Sprout Path · Clinical Nursing Reference Series · Book 2

Eldercare Documentation & Bedside Companion Portal

Welcome to the official bedside companion for Gerontological Nursing & Eldercare Documentation by Corinne Hollings. Every tool below is full-size, completely free, and ungated. Designed to be printed, folded, and carried in a scrub pocket or referenced at the nurses' station.

📄 Printable Shift Brain Sheets 📊 Section GG Scoring Crosswalk 📞 Condition-Specific SBAR Scripts

Tool 1: Bedside Organization

Printable Clinical Shift Brain Sheets

Organized for post-acute and skilled nursing units. Captures vital signs, code status, diet/IDDSI consistency, fall & skin risk scores, PRN effectiveness windows, and Section GG admission window tracking.

💡 Set print layout to Portrait or Landscape. Page headers and footers are suppressed automatically.

SKILLED NURSING SHIFT REPORT SHEET

Precision Coding Press / Sprout Path · Post-Acute Clinical Series

Date: ________________ Shift: [ ] Day [ ] Eve [ ] Night Nurse: ________________

RM: _____ Resident: ________________________ Code: [ ] Full [ ] DNR / POLST: [ ] Comfort [ ] Ltd

Admit: _____ Day #: ___ Part A

Pillar: [ ] IV [ ] Tube [ ] Wound [ ] Complex [ ] Teach

Diet / IDDSI: Food: ______ / Drink: ______

Allergies: ___________________________

Braden: ___ (High ≤14) Morse: ___ (High ≥45)

Section GG ARD: Day [ ] 1 [ ] 2 [ ] 3

Neuro / BIMS: ___ / 15 CAM: [ ] Neg [ ] Pos

Last BM: Date: _____ / Type: ___ (Bristol)

T: ____ BP: ______ HR: ____ RR: ____ SpO2: ____% on [ ] RA [ ] ___ L Pain: ___/10 (PAINAD ___) BG: ____

SKILLED INTERVENTIONS & PRN MONITORING (Time · Dose · Indication · Response)

____________________________________________________________________________________

RM: _____ Resident: ________________________ Code: [ ] Full [ ] DNR / POLST: [ ] Comfort [ ] Ltd

Admit: _____ Day #: ___ Part A

Pillar: [ ] IV [ ] Tube [ ] Wound [ ] Complex [ ] Teach

Diet / IDDSI: Food: ______ / Drink: ______

Allergies: ___________________________

Braden: ___ (High ≤14) Morse: ___ (High ≥45)

Section GG ARD: Day [ ] 1 [ ] 2 [ ] 3

Neuro / BIMS: ___ / 15 CAM: [ ] Neg [ ] Pos

Last BM: Date: _____ / Type: ___ (Bristol)

T: ____ BP: ______ HR: ____ RR: ____ SpO2: ____% on [ ] RA [ ] ___ L Pain: ___/10 (PAINAD ___) BG: ____

SKILLED INTERVENTIONS & PRN MONITORING (Time · Dose · Indication · Response)

____________________________________________________________________________________

RM: _____ Resident: ________________________ Code: [ ] Full [ ] DNR / POLST: [ ] Comfort [ ] Ltd

Admit: _____ Day #: ___ Part A

Pillar: [ ] IV [ ] Tube [ ] Wound [ ] Complex [ ] Teach

Diet / IDDSI: Food: ______ / Drink: ______

Allergies: ___________________________

Braden: ___ (High ≤14) Morse: ___ (High ≥45)

Section GG ARD: Day [ ] 1 [ ] 2 [ ] 3

Neuro / BIMS: ___ / 15 CAM: [ ] Neg [ ] Pos

Last BM: Date: _____ / Type: ___ (Bristol)

T: ____ BP: ______ HR: ____ RR: ____ SpO2: ____% on [ ] RA [ ] ___ L Pain: ___/10 (PAINAD ___) BG: ____

SKILLED INTERVENTIONS & PRN MONITORING (Time · Dose · Indication · Response)

____________________________________________________________________________________

RM: _____ Resident: ________________________ Code: [ ] Full [ ] DNR / POLST: [ ] Comfort [ ] Ltd

Admit: _____ Day #: ___ Part A

Pillar: [ ] IV [ ] Tube [ ] Wound [ ] Complex [ ] Teach

Diet / IDDSI: Food: ______ / Drink: ______

Allergies: ___________________________

Braden: ___ (High ≤14) Morse: ___ (High ≥45)

Section GG ARD: Day [ ] 1 [ ] 2 [ ] 3

Neuro / BIMS: ___ / 15 CAM: [ ] Neg [ ] Pos

Last BM: Date: _____ / Type: ___ (Bristol)

T: ____ BP: ______ HR: ____ RR: ____ SpO2: ____% on [ ] RA [ ] ___ L Pain: ___/10 (PAINAD ___) BG: ____

SKILLED INTERVENTIONS & PRN MONITORING (Time · Dose · Indication · Response)

____________________________________________________________________________________

Tool 2: CMS Reimbursement & PDPM

Section GG Admission Performance Crosswalk (MDS 3.0 v1.20.1)

Side-by-side reference connecting clinical bedside shift charting to CMS Section GG self-care and mobility items. Use this to defensibly record usual performance during the 3-day admission window (Days 1–3) without triggering RAC audit upcoding flags.

