1. Short Term Health Monitoring & Change of Condition
The Key to Communication

2. Short Term Health Monitoring & Change of Condition form
SHORT-TERM HEALTH MONITOR/CHANGE OF CONDITION REPORT
Date
Resident Name
Describe Changes of Condition; Health Concerns; Behavior Strategies
Current Status (in-house, hospital, hospice, SNF, other)
Interventions Initiated: Orders, TX, Meds, Diet
Staff Direction/ Documentation Instructions
Expected Outcome/ Anticipated Return
DC Date/ Review Date
Incident Report
Purpose:
Residence Nurse staff instruction
Stand up shift report between staff
Communication report for weekly to Quality
Assurance Director for All Reportable Events by Thursday.

3. Short Term Health Monitoring & Change of Condition
Administrator, Nurse & Staff Instruction
Form allows for simple communication between All parties caring for Residents and allows for us to Create a Target list of High Risk Residents
Instructs Caregivers on specific acute conditions/changes of condition that need to be monitored & documented in the Residence Progress Notes
Change of Condition: a change in mental or physical status that results in a need for us to provide extra or different services. A change in resident’s ability to participate in 2 or more activities of daily living, such as eating, bathing or dressing.

4. Short Term Health Monitoring & Change of Condition
Stand-up shift report between staff
Creation of a standard tool for communicating between shifts.
Residence nurse, staff and Administrator to update Short Term Health Monitoring/Change of Condition form a review with staff during staff meetings.
Caregivers are to communicate/update oncoming staff to status of identified residents.
GOAL: Enhance Continuity of Care & Spot-Light Resident who are higher Risk of Debilitating COC…Bottom-Line will create a probability of Greater Length of Stay

5. Short Term Health Monitoring & Change of Condition
Residence Nurse/Administrator
Communication Report
GOALS:
To enhance the residents quality of care
Spot-Light Resident who are higher Risk of Debilitating COC…Bottom-Line will create a probability of Greater Length of Stay
To insure continuity of care
To insure appropriate updates to Negotiated Service Plans

6. Short Term Health Monitoring & Change of Condition
Weekly Regional Nurse Consultant Report
Consolidate forms used by residence nurses and meet reporting requirements
Completion of report by residence nurses to include incidents identified on Decision Tree for Event Reporting
Assist RNCs with case management of complex resident issues

7. How to complete the Short Term Health Monitoring & Change of Condition
Once a resident is identified as requiring short term monitoring, the Change of Condition form should be updated
Begin with the first two columns: add the date and resident name
In the 3rd column, the residence Admin &/or nurse should specify the specific condition they wish the staff to monitor & report on

8. How to complete the Short Term Health Monitoring & Change of Condition
In the 4th column the residence nurse should indicate the current status of the resident:
Did the resident remain in the house?
Was the resident admitted to the hospital?
Is the resident receiving services from home health, hospice out patient rehab services?

9. How to complete the Short Term Health Monitoring & Change of Condition
The residence Admin &/or nurse should list all interventions, orders or treatments initiated due to the change of condition
The residence nurse should indicate who is providing the services: home health PT, OT, Nursing, Residence Nurse, Caregivers

10. How to complete the Short Term Health Monitoring & Change of Condition
The residence Admin & nurse should provide staff with detailed instructions for monitoring, treatments/interventions & documenting

11. How to complete the Short Term Health Monitoring & Change of Condition
The residence Admin & nurse should indicate the residents expected outcome.
Examples: skin tears/wounds-indicate the anticipated healing date, rehab services- indicate expected goal/outcome from services
The Residence Admin & nurse should also indicate the anticipated return date if the resident is hospitalized or in a rehab facility

12. How to complete the Short Term Health Monitoring & Change of Condition
The residence Admin & nurse should indicate whether they are reviewing or discontinuing the monitoring of the resident and supply date
The Residence Admin & Nurse should verify that an incident report was completed by a “Yes or No” response
Expected Outcome/ Anticipated Return
DC Date/ Review Date
Incident Report