement, foot tapping, heel dropping, foot squirming, inversion and eversion of foot
SECTION C. TRUNK MOVEMENTS
7. NECK, SHOULDERS, HIPS
e.g., rocking, twisting, squirming, pelvic gyrations
•Monitor the
development
of involuntary
movement
disorders from
drug-induced,
Parkinsoniantype symptoms
to tardive dyskinesia
• Printed 2 sides different
• 5-hole punched
9. INCAPACITATION DUE TO ABNORMAL
MOVEMENTS
10. AWARENESS OF ABNORMAL MOVEMENTS
Rate only the person’s report
$32.45
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 = No awareness
0 = No awareness
0 = No awareness
0 = No awareness
1 = Aware, no distress
1 = Aware, no distress
1 = Aware, no distress
1 = Aware, no distress
2 = Aware, mild distress
2 = Aware, mild distress
2 = Aware, mild distress
2 = Aware, mild distress
3 = Aware, moderate distress 3 = Aware, moderate distress 3 = Aware, moderate distress 3 = Aware, moderate distress
4 = Aware, severe distress
4 = Aware, severe distress
4 = Aware, severe distress
4 = Aware, severe distress
SECTION E. DENTAL STATUS
11. CURRENT PROBLEMS WITH TEETH AND/OR
DENTURES
Item #
CFS3-7HH
CFS3-7HF
0 1 2 3 4
0 1 2 3 4
6. LOWER (LEGS, KNEES, ANKLES, TOES)
0 = No
1 = Yes
0 = No
1 = Yes
0 = No
1 = Yes
0 = No
1 = Yes
0 = No
1 = Yes
0 = No
1 = Yes
0 = No
1 = Yes
0 = No
1 = Yes
EVALUATOR SIGNATURES
Date
Date
First
Middle
CFS3-7HH Rev. 4/07 © 1992 BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
PSYCHOACTIVE MEDICATION
INFORMED CONSENT
4 = Severe
SECTION B. EXTREMITY MOVEMENTS
5. UPPER (ARMS, WRISTS, HANDS, FINGERS)
NAME–Last
Room/Bed
3 = Moderate
4. TONGUE
Signature/Title
Date
Record No.
2 = Mild
ASSESSMENT DATES
Signature/Title
Relationship
Person Completing This Form
NAME–Last
1 = Minimal/Normal
SECTION A. FACIAL AND ORAL MOVEMENTS
1. MUSCLES OF FACIAL EXPRESSION
12. ARE DENTURES USUALLY WORN?
Date
If signed by Resident Representative, complete the following:
Print Name
SCORING CODES: 0 = None
SECTION D. GLOBAL JUDGMENTS
8. SEVERITY OF ABNORMAL MOVEMENTS
STATEMENT OF CONSENT
I DO desire the use of the medication(s) indicated above and DO consent to their use. I
understand that once the target behavior is controlled, the dose should be gradually
decreased to the lowest possible dosage and frequency, or discontinued unless contraindicated by my physician.
I DO consent to the use of medication interventions but only on a temporary basis for
treatment of life-threatening medical symptoms only.
I DO NOT desire, nor consent to, the use of medication interventions on a regular or
temporary basis.
I understand that I may reevaluate the need for medication intervention at any time, and that this will
be reviewed at each quarterly Care Planning Meeting.
Item #
CFS3-8/2P
INSTRUCTIONS: Complete examination procedure before making ratings. While conducting the examination, have
them sit in a firm chair without arms. For all MOVEMENT ratings (sections A, B and C) rate highest severity observed.
Circle only one code for each evaluation.
PSYCHOACTIVE MEDICATION INFORMED CONSENT
In order to protect our residents from harm or to promote them to a higher level of independence, it
is sometimes necessary to utilize medication interventions. Medication interventions are NEVER used
for disciplinary action or for the convenience of the facility to control behavior.
Psychoactive medication intervention would be initiated only after less restrictive non-drug measures
were attempted and found to be ineffective. Examples of non-drug approaches include behavior
programming, specific staff approaches, environmental evaluation, i.e., temperature, noise, roommates, tablemates, or physical restraints utilized as enablers.
The following less restrictive non-drug approaches have proven to be INEFFECTIVE:
_______________________________________________________________________________________
Medical Diagnosis: ______________________________________________________________________
Description
Side Punched
Top Punched
Signature/Title
Date
Signature/Title
Attending Physician
Date
Record No.
Room/Bed
ABNORMAL INVOLUNTARY
MOVEMENT SCALE (AIMS)
Price Per Pad (100/pd)
$13.05
$13.05
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Have Briggs® Inside?
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to find out more!
16
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F329 – Drug Regimen is Free from Unnecessary Drugs
CFS3-10HH
PSYCHOACTIVE MEDICATION QUARTERLY EVALUATION
FIRST QUARTER
Evaluation Date
Drug __________________________ Dosage __________________________ Frequency ___________________________
Diagnosis _____________________________________________________________________________________________
Behavior warranting use of medication ___________________________________________________________________
______________________________________________________________________________________________________
_________________________________________________________________ Episodes Per Week___________________
Medicated for pain? ❑ No ❑ Yes, Drug __________________________________________________________________
Ineffective interventions: ________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Allergies_______________________
Month________________________
MONTHLY BEHAVIOR MONITORING FLOWSHEET
Adverse reactions
(check
all that
apply):
None
appetite
❑ Dehydration
❑ Sedation
INSTRUCTIONS:
Specify
each target
behavior❑
in one
of theapparent
spaces provided.❑
ForPoor
each shift,
chart the number
of episodes (target behavior
occurrences). C = Continuous. Identify intervention(s) used,
outcome and any possible medication side effects, using the codes provided. Initial each entry. Identify initials on the reverse. List of behaviors and possible side effects available on the reverse.
❑ Constipation
❑ Ataxia ❑ Hypotension ❑ Tachycardia ❑ EPS / AIMS Assessment: ❑ Normal
DIAGNOSIS
❑ Abnormal
1 TARGET
2 TARGET
3 TARGET
BEHAVIOR: ❑ Other ____________________________________
BEHAVIOR:
BEHAVIOR:
❑ Urine retention
DAY
EVENING
NIGHT
DAY
EVENING
NIGHT
DAY
EVENING
NIGHT
D
Physician aware
of adverse effects? ❑ No ❑ Yes; first made aware
Last dosage
A
Evaluation: T ❑ No change noted ❑ Shows improvement ❑ Appears controlled
reduction
PSYCHOACTIVE MED
E
Plan of care updated? ❑ Yes ❑ No Date
1
Other comments
/ recommendations: ____________________________________________________________________
2
INTERVENTION CODES
1. Toilet
8. Change position
3
______________________________________________________________________________________________________
2. Redirect
9. Backrub
3801HH
18
Medicated for
pain? ❑ No ❑ Yes, Drug __________________________________________________________________
19
Ineffective interventions:
________________________________________________________________________________
20
21
______________________________________________________________________________________________________
22
______________________________________________________________________________________________________
23
24
______________________________________________________________________________________________________
25
Adverse reactions
(check all that apply): ❑ None apparent ❑ Poor appetite ❑ Dehydration ❑ Sedation
26
27
❑ Constipation
❑ Ataxia ❑ Hypotension ❑ Tachycardia ❑ EPS / AIMS Assessment: ❑ Normal
28
❑ Abnormal
❑ Urine retention ❑ Other ____________________________________
29
3. 1 on 1
4. Offer food
5. Offer fluids
6. Activity
7. Refer to
Nurses Notes
10.Return to room
11.Change room
temperature
12.Medication
(should not be
1st choice)
13. ________________________________
14. ________________________________
15. ________________________________
SIDE EFFECTS
(Blank box = no side effects observed)
1. __________________________
1 2. __________________________
3. __________________________
1. __________________________
2 2. __________________________
3. __________________________
1. __________________________
3 2. __________________________
3. __________________________
SAFETY CONCERNS
❑ Threat to self
❑ Threat to others
❑ Interferes with care
❑ Other_________________________
This form may be used for the
following drug classes, if appropriate.
(Check one)
❑ Antianxiety
❑ Antipsychotic
❑ Antidepressant
❑ Sedative/Hypnotic
30
Physician aware
of adverse effects? ❑ No ❑ Yes; first made aware
EPISODE TOTALS
Last dosage
31
1
2
3
Evaluation: EPISODE
❑ No change noted ❑ Shows improvement ❑ Appears controlled
reduction
SUBTOTAL
Plan of careNAME–Last
updated? ❑ Yes ❑ No First
Date
Middle
Attending Physician
Room/Bed
Record No.
Other comments / recommendations: ____________________________________________________________________
Form 3801HH Rev. 8/10 © BRIGGS, Des Moines, IA (800) 247-2343
MONTHLY
BEHAVIOR
MONITORING
FLOWSHEET
______________________________________________________________________________________________________
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
PRINTED IN U.S.A.
PRE-PSYCHOACTIVE
Nurse Signature
❑ Continued on Reverse
MEDICATION RECORD
Date
This form has been
developed to adequately assess
all aspects of the resident’s
(physical,
mental, emotional, environmental
NAME–Last
First
Middlewell-beingAttending
Physician
Record No. and socialRoom/Bed
considerations) prior to the use of medication interventions in order to identify the least restrictive intervention. It is to be completed by a nurse.
Primary medical reason(s) or behavior(s) exhibited by resident to indicate a need to complete a Pre–Psychoactive Medication Assessment:
PSYCHOACTIVE MEDICATION
EVALUATION
CFS 3-10HH Rev. 5/00 © 1992 BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
•Provides an evaluation summary for residents taking
psychoactive medication with emphasis on monitoring
for potential side effects
• Printed 2 sides different
• 5-hole punched
Item #
CFS3-10HH
CFS3-10HF
Description
Side Punched Top Punched Price Per Pad (100/pd)
$10.85
$10.85
OUTCOME CODES
E = Excellent (no outbursts)
I = Improved
U = Unchanged
W = Worsened
TARGET BEHAVIOR
Date
SECOND QUARTER
7
8
9
Evaluation Date
10
11
Drug __________________________
Dosage __________________________ Frequency ___________________________
12
Diagnosis ______
_______________________________________________________________________________________
13
14
Behavior warranting
use of medication ___________________________________________________________________
15
______________________________________________________________________________________________________
16
17
_________________________________________________________________
Episodes Per Week___________________
Initials
Initials
Outcome
Side Effect
# Episodes
Intervention
Initials
Outcome
Side Effect
# Episodes
Intervention
Initials
Outcome
Side Effect
# Episodes
Intervention
Initials
Outcome
Side Effect
# Episodes
Intervention
Initials
Outcome
Side Effect
# Episodes
Intervention
Initials
Outcome
Side Effect
Side Effect
# Episodes
Intervention
Initials
Outcome
Side Effect
# Episodes
Intervention
Initials
Outcome
Outcome
Side Effect
# Episodes
Intervention
# Episodes
Intervention
Nurse
4
5
Signature
6
Psychoactive Medication Quarterly Evaluation
_______________________________________________________________________________________________________________________________________
QUARTERLY
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Monthly Behavior Monitoring Flowsheet
•Monitor 3 target behaviors over 3 shifts for 1 month,
including episodes, interventions, outcomes and
side effects
•Behavior and Side Effect codes
• Room for comments on reverse
• 11” x 8-1/2”, 2 sides different
• 5-hole punched
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
The following non-medication approaches or interventions have proven to be INEFFECTIVE: _____________________________________________________
Item #
3801HH
3801HF
3697HH
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
BIMS Score (00-15)__________
CAM Score (00-08)__________
PHQ-9© Severity Score (00-30)__________
PHYSICAL AND MENTAL CONSIDERATIONS
BEHAVIOR INTERVENTION MONITORING
YES
NO
MENTAL STATUS/COMPREHENSION
Oriented X3. . . . . . . . . . . . . . . . . . . . . . . . . .DATE
. . . . . . . . . . . TIME
. . . . . . . . . . . SYMPTOMS
Disoriented X1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Disoriented X2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Disoriented X3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Short attention span . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Unable to follow/remember simple directions . . . . . . . . . . . .
Other: ____________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
YES
NO
AMBULATION/BALANCE WHILE STANDING
Unsteady on feet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Loses balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
History of falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Leans to side. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Leans backward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Leans forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
W/C mobility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Independent with or without cane, walker . . . . . . . . . . . . . . . .
Other: ____________________________________________
__________________________________________________
__________________________________________________
NO
POTENTIAL MEDICAL FACTORS AFFECTING BEHAVIOR YES
INTERVENTIONS OUTCOME INIT.
TIME
SYMPTOMS
Psychoactive
medication change or addition inDATE
past month?
Possible infection? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dehydration or electrolyte imbalance?. . . . . . . . . . . . . . . . . . . .
Toxic drug levels? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Change in baseline vitals? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Recent trauma (i.e., hip fracture)? . . . . . . . . . . . . . . . . . . . . . . . .
History of vertigo, hypotension, seizures? . . . . . . . . . . . . . . . .
Significant weight loss? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Undiagnosed/untreated pain: Location _______________
Ineffective pain management? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
History of bowel impactions? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Recent surgical procedure? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other: _____________________________________________
___________________________________________________
___________________________________________________
YES
NO
HAS RESIDENT EXPERIENCED A RECENT:
Change of roommate? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Room change? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Transfer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Care giver or staff change? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other: ____________________________________________
__________________________________________________
NAME–Last
First
OUTCOME
INIT.
Anti-Psychotic
MEDICATION _____________________
Observe the patient closely for significant
side effects and report to the Physician.
NO
YES
NO
POTENTIAL CONTRIBUTING BEHAVIORAL FACTOR
Does not understand what is being said . . . . . . . . . . . . . . . .
Can not comprehend surroundings . . . . . . . . . . . . . . . . . . . . . .
Affected by environmental noise level (i.e., radio, television, staff)
Recent lossKEY
dueFOR
to own
illness
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
OUTCOME: I = Improved U = Unchanged W = Worse
Recent
death/loss
of a loved one . . . . . . . . . . . . . . . . . . . . . . . .
BEHAVIOR
SYMPTOMS
CODES
BEHAVIOR INTERVENTION CODES
change in financial
status . . . . . . . . . . . . . . . . . . . . . . . .
1. Take to bathroom
11. One-on-one/group activity
2. VerbalRecent
abuse
4. Disruptive/Inappropriate
2. Assess for pain
12. Assist with tasks/cueing
a. Screaming/yelling at someone
a. Sexually inappropriate
Loss of self-control. . . . . . . .b.. .Throws
. . . . . .or. .smears
. . . . . .feces
. . . .or. .food
..........
3. Positive reinforcement
13. Calm reassurance
b. Cursing
4. Redirection
14. Engage in physical activity
c. Threatening
c. Spitting
Experiencing feelings of anger,
fear, abandonment . . . . . .
5. Food/fluids offered
15. Symptom evaluation
d. Baiting/provoking
d. Stealing
6.
Music/activity
offered
16. Mental health specialist evaluation
Experiencing
feelings
of
loneliness
or
isolation
.
.
.
.
.
.
.
.
.
.
3. Physical abuse
e. Disrobing inappropriately
7. Adjust environment
17. Anti-psychotic/PRN medication
a. Hits self or others
f. Wanders unsafely
Other:
____________________________________________
8.
“Live
the
Moment”
validation
18. Physical restraint
b. Shoves
g. Destructs property
9. Reduce light/noise
19. __________________________________
c. Scratches
h. Refuses treatment/ADLs
__________________________________________________
10. Familiar items/routines
20. __________________________________
__________________________________________________
First
Middle
Attending Physician
Room/Bed
Record No.
__________________________________________________
Middle
Attending Physician
Record No.
Room/Bed
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
Form 3697HH Rev. 8/10 © 1997 BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
PRINTED IN U.S.A.
Anti-Anxiety
MEDICATION ______________________
Observe the patient closely for significant
side effects and report to the Physician.
SIDE EFFECTS: Common - Sedation,
Drowsiness, Dry Mouth, Constipation,
SIDE EFFECTS: Sedation, Drowsiness,
Blurred Vision. EXTRAPYRAMIDAL
Ataxia (drunk walk), Dizziness, Nausea,
REACTION. Weight Gain, Edema.
Vomiting, Confusion, Headache, Blurred
POSTURAL HYPOTENSION. Sweating,
Vision, Skin Rash.
Loss of Appetite, Urinary Retention.
NURSING ALERT: If given with other
NURSING ALERT: Tardive Dyskinesia,
sedatives or hypnotics, Alcohol.
Seizure Disorder, Chronic Constipation,
Monitor behavior on medication sheet.
Glaucoma, Diabetes, Skin Pigmentation,
Jaundice. Monitor behavior on sheet.
Anti-Depressant
MEDICATION___________________
Observe the patient closely for significant
side effects and report to the physician.
L-2990
Black Ink
L-2991
Blue Ink
SIDE EFFECTS: Common – Sedation,
BEHAVIOR INTERVENTION MONITORING
Form 3079HH Rev. 1/13 © BRIGGS, Des Moines, IA (800) 247-2343
Price Per Pad (100/pd)
$13.05
$13.05
Month /Year_________________________
INTERVENTIONS
EMOTIONAL, ENVIRONMENTAL AND SOCIAL CONSIDERATIONS
YES
POTENTIAL CONTRIBUTING BEHAVIORAL FACTOR
Glasses: ill-fitting, dirty or missing . . . . . . . . . . . . . . . . . . . . . . . .
