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As a patient, you have the right to provide feedback on your care and treatment. The Patient Review Insterment Form is one way to do that. This form can be used to provide information about your overall satisfaction with the hospital or healthcare services you received, as well as rating key aspects of your care. It can also be used to make suggestions for improvement. completing this form is voluntary, but we hope that you will take the time to fill it out so that we can continue to improve our services.

Listed below are some facts you might want to review before working with the patient review insterment.

QuestionAnswer
Form NamePatient Review Insterment
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesblank pri forms, printable pri form, pri document nys, nys pri form

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NEW YORK STATE DEPARTMENT OF HEALTH

OHSM-Division of Quality and Surveillance for Nursing Homes and ICFs/MR

Hospital and Community Patient Review Instrument (HC-PRI)

RUG II Group (print name)

RHCF Level of Care:

HRF

SNF

Use with separate Hospital and Community PRI Instructions

I. ADMINISTRATIVE DATA

1. OPERATING CERTIFICATE NUMBER

2.

SOCIAL SECURITY NUMBER

(1-8)

(9-17)

- -

 

3.OFFICIAL NAME OF HOSPITAL OR OTHER AGENCY/FACILITY COMPLETING THIS REVIEW

4A. PATIENT NAME (AND COMMUNITY ADDRESS IF REVIEWED IN COMMUNITY)

4B. COUNTY OF RESIDENCE

5. DATE OF PRI COMPLETION

(18-25)- -

MO DAY YEAR

6.MEDICAL RECORD NUMBER/CASE NUMBER

(26-34)

7.HOSPITAL ROOM NUMBER

(35-39)

8.NAME OF HOSPITAL UNIT/DIVISION/BUILDING

9.DATE OF BIRTH

(40-47)

- -

 

MO DAY YEAR

10. SEX (48)

1=Male

 

2=Female

II. MEDICAL EVENTS

16.DECUBITUS LEVEL: ENTER THE MOST SEVERE LEVEL (0-5) AS DEFINED IN THE INSTRUCTIONS.

17.MEDICAL CONDITIONS: DURING THE PAST WEEK. READ THE INSTRUCTIONS FOR SPECIFIC DEFINITIONS

1=YES

2=NO

A. Comatose B. Dehydration

C. Internal Bleeding D. Stasis Ulcer

E. Terminally Ill F. Contractures

G. Diabetes Mellitus

H. Urinary Tract Infection

I. HIV Infection Symptomatic J. Accident

K. Ventilator Dependent

11A. DATE OF HOSPITAL ADMISSION OR INITIAL AGENCY VISIT

 

(49-56)

-

-

 

 

MO DAY YEAR

 

11B. DATE OF ALTERNATE LEVEL OF CARE STATUS IN HOSPITAL

(IF APPLICABLE)

 

 

(57-64)

-

-

 

 

 

MO

DAY YEAR

 

12.

MEDICAID NUMBER

 

(65-75)

 

 

 

 

13.

MEDICARE NUMBER

 

(76-85)

 

 

 

 

14.

PRIMARY PAYOR

(86)

1=Medicaid

2=Medicare 3= Other

15.REASON FOR PRI COMPLETION (87)

1.RHCF Application from Hospital

2.RHCF Application from Community

3. Other (Specify:

)

18.MEDICAL TREATEMENTS: READ THE INSTRUCTIONS FOR THE QUALIFIERS.

1=YES

2=NO

A.Trachesotomy Care/Suctioning (Daily—Exclude self-care)

B.Suctioning-General (Daily)

C.Oxygen (Daily)

D.Respiratory Care (Daily)

E.Nasal Gastric Feeding

F.Parenteral Feeding

G.Wound Care

H.Chemotherapy

I.Transfusion

J.Dialysis

K.Bowel and Bladder Rehabilitation (SEE INSTRUCTIONS)

L.Catheter (Indwelling or External)

M.Physical Restraints (Daytime Only)

DOH-694 (12/05) Page 1 of 4

III. ACTIVITIES OF DAILY LIVING (ADLs)

Measure the capability of the patient to perform each ADL 60% or more of the time it is performed during the past week (7 days). Read the Instructions for the Changed Condition Rule and the definitions of the ADL terms.

19. EATING: PROCESS OF GETTING FOOD BY ANY MEANS FROM THE RECEPTACLE INTO THE BODY (FOR EXAMPLE:

19.

PLATE, CUP, TUBE)

 

(113)

1=Feeds self without supervision or physical assistance. May use

3= Requires continual help (encouragement/teaching/physical assistance)

adaptive equipment.

with eating or meal will not be completed.

 

2=Requires intermittent supervision (that is, verbal

4=Totally fed by hand, patient does not manually participate

 

encouragement/guidance) and/or minimal physical assistance with

 

 

minor parts of eating, such as cutting food, buttering bread or

5=Tube or parenteral feeding for primary intake of food. (Not just for

opening milk carton.

supplemental nourishments)

 

20. MOBILITY: HOW THE PATIENT MOVES ABOUT

 

20.

 

 

(114)

1=Walks with no supervision or human assistance. May require mechanical device (for example, a walker), but not a wheelchair. 2=Walks with intermittent supervision (that is, verbal cueing and observation). May require human assistance for difficult parts of walking (for example, stairs, ramps).

3= Walks with constant one-to-one supervision and/or constant physical assistance.

4= Wheels with no supervision or assistance, except for difficult maneuvers (for example, elevators, ramps). May actually be able to walk, but generally does not move.

5= Is wheeled, chairfast or bedfast. Relies on someone else to move about, if at all.

