Long Term Care Champion - Monthly Reporting Tool Please email this report to the AR Quality Partners (AQP) by the 15th of each month. or Fax to 501-374-1077 GENERAL INFORMATION TODAY’S NURSING HOME NAME REPORT PREPARED BY: ARE YOU THE CHAMPION FOR THE HOME? DATE PRINT NAME & EMAIL CONTACT GIVE CHAMPION NAME IF NOT ANTIPSYCHOTIC MEDICATIONS / DIAGNOSIS / GRADUAL DOSE REDUCTIONS (GDR) / DISCONTINUED USE OF ANTIPSYCHOTIC MEDICATIONS TODAY’S NUMBER OF OF THOSE NUMBER OF RESIDENTS NUMBER OF NUMBER OF RESIDENTS GDR MONTHLY RESIDENTS RESIDENTS, WHOSE RESIDENTS WITH WITH DIAGNOSIS OF REMINDER: CENSUS RECEIVING AN NUMBER WITH A ANTIPSYCHOTIC DIAGNOSIS OF DEMENTIA THAT ARE REVIEW GDR SCHEDULE ANTIPSYCHOTIC DIAGNOSIS OF MEDICATION WAS AND SUPPORTING ARE NOT DEMENTIA AND RECEIVING AN MEDICATION TOURETTE’S, DISCONTINUED IN THE DOCUMENTATION RECEIVING AN ANTIPSYCHOTIC SCHIZOPHRENIA, PAST 30 DAYS (NURSES NOTES) OF ANTIPSYCHOTIC OR HUNTINGTON’S RESIDENTS ON GDR FOR ANTIPSYCHOTIC MEDICATIONS. STAFF EDUCATION / WINS / COMMENTS NUMBER OF TEAM TOTAL NUMBER OF TEAM SHARE A WIN THAT YOU HAVE CELEBRATED IN THE PAST 30 DAYS MEMBERS TRAINED ON MEMBERS TRAINED ON (use additional page if needed – include NH name) THE WELL-BEING MODEL WELL-BEING MODEL THE AS OF TODAY IN THE PAST 30 DAYS REVISED NOVEMBER 29, 2017 Additional copies: arhealthcare.com
Long Term Care Champion - Monthly Reporting Tool Please email this report to the AR Quality Partners (AQP) by the 15th of each month. or Fax to 501-374-1077 GENERAL INFORMATION TODAY’S DATE NURSING HOME NAME REPORT PREPARED BY: PRINT NAME & EMAIL CONTACT ARE YOU THE CHAMPION FOR THE HOME? GIVE CHAMPION NAME IF NOT ANTIPSYCHOTIC MEDICATIONS / DIAGNOSIS / GRADUAL DOSE REDUCTIONS (GDR) / DISCONTINUED USE OF ANTIPSYCHOTIC MEDICATIONS TODAY’S CENSUS NUMBER OF RESIDENTS RECEIVING AN ANTIPSYCHOTIC MEDICATION OF THOSE RESIDENTS, NUMBER WITH A DIAGNOSIS OF TOURETTE’S, SCHIZOPHRENIA, OR HUNTINGTON’S NUMBER OF RESIDENTS WHOSE ANTIPSYCHOTIC MEDICATION WAS DISCONTINUED IN THE PAST 30 DAYS NUMBER OF RESIDENTS WITH DIAGNOSIS OF DEMENTIA AND ARE RECEIVING AN ANTIPSYCHOTIC NUMBER OF RESIDENTS WITH DIAGNOSIS OF DEMENTIA THAT ARE NOT RECEIVING AN ANTIPSYCHOTIC GDR MONTHLY REMINDER: REVIEW GDR SCHEDULE AND SUPPORTING DOCUMENTATION (NURSES NOTES) OF RESIDENTS ON GDR FOR ANTIPSYCHOTIC MEDICATIONS. STAFF EDUCATION / WINS / COMMENTS NUMBER OF TEAM MEMBERS TRAINED ON THE WELL-BEING MODEL IN THE PAST 30 DAYS TOTAL NUMBER OF TEAM MEMBERS TRAINED ON THE WELL-BEING MODEL AS OF TODAY SHARE A WIN THAT YOU HAVE CELEBRATED IN THE PAST 30 DAYS (use additional page if needed – include NH name) REVISED NOVEMBER 29, 2017 Additional copies: arhealthcare.com