Dentures: improper fitting or uncomfortable . . . . . . . . . . . . . .
Ears impacted with cerumen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hearing aid malfunctioning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Poor lighting or flickering lights . . . . . . . . . . . . . . . . . . . . . . . . . .
Needs to go to the bathroom . . . . . . 1.. . Sad/anxious
. . . . . . . . . .mood
..........
a. Verbal distress, tearful
Has wet or soiled clothing, bed linen b.
. . Failure
. . . . . .to. .eat/withdrawn
. . . . . . . . . . due to mood
Is hungry or thirsty . . . . . . . . . . . . . . . . . . . . c.. . Recurrent
. . . . . . . .thoughts
. . . . . . .of. .death,
.
suicidal thoughts or actions
Needs position changed; is cold/warmd. Grieving
..................
Severe hopelessness
Environmental barriers . . . . . . . . . . . . . . . . e.
.f. . Anxious,
. . . . . . . persistent
. . . . . . . .attention
...
seeking
Misinterprets words, sounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Feels threatened by other residents . . . . . . . . . . . . . . . . . . . . . .
Is searching for a missing item. . . .NAME–Last
........................
Description
Side Punched Top Punched Drowsiness, Dry Mouth, Blurred Vision,
Urinary Retention, Tachycardia, Muscle
Tremor, Agitation, Headache, Skin Rash,
Photosensitivity (skin), Excess Weight Gain.
❑ Continued on Reverse
PRE-PSYCHOACTIVE MEDICATION RECORD
❑ Continued on Reverse
3079HH
L-2993
Black Ink
SPECIAL ATTENTION FOR: Heart
Pre-Psychoactive Med Record
•Adequately assess all aspects of resident’s well-being
prior to medicating, to identify the least restrictive
intervention
• Printed 2 sides different
• 5-hole punched top
Item #
3697HH
Description
Price Per Pad (100/pd)
Pre-Psych Med Assessment
$13.05
Behavior Intervention Record
•
•
•
•
•
Monitors interventions, alternative treatments and
resulting outcomes
Assist with justification of medication
11” x 8-1/2”
White paper
Black ink, printed two sides same
Item #
3079HH
Description
Price Per Pad (100/pd)
Behavior Intervention Monitoring
$13.05
Disease, Glaucoma, Chronic Constipation, Seizure Disorder, Edema.
HYPNOTICS/BENZODIAZEPINES
MEDICATION ________________________
Observe the patient closely for significant
side effects and report to the physician.
SIDE EFFECTS: Dry Mouth, Constipation,
Blurred Vision, Retention of Urine, Headache,
Vertigo, Nausea, Fall In Blood Pressure,
Rapid Heart Beat, Weakness, Sedation,
Lethargy, Confusion, Memory Loss, Allergic
Reactions, and Dependence.
Sedative/Tranquilizer
MEDICATION ___________________
Observe the patient closely for significant
side effects.
SIDE EFFECTS: Common - Sedation,
Drowsiness, Morning Hangover, Ataxia
(drunk walk)
NURSING ALERT: If given with other
sedatives or hypnotics, and alcohol.
Monitor behavior on medication sheet.
NURSING ALERT: Observe for decrease
in mental and physical functioning.
L-2992
Red Ink
L-2994
Green Ink
Chemical Restraint Psychotropic/
Psychoactive Drug Labels
•Place on the care plan to alert staff when a
resident is receiving a specific type of medication
• Permanent adhesive
•250/box
Price Per Box (250/bx)
Item #
Size
1241020
See Above
2” x 1-15/16”
$16.50$15.20$13.60 $12.60 $11.40
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
17
F329 – Drug Regimen is Free from Unnecessary Drugs
Medication Reconciliation Form
MEDICATION RECONCILIATION FORM
❑ Admission ❑ Readmission
•
•
•
•
INSTRUCTIONS: Complete upon admission or readmission for medication verification of resident.
Primary Care Physician: ____________________________________________________________ Phone: _________________________ Fax:_________________________
Pharmacy: _______________________________________________________________________ Phone: _________________________ Fax:_________________________
Caregiver:__________________________________________________________ Relationship: __________________________________ Phone: ______________________
Allergies/Reactions: _______________________________________________________________
_______________________________________________________________________________
Comments: ______________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Vaccinations: (date of last immunization)
Influenza:____________________ Pneumococcal:___________________
Medical Conditions:
❑ Asthma ❑ Heart disease
❑ Cancer ❑ Kidney disease
❑ Diabetes ❑ High blood pressure
❑ Other: _________________________
List All Prescription, Over-The-Counter, Herbal, and Inhalation Medications (Includes Oxygen, CPAP, Nebulizer, BiPAP)
Medication
Dose
Route
Check Box to Identify
Field Discrepancy
Time of
Last Dose
Prior to
Admission
Freq.
Med.
Dose
Route
Medication Discrepancy
Resolution Contact
RN
Hospital
Freq.
MD/
ARNP
If Not Resolved,
Contact Was Made to:
Resolved
Pharmacy
Family
Yes
RN
No
MD
Shift
Other
Used to reconcile the resident’s medication at the time
of admission or readmission to the facility
8-1/2” x 11”
White paper, black ink, printed front and back
5-hole punched top and side
Item #
1888P Description
Price Per Pad (100/pd)
Medication Reconciliation Form $13.05
ANTICOAGULANT THERAPY FLOW SHEET
Diagnosis requiring Anticoagulant Therapy:_______________________________________________________________
PT
DATE
INR
CURRENT COUMADIN DOSE
PTT
Reconciliation Completed By:_________________________________________________________________________
NAME–Last
First
Middle
Form 1888P 4/13 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
CURRENT HEPARIN DOSE
NEW ORDER
INITIALS
Attending Physician
Room/Bed
DOB
MEDICATION RECONCILIATION FORM
PRINTED IN U.S.A.
Anticoagulant Therapy Flowsheet
•Monitor lab values when your resident is on an
anticoagulant therapy i.e. heparin or coumadin
• Printed 1 side
• 5-hole punched side
Date/Time:__________________________________
1888P
Item #
2241
Description
Price Per Pad (100/pd)
Anticoagulant Therapy Flowsheet
$10.85
ACCUMULATIVE DIAGNOSIS RECORD
DATE
DATE
RESOLVED
DIAGNOSIS
ICD CODE
Accumulative Diagnosis Record
•Document ongoing diagnosis with Briggs® Form
1141P that includes a column for ICD codes
• Printed 1 side
• 5-hole punched top and side
IDENTIFY INITIALS WITH SIGNATURE
Initials
Signature
NAME–Last
Initials
First
Middle
Signature
Attending Physician
Room/Bed
Record No.
ANTICOAGULANT THERAPY FLOW SHEET
Form 2241 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
Item #
1141P
Description
Price Per Pad (100/pd)
Accumulative Diagnosis Record
$13.05
2241
Psychoactive Drug Audit
•Review the medical records of residents receiving
psychoactive medications
•White paper, blue ink
•Printed 1 side
•3-hole top punched (11” edge)
First
Reviewer Signature/Title
Form 3641 Rev. 2/99 © 1993 BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
NAME–Last
Form 1141P 4/03 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
1141P
D
sp oes
ec th
ific e
be Phy
ha sic
D
vio ian
fo oes
r to ’s
r th th
be Ord
e e re
dru s
tre er id
ate e
g ide
an nt’
d? ntify
Do
d s
fo es
th
ap Ca
r re th
e
pro re
du e re
pri Pla
cin s
ate n
g ide
or nt’
inteinclu
Do
eli s C
m th
rv de
m a
ed e
en th
ina re
ica Nu
tio e
tin Pla
ns rea
tio rs
g n
? so
n es’
th in
an N
n
e clu
Is
d ote
us d
an s
m th
e e
y
of a
us eth ere
sid spe
th go
e o od do
e cif
e al
f m (s)/ cu
eff y
dru
ed me men
ec the
g?
ica as ta
ts e
Is
? ffe
tio ure tio
co a B
ct
n? (s) n th
m eh
of
ple a
* If hav at o
th
v
e
te io
ye b th
e
d, r M
s, ee er
sig o
sp n le
H
ec trie ss
ne nito
re as
ify d re
d r
fo pre the
an - Q
loc pri stric
r th se re
d u
ati or tiv
e nta sid
da art
on to e
us ti e
te erl
th
e ve nt
d? y
e
of s o
Su
ps ign r a
m
yc ed n a
m
ho a pp
ary
ac n In ro
tiv fo pri
e rm ate
dru e
gs d C res
? on ide
se nt
nt
PSYCHOACTIVE DRUG DOCUMENTATION AUDIT
INSTRUCTIONS: Review the medical records of residents receiving
psychoactive medications to answer the questions listed.
Identify the resident (by name and/or facility ID#), age,
sex, drug (name/dose/frequency), behavior treated,
original and
current order
dates.Physician
Check the approMiddle
Attending
Record No.
priate response for each question. Any “No”
response should be communicated in accordance
with facility policy. Sign and date when completed.
Room/Bed
ACCUMULATIVE DIAGNOSIS RECORD
PRINTED IN U.S.A.
Y = Yes
N = No
* In space provided under “Yes” response, specify:
SS (Social Svc.)
A (Activity)
Age
Sex
Age
Sex
N (Nursing)
D (Dietary)
DRUG NAME,
DOSE AND
FREQUENCY
RESIDENT,
AGE AND SEX
CURRENT
BEHAVIOR ORIGINAL
ORDER ORDER
Y
TREATED
DATE
DATE
N
Y
N
Y
N
Y
N
Y
*
N
Y
N
Y
N
Y
N
COMMENTS
17. PSYCHOTROPIC MEDICATION USE CARE AREA ASSESSMENT (CAA)
Item #
3641
Description
11” x 8-1/2”
Price Per Pad (100/pd)
$11.40
Review of Indicators
of Psychotropic Drug Use
Age
Sex
Supporting Documentation
✓ Class(es) of medication this residentAgeis taking
❑
❑
❑
❑
Antipsychotic (N0410A)
Antianxiety (N0410B)
Antidepressant (N0410C)
Sedative/Hypnotic (N0410D)
Basis/reason for checking the item, including the location,
date and source (if applicable) of that information
Sex
Age
Sex
Age
Sex
MDS 3.0 Care Area Assessments
❑
❑
Review Date
❑
❑
❑
DOCUMENTATION AUDIT
PSYCHOACTIVE DRUG
✓ Unnecessary drug evaluation (from clinical record)
Age
Sex
Excessive dose, including duplicate medications
Excessive duration and/or without gradual dose reductions
Age
Sex
Inadequate monitoring for effectiveness and/or adverse
consequences
Agefor use
Sex
Inadequate or inappropriate indications
In presence of adverse consequences of the drug
Sex drug
✓ Treatable/reversible reasons for useAgeof psychotropic
❑
❑
❑
Environmental stressors such as excessive heat, noise,
overcrowding, etc. (observation, clinical record)
Psychosocial stressors such as abuse, taunting, not
following resident’s customary routine, etc. (observation,
clinical record) (F0300 - F0800)
Treatable medical conditions, such as heart disease
(I0200 - I0900), diabetes (I2900), or respiratory disease
(from medical evaluation) (I6200, I6300)
3641
✓ Adverse consequences of ANTIDEPRESSANTS exhibited by this resident
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
Worsening of depression and/or suicidal behavior or
thinking (D0350, D0650, V0100E, V0100F, clinical record)
Delirium unrelated to medical illness or severe depression
(C1600, clinical record)
Hallucinations (E0100A)
Dizziness (clinical record)
Nausea (clinical record)
Diarrhea (clinical record)
Anxiety (I5700, clinical record)
Nervousness, fidgety or restless (clinical record)
Insomnia (clinical record)
Somnolence (clinical record)
Weight gain (K0310, clinical record)
Anorexia or increased appetite (clinical record)
Increased risk for falls (clinical record), falls (J1700-J1900)
Seizures (I5400)
Hypertensive crisis if combined with certain foods, cheese,
wine (MAO inhibitors)
Anticholinergic (tricyclics), such as constipation, dry mouth,
blurred vision, urinary retention, etc. (clinical record)
Postural hypotension (tricyclics) (I0800, clinical record)
NAME–Last
First
Middle
Form 1917P Rev. 5/12 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
PRINTED IN U.S.A.
Attending Physician
•Establishes a logical flow for assessing multiple
problems, complications and risk factors
• Provides the location of supporting documentation
•Directs the staff to appropriate care plans
Record No.
Room/Bed
PSYCHOTROPIC MEDICATION USE
CARE AREA ASSESSMENT
Item #
1908P
1909P
1917P
Description
Price Per Pack (25/pk)
Mood Stare
$12.00
Behavioral Symptoms
$12.00
Psychotropic Medication Use
$12.00
Visit www.BriggsCorp.com for a complete
listing of MDS 3.0 Care Area Assessments!
1917P
18
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
Ensure medication is administered in accordance with:
Physician’s orders, manufacturers’ specifications & accepted
professional standards & principles!
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•49 brand-new FDA-approved drugs in this edition-with 36 new
comprehensive drug monographs, alphabetized and conveniently grouped
in a handy
“new drugs” section
•Over 6,000 clinical updates-new dosages and indications, Black Box warnings,
adverse reactions, nursing considerations, clinical alerts, and patient
teaching information
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Item #
8248-17
Description
Lippincott’s Nursing2017 Drug Handbook, 37th Edition
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$44.99
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2017 Nursing Drug Reference makes it easy to find the most vital information
on the drugs you administer most frequently. More than 5,000 drugs are
profiled - including 20 new entries for drugs recently approved by the FDA.
And no other drug guide places a higher emphasis on patient safety, with
Black Box Warnings for dangerous adverse reactions, Safety Alerts for
situations requiring special attention, and a focus on both common and lifethreatening side effects.
Item #
8115-17
Description
Mosby’s 2017 Nursing Drug Reference, 30th Edition Price Per Each
$44.95
NEW! Saunders Nursing Drug Handbook 2017
Saunders Nursing Drug Handbook 2017 gives you all the expert drug
information you need right in the palm of your hand. In addition to its detailed
and thoroughly updated drug coverage (including Black Box Alerts), this
convenient handbook also includes the precautionary information nurses need
to provide safer patient care - such as guidance on clinical priorities in the
practice setting and IV drug administration.
Item #
8165-17
Description
Saunders Nursing Drug Handbook 2017
Price Per Each
$39.95
NEW! Clinical Calculations Made Easy, 6th Edition
Clinical Calculations Made Easy is a compact, easy-to-use, pocket-sized guide/
reference to dosage calculation and drug administration. It includes a review
of basic math skills, measurement systems, and drug calculations/preparations
using dimensional analysis. The sixth edition provides many opportunities for
students to practice their skills.
Item #
7928-6ED Description
Clinical Calculations Made Easy, 6th Edition
Price Per Each
$81.99
Shop www.BriggsCorp.com for complete offering of up-to-date drug references!
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
19
F431 | Drug Records, Label/Store Drugs & Biologicals
Service Consultation
The facility must employ or obtain the services of a
licensed pharmacist who-(1) Establishes a system of records of receipt and
disposition of all controlled drugs in sufficient detail
to enable an accurate reconciliation; and
(2) Determines that drug records are in order and
that an account of all controlled drugs is maintained
and periodically reconciled.
Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be
labeled in accordance with currently accepted
professional principles, and include the appropriate
accessory and cautionary instructions, and the
expiration date when applicable.
Storage of Drugs and Biologicals
(1) In accordance with State and Federal laws, the
facility must store all drugs and biologicals in locked
compartments under proper temperature controls,
and permit only authorized personnel to have access
to the keys.
(2) The facility must provide separately locked,
permanently affixed compartments for storage of
controlled drugs listed in Schedule II of the
Comprehensive Drug Abuse Prevention and Control
Act of 1976 and other drugs subject to abuse, except
when the facility uses single unit package drug
distribution systems in which the quantity stored is
minimal and a missing dose can be readily detected.
2014 Ranking – #6 Most Cited | Also #5 for First 6 Months of 2015
Shop these products to find compliance solutions!
ST R
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SE
Medication Distribution Cabinet
•Includes a convenient instruction page and
160 consecutively numbered pages
•8-1/2” x 11”
•Black ink on white ledger paper
• Durable, all-steel construction
•
Double lock security makes cabinet suitable for the
storage of Class II drugs
•Each lock is keyed differently and is supplied with 3 keys
•Cabinet includes 1 fixed shelf and storage compartment
for blister packs
•Door folds down manually providing a writing or
medication preparation surface
Item #
699-B Item #
5852
Narcotic Record Book
20
Description
Narcotic Record Book
Price Per Each
$100.15
Color
Beige
Size (H x W x D)
18” x 14” x 3-1/2”
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
Price Per Each
$230.00
F431 – Drug Records, Label/Store Drugs & Biologicals
3105
ST R
B E LLE
SE
Individual Patient’s
Narcotics Record
Description
Narcotics Record
ADMISSION
DATE
AMOUNT
ORDERED
AMOUNT
REC’D.
