LOGS: Be organized

Emergency Plan

Same month every year (annually)

Complete the Data Sheet.

Complete the Agreement with another Agency. (Fax to us the information to complete/submit the Plan)

Your License must be renewed every 2 years

Renew License Form: 60 days before to expiration date.    CLIA application form

Medical Record: Clinical Record Entry Log: Clinical Record entry Log

(by authorized staff only)

DON: Referral Log (Admitted / Non Admission): Referral Log

DON: High Risk/Alert Medication LOG (This log document the control of High Alert Medications)           Section 1557:   Language Assistance Language Log

High Alert/Risk Medications                        Auxiliary Aide Log  Auxiliary Log

DON: Medication Reconciliation LOG (This log document the Medication reconciliation)

Medication Reconciliation      Hospitalization Log:  Hospitalization

Medication/Drugs/Supplies list:

DON: Sound/Look alike:             Supplies Inventory/Cleaning Storage               

 Sounds/Looks Alike               Supplies Inventory/Cleaning Storage       

Equipment Maintenance:   Log EM       

DON: Fall Injury review tool LOG

Fall Injury Review Tool (as needed)      OSHA’s Form 300  Osha's 300

Ass needed:

ON CALL:  Report: ON Call Report     On Call Log/Calendar: ON Call Log

            Visitor Log: Visitor Log    (Front desk clip board)

Administrator/DON: Emergency Control Log (Monthly)  Hazard Vulnerability

(Included in the Safety Minutes reports)

Emergency Control Log      (All reports in the Safety minutes must be completed)

Hazard Vulnerability Analyzes      Hazard Vulnerability Log

Administrator/DON: Safety Tracking LOG (All year long)   Safety Tracking Log

Administrator/DON: Complaints

Complaint, ON-CALL  report:  Complaints Report

Med Watch 3500 Log  Med Watch Log

Administrator/DON: Orders Movement Log (needed if late signed focus detected)

Orders Movement Log

Administrator/DON: INCIDENT REPORTS

 (Must be completed as applicable)

Accident Incident Report       

DON: FALL INCIDENT Report (Must be completed as applicable)

Fall Incident Report    

DON: MEDICAL ERROR Report                Anti-coagulant Incident

Medical Error Report                             Anti Coagulant Report

DON: SHARP INJURY INCIDENT Report (Must be completed as applicable)

Sharp Injury Incident Report    

Multiple incident report forms: Multiple  Incident Report forms 

DON: Adverse Event Incident Report Form: (if needed, fall, severe patient's health impact, etc.)

Adverse Event Incident               UTI: Adverse UTI Event Incident

Abuse:

Abuse Incident Report          Plan to Prevent Abuse Incident

Administrator/DON/QA: Patients/MD Survey Summary Table Analyzes (Quarterly)

(HCAPS reports can replace this sumaries)     Patients Survey Form    

Physicians survey (at least yearly):  Physicians Survey Form

Results of Patients survey analyzes, possible Adverse Event

Patients Survey Summary                 Adverse Event Patient Survey

Administrator: Extinguisher Log (Monthly-Yearly)

Extinguisher Maintenance Log

Administrator: Visitor Log (all year long, front desk) 

Disclaimer: Every log template is only your Guide/Agenda to complete each log, your Agency Officials must assure that every member had active participation in the discussion and confection of the Log, Reports, Evaluations, Documents.

This service reflects the author’s own opinions about Home Health Care services. Although the information and Policies are from sources deemed very reliable, they are not guaranteed. PN System © owner disclaims any personal liability for loss incurred as a result of the applications of any information offered in this application process, or in the use of our services. If expert, professional, medical, clinical assistance is required, the services of a component professional person should be sought. Your Director of Nursing, MUST review/approve the Policies / Procedures/ Forms.

Also you and your Agency guarantees to comply with all Federal/Local/State laws to use our services.

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Over 20 years serving more than 2000 Home Health Agencies nationwide.

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