Target Behavior Identification and Tracking Form

Initial clinical documentation form for identifying and tracking target behaviors related to psychotropic medication use, supporting required documentation under F-tag 758.

Documentation Overview

• Resident Identifier
  Enter the resident's internal identifier or chart number. Avoid collecting unnecessary PII.
• Documentation Date
  Date this target behavior tracking form is completed.
• Documented By
  Name and role of the staff member completing this form.
• Reason for Tracking
  Select the primary reason the behavior is being tracked.
• Other Reason
  Provide a brief explanation if 'Other' was selected.
• Tracking Start Date
  Date the target behavior baseline tracking begins.

Target Behavior Definition

• Behavior Category
  Select all categories that apply to the target behavior.
• Objective Behavior Description
  Describe exactly what the resident does, including observable actions, words, and context. Example: 'Hits staff with open hand during bathing assistance.'
• Known Triggers or Antecedents
  Select known triggers that appear to precede the behavior.
• Trigger Details
  Describe any trigger not listed above.
• Observed Frequency
  Number of times the behavior is observed per shift, day, or other defined period.
• Frequency Unit
  Select the time period used for the frequency count.

Impact and Safety Assessment

• Observed Impact
  Select all impacts that have been observed.
• Impact Details
  Describe the specific impact observed and any immediate response required.
• Did injury or harm occur?
• Injury or Harm Details
  Document the nature of the injury or harm, including who was affected and what intervention was provided.

Baseline Tracking and Follow-Up

• Baseline Measurement Method
  Select how the behavior will be measured during baseline tracking.
• Baseline Tracking Duration (Days)
  Number of days planned for baseline tracking before review.
• Follow-Up Review Date
  Date the care team will review the tracked behavior and response.
• Planned Follow-Up Action
  Select the next action after baseline tracking.
• Additional Notes
  Include any other clinically relevant information needed for the audit trail.

Consent and Submission

• PII and Minimum-Necessary Notice Acknowledged
  I understand this form collects only the minimum necessary information for clinical documentation and audit trail purposes.
• Information Accuracy Confirmed
  I confirm the information entered is accurate to the best of my knowledge.
• Submission Attestation
  Electronic attestation by the staff member submitting this form.