PRESCRIBED BY
DOSAGE
METHOD
OF ADMIN.
PRESCRIP.
NO.
PHARMACIST’S
NAME
REMARKS:
•Provides a detailed and accurate record of
narcotics administered, including space to
document the disposition of any unused portion
•Printed 1 side
Item #
3105 INDIVIDUAL PATIENT’S NARCOTICS RECORD
PATIENT
NAME
ROOM
NO.
MEDICATION
NAME
CFS12-4
NAME OF PERSON GIVING
DATE
AMOUNT
ON HAND
TIME
AMOUNT
RECEIVED
AMOUNT
GIVEN
AMOUNT
REMAINING
CONTROLLED DRUGS–COUNT RECORD
Month/Year
FACILITY
UNIT
Signing below acknowledges that you have counted the controlled drugs on hand and have found that the
quantity of each medication counted is in agreement with the quantity stated on the Controlled Drug
Administration Record.
Price Per Pad (100/pd)
$10.15
DATE
7-3 SHIFT
Nurse Off
(11-7)
3-11 SHIFT
Nurse On
(7-3)
Nurse Off
(7-3)
11-7 SHIFT
Nurse On
(3-11)
Nurse Off
(3-11)
COMMENTS
Nurse On
(11-7)
1
2
3
4
Controlled Drugs-Count
5
6
7
8
•Ensures that nursing personnel complete a changeof-shift count of all controlled drugs as required per
facility policy
•Printed 1 side
•3-hole side punched
9
CONTROLLED MEDICATION ADMINISTRATION RECORD
10
11
MEDICATION
NAME
12
13
14
15
METHOD OF
ADMINISTRATION
DOSAGE
PRESCRIBED BY
AMOUNT
ORDERED
AMOUNT
RECEIVED
PRESCRIPTION
NO.
PHARMACIST
REMARKS/COMMENTS
16
17
DISPOSITION OF UNUSED
PORTION OF PRESCRIPTION:
18
SIGNATURE OF NURSE
ADMINISTERING
DATE
AMOUNT AMOUNT AMOUNT AMOUNT
RECEIVED ON HAND ADMIN’D. REMAINING
TIME
VERIFICATION BY
INIT./DATE/TIME
19
Item #
DescriptionPrice Per Pad (100/pd)
CFS12-4 Controlled Drugs-Count
20
21
$10.85
Form 3105 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
22
INDIVIDUAL PATIENT’S NARCOTICS RECORD
PRINTED IN U.S.A.
23
24
25
Controlled Medication
Administration Record
26
27
28
29
30
31
•Accurately record the receipt and disposition of any
controlled drug needed for individual resident
administration
•Printed 1 side
•5-hole punched
CONTROLLED DRUGS–COUNT RECORD
CFS 12-4 Rev. 1/08 © 1992 BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
DRUG DESTRUCTION LOG
Item #
CFS12-3HH
CFS12-3HF
DescriptionPrice Per Pad (100/pd)
Side Punched
$10.85
Top Punched
$10.85
RESIDENT NAME
DATE
OF
DISPOSITION
AMOUNT
DESTROYED
DRUG NAME AND STRENGTH
METHOD
OF
DISPOSITION
SIGNATURE OF NURSES
WITNESSING DISPOSITION
DISPOSITION OF UNUSED PORTION
DATE & METHOD OF DISPOSITION
NAME–Last
First
Middle
Attending Physician
Room/Bed
Record No.
CONTROLLED MEDICATION
ADMINISTRATION RECORD
CFS 12-3HH Rev. 11/12 © 1992 BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
Drug Destruction Log
CFS12-3HH
Use to document the amount, date and method of
disposition of the resident medication
Item #
582
DescriptionPrice Per Pad (100/pd)
Drug Destruction Log
$10.85
12-Hour Controlled Drugs
NEW! Count Record
Ensures that nursing personnel carry out a change-of-shift
count of all controlled drugs as required per facility policy. This
new form accommodates facilities that have 12-hour shifts.
• White paper, black ink
• Printed one side
• 3-hole side punched
12-HOUR CONTROLLED DRUGS – COUNT RECORD
Month/Year______________________ /___________
FACILITY_____________________________________________________________ UNIT_____________________________
Signing below acknowledges that you have counted the controlled drugs on hand and have found that the
quantity of each medication counted is in agreement with the quantity stated on the Controlled Drug
Administration Record.
DATE
1st SHIFT
Nurse On
2nd SHIFT
Nurse Off
Nurse On
DescriptionPrice Per Pad (100/pd)
12-Hour Controlled Drugs Count Record
$10.85
Medication Reconciliation Form
•Used to reconcile the resident’s medication at the
time of admission or readmission to the facility
• White paper, black ink, printed front and back
• 5-hole punched top and side
2
3
4
5Form 582
Rev. 7/00 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
582
DRUG DESTRUCTION LOG
PRINTED IN U.S.A.
6
7
8
9
10
11
12
13
14
15
16
17
18
MEDICATION RECONCILIATION FORM
❑ Admission ❑ Readmission
INSTRUCTIONS: Complete upon admission or readmission for medication verification of resident.
Primary Care Physician: ____________________________________________________________ Phone: _________________________ Fax:_________________________
Pharmacy: _______________________________________________________________________ Phone: _________________________ Fax:_________________________
Caregiver:__________________________________________________________ Relationship: __________________________________ Phone: ______________________
Allergies/Reactions: _______________________________________________________________
_______________________________________________________________________________
Comments: ______________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Vaccinations: (date of last immunization)
Influenza:____________________ Pneumococcal:___________________
Medical Conditions:
❑ Asthma ❑ Heart disease
❑ Cancer ❑ Kidney disease
❑ Diabetes ❑ High blood pressure
❑ Other: _________________________
List All Prescription, Over-The-Counter, Herbal, and Inhalation Medications (Includes Oxygen, CPAP, Nebulizer, BiPAP)
20
Medication
Dose
Route
21
Freq.
Time of
Last Dose
Prior to
Admission
Check Box to Identify
Field Discrepancy
Med.
Dose
Route
Medication Discrepancy
Resolution Contact
Freq.
RN
Hospital
MD/
ARNP
If Not Resolved,
Contact Was Made to:
Resolved
Pharmacy
Family
Yes
RN
No
Shift
MD
Other
22
23
24
25
26
27
28
29
30
31
CFS 12-12 3/15 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
CFS12-12
12-HOUR CONTROLLED DRUGS –
COUNT RECORD
PRINTED IN U.S.A.
Reconciliation Completed By:_________________________________________________________________________
NAME–Last
First
Form 1888P 4/13 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
Item #
1888P COMMENTS
Nurse Off
1
19
Item #
CFS12-12
DATE
AUTHORIZED SIGNATURE/TITLE
AMOUNT REMAINING
Middle
Attending Physician
PRINTED IN U.S.A.
DescriptionPrice Per Pad (100/pd)
Medication Reconciliation Form $13.05
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
Date/Time:__________________________________
DOB
Room/Bed
MEDICATION RECONCILIATION FORM
1888P
21
F431 – Drug Records, Label/Store Drugs & Biologicals
Labels
Size
These labels feature
15/16” x 2-1/4”
removable adhesive.
15/16” x 2-1/4”
5/16” x 1-1/4”
Price Per Box
Qty 1
2
4 10
20
250/bx$11.85 $10.40 $9.95 $9.00 $8.30
500/bx$19.55 $18.85 $17.80 $16.70 $15.40
500/bx$14.30 $10.90 $10.50 $10.15 $9.70
EXPIRED
L-2189
5/16” x 1-1/4”
L-5730
Fl. Yellow
5/16” x 1-1/4”
500/bx
Fl. Red
500/bx
DIRECTION CHANGE
REFER TO MED SHEET
L-4924
5/16” x 1-1/4”
L-2304
L-8063N
5/16” x 1-1/4”
Fl. Red
500/bx
L-2121N
5/16” x 1-1/4”
L-4807
5/16” x 1-1/4”
Fl. Red
500/bx
L-4919
5/16” x 1-1/4”
Fl. Green
500/bx
L-4834
Fl. Orange
5/16” x 1-1/4”
500/bx
DATE EXPIRES
____/____/____
L-4918
Fl. Orange
5/16” x 1-1/4”
500/bx
L-4920
5/16” x 1-1/4”
CRUSH MEDS
DO NOT CRUSH
L-4926
Fl. Orange
5/16” x 1-1/4”
500/bx
15/16” x 2-1/4”
Fl. Pink
250/bx
L-3024
15/16” x 2-1/4”
L-6212N 15/16” x 2-1/4”
Fl. Red
250/bx
L-2152
15/16” x 2-1/4” Fl. Yellow 250/bx
Fl. Red
Fl. Red
500/bx
DATE OPENED
____/____/____
Directions Changed
Refer To Chart
DATE VIAL OPENED
__/__/__INITIAL____
Fl. Green
500/bx
ALERT!
NEW ORDERS
500/bx
L-4561
L-4921
5/16” x 1-1/4”
Fl. Red
500/bx
Fl. Pink
500/bx
15/16” x 2-1/4” Fl. Orange 250/bx
L-2092N 15/16” x 2-1/4”
Fl. Red 500/bx
Narcotic Control Cabinets
These products will drop ship from
the manufacturer and are exempt
from our Freight-Free Policy. Please
allow 2-3 weeks delivery time.
5845
5803
5804
5805
Stainless-steel all welded construction
• A controlled system for storing and dispensing narcotics
• Two key/two person safety system; three keys per
lock provided. Can be keyed alike
•Cabinet is stainless steel; aluminum shelves are adjustable and removable
•Both doors have piano-hinge suspension; outer door
has triple-bolt lock; inner door has single-bolt lock
22
Item #
5845
5803
5804
5805
Description
No shelves
2 shelves
2 shelves
4 shelves
Size
9” x 8” x 5-5/8”
15” x 11” x 4”
15” x 11” x 8”
24” x 16” x 8”
Complies with Department of Justice Drug
Enforcement and the Joint Commission on
Accreditation of Health Care Organizations
requirements. Check your state codes.
•Top can be placed on either end for left- or rightopening front door
• Pre-drilled holes for wall mounting
•10-year warranty against defects in materials and
workmanship
• 90-day warranty on lock and key
Qty
1 ea
1 ea
1 ea
1 ea
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
Price
$319.30
$442.90
$545.90
$623.15
F441 - Infection Control, Prevent Spread, Linens
F279 | Develop Comprehensive Care Plans
A facility must use the results of the assessment to develop, review and revise the resident’s comprehensive
plan of care.
The facility must develop a comprehensive care plan for each resident that includes measurable objectives
and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified
in the comprehensive assessment.
The care plan must describe the following:
(1) The services that are to be furnished to attain or maintain the resident’s highest practicable physical,
mental, and psychosocial well-being as required under §483.25; and
(2) Any services that would otherwise be required under §483.25 but are not provided due to the resident’s
exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4).
2014 Ranking – #7 Most Cited
Shop these products to find compliance solutions!
Resident
Identifier
Date
MINIMUM DATA SET (MDS) - Version 3.0
CAA’s =
QM’s =
RESIDENT ASSESSMENT AND CARE SCREENING
Nursing Home Comprehensive (NC) Item Set
PPS =
Section A
Code “-” if information
unavailable or unknown
Identification Information
A0050. Type of Record
1.
2.
3.
Enter Code
Add new record g Continue to A0100, Facility Provider Numbers
Modify existing record g Continue to A0100, Facility Provider Numbers
Inactivate existing record g Skip to X0150, Type of Provider
A0100. Facility Provider Numbers
A.
National Provider Identifier (NPI):
B.
CMS Certification Number (CCN):
C.
State Provider Number:
A0200. Type of Provider
Enter Code
Type of provider
1. Nursing home (SNF/NF)
2. Swing Bed
A0310. Type of Assessment
CAA
Enter Code
A.
Federal OBRA Reason for Assessment
01. Admission assessment (required by day 14) 11 2
02. Quarterly review assessment
03. Annual assessment 1 2 8 2
04. Significant change in status assessment 1 2 8 2
05. Significant correction to prior comprehensive assessment
06. Significant correction to prior quarterly assessment
99. None of the above
Enter Code
B.
PPS Assessment
PPS Scheduled Assessments for a Medicare Part A Stay
01. 5-day scheduled assessment
02. 14-day scheduled assessment
03. 30-day scheduled assessment
04. 60-day scheduled assessment
05. 90-day scheduled assessment
06. Readmission/return assessment
PPS Unscheduled Assessments for a Medicare Part A Stay
07. Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment)
Not PPS Assessment
A0310 continued on next page
99. None of the above
1
2
8
MDS Cue Cards
2
QUALITY MEASURES (QM)
SHORT STAY QUALITY MEASURES:
01.01 Residents who self-report moderate to severe pain
02.01 Residents with Pressure Ulcers that are new or worsened
03.01 Residents who were assessed and appropriately given the
seasonal Influenza Vaccine
04.01 Residents who received the seasonal Influenza Vaccine
05.01 Residents who were offered and declined the seasonal
Influenza Vaccine
06.01 Residents who did not receive, due to medical
contraindication, the seasonal Influenza Vaccine
07.01 Residents assessed and appropriately given the
Pneumococcal Vaccine
08.01 Residents who received the Pneumococcal Vaccine
09.01 Residents who were offered and declined the
Pneumococcal Vaccine
10.01 Residents who did not receive, due to medical
contraindication, the Pneumococcal Vaccine
11.01 Residents who newly received an Antipsychotic Medication
LONG STAY QUALITY MEASURES:
13.01 Residents experiencing one or more Falls with Major Injury
14.01 Residents who self-report moderate to severe pain
15.01 Residents (high risk) with Pressure Ulcers
16.01 Residents assessed and appropriately given the seasonal
Influenza Vaccine
17.01 Residents who received the seasonal Influenza Vaccine
18.01 Residents who were offered and declined the seasonal
Influenza Vaccine
19.01 Residents who did not receive, due to medical
contraindication, the seasonal Influenza Vaccine
20.01 Residents assessed and appropriately given the
Pneumococcal Vaccine
21.01 Residents who received the Pneumococcal Vaccine
22.01 Residents who were offered and declined the
Pneumococcal Vaccine
23.01 Residents who did not receive, due to medical
contraindication, the Pneumococcal Vaccine
CMS ID
CMS ID
Indicates responses that may impact QM items identified by a number in a solid blue oval
LONG STAY QUALITY MEASURES:
24.01 Residents with a Urinary Tract Infection
25.01 Residents (low risk) who lose control of their bowel or
bladder
26.01 Residents who have/had a catheter inserted and left
in their bladder
27.01 Residents who were physically restrained
28.01 Residents whose need for help with Activities of Daily
Living has increased
29.01 Residents who lose too much weight
30.01 Residents who have Depressive Symptoms
31.02 Residents (long stay) who received an Antipsychotic
Medication
32.01 Falls
33.01 Anti-anxiety/Hypnotic Medication use
34.01 Behavior Symptoms affecting others
CMS ID
•Pocket sized
laminated cards
•Printed front/back
•Black Ink
Item #
1870
Description
MDS Cue Cards
Price Per Pack
$21.00
Indicates responses that may impact covariate for the QM identified by a number in an outline blue oval
CARE AREA ASSESSMENT LEGEND
1 Delirium
2 Cognitive Loss/Dementia
3 Visual Function
4 Communication
5 ADL Function/
Rehabilitation Potential
6 Urinary Incontinence &
Indwelling Catheter
7 Psychosocial Well-Being
Form 1851P-13 2013 BRIGGS, Des Moines, IA 50306 (800) 247-2343
10/13
8 Mood State
9 Behavioral Symptoms
10 Activities
11 Falls
www.BriggsCorp.com
12 Nutritional Status
13 Feeding Tubes
14 Dehydration/Fluid Maintenance
15 Dental Care
16 Pressure Ulcer
17 Psychotropic Drug Use
18 Physical Restraints
19 Pain
20 Return to Community
Referral
2
3
2 Items Trigger
3 or More Items Trigger
MDS 3.0 Nursing Home Comprehensive (NC)
Version 1.11.2 Effective 10/01/2013
1 of 40
MDS 3.0 Nursing Home
NEW! Comprehensive Assessment (NC)
• 40 page booklet
• 4 colors – Red/Black/Green/Blue inks
• Now with PEPPER Indicators
• 5 hole punched side
Briggs’ Comprehensive Assessment is enhanced with
Quality Measures easily identified in blue, PPS items
identified in green and CAA’s in red. A RUG IV calculator
is provided on the back.
