Registered Nurse Review (Streamlined Version)

Information provided from Quality Management Information System
Individual’s Name:DOB:UCI#:
Service Provider: (name of home or program):
Street address:City, ZIP:
Phone: Date individual entered this home/service (mm/dd/yy): / /
Visit Announced  or Unannounced 
Monthly (SB 962) QuarterlyOther(reason): Date of Visit (mm/dd/yy): / /
Nurse(name):
Print Signature
SB 962 Homes Only (22a,b)
The Individual Health Care Planning (IHCP) Team includes the following at a minimum:
Service Coordinator, Individual, where appropriate Parents/Legal Guardian/Authorized Representative, Physician, Administrator, Registered Nurse. / Yes  No 
The IHCP is implemented. / Yes  No 
The IHCP Team meets every 6 months. / Yes  No 
Changes in health status are reviewed by the health care team and revised as needed. / Yes  No 
The Primary Care Physician examines this individual at least every 60 days. / Yes  No 
Health and Wellness
  1. The individual receives prompt, routine, specialized and preventative medical services as documented in the health plan or as recommended by the primary care physician. (20b)
/ Yes  No 
  1. Medical assessments (e.g. lab work, annual physical, planned hospitalizations, nursing assessments, etc.) and services are completed and appropriately documented. (20b)?
/ Yes  No 
  1. The individual receives dental care and oral care as identified in the oral health care plan or IPP. (21b,c)
/ Yes  No 
  1. Staff can describe how to implement the health plan [or objectives in the Health Domain of the IPP]. (22c)
/ Yes  No 
Medication
  1. The individual’s medication administration records are complete and
    accurate. (16b)
/ Yes  No  N/A 
  1. Staff demonstrate or describe proper medication management
    procedures. (16e)
/ Yes  No  N/A 
Safeguards
  1. Health-related, risk prevention strategies (e.g., hand railings to reduce risk of falling, turning individual every two hours, etc.) are documented, implemented and successful. (15a, 22d)
/ Yes  No  N/A 
  1. Specialized health-related equipment is accessible, clean, and in good working order (e.g., a wheelchair is the appropriate size for the individual). (14a,b)
/ Yes  No  N/A 
If “no” to ANY of the above questions, recommended follow-up?
Is there anything that you became aware of that is working well? (Note: You can also use this space to describe examples of best practices that are reported or observed.)
Nursing Assessment Notes (Attach Additional Notes; If a Nursing Assessment has been completed, please attach):

11/1/10