INSTRUCTIONS FOR USE OF
QUALITY/PERFORMANCE IMPROVEMENT
MONITOR WORKSHEETS
Choose Subject
o Choose subject to be monitored
 Height Documentation
 Weight Documentation
 Food/Fluid Intake Documentation
o Establish a threshold for compliance for each indicator in monitor
worksheet
Collect Data
o Choose a sample of at least 20% of resident population
o Complete one worksheet for each resident in sample
o Determine the correct answer for each indicator in monitor worksheet
Determine Percent Compliance
o Calculate percent compliance for each indicator using the following
formula:
Total # of yes responses
x 100 = % compliance
Total # of yes + no responses
Note: N/A responses are not counted
Develop a Plan of Correction
o Develop a plan of correction for indicators that do not meet established
threshold for compliance
1
Quality/Performance Improvement Monitor Worksheet
Height Documentation
Resident’s Initials_________
Resident’s Room Number__________
Indicators
Yes No
1. Knee height measurement is recorded within 24 hours of admission (if
unable to obtain knee height due to amputation or contractures, actual
height is measured and recorded)
2. Knee height measurement is accurately converted to estimated
standing height
3. Height (estimated or actual) is measured and recorded annually
Comments:
Date of Review: _______ Reviewer’s Signature: __________________________
2
N/A
Quality/Performance Improvement Monitor Worksheet
Weight Documentation
Resident’s Initials_________
Resident’s Room Number__________
Indicators
Yes No
1. Initial weight is recorded within 24 hours of admission
2. Weekly weights are recorded for 4 consecutive weeks following
admission
3. Weekly weights are recorded if on “Intake Watch”
4. Weights are trended on the Body Weight Tracking Graph
5. RD/DTR and Nursing Supervisor are notified by FHA if significant
weight change occurred
6. Assessment is completed within 72 hours by the RD/DTR for
significant weight change
Comments:
Date of Review: _______ Reviewer’s Signature: _________________________
3
N/A
Quality/Performance Improvement Monitor Worksheet
Food/Fluid Intake Documentation
Resident’s Initials_________
Resident’s Room Number__________
Indicators
Yes No
1. Food/fluid intake at meals is tallied and trended daily
2. Between meal fluid intake is tallied and trended for residents on “Intake
Watch”, I&O monitoring and/or calorie count
3. RD/DTR and Nursing Supervisor are notified by FHA if resident has
poor food/fluid intake based on established parameters
4. Assessment is completed by the RD/DTR within 72 hours for referral
due to poor food/fluid intake
5. If goal amount for fluid intake at meals is not met, RD/DTR assessed
for clinical signs and symptoms of dehydration within 72 hours of
notification
6. A visual indicator for “Intake Watch” is posted next to the resident’s
name outside of his/her door
Comments:
Date of Review: _______ Reviewer’s Signature: _________________________
4
N/A