Item #Price Per Pack (25/pk)
1851P-15
$16.50
NURSES’ SUMMARY: SEVEN DAY LOOK BACK
VITAL SIGNS: T_________ P_________ R_________ B/P____________ WT_________
HEARING, SPEECH AND VISION
Section B
HEARING: Ability to hear (with hearing aid or hearing
appliances if normally used)
❑ Adequate – no difficulty in normal conversation, social
interaction, listening to TV
❑ Minimal difficulty – difficulty in some environments (e.g. when
person speaks softly or setting is noisy)
❑ Moderate difficulty – speaker has to increase volume and
speak distinctly
❑ Highly impaired – absence of useful hearing
HEARING AID: Hearing aid or other hearing appliance used
❑ No
❑ Yes: ___Rt ___Lt
❑ Present and not regularly used
SPEECH CLARITY: Select best description of speech pattern
❑ Clear speech – distinct intelligible words
❑ Unclear speech – slurred or mumbled words
❑ No speech – absence of spoken words
Nurses’ Summary –
7-Day Look Back
MAKES SELF UNDERSTOOD: Ability to express ideas and
wants, consider both verbal and non-verbal expression
❑ Understood
❑ Usually understood – difficulty communicating some words or
finishing thoughts but is able if prompted or given time
❑ Sometimes understood – ability is limited to making concrete
requests
❑ Rarely/never understood
ABILITY TO UNDERSTAND OTHERS: Understanding verbal
content, however able (with hearing aid or device if used)
❑ Understands – clear comprehension
❑ Usually understands – misses some part/intent of message
but comprehends most conversation
❑ Sometimes understands – responds adequately to simple,
direct communication only
❑ Rarely/never understands
VISION: Ability to see in adequate light (with glasses or other
visual appliances)
❑ Adequate – sees fine detail, including regular print in
newspapers/books
❑ Impaired – sees large print, but not regular print in
newspapers/books
❑ Moderately impaired – limited vision; not able to see
newspaper headlines but can identify objects
❑ Highly impaired – object identification in question, but eyes
appear to follow objects
❑ Severely impaired – no vision or sees only light, colors or
shapes; eyes do not appear to follow objects
•Allows accurate
assessment over all
shifts of the data
elements used with
MDS 3.0
• 4-page booklet
•Printed 2 sides
different, head-to-head
• 5-hole punched top and side
COGNITIVE PATTERNS
NAME–Last
First
Form 1950P Rev. 8/12 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
Visit www.BriggsCorp.com/BriggsInside
to find out more!
Item #
1950P
Middle
PRINTED IN U.S.A.
Section C
SHORT TERM MEMORY:
❑ Seems or appears to recall after 5 minutes
❑ Memory problem
LONG TERM MEMORY:
❑ Seems or appears to recall long past
❑ Memory problem
MEMORY/RECALL ABILITY:
❑ Current season
❑ Location of own room
❑ Staff names and faces
❑ That he or she is in a nursing home
❑ None of the above were recalled
COGNITIVE SKILLS FOR DAILY DECISION MAKING:
❑ Independent – decisions consistent/reasonable
❑ Modified independence – some difficulty in new situations
only
❑ Modified impaired – decisions poor, cues/supervision
required
❑ Severely impaired – never/rarely made decisions
Comments:__________________________________________
___________________________________________________
DELIRIUM:
❑ Inattention – Did the resident have difficulty focusing
attention (easily distracted, out of touch or difficulty following
what was said)?
❑ Disorganized thinking – Was the resident’s thinking
disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable
switching from subject to subject)?
❑ Altered level of consciousness – Did the resident have
altered level of consciousness? (e.g., vigilant – startled
easily to any sound or touch; lethargic – repeatedly dozed off
when being asked questions, but responds to voice or touch;
stuporous – very difficult to arouse and keep aroused for the
interview; comatose – could not be aroused)
❑ Psychomotor retardation – Did the resident have an unusually
decreased level of activity such as sluggishness, staring into
space, staying in one position, moving very slowly?
MOOD
❑
Section C
consciousness
COGNITIVE PATTERNS (Cont’d.)
❑
❑
❑
❑
❑
❑
CORRECTIVE LENSES: (Contacts, glasses, or magnifying
glass used) ❑ No ❑ Yes
❑ Eye prosthesis: ___Rt ___Lt
❑ Present and not regularly used
❑ Alert and oriented x 3
❑ Disoriented: Person, Place, Time
❑ Comatose: Persistent, vegetative state/no discernable
Does Your
Software
Provider Have
Briggs® Inside?
Date:_______________
Check/circle appropriate responses and fill in the box.
❑
❑
❑
Section D
❑ NA
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself – or that you are a failure or have
let yourself or your family down
Trouble concentrating on things, such as reading the
newspaper or watching television
Moving or speaking so slowly that other people could have
noticed. Or the opposite – being so fidgety or restless that
you have been moving around a lot more than usual
Thoughts that you would be better off dead, or of hurting
yourself in some way
Short-tempered, easily annoyed
Attending Physician
Record No.
Room/Bed
NURSES’ SUMMARY: SEVEN DAY LOOK BACK
Description
Price Per Pack (100/pk)
Nursing Summary – 7-Day
$30.50
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
23
F279 – Develop Comprehensive Care Plans
CFS4-1/2P-10
❑ Re-admission
❑ Quarterly
❑ Annual
❑ Significant Change
❑ Other_______________________
BACKGROUND/FACTUAL INFORMATION
If no, should the facility contact? ❑ Yes ❑ No
If yes, contact person and phone no._____________________________________
PREFERENCE INTERVIEWS
❑ Resident ❑ Family or Significant Other ❑ Staff
Show resident the response options and say: “While you are in this facility...” Enter codes in boxes.
Coding: 1. Very important
3. Not very important
5. Important, but can’t do or no choice
2. Somewhat important 4. Not important at all
9. No response or non-responsive
Interview for Daily Preferences
Interview for Activity Preferences
A. how important is it to you to have books, newspapers, and
magazines to read?
A. how important is it to you to choose what clothes to wear?
B. how important is it to you to take care of your personal
belongings or things?
B. how important is it to you to listen to music you like?
C. how important is it to you to choose between a tub bath,
shower, bed bath, or sponge bath?
C. how important is it to you to be around animals such as
pets?
D. how important is it to you to have snacks available between
meals?
D. how important is it to you to keep up with news?
E. how important is it to you to do things with groups of
people?
E. how important is it to you to choose your own bedtime?
F. how important is it to you to have your family or a close
friend involved in discussions about your care?
F. how important is it to you to do your favorite activities?
G. how important is it to you to go outside to get fresh air when
the weather is good?
G. how important is to you to be able to use the phone in private?
H. how important is it to you to participate in religious services
or practices?
H. how important is it to you to have a place to lock your things
to keep them safe?
ACTIVITY PURSUIT PATTERNS (P - Past interest; C - Current interest; N - No interest)
*Specify type of activity on resident’s plan of care (example: Cards - Bridge)
P C N
CFS4-2HH
ACTIVITY
P C N
Cards
Games
Crafts / arts / hobbies
Exercise / walking / jogging
Sports
Music
Reading / audio books
ACTIVITY
P C N
Spiritual / religious activities
Trips / shopping
ACTIVITY
Golfing
Helping others / volunteer work
Spending time outdoors
Walking /wheeling outdoors
Watching TV / radio
Watching movies
Gardening / plants
Writing
Talking / conversing
Baking
/cooking
Woodshop
Instructions: For each evaluation type (Admission, Annual, etc.) identify the corresponding number
in the/ toolshop
space provided to the right
Computer
Hunting / fishing
(i.e. Admission____
1 , Annual____
2 ).
ACTIVITY EVALUATION
Parties / social events
Keeping up with the news
Community outings
Groups / organizations
Other:
Other:
Other:
Other:
would you prefer to
in scheduled
activities?
❑ Morning❑ Other______
❑ Afternoon
❑ Admission_____ ❑ Re-admission_____ ❑When
Quarterly__________
❑participate
Annual_____
❑ Significant
Change_____
▲
❑ Evening ❑ Night
❑6None of these,
explain
1
2
3
4
5
7
8 ______________________________________
Preferred activity setting: ❑ Own room ❑ Day/activities room ❑ Inside facility/off unit ❑ Outside facility
DATE: (must include month/day/year)
❑ Other, explain ______________________________________________________________________________
PARTICIPATION IN ACTIVITIES:
Do you take naps? ❑ Yes ❑ No If yes, what time of day and how long? _________________________________________________
Participates in: all activities
Would you like to have a service-related job assignment? ❑ Yes ❑ No If yes, type ________________________________________
Participates in: 6 or more activities/week
NAME–Last
First
Participates in: 3-5 activities/week
Participates in: 2 activities/week
CFS 4-1/2P-10 9/10 © 1992 BRIGGS, Des Moines, IA (800) 247-2343
Participates in: 1 activity/week
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
Unable to participate in group activities (large/small)
Chooses not to participate in group activities (large/small)
Participates in: independent activities of choice
Participates in: one-to-one programs
Participates in: one-to-one visits
Middle
Attending Physician
Room/Bed
Record No.
ACTIVITY EVALUATION
❑ Continued on Reverse
PARTICIPATION LEVEL IN ACTIVITIES:
Attends activities independently
Requires reminding to attend activities
Requires assistance to attend activities
Is an active participant
Is a passive participant
Participates: independently
Participates: with assistance
Behavior in activities is: appropriate
Behavior in activities is: inappropriate
Responsive to one-to-one programs
Unresponsive to one-to-one programs
Responsive to one-to-one visits
NAME–Last
Hair Care
____ Independent
____ By Staff
____ Staff Assembles Equipment
____ Shampoo by Staff
____ Shampoo by Beauty Shop
Nail Care
____ Independent
____ Podiatrist
____ By Staff
Mouth Care
Freq: ________________
____ Independent
____ By Staff
____ Dentures
____ U ____ L
____ No Dentures
____ No Teeth
Describe what is done by staff:
_________________________________________
_________________________________________
_________________________________________
_________________________________________
Toileting
____ BRP
____ Bedside Commode
____ Urinal
____ Bedpan
REVIEW DATE
____ Independent ____ By Staff
Describe what is done by staff:
_________________________________________
_________________________________________
_________________________________________
_________________________________________
NAME–Last
Item #
CFS4-1/2P-10
CFS4-1/2TP-10
Description
Side Punched
Top Punched
Price Per Pack (100/pk)
$40.80
$40.80
Item #
Description
Price Per Pad (100/pd)
CFS4-1HH-10
CFS4-1HF-10
Side Punched
Top Punched
Item #
CFS4-2HH
First
Shaving
____ Independent
____ By staff
Describe what is done by staff:
_________________________________________
_________________________________________
_________________________________________
_________________________________________
•Identifies a resident’s preferences
related to daily routines and leisure activities
•CFS4-1/2:
– Printed 2 sides different
– 2-part form
– 5-hole punched
•CFS4-1:
– Single-sheet
– Printed 2 sides different
– 5-hole punched
Middle
Attending Physician
Diet
____ Regular
____ Therapeutic: ________________________
____ Mechanically Altered: ________________
____ NPO
____ Tube Feedings
Fluids
____ Regular
____ Thickened
Consistency: _______________________
3. MOBILITY
____ Walks Independently
____ Ambulation Device:
____ W/C
____ Walker
____ Cane
____ Independent
____ By Staff
____ ROM ____ Active
____ Passive
____ LUE
____ LLE
____ RUE
____ RLE
____ Turn q ____ hr and Position
____ Transfer
____ Assist
____ Lift
____ Bed
____ Chair
____ 1 Person
____ 2 Person
____ NWB
____ PWB
____ FWB
Describe what is done by staff:
_________________________________________
___________
______________________________
SIGNATURE/TITLE
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
5. SKIN INTEGRITY
____ Preventive Care _____________________
_________________________________________
____ Whirlpool
Freq: ________________
____ Wound Care
Describe: _______________________________
_________________________________________
____ Pressure Ulcer
Stages and Locations: ___________________
_________________________________________
_________________________________________
_________________________________________
6. BLADDER/BOWEL STATUS
____ Self Control
____ Bladder Incontinence Freq:__________
____ Bowel Incontinence Freq:__________
____ Toileting Management
Schedule:_______________________________
_________________________________________
____ Bowel/Bladder Training
Schedule:_______________________________
_________________________________________
____ Indwelling Catheter
____ Ostomy Care
____ Independent ____ By Staff
Describe what is done by staff:
_________________________________________
_________________________________________
_________________________________________
_________________________________________
____ Impaired
____ Left
____ Right
COMPREHENSIVE
PLAN
OF CARE
Middle
Interim Plan of Care
ACTIVITY EVALUATION
Date: __________________________
4. SPECIAL EQUIPMENT
____ Brace: _____________________________
____ Prosthesis: _________________________
____ Other: _____________________________
____ Independent
____ By Staff
Above needed due to:____________________
_________________________________________
_________________________________________
_________________________________________
7. VISION
____ Normal
____ Glasses
____ Blind
Other:__________________________________
8. HEARING
____ Normal
____ Impaired
____ Left
____ Right
____ Hearing Aid
Other:__________________________________
Attending Physician
DescriptionPrice Per Pad (100/pd)
Activity Assessment
$13.95
Room/Bed
Record No.
INTERIM PLAN OF CARE
2. EATING
____ Independent
____ By Staff
____ Supervise
____ Assist
____ Feed
____ Restorative
First
9. SPEECH
____ Normal
____ Impaired
Other:__________________________________
10. THERAPY
____ PT
____ OT
____ Speech
____ RT
Reason: ________________________________
_________________________________________
•Provides an overview of the resident’s functional status
and care needs for temporary use until MDS and CAAs
are completed
• White heavy cardstock
• Printed 2 sides different
• 5-hole punched top and side
• 11” x 8-1/2”
11. NURSING REHAB/RESTORATIVE SERVICES
____ Current program
Type: ______________________________
_________________________________________
12.BEHAVIORAL/MENTAL STATUS
Problem/Strength
____ Alert
____ Antisocial
____ Depressed
____ Noisy
____ Irritable
____ Uncooperative
____ Confused
____ Forgetful
____ Other (Describe) ____________________
___________________________________
Intervention
____ Reality Orientation
____ Reassurance
____ Behavior Mood Program (Specify)
___________________________________
___________________________________
___________________________________
___________________________________
13. PHYSICAL RESTRAINT
Type:__________________________________
Duration: _______________________________
Medical Reason: ________________________
_________________________________________
_________________________________________
_________________________________________
Item #
1176P
Observe q 30 minutes, release and
reposition q 2 hours for toilet and exercise.
14. OTHER INFORMATION
_________________________________________
_________________________________________
COMMENTS
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________
Record No.
DescriptionPrice Per Pad (100/pk)
Interim Plan of Care
$37.00
Room/Bed
INTERIM PLAN OF CARE
Form 1176P Rev. 8/12 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
Comprehensive Plan of Care
1176P
LONG TERM GOALS
NAME–Last
First
Form 1177P Rev. 8/12 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
•
•
•
•
RESIDENT STRENGTHS
Middle
Attending Physician
Record No.
