Documenting Expressions

Documentation in health care is an important communication tool for the health care team as they care for residents/patients. It is important to have medical documentation of individuals’ expressions/ behaviors and the events that precipitated the expressions/behaviors. Without documentation, there is no evidence of what occurred or how to mitigate expressions/behaviors in the future. Included is Tips for Use to help your team get the most out of the “Documentation of Expressions (Behaviors)” resource, which provides examples of both best practices and poor practices for documentation of expressions. The one-page “Documentation of Expressions” resource paired with pre- and post-tests will provide nurses with a solid foundation for clearly communicating what occurred and the steps that were taken by staff to de-escalate the expression or behavior.

Documentation of Expressions: Tips for Use

Documentation of Expressions

Education for Documentation: Pre and Post Learning Assessment

Answer Key: Pre & Post Assessment

PDSA Steps and Tools

This is a guide to the 11 steps through a Plan Do Study Act Cycle. Included for each step: the purpose, procedures, a list of possible tools an improvement team might use to accomplish their goals and the outcome.

Psychotropic Action Plan Data Collection Table

Data collection tool to assist with baseline data collection and ongoing data monitoring for use in conjunction with the IPRO PSYCHOTROPIC REDUCTION ACTION PLAN.
The goal is to document the status at the start of your action plan intervention. With a proper baseline, you can later demonstrate the efficacy of your interventions with improved numbers.

Psychotropic Review Worksheet

Resident-level review worksheet to facilitate providers with ensuring documentation, assessments, diagnoses, and other elements are considered when reviewing a resident record who is on a psychotropic.
This worksheet can be used as part of the facility’s overall Quality Assurance and Performance (QAPI) program, to assist MDS coordinators in completing the CMS Minimum Data Set (MDS) or to prepare for medical provider resident review for gradual dose reduction.

Quality Improvement: A Guide to Root Cause Analysis Tools

Conducting a Root Cause Analysis (RCA) is an important step to identifying areas of opportunity for improvement, to reduce avoidable hospital utilization, medication errors, or other issues.
This compendium includes evidence-based and best practice tools to help you get started. After completing the RCA process with your team, we recommend exploring the IPRO QIN-QIO Guide to Improving Care Transitions and other resources on the IPRO QIN-QIO Resource Library (https://qi-library.ipro.org).

Psychotropic: Non-Pharmacological Interventions Table

Document with links for resources for evidence-based resources for non-medication interventions. Includes:
▪ Use of Non-medication Interventions
for residents with expressions due to
cognitive and structural changes have
been demonstrated to be beneficial.
▪ Use of these resources can be
used on orientation, with annual competencies, and individual
resident-centered care planning.

CDC Clinical Practice Guideline for Prescribing Opioids for Pain – Updated November 2022

This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1–49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1–3 months), and chronic (duration of >3 months) pain.

The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care.

The guideline addresses the following four areas:

1) determining whether or not to initiate opioids for pain,

2) selecting opioids and determining opioid dosages,

3) deciding duration of initial opioid prescription and conducting follow-up, and

4) assessing risk and addressing potential harms of opioid use.

CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation.

CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers.

CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient’s circumstances.

Monthly Pressure Ulcer Tracking Form and Guide

The Monthly Pressure Ulcer Tracking Form was developed to assist facilities track their pressure ulcers on a monthly basis with the ability to carry over unhealed/unresolved pressure ulcers unto a new monthly tracking form. It maintains an active list of all current pressure ulcers in real time to assist with the investigation, treatment and provide an important piece in the development of a targeted pressure ulcer prevention program. (See instructions below on how to download the tracking form.)

Complete this form to receive a link to download a zipped folder of the Pressure Ulcer Tracking Resources to include the Excel tracking form as well as a PDF instructional guide that explains the use of the tool: https://forms.office.com/r/369PSU6V4m

For questions on the Monthly Pressure Ulcer Tracking Form and Guide, please contact Dave Johnson (djohnson@ipro.org) or IPRONursingHomeTeam@IPRO.org.