Incontinence Management Project

Forms and Checklists

FORMS FOR STEP 2--PROMPTED VOIDING TRIAL

• Assessing Urinary Incontinence: Pocket Card (PDF)
• Prompted Voiding Procedure (PDF)
• Urinary Continence Assessment Checklist (PDF from the Illinois Foundation for Quality Health Care)
• Toileting Motivation and Preference Assessment Survey (PDF)
• Prompted Voiding Trial (PDF)
• Prompted Voiding Trial (with instructions) (Word Document)
• Prompted Voiding Trial (with instructions) (PDF)
• Calculate Residents' Appropriate Toileting Rate (MS Excel file)
  
• Calculate the Wetness Warning Limit for Program Monitoring (MS Excel file)
  
• Wet Check Form for Program Monitoring (PDF)
  

FORMS FOR ASSESSING INCONTINENCE QUALITY INDICATORS (use together)

• Medical Record Review (PDF)
• Quality Indicator Data Sources and Scoring Rules (PDF)

We worked with researchers at RAND, a southern California think tank, to develop a series of nine quality indicators (QI) related to incontinence care for nursing home residents. Presented as a series of if/then statements, these QIs outline minimally acceptable care for the assessment and treatment of incontinent residents. QIs, writes RAND, "set a minimal standard for acceptable care-standards that, if not met, almost ensure that the care is of poor quality."

Based on expert opinion and existing best-practice guidelines, all of our QI-associated assessment and treatment tasks are both related to positive outcomes for residents and feasible for nursing home staff to implement. Use the two QI forms listed above to evaluate incontinence care in your facility.