⚠️

Standing RAC Audit & Anti-Upcoding Rule: Always code usual performance across the entire assessment window—never the single best or worst episode. GG scores directly calculate PDPM case-mix group payment. Code 88 is worth zero points (same as 01) and requires charted clinical rationale showing why attempting the activity was medically unsafe.

Code	CMS Performance Label	Helper Effort Required	Bedside Documentation Phrasing Example
06	Independent	0% helper effort (including setup/cleanup)	"Resident retrieves rolling walker from bedside, stands without cues, ambulates 150 ft in corridor unassisted with steady gait."
05	Setup or Clean-Up Assist	Helper assists only before or after activity	"CNA opened milk carton, peeled fruit, and applied built-up spoon. Resident completed 100% of meal independently."
04	Supervision / Touching Assist	Verbal cues, steadying, or contact guard assist (CGA)	"Contact guard assist at gait belt during sit-to-stand; verbal cue 'nose over toes'. Resident provided 100% of physical lifting effort."
03	Partial / Moderate Assist	Helper provides less than half (<50%) of physical effort	"Resident initiated sit-to-lying, pushed with elbows; nurse supported left surgical leg and guided trunk for final 30° of descent."
02	Substantial / Maximal Assist	Helper provides more than half (>50%) of physical effort	"Nurse lifted bilateral lower extremities into bed and bore majority of trunk weight; resident assisted by holding rail with right hand."
01	Dependent	Helper provides 100% effort, or 2+ helpers required	"Mechanical ceiling lift transfer bed to wheelchair with 2 staff members assisting per facility safety protocol."

Activity Not Attempted (ANA) Decision Matrix

Use an ANA code only when the activity was not attempted at any point during the entire 3-day admission window:

ANA Code	CMS Category	Correct Clinical Use	Auditor Trap / Common Misuse
07	Resident Refused	Resident declined every offer of shower/mobility across all 3 days; each refusal charted with time and rationale.	Coding 07 because the resident refused a single 0545 transfer offer while sleeping.
09	Not Applicable	Resident did not perform activity prior to acute illness (e.g., wheelchair user for 10 years coded on 12-step stairs).	Coding 09 because resident "cannot walk today." (That is Code 88 or 01, not 09).
10	Environmental Limitation	Equipment unavailable, severe weather blocked outdoor curb/ramp testing, or structural barrier.	Coding 10 to cover a temporary shift staffing shortage.
88	Medical Condition / Safety	Active order for strict bedrest, bilateral NWB, symptomatic orthostasis (SBP 76), or acute cardiac instability.	Coding 88 for routine subjective pain without documentation of physiological safety hazard.

Tool 3: Physician Communication

Condition-Specific SBAR Escalation Flowsheets

Structured call scripts with vital sign thresholds, scale scores, and clinical data to gather before calling the attending practitioner or on-call provider. Click "Copy SBAR Script" to copy a structured phone frame directly to your clipboard.

Scenario 1: Neurological

Acute Mental Status Change & Suspected Delirium

Pre-Call Data Checklist:

Baseline vs. Current BIMS score (or prior cognitive baseline)
CAM Screen (Onset acute? Inattention? Disorganized thinking? Altered LOC?)
Vitals: T, HR, BP, RR, SpO2, and immediate Accu-Chek BG
Bladder scan volume (rule out urinary retention) & Last BM date (impaction)

S: "Dr. [Name], this is [Nurse] at [Facility], calling regarding [Resident, Room]. Resident has acute onset of delirium with CAM positive, unable to recognize family as of 1400."

B: "84yo female admitted [date] for hip fracture rehab. Baseline BIMS 13/15. Last dose of oxycodone 5mg at 0800. No history of baseline psychotic symptoms."

A: "Current vitals: T 99.4°F, BP 138/82, HR 96, RR 20, SpO2 96% RA, fingerstick BG 112. Bladder scan shows 480 mL; abdomen soft, last BM yesterday. Lethargic, inattentive, picking at air."