Room/Bed
COMPREHENSIVE PLAN OF CARE
Can be used in a resident’s chart or in a visible file panel
White heavy cardstock
Printed 2 sides different
5-hole punched top and side
Item #
1177P
1178P
Size
Price Per Pack (100/pk)
17” x 11” (Overall), 8-1/2” x 11” (Folded)
$62.15
11” x 8-1/2”
$28.55
1177P
24
$13.95
$13.95
•Record a resident’s activity participation based on
preference, social ability and functional skill
• Printed 2 sides different; 5-hole punched side
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
1. PERSONAL HYGIENE
Bath Days: ______________________________
Shift: ___________________________________
____ Tub
____ Shower
____ Whirlpool
____ Bed Bath
____ Pericare, Frequency _________________
____ Independent
Describe what is done by staff:
_________________________________________
_________________________________________
_________________________________________
_________________________________________
Initial Activity Evaluation
Activity Evaluation
SOCIALIZATION PATTERNS:
Prefers to be alone
Prefers to be with people
Makes friends easily
Has difficulty in making friends
Initiates conversations
Rarely initiates conversations
Prefers to stay in room
Prefers to be out of room
Enjoys large groups
Enjoys small groups
Visits with family and friends
Communicates verbally
Communicates nonverbally
Able to make needs known
Unable to make needs known
Short attention span
CFS 4-2HH Rev. 5/13 © 1992 BRIGGS, Des Moines, IA (800) 247-2343
ST R S
BELLE
SE
ACTIVITY EVALUATION
❑ Admission
Personal Preferences: Name______________________________________________ Color(s) ____________________________________
Animal________________________________ Food______________________________ Alcohol/Tobacco use ________________________
Birthdate______ /______ /______ Birthplace_____________________________________________ Date of admission______ /______ /______
Living arrangements prior to admission: _________________________________________________________________________________
Marital status: ❑ M ❑ D ❑ W ❑ S Spouse’s/ significant other’s name:_______________________________ Veteran? ❑ Yes ❑ No
Language spoken _________________________________________ Speech: ❑ Clear ❑ Unclear, explain __________________________
Former occupation ________________________________________ Education (able to read and write?): ____________________________
Clubs/Organizations __________________________________________________________________________________________________
Voting Interests: Registered voter? ❑ Yes ❑ No Interested in voting? ❑ Yes ❑ No If yes ❑ Absentee ❑ Go to polls
Spiritual Involvement: Church/religious preference and level of participation: ________________________________________________
If currently a member of a church, was church notified of resident’s admission? ❑ Yes ❑ No
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
F279 – Develop Comprehensive Care Plans
Nutritional Evaluation
Date of Admission:______/______/______ Date of Birth:______/______/______ Age:_______
Diagnosis:________________________________________________________________________________________________
__________________________________________________________________________________________________________
Diet Order: _________________________________________________________________________________________________
Allergies: __________________________________________________________________________________________________
PHYSICAL CHARACTERISTICS
Sex: ❑ M ❑ F
Height:__________ Weight:__________ Usual weight:__________
BMI:__________ IBW:__________ Adjusted body weight:__________
Amputation: ❑ No ❑ Yes (if yes, specify body part and adjust IBW) __________________________________________________
Recent weight change (specify): ________________________________________________________________________________
ENERGY NEEDS
Needs__________________cal __________ gm prot __________mL fluid
calculated by __________________________________________ formula /method
DENTAL STATUS
❑ Yes
❑ No
Own teeth:
DescriptionPrice Per Pad (100/pd)
Side Punched $13.95
Top Punched
$13.95
❑ Decay ❑ Tooth loss ❑ Gum Disease ❑ No teeth ❑ Mouth pain, specify __________________________
❑ Upper
❑ Lower
❑ Dentures:
Item #
CFS5-5HH
CFS5-5HF
NUTRITIONAL EVALUATION
History and Data Collection
❑ Admission
❑ Significant Change
❑ Re-admission ❑ Annual
•Assists staff in determining the resident’s nutritional
status by focusing on clinical conditions that may
interfere with acceptable nutritional status
• Use to record resident’s nutritional history
•Printed 2 sides different
•5-hole punched
Fit_______________
❑ Upper
❑ Lower
❑ Partial:
Fit_______________
❑ Will not wear dentures/partials
EATING ABILITY
❑ Self-help device needed, type__________________________ ❑ Chewing problems ___________________________________
❑ Swallowing problems _______________________________________________________________________________________
Tube Fed: ❑ Yes ❑ No If yes, current order: ❑ Pump ❑ Gravity ❑ Bolus
Formula provides __________cal/day __________gm prot/day __________mL fluid/day
Does feeding provide 100% USRDA for vitamins/minerals as ordered? ❑ Yes ❑ No If no, _______%
Flush orders:_______________________________________________________________________________________________
Tolerant of tube feeding? ❑ Yes ❑ No If no, state probable cause: __________________________________________________
Ability to return to oral food intake:______________________________________________________________________________
PHYSICAL / MENTAL LIMITATIONS
Care Plan Conference Summary
•Record resident and/or resident representative;
participation in the care plan decision-making process
• Printed 2 sides same
• 5-hole punched
❑ Paralysis ❑ Upper limb immobility ❑ Aphasia ❑ Contractures ❑ Confused ❑ Combative ❑ Non-responsive ❑ Disoriented
❑ Alert ❑ Language barrier Ambulation: ❑ Independent ❑ With assist ❑ Wheelchair ❑ No ambulation ❑ Paces
Comments:___________________________________________________________
___________________________________________________________________________________________________________
CARE PLAN CONFERENCE
SUMMARY
❑ Ambulation (Other)___________________
RESIDENT REPRESENTATIVE ____________________________________________ PHONE NO. ______________________
CLINICAL OBSERVATIONS
RELATIONSHIP_______________________________________________ CARE PLAN CONF. DATE______ /______ /______
(See Admission Nursing Assessment and check all that apply): ❑ Edema ❑ Diarrhea ❑ Constipation ❑ Vision impairment
INSTRUCTIONS: Check all items below that were discussed during
the care ❑
plan
conference
whether
the discussion
involved ❑
theNausea
resident Skin intact: ❑ Yes ❑ No If no, explain _____________
❑ Glasses
Hearing
aid: by
❑ indicating
L ❑R ❑
Poor appetite
❑ Vomiting
and/or resident representative(s). In the Comments section indicate how the individual(s) involved feel (i.e., approve/disapprove, agree/disagree). Note any
Comments: ________________________________________________________________________________________________
special requests, choices and/or conditions indicated by the resident/resident
representative(s) in the space provided. NOTE: Address in the Care Plan
Conference: Resident condition, treatment options, expected outcomes, consequence of refusing APPLICABLE
treatment, resident’s
concerns and offer
relevant
MEDICATIONS
(specify
type and frequency)
altenatives if the resident has refused treatment(s). If the resident representative is included via a phone contact only, indicate this in the Comments section.
Plan of Care:
DescriptionPrice Per Pad (100/pd)
Side Punched $13.05
Top Punched $13.05
TYPE
DRUG
Antacids
COMMENTS
Anti-inflammatory
Herbal Supplements
Appetite Stimulant
Diuretics
Anti-nausea
Potassium (K+)
Oral Agents
Psychotropic Drugs
Anticonvulsants
Cardiac Glycosides
Nursing
Insulin
Laxatives
Dietary
Item #
CFS5-13HH
CFS5-13HF
DRUG
TYPE
DISCUSSED WITH Vitamin/Mineral Supplement(s)
Resident Res. Rep.Antibiotics
CARE PLAN ELEMENT
Diagnosis
NAME–Last
Activities
Social Service
First
Middle
CFS 5-5HH Rev. 8/10 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
Rehab
Attending Physician
Room/Bed
Record No.
NUTRITIONAL EVALUATION
PRINTED IN U.S.A.
Risks/Consequences
CFS5-5HH
Discharge Potential / Return
to Community Referral
Special Requests /
Choices /Conditions
Initial Psychosocial Evaluation
and Social History
•Gather required psychosocial data about the
resident and identify needs, concerns or behavioral
interventions required
•4-page booklet-style
•Printed 2 sides different
•5-hole punched top or side
SUMMARY OF CARE PLAN CONFERENCE DISCUSSION
INITIAL PSYCHOSOCIAL EVALUATION AND SOCIAL HISTORY
PART 1 - TO BE COMPLETED PER STATE REGULATION AND FORM INSTRUCTIONS
ALL CARE PLAN CONFERENCE ATTENDEES
MUST SIGN
BELOW
A. If able to understand,
has the
resident read the
Facility Staff (include signature and title)
Resident/Family (include relationship)
information concerning resident rights?
❑ Yes ❑ No
I agree with the plan of care established: ❑ Yes
A. Can the resident follow simple instructions? (i.e. touch
your nose with thumb)
B. Can the resident make serious medical decisions
Guardian, Durable Power of Attorney, or Surrogate been
identified in the chart?
for self?
C. Does the resident have adequate safety awareness?
(if resident incapacitated-skip to II)
❑ Yes ❑ No
Family/Responsible
Party
Signature
C. If the resident has an
Advanced
Directive, is the resident
NAME–Last
First
satisfied with the Advance Directives they have written?
Middle
Attending Physician
❑ Yes ❑ No
IV. MOOD AND BEHAVIOR
A. Has the resident been free of weight loss and sleep
pattern disturbance?
D. Does the residentCARE
know how
to obtain
spending money?
PLAN
CONFERENCE
SUMMARY
CFS 5-13HH Rev. 11/12 © 1992 BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
Room/Bed
Record No.
PRINTED IN U.S.A.
B. Has the resident been free of abuse?
telephone call?
❑ Yes ❑ No
problem? (circle applicable)
medication (vs. self-medication)?
❑ Yes ❑ No
D. Does the resident have family/significant other that is
involved, supportive, and coping well at this time?
❑ Yes ❑ No
contact should there be a concern or if they feel they
are mistreated?
❑ Yes ❑ No
E. If applicable, is the resident being followed by their
psychiatrist or psychologist (counselor) to this
H. Is the resident free from (history of) drug, alcohol and
placement?
❑ Yes ❑ No
smoking/tobacco issues? (circle applicable)
❑ Yes ❑ No
F. Is there a history of MI/MR and/or mental health
treatment?
❑ Yes ❑ No
❑ Yes ❑ No
B. Does the resident feel compatible with roommate?
❑ Yes ❑ No
C. Is the resident’s room personalized and homelike?
THERAPEUTIC RECREATION/ACTIVITY EVALUATION
❑ Yes
❑ New Admission
❑ Annual
SOCIAL SUPPORT SYSTEMS
RECREATION INTERESTS/NEEDS
❑ Groups:
❑ Large
❑ Small
❑ Special Needs
❑ Independent (self-directed)
❑ One-to-one
❑ Community
❑ Own room
❑ Day/Activities room
❑ Inside facility/off unit
❑ Indoor
❑ Outdoor
❑ Other___________________________________________
❑ No Interest
❑
❑
❑
❑
❑
❑
NAME–Last
ACTIVITY
C - Current Interest
P C N
N - No Interest)
ACTIVITY
P C N
ACTIVITY
Education/intellectual
Watching TV
Special interests
Games
Watching movies
Resident council
Crafts/arts
Walking/wheeling
outdoors
Citizenship/voting
Computer
Exercise
Trips
Parties/social events
Being around pets
Sports
Shopping
Radio
Current news events
Music
Writing
Hobbies
Other:
Reading
Talking/conversing
Community outings
Spiritual/religious
Gardening/plants
Groups/organizations
First
Middle
1173HH
Active participation
Passive participation
Independent/Individual
Leadership exhibited
Encouragement needed
No Interest
Cards
Form 3646HH Rev. 9/10 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
Page 1 of 4
❑ Morning
❑ Afternoon
❑ Evening
❑ None of these, (explain) _________________________
___________________________________________________
___________________________________________________
___________________________________________________
(P - Past Interest
P C N
Room/Bed
INITIAL PSYCHOSOCIAL EVALUATION
AND SOCIAL HISTORY
C. ACTIVITY SCHEDULE PREFERENCE
❑ Volunteer:
❑ Community
❑ Facility
Therapeutic Work
Friendly visitor
Activity leader
Other __________________________________________
No interest
❑
❑
❑
❑
❑
PURSUIT PATTERNS
❑ Yes ❑ No ❑ N/A
Record No.
B. PARTICIPATION IN ACTIVITIES
C. HELPS OTHERS
ACTIVITY
or transportation help, diabetes info etc.)
❑ Yes ❑ No
A. ACTIVITY ENVIRONMENT
Visits
Telephone
Mail
Outings
Other __________________________________________
❑ Yes ❑ No
community referral information? (home health, shopping
Form 1173HH Rev. 9/10 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
❑ Family
❑ Friend / Peer
❑ Volunteer:
❑ Community
❑ Facility
❑ Religious
❑ Pet
❑ No visitors
❑ Other __________________________________________
P C N
20 days?
B. Has the resident been given educational and
❑ Sense of humor
❑ Able to make needs known
NOTE: All “no” answers should be reflected on the resident’s plan of care
❑ Decisive
❑ Feels useful
NAME–Last
Middle
Attending Physician
❑ Other: _________________
❑ Developed
coping skills First
❑ Cheerful
❑ Leisure interests
❑ Independent
A. PRIMARY VISITORS
❑
❑
❑
❑
❑
A. Will the resident be staying in the facility for more than
D. Is the resident aware of the spiritual services offered in
PERSONAL STRENGTHS
the facility and how to engage in them?
❑ Motivated
❑ Cooperative
❑ Adapts to change
❑ No
V. DISCHARGE
❑ Significant Change of Condition
B. TYPES OF CONTACT
Visit www.BriggsCorp.com/BriggsInside
to find out more!
❑ Yes ❑ No
F. Does the resident only want the nurse to give them their
G. Can the resident accurately explain who they are to
Therapeutic Recreation/Activity Assessment
Does Your
Software
Provider Have
Briggs® Inside?
❑ Yes ❑ No
C. Is the resident free from any adjustment/mood/behavior
II. QUALITY OF LIFE
DescriptionPrice Per Pad (100/pd)
Therapeutic Rec/Activity Assessment
$13.95
❑ Yes ❑ No
❑
❑ Continued
Yes ❑ Noon Reverse
E. Does the resident know where they can make a private
A. Does the resident have enough clothing?
Item #
3646HH
❑ Yes ❑ No
❑ Yes ❑ No
Resident Signature
DescriptionPrice Per Pack (100/pk)
Side Punched $32.60
Top Punched
$32.60
•Defines the residents’ mental, functional, and social
skills related to activity preference, daily routine and
community interests
• Beneficial for Recreation Therapists
•Printed 2 sides different
•5-hole punched top or side
❑ Yes ❑ No
❑ No
B. If the resident is incompetent (incapacitated), has a
CFS5-13HH
Item #
1173HH
1173HF
III. COGNITIVE
I. RESIDENT RIGHTS
Attending Physician
Record No.
Room/Bed
THERAPEUTIC RECREATION/
ACTIVITY EVALUATION
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
3646HH
25
F279 – Develop Comprehensive Care Plans
ST R S
BELLE
SE
MDS 3.0
Psychosocial
Care Plan Almanac,
2nd Edition
DS 3.0 Care Plan
M
Cookbook for
Preferences and
Activities, 6th Edition
The 6th edition includes:
•Over 150 care plans designed as “template pages” ready to photocopy, individualize with preferences and
needs and place directly
into resident charts! Faster, easier care plan
individualization!
•Care plans have all been re-organized, composed for
check box selections with room for additional content
and “coded” for the MDS 3.0 sections and relevant CAA’s.
•The exhibits have been updated with Care Area
Trigger and Care Area Assessment resources, CMS
terminology, acronyms, abbreviations and diagnoses.
Item #
7059R
Description
Price Per Each
MDS 3.0 Care Plan Cookbook for
Preferences and Activities, 6th Edition $48.00
Includes care plan
“templates” for faster, easier
care plan individualization.
Social service staff can use
the “Almanac” to select the
best care plan for a Resident,
make a copy and personalize
using check boxes and individualized entries.
Care plans have been developed and organized
specifically for the MDS 3.0 and Care Area Assessment
(CAA) coordination. Includes extensive exhibits with
glossaries and CMS CATs and CAAs.
Item #
7670
Description
MDS 3.0 Psychosocial Care Plan
Almanac, 2nd Edition
Written for assisted living and dementia care centers, adult day and board and
care centers, personal caregivers, family members, recreation therapists and activity
professionals, this book has over 50 care plans.
Each care plan is alphabetically indexed and based on the common but difficult
behaviors and need areas associated with dementia.
Includes possible antecedents to behaviors, potential consequences, countless
intervention ideas and a glossary of terms.
Description The Dementia Care Plan Dictionary
$48.00
ST R
B E LLE
SE
The Dementia Care Plan Dictionary
Item # 4372
Price Per Each
Price Per Each
$35.00
MDS 3.0 User’s Manual
•Updateable
•Item-by-item instructions for completion of MDS
•Each manual is sized to fit in a user’s lap
•Includes a CD and features red and white tabs for each section
•Briggs Healthcare’s on-staff clinicians monitor regulations to help you stay
up-to-date
•Updates show the changes highlighted in red so they are
easily identifiable
•Flexible package options are available, including FutureSafe™ with
auto-renewal updates every year
Item #
1862 1865
1862RNW
Item #
1862A 26
Description Price Per Each
PremiumPlusOne Package
$96.85
PremiumPlusThree Package
$193.75
MDS 3.0 Yearly Renewal Package
$50.95
Description
FutureSafe™ Package
Price Per Each
$96.85
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
Ea Add’l Yr
$50.95
F441 - Infection Control, Prevent Spread, Linens
F241 | Dignity and Respect of Individuality
The facility must promote care for residents in a manner and in an environment that maintains or enhances
each resident’s dignity and respect in full recognition of his or her individuality.
2014 Ranking – #8 Most Cited
Shop these products to find compliance solutions!
ST E R
B E LL
SE
Resident Rights —
Meets OBRA Regulations
•Provide each resident with a copy of his/her
rights (in English) as stated in the OBRA regulations
• Printed in easy-to-read 12-pt. type
•8-page booklet-style form
Item #
3126R
Description
Resident Rights
Price Per Pack (100/pk)
$64.15
Resident Rights Poster—English/Spanish
•Printed in both English and Spanish, this large-print poster
will aide in supporting Tag Numbers F150 and F154
•Uses language that conveys the rights in clear and
understandable text
• Manila cardstock
Item #
6705R
SizePrice Per Pack (3/pk)
22-1/2” x 28-1/2”
$16.70
RESIDENT RIGHTS
§483.10 RESIDENT RIGHTS
Medicaid benefits, in writing, at the time of
admission to the nursing facility or, when the
The resident has a right to a dignified existence, selfresident becomes eligible for Medicaid of –
determination, and communication with and access to
(A) The items and services that are included
persons and services inside and outside the facility. A
in nursing facility services under the
facility must protect and promote the rights of each
State plan and for which the resident may
resident, including each of the following rights:
not be charged;
(a) Exercise of rights.
(B) Those other items and services that the
(1) The resident has the right to exercise his or her
facility offers and for which the resident
rights as a resident of the facility and as a citizen
may be charged, and the amount of
or resident of the United States.
charges for those services; and
(2) The resident has the right to be free of inter(ii) Inform each resident when changes are
ference, coercion, discrimination, and reprisal
made to the items and services specified in
from the facility in exercising his or her rights.
paragraphs (5)(i)(A) and (B) of this section.
