Example template for recording data for Quality Indicator 3: Unplanned weight loss

Quality indicator 3. Unplanned weight loss
(please note that all weights are in kgs)
Facility name
Reporting quarter date
Assessment date
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12
Resident / Weight carried forward from previous month / July/
Oct/
Jan/
Apri / Kgs
+
Or
- / Aug/
Nov/
Feb/
May / Kgs
+
Or
- / Sep/
Dec/
Mar/
Jun / Kgs
+
Or
- / Total + or – for Quarter / 1*
Lost 3 Kg or more this quarter Y or N / 2#
Lost every month Y or N / Comments
Mrs Example Code 114 / 83.5 / 83.7 / +0.2 / 82.8 / -0.9 / 80.4 / -2.4 / -3.1 / Y / N
Mr Example Code 115 / 76.3 / 76.0 / -0.3 / 75.5 / -0.5 / 75.3 / -0.2 / -1.0 / N / Y
Ms Example Code 116 / 80.0 / 80.0 / - / - / - / 80.5 / +0.5 / +0.5 / N / N/A / In hospitalin February and weight could not bemeasured,thereforenot included
for either
measure in
the total
Total / 1 / 1

*Measure 1: Significant unplanned weight loss#Measure 2: Consecutive unplanned weight loss

Unplanned Weight Loss data recording sheet

Unplanned weight loss
Name of facility
Reporting quarter date
Assessment date

Measure 1: Significant unplanned weight loss.This is the number of residents who experienced over the three month period unplanned weight loss equal to or greater than three kilograms.

Number of residents whose weight was monitored* / Number of residents who experienced significant unplanned weight loss

Measure 2: Consecutive unplanned weight loss.This is if a resident experiences unplanned weight loss of any amount every month over the three consecutive months of the quarter. This can only be determined if the resident is weighed on all three occasions.

Number of residents whose weight was monitored* / Number of residents who experienced consecutive unplanned weight loss

*Note: If a resident is in hospital on any of the weigh dates they are excluded from bothmeasures.

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