Individual Forms for L&C Agency

Appointment of Administrator	Appointment of DON
60 Day Care Summary	Blood Sugar Log
Glucometer Control Log	Employee Checklist
Care Summary	Blood Pressure Log
60 Day Chart Audit	Comprehensive Chart Audit
Complaint Form	Case Conference
Comprehensive Assessment	Comprehensive Assessment (Short Version)
Detailed Expedition Explanation	Communications
Documentation Guidelines for Rehab Department	Documentation Review Checklist for Rehab Department
Daily Weight Log	DME Referral
Employee Infection Control Log	Employee Discipline
Ethics Complaint Form	Expense Report
Employee Termination	Employee Visit Log
Generic Expedited Determination	Fax Cover
HHA Care Plan	Key Field Correction
Key and Non-Key Description	Non Key Field Correction Form
Hourly Time Sheet 1-15	Hourly Time Sheet 16-31
Inservice Minutes	Individual Inservice Minutes
Infection Control Log	Infection Surveillance
Incident Report	Incident Report Log
IV Therapy Order	Insurance Verification
Marketing Time Sheet	Hazardous Materials Log
LVN Performance Appraisal	RN Performance Appraisal
HHABN	HHABN and Triggering Events Chart
Medication Error Report	Medication Profile
MAR (2 layouts)	Medication Education Sheet
Missed Visit Report	Narrative Therapy Note
Needlestick Injury Log	Nurses Notes
Occupational Therapy Evaluation Form	Occupational Therapy Visit Note
Pain Assessment	Patient Infection Log
Patient Calendar	Patient Elected Transfer
Patient Discharge Teaching	Patient Fall Log
Patient Infection Control Log	Patient Progress Notes
Patient Satisfaction Survey	Patient Satisfaction Survey Quarterly Report
Payroll Deduction	Personalized Referral Forms
Physical Therapy Evaluation Form	Physical Therapy Visit Note
Photograph Consent	Physician Orders (two layouts)
Personal Protective Equipment	Post Hospital Orders
QAPI Action Plan	Prioritized Infection Risks
Referral Sheet	Release of Information Request
Referral Tracking	Requested Leave
Release of Medical Records to Patient	Resource Documentation
Root Cause Analysis	Root Cause Analysis Log
Social Work Referral	Social Worker Visit Note
Speech Therapy Eval	Speech Therapy Visit Note
Supervisory Visit Generic	Supervisory Visit LVN
Sphygmomanometer Log	Supervisory Visit HHA
Tinetti Assessment	Utilization Review Minutes
Wound Care Flow Sheet	Wound Care Documentation Sheet

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