(3) In the case of a resident adjudged incompetent
(6) The facility must inform each resident before, or
under the laws of a State by a court of competent
at the time of admission, and periodically during
jurisdiction, the rights of the resident are
theRESIDENT
resident’s stay, ofRIGHTS
services available in the
exercised by the person appointed under State
facility and of charges for those services,
law to act on the resident’s behalf.
charges
for services
not covered
(4) In the case of a resident
has of
notthis
been
As a who
resident
facility, you including
have theany
right
to a dignified
existence
and to communicate with
under
Medicare
by the facility’s
per diem
rate.
adjudged incompetent individuals
by the Stateand
court,
any
representatives
of
choice.
Theorfacility
will protect
and
promote your rights as
(7) The facility must furnish a written description of
legal surrogate designated
in accordance
designated
below. with
legal rights which includes –
State law may exercise the resident’s rights to the
(i) A description of the manner of protecting
extent provided by State
law.
Exercise
of Rights–
personal funds, under paragraph (c) of this
(b) Notice of rights and services.
• You have the right and freedomsection;
to exercise your rights as a resident of this facility and as a
(1) The facility must inform the resident both orally
citizen
without
discrimination,
(ii) A States
description
of fear
the of
requirements
and restraint, interference,
and in writing in a language
that or
the resident
resident of the United
coercion
reprisal.
procedures for establishing eligibility for
understands of his or her rights
and all or
rules
and
Medicaid,
including
the right
request an
regulations governing resident
andto act in your own
• If you conduct
are unable
behalf,
your rights
are to
exercised
by the person appointed
assessment under section 1924(c) which
responsibilities during the stay
in the
facility.
under
state
lawThe
to act in your behalf.
determines the extent of a couple’s nonfacility must also provide the resident with the
exempt resources at the time of institutionnotice (if any) of theNotice
State developed
of Rights under
and Services–
alization
and
attributes
to
the
community
section 1919(e)(6) of the Act. Such notification
You will
be informed
of your rights
and of
rules and
regulations
governing resident conduct
spouse
an all
equitable
share
of resources
must be made prior to or• upon
admission
and
responsibilities
in cannot
writing be
in an
understandable
which
considered
availablemanner.
for
during the resident’s stay.and
Receipt
of such both orally and
payment
toward
the cost ofofthe
institution
information, and any amendments
to it,the
must
be to inspect and
• You have
right
purchase
photocopies
your
records.
alized spouse’s medical care in his or her
acknowledged in writing;
• You
the right to be fully informed
your
total health
in an understandable manner.
processofof
spending
downstatus
to Medicaid
(2) The resident or his or her
legalhave
representative
• You have the right to refuse medication
or treatment and the right to refuse to participate in
eligibility levels;
has the right —
(iii) A posting of names, addresses, and tele(i) Upon an oral or written request,
to access
all
experimental
research.
numbers of all pertinent State client
records pertaining to• You
himself
herself
haveor the
right to formulatephone
an advance
directive in accordance with facility policy and
advocacy groups such as the State survey
including current clinical records within 24
applicable
state law.
and certification agency, the State licensure
hours (excluding weekends
and holidays);
office,
theMedicaid
State ombudsman
program,
• You must be informed of Medicare
and
benefits both
orallythe
and in writing, including
and
protection and advocacy network, and the
(ii) After receipt of his or
herto records
for
how
receive refunds.
Medicaid fraud control unit; and
inspection, to purchase
at must
a costbenot
to
• You
informed
of facility
services and charges and any changes to benefits or charges.
(iv) A statement that the resident may file a
exceed the community standard photocopies
The facility
must
forthe
protecting
personal
funds.
complaint with
State survey
and certifiof the records or any •
portions
of them
uponinform you of procedures
cation agency
resident
abuse,
request and 2 working• days
You advance
must be notice
informed of your physician,
his or concerning
her specialty,
and ways
of contacting him or her.
neglect, misappropriation of resident property
to the facility.
facility
must in
consult with youinand
and interested
the notify
facility,your
and physician
non-compliance
with the family member of any
(3) The resident has the right•toThe
be fully
informed
significant
change
in
your
condition
or
treatment,
or
of
any
decision
to transfer or discharge.
advance directives requirements.
language that he or she can understand of his or
(8) and
The interested
facility mustfamily
comply
with theofrequirements
her total health status, including
not limited
• Thebut
facility
mustto,notify you
member
a room or roommate change.
specified in subpart I of part 489 of this chapter
his or her medical condition;
have
the right
room changes
requested
by thepolicies
facility.and
to maintaining
written
(4) The resident has the right •to You
refuse
treatment,
to to refuse relating
• The facility
must periodicallyprocedures
record and
updateadvance
the address
and
telephone number of your
regarding
directives.
These
refuse to participate in experimental
research,
requirements
include provisions to inform and
and to formulate an advance
directive
as or interested
legal repre
sentative
family member.
provide written information to all adult residents
specified in paragraph (8) •of The
this section;
and
facility must notify you and
interested family member of changes in your rights.
concerning the right to accept or refuse medical
(5) The facility must –
musttopost the names,
addresses
and telephone
numbers
of all pertinent state client
or surgical
treatment
and, at the
individual’s
(i) Inform each resident• The
who facility
is entitled
Form 3126R Rev. 8/13 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com
Resident Right – Easy-To-Read
•Easy-to-read format and language, English
•Used to inform each resident in writing of his/her
rights prior to or upon admission
•4-page book-style form
Item #
CFS1-3
SizePrice Per Pack (100/pk)
17” x 11” overall (8-1/2” x 11” folded)
$32.60
Notification and Consent
•Protects the facility by providing the resident (or
resident representative) notification and consent
regarding various areas from Mail to Dental Serv
•4-page booklet-style form
• 5-hole punched side
advocacy groups. If you deem necessary, you may file a complaint with the state survey and
certification agency concerning resident abuse, neglect, misappropriation
Page 1 of resident property,
and non-adherence to advance directive requirements.
PRINTED IN U.S.A.
Protection of Funds–
• You may manage your own financial affairs. You are not required to deposit personal funds with
the facility.
• The facility must manage your deposited funds with your best interests in mind. Your money
must not be commingled with facility funds.
• The facility will provide you with an individualized financial report quarterly and upon your request.
• Any remaining estate will be conveyed to your named successor.
• All funds held by the facility will be protected by a security bond.
• The facility must not charge you for any items or services you do not request or which are
NOTIFICATION
AND
included
in your Medicare
or CONSENT
Medicaid payment. The facility must tell you what the charge will
be for any of these requested items or services.
INSTRUCTIONS: Each section of this form must be reviewed and signed by the resident and/or the
appropriate resident’s representative if the resident is considered to be mentally incompetent or
CFS 1-3 Rev. 8/11 © 1992 BRIGGS, Des Moines, IA (800) 247-2343
otherwise unable to sign.
Ifcopying
signed
bycopyright
thelaw.resident’s
representative, complete the following information:
Unauthorized
or use violates
www.BriggsCorp.com
3126R
PRINTED IN U.S.A.
RESIDENT REPRESENTATIVE
Print Name:
I have been informed verbally and in writing of my rights as a resident of this facility.
Size
Price Per Pack (100/pk)
17” x 11” overall (side punched version)
fold to 8-1/2” x 11”
$30.50
FACILITY RULES AND REGULATIONS
BACKGROUND
INFORMATION
VISITATION
RIGHTS
Date
CURRENT ABILITIES
Check (✓) areas that accurately describe your relative at this time.
Resident
Name
I have the right to receive visitors of
my choice.
I request, however, that the followingGive
individuals
details as to have
frequency of the situation and how this
impacts your relative.
restricted visitation rights:
Age
Date of Birth
Place of Birth
ORIENTATION
✓
Level of Education Completed
DETAILS
Unaware of day or date
Former Occupations
Doesn’t know home is where they live
MEDICARE AND MEDICAID
Wandering or getting lost
DETAILS
remembering events:
I have received a list of services provided at this facility which are covered by MedicareTrouble
and Medicaid.
This information explains how I may apply for and use Medicare and Medicaid benefitsChildhood
and how to
receive refunds for previous personal payments made which may be covered by such benefits.
Middle years
Marital Status:
❑LaterYes
❑ No
years (retirement)
❑ Single
❑ Married
❑ Widowed
❑ Divorced
❑ Separated
PHYSICIAN SERVICES
Male:
living
✓
deceased
DETAILS
RECOGNITION
to recognize
self
I have designated the physician identified below as my personal attending physician. IfUnable
he/she
fails to
Female:
living
deceased
fulfill a given requirement, the facility will have the right, after consulting with me, toUnable
seek
another
to recognize
familiar people
Prior Living Situation
another facility)
physician to assure that I am appropriately
and (home,
adequately
cared for and treated.
Unable to recognize familiar
surroundings (neighborhood)
Phone:
Physician Name:
Specialty (If Applicable):
Address:
✓
Unable to write
How Long Has Your Relative Had a Memory Problem?
Unable to read
❑ 1 year
❑ 1-3 years
❑ 3-5 years
❑ 5 years or more
DETAILS
COMMUNICATION
Does your relative have a memory problem? ❑ Yes ❑ No
Unable to communicate needs clearly
SELF-ADMINISTRATION
OF ❑DRUGS
Was the Onset of the Problem: ❑ Sudden
Gradual
Experiences word finding difficulty
I have reviewed and understandHave
thethere
facility
policies
ofto communicate
drugs. I basic needs
been any
changes inregarding
your relative’s the
mood self-administration
or behavior in
Unable
the last
six months
(i.e., falling, increased
confusion,
understand that the interdisciplinary
team
will determine
whether
ormood
not changes)?
to grant me this request after
Unable to understand simple directions
a thorough assessment of my ability❑to
so explain
has been completed.
No do
❑ Yes,
Unable
to understand
❑ Yes
❑ Noany directions
Family Questionnaire
at this time
Details present routines, habits, behaviors, interests and
abilities of the resident prior to admission
•5-page booklet-style form
• 8-1/2” x 11”, white paper, black ink
• 5-hole punched side
I wish to be assessed for self-administration of my medication.
NAME–Last
First
Middle
✓
Attending Physician
DescriptionPrice Per Pack (100/pk)
Family Questionnaire
$34.70
❑ YesCONCENTRATION
❑ No
DETAILS
Room/Bed
Unable
to complete tasks
Record No.
Difficulty concentrating on a task
NOTIFICATION
AND
CONSENT
Gets
up frequently
and leaves task
CFS 1-4HH Rev. 11/12 © 1992 BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
or meal
✓
Does Your Relative Have a History of:
CFS1-4HH
Smoking
❑ Yes ❑ No ❑ Unknown
If yes, specify cigarettes, cigars, pipe etc.,
and average useage ___________________________________________
Alcohol Use
❑ Yes ❑ No ❑ Unknown
Explain: ______________________________________________________
Drug Use
❑ Yes ❑ No ❑ Unknown
If yes, specify type and quantity _________________________________
Psychiatric Illness
NAME–Last
❑ Yes
❑ No
❑ Unknown
First
Middle
Form 3678HH Rev. 1/13 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
Item #
3678HH
❑ Yes ❑ No
I have been informed verbally and in writing of the facility rules and regulations. Any changes in these
rules and regulations will be addressed and discussed at the monthly resident council meetings. I
understand that resident council meeting minutes reflecting changes in the facility rules and
regulations are to be posted for my review.
❑ Yes ❑ No
FAMILY QUESTIONNAIRE
Number of Children
Item #
CFS1-4HH
CFS1-3
Relationship:
RESIDENT RIGHTS
Page 1
AMBULATION
DETAILS
Loss of balance or falling when walking
Unusual gait (shuffling, leaning,
fast pacing)
Has difficulty sitting in a chair
Bumps into things (walls, furniture)
Do you sometimes have to assist
them in walking?
Attending Physician
Record No.
Room/Bed
FAMILY QUESTIONNAIRE
Page 1 of 5
3678HH
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
27
F241 – Dignity and Respect of Individuality
Date and hour
given to
resident
VEGETABLES/MEATS
DIET PREFERENCE LIST
SOUPS
Likes Dislikes
Likes Dislikes
Diet Preference List
Date and hour
returned to
diet kitchen
Likes Dislikes
DESSERTS
Potatoes _____________________________________ Vegetable soup ________________________________ Jello __________________________________________
Sweet potatoes _______________________________ Potato soup ___________________________________ Ice cream _____________________________________
Rice _________________________________________ Cream soup ___________________________________ White cake ___________________________________
_________________ Chocolate cake _______________________________
Noodles ______________________________________ Meat soup _______________________
Macaroni _____________________________________ Chicken soup __________________________________ Custard ______________________________________
Pumpkin pie __________________________________
Spaghetti _____________________________________
CEREALS
Likes Dislikes Tapioca pudding ______________________________
Fish __________________________________________
Salmon _______________________________________ Cream of wheat ________________________________
DIET HISTORY
Tuna fish _____________________________________ Malto meal ____________________________________
Oysters ______________________________________ Oatmeal _______________________________________ Preferred Portions
❑ Large
Rice Krispies ___________________________________
Eggs ________________________________________
❑ Average
Shredded wheat _______________________________
Cottage cheese_______________________________
❑ Small
Wheaties ______________________________________
Food Allergies/Intolerance
Bacon _______________________________________
Puffed wheat __________________________________
A. DIET
❑ HISTORY
Shellfish
Veal _________________________________________
❑ Milk
Puffed rice _____________________________________
Appetite
Preferred Portions
Food Allergies/Intolerance
Past Food Restrictions
Beef stew ____________________________________
❑ Chocolate
❑ Good
❑ Large
❑ Shellfish
❑ Salt
Chicken______________________________________
❑
Other___________________________________
Likes Dislikes
FRUITS
❑ Fair
❑ Average
❑ Milk
❑ Sugar
❑ None
Beef liver _____________________________________
❑ Poor
❑ Small
❑ Chocolate
❑ Other___________________
Prunes________________________________________ Past Food Restrictions
❑ Other___________________ ❑ None
Beef tongue __________________________________
❑ Salt
Oranges ______________________________________
❑ None
Lettuce ______________________________________
❑ Sugar
Grapefruit _____________________________________
B. PAST MEAL PATTERNS
Celery _______________________________________
❑ Other___________________________________
Plums _________________________________________
Lunch
Dinner
❑ None Breakfast
Raisins _______________________________________
Peaches ______________________________________
❑ Hot Meal
❑ Hot
Foods
Cultural/Ethnic/Religious
Food Requests ❑ Hot Meal
Dates ________________________________________
❑ Sandwich / Soup
Cereal
Pears _________________________________________❑ Hot ❑
None _____________________ ❑ Sandwich / Soup
Carrots ______________________________________
❑ Snacks
❑ Snacks
❑ Yes (specify) ____________________________
Watermelon ___________________________________❑ Eggs
❑ Other ___________________________ ❑ Cold Cereal ______________________
❑ Bacon________________________________________
String beans __________________________________
Bananas ______________________________________
_______________________ ❑ None
❑ Other ___________________________
________________________________________
Peas _________________________________________ Cantaloupe ____________________________________❑ Sausage
Location: __________________________ ❑ None
❑ Toast
Cauliflower ___________________________________ Pineapple _____________________________________
❑ Cold Cereal ______________________
Location: ___________________________
COMMENTS or REMARKS:
Beets________________________________________ Apricots ______________________________________
❑ Other___________________________
❑ None
Parsnips _____________________________________ Lemonade ____________________________________
Location:__________________________
Tomatoes (raw) _______________________________ Tomato juice __________________________________
C. CURRENT BEVERAGE PREFERENCES
(cooked) ______________________________ V-8___________________________________________
Breakfast
Lunch
Dinner
Asparagus ____________________________________ Grape juice ____________________________________
INSTRUCTIONS: For each activity that applies ❑
to Juice
the resident,
check “P” for past interest or
current interest. Note particular
____________________________
❑ Juice ____________________________
❑ “C”
Juicefor
___________________________
Squash ______________________________________
Raw
apples
games,
types
of ___________________________________
crafts, etc. as applicable. For those
checked
“P” ask how the past interest can❑still
pursued.
