Ask the nursing expert: How do you keep records organized in preparation for annual reviews?

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Ask the nursing expert
Ask the nursing expert
Q: We have finished our annual survey (my first one) and are writing our plan of correction. What would you recommend for organizing audits, in-services, etc., for ongoing review?

A: I select a member of the nursing leadership team, (usually my ADON) to be the “record keeper” for survey information. She develops a binder titled “Credible Evidence, Survey 2011” and uses tabs to identify the F-tags cited.

The binder is professionally labeled. In the front is the 2567 with plan of correction. The ADON organizes the information to be gathered under the F-tag, such as audits, logs, in-service sign-in sheets and content, etc. She reviews the binder on a monthly basis to ensure that we are on track and gives a monthly report to the QA Committee for review.

When the survey team enters the facility the next year and asks for information related to the previous plan of correction, the binder is then given to the survey leader. I believe that “presentation” of information requested sets the tone of your survey.

Q: What would you say to a nurse who puts in a request for time off, with a note stating “I have bought my plane tickets, so I must have this time off?”

A: I am very clear about vacation requests: “Do not buy plane tickets until time off requested is approved!”

I always want to check if the staff member has enough leave time and review the facility policy. My facility policy is two weeks together during the summer months and up to three weeks at other times, with exceptions being in November and December.

Sometimes staff try to put pressure on the DON, stating that they are in a “use-or-lose” situation, especially in December. I do not give in, as time-off request parameters are made very clear in staff meetings.

Please send your nursing-related questions to Anne Marie Barnett at

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