R: "I recommend an in-and-out catheterization for the 480 mL retention, a STAT urinalysis and culture, and basic metabolic panel. Would you like to evaluate or order haloperidol 0.5mg if severe agitation develops?"

Scenario 2: Fall Incident

Post-Fall Assessment (Suspected Head Strike / Anticoagulant)

Pre-Call Data Checklist:

Anticoagulant status verified on MAR (Apixaban, Warfarin, Rivaroxaban)
Neuro checks: PERRLA, Glasgow Coma Scale / orientation, limb strength (1-5)
Limb inspection: Shortening or external rotation of hips, deformity, swelling
Immediate vital signs, blood glucose, and ROM evaluation

S: "Dr. [Name], this is [Nurse] calling regarding [Resident, Room]. Resident experienced an unobserved fall at 0215 with suspected head strike. Resident is on active anticoagulant therapy."

B: "81yo male with atrial fibrillation on Eliquis 5mg BID. Admitted post-stroke. DNR order confirmed on file."

A: "Found sitting on floor beside bed. 2.5 cm hematoma right frontal scalp; pupils equal and brisk at 3mm; oriented x2 (person, place; forgot room number). Moving all 4 extremities symmetrically. BP 164/92, HR 78, RR 18, SpO2 97%, BG 124. No hip shortening or external rotation."

R: "Given active Eliquis and scalp hematoma, I recommend a transfer to the emergency department for a STAT non-contrast head CT and trauma evaluation. Do you approve transfer orders?"

Scenario 3: Cardiopulmonary

Acute Dyspnea, Hypoxia & Heart Failure Decompensation

Pre-Call Data Checklist:

Auscultated lung sounds by field (crackles, wheezing, rhonchi, clear)
SpO2 on room air vs. ordered oxygen liter flow
Weight gain trend (e.g., ≥2 lb in 24h or ≥5 lb in 1 week)
Dependent peripheral edema grade (1+ to 4+) and JVD assessment

S: "Dr. [Name], this is [Nurse] calling about [Resident, Room]. Resident has new acute shortness of breath and desaturation to 88% on room air at 0630."

B: "78yo female with systolic heart failure (EF 35%) and CKD Stage 3. Baseline weight 142 lb; morning weight 146.4 lb (+4.4 lb in 48 hours)."

A: "Coarse bilateral basilar crackles halfway up posterior fields. RR 26, shallow, using accessory neck muscles. 3+ pitting edema bilateral lower extremities to mid-calf. BP 168/96, HR 104 irregular. O2 applied at 2L NC with SpO2 rising to 92%."

R: "I recommend a STAT one-time dose of furosemide 40mg IV, a portable chest x-ray, STAT BMP and BNP, and titration of O2 to maintain SpO2 ≥92%. Would you also like strict fluid restrictions ordered?"

Scenario 4: Infection / Sepsis

Suspected Sepsis & Hemodynamic Instability

Pre-Call Data Checklist:

Temperature curve (fever >100.4°F or hypothermia <96.8°F)
Hemodynamics: SBP drop <100 mmHg or >40 mmHg below baseline; HR >90
Suspected focus: Lung (cough/sputum), Urine (cloudy/odor/frequency), Skin (cellulitis/wound)
Lactate / CBC / Blood culture availability at facility

S: "Dr. [Name], this is [Nurse] calling regarding [Resident, Room]. Resident meets clinical sepsis screening criteria with fever, tachycardia, and a 30-point blood pressure drop."

B: "86yo male with indwelling Foley catheter for urinary retention and Parkinson's. Baseline BP is 130/74."

A: "Current vitals: T 101.8°F, BP 92/56, HR 114, RR 24, SpO2 93% on RA. Urine in drainage bag is cloudy, dark amber with heavy sediment and foul odor; output only 60 mL in past 4 hours. Lethargic, skin hot and flushed."

R: "Resident appears in septic shock secondary to CAUTI. I recommend STAT 500 mL normal saline IV bolus, STAT blood and urine cultures, and transfer to the hospital emergency department for IV antibiotic therapy and resuscitation."

Companion Handbook

Gerontological Nursing & Eldercare Documentation

The Clinical Bedside Guide to Skilled Nursing Charting, MDS 3.0 / Section GG, Care Plans, and SBAR Communications

54,000+ words across 10 tactical clinical modules. Master 42 CFR §409 skilled coverage rules, Section GG usual-performance scoring, fall incident reporting without QA privilege traps, NPIAP wound staging, and 25 full-page fill-in DAR shift note templates.

Explore Book 1: Clinical Nursing Care Plans →

10 Clinical Modules

25 DAR Note Templates

100% Audit-Proof Phrasing