Milkbe
_____________________________
❑ Milk _____________________________
❑ Milk
____________________________
Summer Squash ______________________________ Cooked apples ________________________________
❑ Coffee: ❑ Regular ❑ Decaf
❑ Coffee: ❑ Regular ❑ Decaf
❑ Coffee: ❑ Regular ❑ Decaf
P C
LEISURE INTERESTS❑ Hot Tea
RESIDENT
PREFERENCES
❑ Tea:
❑ Hot ❑ Iced
❑ Tea: ❑ Hot ❑ Iced
Mushrooms __________________________________ Cranberries ____________________________________
❑ Hot Chocolate
❑ Hot Chocolate
❑ Hot Chocolate Name preference:
Playing cards:
Rutabaga ____________________________________
❑ Water
❑ Water
❑ Water
BREADS
Likes Dislikes
Playing
games:
Favorite color:
White turnip __________________________________
D. SPECIAL FOOD REQUESTS
Crafts/Arts:
Favorite season:
Egg plant ____________________________________ Rye __________________________________________
Cultural / Ethnic / Religious Food Requests? ❑ None ❑ Yes_______________________________________________________
Peppers _____________________________________ Whole
Exercise:
Favorite pet/animal:
wheat __________________________________
E. FOOD DISLIKES
Spinach _____________________________________ Corn _________________________________________
DIET HISTORY/FOOD PREFERENCE LIST
•Obtain a complete record of resident’s dietary likes
and dislikes
•Blue ink
•Printed 1 side
•3-hole side punched
Item #
505
DescriptionPrice Per Pad (100/pd)
Diet Preference List $10.85
ACTIVITY INTEREST SURVEY
Sports interests:
Broccoli ______________________________________
Preferred Drink
Alcohol use:
❑ No Dislikes Stated
White_________________________________________
Music/Singing/Dancing:
Tobacco use:
Meat / Meat
Substitutes
Yes No
books:
BreakfastReading/Talking
Lunch
Writing:
Cream
Cream
Vegetables
VOTING RIGHT
Supper
Fruits/Desserts
Bread
❑ Biscuits
❑ Beets
❑ Apple
❑ Bacon
❑ Lasagna
Is residentMeat
interested❑inBlackeyed
voting? Peas
Cream
❑ Cornbread
❑ Apricots
❑ Beef Liver
❑ Luncheon
Broccoli
Coffee _______________________________________________________________________________________
❑ Crackers
❑ Banana
❑ Beef
❑ Peanut Butter
SPIRITUAL❑
INVOLVEMENT
Yes No
Spiritual/Religious activity:
❑ Cabbage
❑ French toast
❑ Berries
❑ Veal
❑ Pork
Sanka _______________________________________________________________________________________
❑ Pancakes
❑ Cantaloupe
Trips/Travel/Shopping/Dining:
Religious preference:❑ Carrots
❑ Bologna
❑ Sausage
Milk _________________________________________________________________________________________
❑ Cauliflower
❑ Roll
❑ Grapefruit
❑ Cheese
❑ Shrimp
Walking/Wheeling outdoors:
Is resident a member❑ofColeslaw
a church?
❑ Toast
❑
Mixed
Fruit
Ovaltine _____________________________________________________________________________________
❑ Chicken Liver
❑ Spaghetti Sauce
❑ Corn
❑ Waffles
❑ Oranges
TV/Radio/Movies:
Has the church been❑notified
of resident’s admission?
❑ Chicken
❑ Tuna
Cocoa _______________________________________________________________________________________
Dried Beans
❑ White
❑ Peach
❑ Chili
❑ Turkey
❑ Green Peas
❑ Whole Wheat
❑ Pear
Tea (hot) _____________________________________________________________________________________
Gardening/Plants:
Should the facility contact
theBeans
church?
❑ Green
❑ Cottage Cheese
❑ Wiener/Hot Dog
❑ Other
❑ Pineapple
Tea (iced) _____________________________________________________________________________________
❑ Greens
❑ Deviled Crab
❑ Other
Talking/Conversing/Telephone:
Telephone #
❑ Plums
___________________
________________ ❑ Lettuce
❑ Eggs
❑ Prunes
___________________
Helping others/Volunteering:
❑ Lima Beans
Contact
person
NAME–Last
First
Middle
Attending Physician
Room/Bed
Record No.
❑ Enchiladas
❑ Watermelon
❑ Okra
❑ Sweets
❑ Fish
Parties/Socials:
Onionsreligious services?
Would resident like to❑ attend
_______________
❑
Other
❑ Ham
❑ Potatoes
Intergenerational activities:
Form 505 Rev. 5/00 © BRIGGS, Des Moines, IA (800) 247-2343
DIET PREFERENCE
LIST
❑ Sauerkraut
Comments:
Cereal
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
Starches
❑ Spinach
Pet visits:
❑ Tomatoes
❑ Malt-O-Meal
❑ Cream of Wheat
❑ Rice
❑ Macaroni
Relaxation activities:
❑ Wax Beans
❑ Spaghetti
❑ Noodles
❑ Oatmeal
❑ Cold Cereal
❑ Yellow
Squash
Are there specific religious
holidays
that the resident
❑ Other
❑ Other
❑ Other
❑ Grits
Hobbies/Special talents:
❑ Zucchini
celebrates?
___________________
___________________
______
__________ ❑ Other
Current new events:
___________________
___________________
Specify:
______
__________
___________________
505
Groups/Organizations:
Person Completing this Form_____________________________________________________________ Date_____/_____/_____
How can the facility meet the spiritual
needs of the
Signature and Title
resident?
Household tasks:
Other:
NAME–Last
Other:
Other:
First
Middle
Attending Physician
Room/Bed
Record No.
PRINTED IN U.S.A.
White - Chart Yellow - Dietary Department
Additional resident lifestyle preferences (i.e.: prefers individual activities, large group, etc.)
1184P
Other comments:
❑ Resident
Resident or
Facility Representative
❑ Family
NAME–Last
Middle
DescriptionPrice Per Pack (100/pk)
Diet History/Food Preference List $30.35
Date
Title
First
Item #
1184P
❑ Other
Signature
PART 1 – Resident Chart
•Ensure residents receive food according to past habits
and preferences
•2-part edge-glued form
•White and canary paper
•5-hole punched top and side
DIET HISTORY/FOOD PREFERENCE LIST
Form 1184P 8/02 © BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or
use violates copyright
law. www.BriggsCorp.com
ADDITIONAL
ACTIVITY
INFORMATION
Information obtained from:
Diet History/Food Preference List
PART 2 – Activity Office
Attending Physician
Room/Bed
Record No.
ACTIVITY INTEREST SURVEY
Form 3683/2P Rev. 9/10 © 1997 BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
Activity Interest Survey
3683/2P
Quality of Life
Census Development
A FULL HOUSE
•Identifies (past and current) personal leisure interests
and lifestyle
•2-part set
•White original, yellow copy
•5-hole punched top and side
Item #
3683/2P
DescriptionPrice Per Pack (100/pk)
Activity Interest Survey
$34.65
A LONG TERM CARE GUIDE TO FULL OCCUPANCY
by Nina See-Quick
Marketing
Enhanced Activities
NEW!
A Full House
Manual
A FULL HOUSE – manual by Nina See-Quick will show you
cost effective, creative ideas to develop and increase
your census, improve quality of life for your residents,
improve staff morale, and create family, legislative,
and community partnerships. CD Rom included for
customization to meet the needs of your facility.
• Over 240 Different Ideas • Resident Partnerships
•Community Partnerships • Activity Programs
• Staff Partnerships •And MORE!
Item #
7455
28
Description
Full House Manual Price Per Each
$125.00
Does Your Software Provider
Have Briggs® Inside?
Visit www.BriggsCorp.com/BriggsInside
to find out more!
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
F441 - Infection Control, Prevent Spread, Linens
F514 | Resident Records – Complete/Accurate/Accessible
The facility must maintain clinical records on each resident in accordance with accepted professional
standards and practices that are--(i) Complete;(ii) Accurately documented;(iii) Readily accessible; and (iv)
Systematically organized
2014 Ranking – #9 Most Cited
Shop these products to find compliance solutions!
Compliance is not an easy task given the continuous changes in the way medical records
data is collected, stored and shared today. Briggs® is here to help with a robust offering
of products to support your charting system whether it be electronic, paper-based or a
blend of both.
Keep Records Readily Accessible
with Briggs Storage Options
Charting Electronically?
Briggs® Computer Workstations and Transport Carts
are designed to be an answer to your changing and
challenging information technology, storage and security
needs and feature:
• State-of-the-art Designs provide ergonomically
functional workstations that help you increase
productivity and ensure employee safety
• Durable Construction delivers dependable service and
holds up in even the toughest medical settings
• Full Warranties. No prorated schedules. No fine
print. Any defective product or parts will be replaced
or repaired at no charge up until the end of the
warranty term
Visit www.BriggsCorp.com for our complete offering of Record Storage Solutions!
Need Storage Options for Paper Records?
Choose Briggs® for your Chart Racks!
•
Superior strength & durability – all Briggs chart racks
feature welded frames – no creaks squeaks or loose
bolts
•
Versatility – Briggs® offers the widest selection of chart
racks – economy, cabinet, rotary, desktop and more!
And we have custom manufacturing capabilities to
meet your special needs!
• Value – Briggs’ pricing is as competitive as ever
• Locking units – ensure privacy of Protected Health
Information (PHI)
• Dependability – Briggs® is so confident in the quality
and durability of our chart racks that they are backed
with a FULL 7-Year Warranty
Compare Quality, Prices and Warranty then choose
Briggs® Charts Racks for the best all-round value!
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
29
F514 – Resident Records – Complete/Accurate/Accessible
Systematically Organizing Records is Easy
with Briggs Chart Divider sets!
Long-Term Care Divider Sets
14-Tab Divider Sets (2 Equal Rows of 7)
16-Tab Divider Sets (2 Equal Rows of 8)
Item # Description
507
Paper, Bottom Tab
508
Paper, Side Tab
Item #
477
478
443
444
25
$4.75
$4.75
Price Per Set (25 sets/bx)*
50
100
200
300
$4.60 $4.30 $3.60 $3.10
$4.60 $4.30 $3.60 $3.10
Price Per Set
Item # Description1
50
100
250
500
5495 Poly, Bottom Tab $15.40 $15.00 $13.95 $12.80 $11.40
5496 Poly, Side Tab
$15.40 $15.00 $13.95 $12.80 $11.40
FULL 3-Year Warranty
Description
Paper, Bottom Tab
Paper, Side Tab
Tyvek, Bottom Tab
Tyvek, Side Tab
25
$5.75
$5.75
$12.30
$12.30
Price Per Set (25 sets/bx)*
50
100
200
$5.50 $5.10 $4.30
$5.50 $5.10 $4.30
$11.50 $10.60 $9.30
$11.50 $10.60 $9.30
300
$3.80
$3.80
$8.40
$8.40
Price Per Set
Item # Description1
50
100
250
500
5489 Poly, Bottom Tab $17.55 $16.70 $15.95 $14.65 $12.95
5490 Poly, Side Tab $17.55 $16.70 $15.95 $14.65 $12.95
FULL 3-Year Warranty
507 Paper 14-Tab Set
477 Paper 16-Tab Set
Don’t see what you need? We have many more stock sets available at www.BriggsCorp.com
or you can order a custom set designed just for you!
YOUR NEXT NEW* CUSTOM PRINT ORDER!
That’s right! We are offering you 40% OFF your next NEW*
custom chart divider order to give our design services a try!
Give us a try today and you will receive:
• Extra savings on already LOW prices
• Personalized, professional service
• Quick turn-around times on orders
• A finished product that will be EXACTLY what you’re looking for!
XT
R TE
YOU RE
HE
30
Call us at 1.800.247.2343 x4555 today!
*NEW is defined as custom products never produced by Briggs Healthcare® for your organization.
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
F514 – Resident Records – Complete/Accurate/Accessible
Briggs® Ringbinders deliver years of
durable, dependable performance
GUARANTEED!
You depend on your ringbinder charts to keep your resident
records organized and readily accessible. They need to be able
to withstand the daily “hard knocks” common in the healthcare
environment to keep the records inside protected and intact.
Constructed of a copolymer polypropylene and elastomer blend
that is perfect when a balance of impact performance and
flexibility is required, Briggs Ringbinders are built to last – no
cracking, no breaking, and no frustration – GUARANTEED!
Industry-Leading
5-Year Guarantee.
Folds Flat.
Won’t Tear.
We guarantee our ringbinders
against defects for a FULL 5-years.
Return any defective product
during the warranty term to
receive FULL credit. It’s that simple.
The ULTRAFlex Twin-Hinge™
minimizes stress a the spine to
prevent splitting or teaing a the spine
and allows the cover to fold back at a
full 360° for easier charting.
U LT RA F l ex
TWIN-HINGE
Price Per Each
1-35 36-7172+
$17.40
$16.70 $15.85
Color
Burgundy
Compare & Save!
Top Open
3-Ring
5130R3N
Side Open
3-Ring
5135R3N
Top Open
Ring Size: 2”
Cover: 13-3/8”H x 9-1/8”W
Spine: 2-3/4”
B ac ti X prote c ti on
Side Open
Ring Size: 2”
Cover: 11-5/8”H x 11-1/8”W
Spine: 2-3/4”
Item #
See Below
Price Per Each
1-3536-71 72+
$14.30
$13.60
$12.65
Color
2-Ring
Top Open
3-Ring
5-Ring
Side Open
3-Ring
5-Ring
Burgundy 3130R2N 3130R3N 3130R5N
3135R3N 3135R5N
Dark Blue 3230R2N 3230R3N 3230R5N
3235R3N 3235R5N
Forest Grn 3330R2N 3330R3N 3330R5N
3335R3N 3335R5N
Dark Blue
5230R3N
5235R3N
Forest Grn
5330R3N
5335R3N
Gray
3430R2N 3430R3N 3430R5N 3435R3N 3435R5N
Plum
3530R2N 3530R3N 3530R5N
Teal
5830R3N
5835R3N
Mauve
5930R3N
5935R3N
Med Blue 3630R2N 3630R3N 3630R5N 3635R3N 3635R5N
Mulberry
51130R3N
51135R3N
3535R3N
3535R5N
Beige
3730R2N 3730R3N 3730R5N
3735R3N
Teal
3830R2N 3830R3N 3830R5N
3835R3N 3835R5N
3735R5N
Sage
51230R3N
51235R3N
Terracotta
—
51335R3N
Mauve
3930R2N 3930R3N 3930R5N 3935R3N 3935R5N
51435R3N
Mulberry
31130R2N 31130R3N 31130R5N 31135R3N 31135R5N
Sage
31230R2N 31230R3N 31230R5N 31235R3N 31235R5N
Terracotta 31330R2N 31330R3N 31330R5N 31335R3N 31335R5N
Red
Red
—
Ringbinders with BactiX™
Antimicrobial Protection also
available. Call 800-247-2343
to learn more!
with
ST R
B E LLE
SE
Side Open
Ring Size: 2-1/2”
Cover: 11-5/8”H x 12-1/2”W
Spine: 3-1/2”
Item #
See Below
Briggs® Ringbinders feature
maximum page capacities they hold an average of 50
pages more than other brands.
without
BactiX
Large (350-Page Capacity)
Jumbo (450-Page Capacity)
Top Open
Ring Size: 2-1/2”
Cover: 14-3/4”H x 9-1/8”W
Spine: 3-1/2”
Stores More.
Costs Less.
31430R2N 31430R3N 31430R5N 31435R3N 31435R5N
with
Colors are reproduced as close to true color
as possible. Call 1.800.247.2343 to requestProvides Safe
Shields Against
Odors,
Molds,
FREE
samples.
Stains and Other Bacteria
Including Staph and E.coli
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
Odors
31
F514 – Resident Records – Complete/Accurate/Accessible
Folds Flat. Won’t Tear.
U LTRAF l ex
TWIN-HINGE
ULT RAF l ex
TWIN-HINGE
ULT RAFlex
TWIN-HINGE
The ULTRAFlex Twin-Hinge
prevents cracks, breaks or
tears by distributing and
minimizing stress at the spine.
Small (175-Page Capacity)
Medium (300-Page Capacity)
Top Open
Ring Size: 1”
Cover: 13-3/8”H x 9-1/8”W
Spine: 1-5/8”
Top Open
Ring Size: 1-1/2”
Cover: 13-3/8”H x 9-1/8”W
Spine: 2-1/8”
Side Open
Ring Size: 1”
Cover: 11-5/8”H x 11-1/8”W
Spine: 1-5/8”
Item #
See Below
Color
Burgundy
Dark Blue
Med Blue
Mulberry
Sage
Side Open
Ring Size: 1-1/2”
Cover: 11-5/8”H x 11-1/8”W
Spine: 2-1/8”
Item #
See Below
Price Per Each
1-35 36-7172+
$11.95
$11.70 $11.45
Top Open
Side Open
3-Ring
3-Ring
6130R3N
6135R3N
6230R3N
6235R3N
6630R3N
6635R3N
61130R3N
61135R3N
61230R3N
61235R3N
Colors are reproduced as close to true
color as possible. Call 1.800.247.2343 to
request FREE samples.
Price Per Each
1-35 36-7172+
$13.35
$12.85 $12.10
Color
2-Ring
Top Open
3-Ring 5-Ring
Side Open
3-Ring
5-Ring
Burgundy
2130R2N 2130R3N 2130R5N 2135R3N 2135R5N
Dark Blue
2230R2N 2230R3N 2230R5N 2235R3N 2235R5N
Forest Grn
2330R2N 2330R3N 2330R5N 2335R3N 2335R5N
Gray
2430R2N 2430R3N 2430R5N 2435R3N 2435R5N
Plum
2530R2N 2530R3N 2530R5N 2535R3N 2535R5N
Med Blue
2630R2N 2630R3N 2630R5N 2635R3N 2635R5N
Beige
2730R2N 2730R3N 2730R5N 2735R3N 2735R5N
Teal
2830R2N 2830R3N 2830R5N 2835R3N 2835R5N
Mauve
2930R2N 2930R3N 2930R5N 2935R3N 2935R5N
Mulberry
21130R2N 21130R3N 21130R5N 21135R3N 21135R5N
Sage
21230R2N 21230R3N21230R5N 21235R3N 21235R5N
Privacy Clipboards Make Critical Records Accessible
at the Point of Care While Protecting Confidentiality!
Keeping your records confidential
Poly
Clipboards
is critical for HIPAA compliance.
