Annual Form and Policy Reviews
GuideOne Risk Resources for Health Care
1111 Ashworth Road
W. Des Moines, IA 50265-3538



Annual Form and Policy Reviews

As we move into the final quarter of the year, many providers are going through the budget process and planning for 2016. A review of all forms and policies should be completed annually. This ensures that your staff stays current with the many regulatory standards of practice and facility changes that frequently occur throughout the year.

The most efficient way to review these documents is to form a committee. Then, divide all forms and policies into 12 categories (falls, skin care, etc.), so they can be completed on a monthly basis instead of all at once.

During the review, committee members should consider the following:

  • Documentation forms to determine if the documentation is required by regulation, standard of practice, or facility policy. For example, care plan flow sheets are not mandated by regulations; however, it's easier to defend nurse's notes that are documented by exception. Facilities should consider revising or discontinuing forms that do not further the goal of quality care.

  • All policies should have an implementation date. Review them routinely and remove old policies, but keep them in an expired policy book for future reference.

  • Discuss any changes with your Medical Director and QAPI Team to seek final input and approval.

Also, you should budget for and plan to update your most-used reference manuals at the end of each year. It's important that your staff has a current version readily available. Some "must-have" manuals that frequently change from year-to-year include the:

  • Interpretive Guidelines Long Term Care Survey Manual;

  • MDS 3.0 User's Manual;

  • Nursing Drug Reference; and

  • Diagnostic and Laboratory Test Reference.

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