COVERED
OVERBED/COVERED
Privacy Poly Clipboards
Using Briggs Privacy Clipboards is a simple,
affordable way to safeguard your documents!
Briggs Privacy Clipboards feature:
• Chart-Lok closures that provide
added security
• Durable, light-weight poly construction
with a FULL 1-Year Warranty
• Strong , low-profile spring clips
• 10” x 13” in size
• S
tandard and over-bed styles available
32
Item #
Covered
Color
6009
6011
6018
Blue
Burgundy
Forest Green
1
Price Per Each
12
24
36
6009
72
6011
Item #
6018
Color
6005
1
6014
6020
Price Per Each
12
24
36
72
Overbed/Covered
$15.95 $15.65 $15.50 $15.10$14.00
$15.95 $15.65 $15.50 $15.10$14.00
$15.95 $15.65 $15.50 $15.10 $14.00
6005
6014
6020
Blue
Burgundy
Forest Green
$17.80 $17.50 $17.15 $16.90$15.40
$17.80 $17.50 $17.15 $16.90$15.40
$17.80 $17.50 $17.15 $16.90$15.40
Call 1.800.247.2343 | Fax 1.800.222.1996 | www.BriggsCorp.com
F441 - Infection Control, Prevent Spread, Linens
F282 | Services Provided by Qualified Persons/Per Care Plan
The services provided or arranged by the facility must be provided by qualified persons in accordance with
each resident’s written plan of care.
2014 Ranking – #10 Most Cited
Shop these products to find compliance solutions!
3429P
ST R
B E LLE
SE
Daily Skilled Nurses Notes
•Check-off-style format makes this form
easy to use
•Ruled lines provide space to record comments
and notes
• Printed 2 sides different, head-to-head
• 5-hole punched top and side
Item #
3429P
Description
Price Per Pad (100/pd)
Daily Skilled Nurses Notes $13.05
DIRECTIONS: (✓) All applicable boxes per shift. Circle appropriate item(s) separated by “/”. Document any specifics on reverse side.
Signature and title of nurse for appropriate shift. If 12 hour shift, do not code in “E” boxes.
Vital Signs
D: T__________ P__________ R__________
B/P__________________ ❑ Abnormal
D E N
Hearing/Speech/Vision
WNL
Comatose
Unable to Hear
Hearing Aid: Rt/Lt
Unable to Speak
Unclear Speech
Unable to Make Self
Understood
Unable to Comprehend
Unable to See
Corrective Lenses: Y / N
Cognitive Patterns
Alert
Disoriented:
Person
Place
Time
Long-term Memory Dx.
Unable to Recall Long
Past
Short-term Memory Dx.
Unable to Recall Last
5 Minutes
Inattention
Disorganized Thinking
Vigilant
Lethargic
Stuporous
Psychomotor Retardation
Mood
Resident Care Plan and Continuation Sheet
•Use in either the resident’s chart or a visible file panel
• Side 1 continues on the back
• White lightweight cardstock
• 5-hole punched side
Little Interest/Pleasure in
DISCHARGE PLANNING
Doing Things
NURSING
Depressed/Hopeless
Abnormal Sleep Patterns
Tired/Little Energy
Poor Appetite/Overeating
Feeling PHYSICIAN
Bad About Yourself
Inability to Concentrate
Restless/Fidgety/Anxious
Self-deprivation/Suicidal
Thoughts
SOCIAL SERVICES
Short-tempered/Annoyed
Behavior
Hallucinations
IllusionsDIETARY
Delusions
Inappropriate Physical
Behaviors (hitting,
scratching)
THERAPIES
DescriptionPrice Per Pack (100/pk)
Care Plan
$17.45
Continuation Sheet
$17.45
a comprehensive listing of various care levels
in an easy check-off format
•For specific areas of Nursing, Dietary, Activities,
Therapies and Social Services
•Discharge Planning and Updates on the back
• White lightweight cardstock
Item #
3178
SizePrice Per Pack (100/pk)
11” x 16” (Overall), 11” x 8-1/2” (Folded)
$44.05
Behavior (Cont’d.)
E:
First
N:
Middle
Attending Physician
Room/Bed
Record No.
COMMUNITY RESOURCES
SKILLED DAILY NURSES NOTE
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
NAME–Last
First
Middle
Attending Physician
Room/Bed
Record No.
FAMILY
RESIDENT CARE PLAN
Form 3268HH
7/03
PLAN OF DISCHARGE RECOMMENDED AT ADMISSION?
❑ Yes Rev.
❑ No
© BRIGGS, Des Moines, IA (800) 247-2343
Unauthorized copying or use violates copyright law. www.BriggsCorp.com PRINTED IN U.S.A.
REASON:
3268HH
BLADDER
•Contains
N: T__________ P__________ R__________
B/P__________________ ❑ Abnormal
D E N
D E N
Bowel & Bladder (Cont’d.)
Cardiovascular (Cont’d.)
Edema (cont’d.)
Bladder Training
Inappropriate Verbal
Behaviors (screaming,
Pedal: Lt /Rt
Prompted Voiding
cursing)
Pitting: +1
Burning
+2
Distention/Retention RESIDENT CARE
Inappropriate Sexual
PAGE
PLAN
Behaviors
+3
Frequency/Urgency
+4
Hematuria
Inappropriate
Social __________________________________________________________________________________________________
Diagnosis
Behaviors (throwing food)
Abnormal Peripheral Pulses
Discharge
Change in Vital Signs
Bladder Incontinence
Wandering
___________________________________________________________________________________________________________
Urine:
Rejects Care
Abnormal Heart Sounds/
Murmur
Color:
Risk for Physical Injury
Allergies____________________________________________________________________________________________________
Dizziness When Standing
Consistency:
Disrupts Care/Living
Environment
Increased Fatique
Odor:
Date of Admission_____________ D.O.B._____________ Age_____ Religion___________ Health Record #______________
Increased Weight
Dialysis
YES NO
Briefs/Pads Utilized
YES NO
YES NO
Ambulatory ❑
❑
Disabilities________________________________
Bowel Incontinence
Functional Status
Postural Supports
Bladder Cont. ❑
Walker
❑
❑
❑
❑
❑
CODE 1: SELF-PERFORMANCE
Respiratory
Ostomy, Type:
Bowel Cont.
Bed Rest
W/C ❑
Bed ❑
❑
❑
❑
❑
Diet______________________________________
Activity 3 or More
Times
Normal
W/C
0. Independent
3. Extensive Assistance Diarrhea
Pelvic ❑
Vest ❑
❑
❑
1. Supervision
4. Total Dependence
Labored Breathing Waist ❑
Constipation/Impaction
BRP
❑
❑
2. Limited Assistance
Shallow Respirations
Bowel Sounds:
Activity 2 or Less
TimesTERM
LONG
DISCHARGE
7. Activity Occurred 1 or 2 Times
Rales/Rhonchi
Present
GOAL:
PLANNING
8. Activity Did Not
Occur Entire
Wheezing
Absent
Code 1
Shift
GOAL:
Cough
Hyperactive
Bed Mobility
BY
RESP. RE-EVALUATION SIGNATURE
DATE # CONCERNS & PROBLEMS
RESIDENT GOALS
APPROACH PLAN
DATE Orthopnea
DISC.
DATE(S)
Hypoactive
Transfer
Dyspnea/SOB Exertion
Walk In Room
Dyspnea/SOB At Rest
Walk In Corridor
Dyspnea/SOB Lying Flat
GI
Locomotion On Unit
O2 ______ LPM
Anorexia
Locomotion Off Unit
Nausea/Vomiting
Dressing
❑ PRN
Epigastric Distress
Toilet Use
❑ Continuous
Difficulty Swallowing
Personal Hygiene
SaO2 ____% ____% ____%
Eating
Difficulty Chewing
Nebulizer Tx
Bathing
No Dental/Mouth c/o
Suctioning
Poor Fitting Denture/Partial
Tracheostomy/Care
CODE 2: SUPPORT PROVIDED
DISCHARGE PLANNING UPDATE
0. No setup or physical help from staff
Abnormal Mouth/Gum
Ventilator/Respirator
1. Setup help only
Edentulous
BiPAP/CPAP
2. One person physical assist
3. Two+ persons physical assist
Fever
8. ADL activity itself did not occur
Code 2 Abdominal Distension
during entire shift
Bed Mobility
Pain
Neuro/Muscular System
Transfer
No c/o’s of Pain
Syncope
Walk In Room
Origin:
Headache
Walk In Corridor
Location:
Abnormal Pupil Reaction
Locomotion On Unit
Intensity (0-10):
Right
Locomotion Off Unit
Left
Dressing
Tremors
Toilet Use
Cardiovascular
Vertigo
Personal Hygiene
Regular Rhythm/WNL
Eating
Radial/Apical Irregular
Decreased Grasp Rt
Bathing
Capillary Refill Sluggish
Lt
Bowel & Bladder
Neck Vein Distention
Decreased Movement
Chest Pain
WNL
❑ RUE ❑ LUE
Edema
Catheter Type:
❑ RLE ❑ LLE
Dependent
Scheduled Toileting
D E N
Form 3429P Rev. 8/13 © BRIGGS, Des Moines, IA (800) 247-2343
Form 3178 BRIGGS, Des Moines, IA 50306 (800) 247-2343
Total Plan of Patient Care
E: T__________ P__________ R__________
B/P__________________ ❑ Abnormal
Signature /
Title:
D:
NAME–Last
Item #
3268HH
3269HH
SKILLED DAILY NURSES NOTE
Date: ______________________
PRINTED IN U.S.A.
FLUIDS
TOTAL PLAN OF PATIENT CARE
LOCOMOTION
SUPPORTIVE
SPEECH
DRESS
Bed cradle
Shoes
Speaks well
Foot board
Stockings
Mumbles
Trapeze
Clothes
Aphasic
Pillows
Self care
Language spoken
Bed board
Assist
Brace
Supervise
EATING HABITS
BATH
BLADDER
INFECTION CONTROL
SIDERAILS
MENTAL
Foam rubber
Total care
❑
Standard
precautions
❑Feeds
Bathroom
❑ Oriented
Special
mattress
self
Tub ❑ Constantly
GROOM
❑
Single
room
isolation
❑ Confused
❑
At
night
❑
Omit
❑Prepare
Bedpan
Water mattress
food
Shower
❑
Transmission
based
❑ Well
Half rail ❑ QuarterComb/brush
rail
❑OOB
Urinal
Water
bed
in chair
hair adjusted
Self ❑
care
precautions
❑ Agitated
❑Feeder
Bedside commode
Alter
pressure pad
Assist
RESTRAINT Shave
❑
Airborne
❑
Forgetful
❑
Tube
fed
❑Tube
Catheter
______________
feeding
Nails
Total care
❑ Bed ❑ Chair
DEXTERITY
SPECIAL
❑ Depressed
❑ EQUIPMENT
Contact ❑ Droplet
Out of Bed for:
Feet
BedType ___________________
❑Size
Continent
❑ Moody
Right
Change
B hand
LLeft hand D
Hairdresser
Prosthesis
LOCOMOTION
❑Date
Incontinent
_______________________
❑ Alert
MOUTH CARE
Self care
Self
❑Assist
Total care
Walks
with:
FRACTIONAL URINE
PARALYSIS
*Check 30 mins. & release Q2H
BATH
Assist
Assist
❑Needs
Assistbib
Out of Bed after:
❑
Cane/quad
Dentures
POSITION DEVICE
D.R.
B
D
S
Self
Supervise ❑ Whirlpool
Total
care
Rt.BArm
Lt.LArm
D
❑
Walker/rolling
Upper
BLADDER TRAINING
Type ❑ Merrywalker
Supplement feeding
Assist/supervise
Total
care
Rt. Leg
Lt. Leg
Type ___________________ ❑ Shower
Lower
Date
started _____________
Salt substitute
_______________________
Total care
Podiatrist ❑ Bed
Rt. side of face
❑ 1 assist
BRACES
No
dentures
Meals
taken
where:
Date
_______________________ ❑ Total care
Sugarcompleted
substitute __________
Schedule
Lt. side of face
❑
2 assist
No teeth
Self
B
L
D
❑
Assist
PRIVILEGES
Quadriplegia
❑
Fully ambulates
BOWEL
BLADDER TRAINING
At bedside SUPPORTIVE
Assist
DR
❑ Supervise
EYE SIGHT
Paraplegia
Bed rest
Self ❑
care
Total
care
❑ Bathroom
Bed cradle
❑
Wheelchair
RM
Bath Days:
Date Started
POSITION
To B.R.
Assist
❑ Gerichair
❑ Foot board
❑Right
Bedpan
Hall
MENTAL
ATTITUDE
Date Completed
T
W T
F
S
Change by self
Up ad lib M
Supervise
❑ Assist transfers
❑ Trapeze
❑Left
Bedside commode
Offer snack at: ❑ 2pm ❑ 8pm Oriented
With 1 assist
Both
BOWEL
OOB schedule
Total❑care
❑ Bed to chair
Pillows
❑ Colostomy
Well adjusted
Shift ___________________
With 2 assist
Cataracts
EYE SIGHT
❑ Lift to chair
Up with assist
❑ Bed board
❑ Continent
B.R.
Moody
2 hrs. ❑ Poor
❑ With 1 assist
Wears glasses
SKIN
❑ Foam rubber
❑Q Good
SKIN CARE
❑ Incontinent
ACTIVITIES
Bedpan
Cheerful
❑
With 2 assist
Blind
❑ Special mattress
❑
Wears
glasses
❑ Total care
RESTRAINTS
Commode
Depressed
❑ Routine
❑
Other ________________Routine
Type ___________________
Right
Both
❑Bed
Blind: ❑Chair
w/glasses
❑ Assist
Incontinent
❑
Special
_______________
Time
P.T.
Confused
_____________________Special
❑ w/o glasses
Left
Legally
Jacket
Waist
Self control
❑ Decubitus
_____________
SPECIAL EQUIPMENT
Time
O.T.
Alert
BOWEL TRAINING
❑ Cataracts
Decubitus
_____________________
Assist
IMPORTANT: CHECK EVERY HOUR
Time
S.T.
Agitated PARALYSIS
❑ Prosthesis ❑ Braces
HEARING
TWO HOURS.
Site:
Date started _____________ AND RELEASE EVERY
HEARING
Total care
Escort needed MOUTH CARE
Forgetful
❑ Splint
❑
Rt./Lt. Arm
SIDERAILS
Date completed __________
Partially deaf
Self care
❑ Partially deaf
Type ___________________
❑ Rt./Lt. Leg
BOWEL TRAINING
ALLERGIES
Contractures
❑ Dentures: ❑ U ❑ L
Right
Left
FLUIDS
❑Constantly
Totally deaf
Church Services
❑ Rt. side of face
❑ No dentures
Site:
❑ Self ❑ Assist
night hearing aid
deaf
Date Started
❑AtUses
LOA permission
❑ Lt. side of face
❑Totally
Restrict_______________
❑ No teeth
❑ Total care
Omit
hearing aid
Date Completed
❑ Quadriplegia
❑Uses
Encourage
_________I&O
SPEECH
B.R.
Bedpan
Urinal
Commode
Catheter
Size
Date Change
Irrigation
c̄
@
Incontinent
Self control
Total care
Assist
3178
Restrict
Force
Intake
Output
Diabetic fluids
❑ Thickened liquids
Type _________________
❑ Diabetic fluids
Hydration program at:
❑ 10am ❑ 2pm
Walks
Crutches
Cane
Walker
Bed to chair
Lift to chair
MEALS
Wheelchair
❑Stretcher
Independent
❑With
Setup
help only
1 assist
❑With
Supervisory/prompt/cue
2 assist
❑Fully
Total
physical assist
ambulatory
NURSE AIDE’S INFORMATION SHEET
❑ Speaks well
❑ Mumbles
❑ Aphasic
❑ Language _____________
_____________________
_____________________
❑ Paraplegia
TURN AND POSITION
❑ Self
❑ Every 2 hours
❑ With 1 assist
❑ With 2 assist
❑ Other _________________
PRIVILEGES
❑ Bed rest
❑ To bathroom
❑ Up ad lib
❑ OOB schedule
❑ Self ❑ Assist
❑ Total care
DRESSING
❑ Self ❑ Assist
❑ Supervise
❑ Total care
❑ Other ________________
GROOMING
❑ Hair
❑ Comb ❑ Brush
❑ Shave ❑ Nails
❑ Feet
❑ Hairdresser
❑ Self ❑ Assist
❑ Supervise
❑ Total GROOMING
care
❑ Other _________________
WANDERGUARD
❑ Yes ❑ No
Placement ______________
_______________________
_______________________
_______________________
*Location check Q15 mins.
Elopement Potential
❑ Yes ❑ No
RESTORATIVE
❑ Ambulate
❑ Device _______________
❑ AROM _______________
❑ PROM _______________
❑ Walk & Dine
❑ Special splint __________
_____________________
❑ Other ________________
_____________________
BEHAVIOR
❑ Verbally abusive
❑ Physically abusive
❑ Wanderer
❑ Combative
❑ Elopement potential
*Note comments below
Comments: ___________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
NAME–Last
First
Middle
Form 1145P Rev. 1/13 © BRIGGS, Des Moines, IA (800) 247-2343
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