21. TRANSFER: PROCESS OF MOVING BETWEEN POSITIONS, TO/FROM BED, CHAIR, STANDING, (EXCLUDE

21.

TRANSFERS TO/FROM BATH AND TOILET).

 

(115)

 

 

1=Requires no supervision or physical assistance to complete

3=Requires one person to provide constant guidance, steadiness and/or

necessary transfers. May use equipment, such as railings, trapeze.

physical assistance. Patient may participate in transfer.

 

2=Requires intermittent supervision (that is, verbal cueing, guidance)

4=Requires two people to provide constant supervision and/or physically lift.

and/or physical assistance for difficult maneuvers only.

May need lifting equipment.

 

 

5=Cannot and is not gotten out of bed.

 

22. TOILETING: PROCESS OF GETTING TO AND FROM A TOILET (OR USE OF OTHER TOILETING EQUIPMENT, SUCH AS

22.

BEDPAN). TRANSFERRING ON AND OFF TOILET, CLEANSING SELF AFTER ELIMINATION AND ADJUSTING CLOTHES.

(116)

 

1=Requires no supervision or physical assistance. May require

3=Continent of bowel and bladder. Requires constant supervision and/or

special equipment, such as a raised toilet or grab bars.

physical assistance with major/all parts of the task, including appliances (i.e.,

 

colostomy, ileostomy, urinary catheter).

 

2=Requires intermittent supervision for safety or encouragement, or

4=Incontinent of bowel and/or bladder and is not taken to a bathroom.

minor physical assistance (for example, clothes adjustment or

5=Incontinent of bowel and/or bladder, but is taken to a bathroom every two

washing hands).

to four hours during the day and as needed at night.

 

IV. BEHAVIORS

23. VERBAL DISRUPTION: BY YELLING, BAITING, THREATENING, ETC.

23.

 

 

(117)

1=No known history

4=Unpredictable, recurring verbal disruption at least once during the past

2=Known history or occurrences, but not during the past week (7

week (7 days) for no foretold reason

 

days)

 

 

3=Short-lived or predictable disruption regardless of frequency (for

5=Patient is at level #4 above, but does not fulfill the active treatment and

example, during specific care routines, such as bathing.)

assessment qualifiers (in the instructions)

 

24. PHYSICAL AGGRESSION: ASSAULTIVE OR COMBATIVE TO SELF OR OTHERS WITH INTENT FOR INJURY. (FOR

24.

EXAMPLE, HITS SELF, THROWS OBJECTS, PUNCHES, DANGEROUS MANEUVERS WITH WHEELCHAIR)

(118)

 

1=No known history.

4=Unpredictable, recurring aggression at least once during the past week (7

2=Known history or occurrences, but not during the past week (7

days) for no apparent or foretold reason (that is, not just during specific care

days).

routines or as a reaction to normal stimuli).

 

3=Predictable aggression during specific care routines or as a

5=Patient is at level #4 above, but does not fulfill the active treatment and

reaction to normal stimuli (for example, bumped into), regardless of

assessment qualifiers (in the instructions).

 

frequency. May strike or fight.

 

 

DOH-694 (12/05) Page 2 of 4

25. DISRUPTIVE, INFANTILE OR SOCIALLY INAPPROPRIATE BEHAVIOR: CHILDISH, REPETITIVE OR ANTISOCIAL

25.

PHYSICAL BEHAVIOR WHICH CREATES DISRUPTION WITH OTHERS. (FOR EXAMPLE, CONSTANTLY UNDRESSING SELF,

(119)

 

STEALING, SMEARING FECES, SEXUALLY DISPLAYING ONESELF TO OTHERS). EXCLUDE VERBAL ACTIONS. READ THE

 

INSTRUCTIONS FOR OTHER EXCLUSIONS.

 

 

 

1=No known history

 

4=Occurences of this disruptive behavior at least once during the past week

2=Displays this behavior, but is not disruptive to others (for example,

(7 days)

 

rocking in place).

 

 

 

3=Known history or occurrences, but not during the past week (7

5=Patient is at level #4 above, but does not fulfill the active treatment and

days).

 

psychiatric assessment qualifiers (in instructions).

 

26. HALLUCINATIONS: EXPERIENCED AT LEAST ONCE DURING THE PAST WEEK. VISUAL, AUDITORY OR TACTILE

26.

PERCEPTIONS THAT HAVE NO BASIS IN EXTERNAL REALITY.

 

(120)

 

 

1=Yes

2=No

3=Yes, but does not fulfill the active treatment

 

 

and psychiatric assessment qualifiers (in the

 

 

instructions)

 

V.SPECIALIZED SERVICES

27.PHYSICAL AND OCCUPATIONAL THERAPIES: READ INSTRUCTIONS AND QUALIFIERS. EXCLUDE REHABILITATIVE NURSES AND OTHER SPECIALIZED THERAPISTS (FOR EXAMPLE, SPEECH THERAPIST). ENTER THE LEVEL, DAYS AND TIME (HOURS AND MINUTES) DURING THE PAST WEEK (7 DAYS).

A. Physical Therapy (P.T.)

P.T. Level

 

 

(121)

 

 

P.T. Days

 

 

(122)

 

 

P.T. Time

 

 

(123-126)

HOURS MIN/WEEK

B. Occupational Therapy (O.T.)

O.T. Level

 

 

(127)

 

 

O.T. Days

 

 

(128)

 

 

O.T. Time

 

 

(129-132)

HOURS MIN/WEEK

LEVEL

3=Restorative Therapy-Requires and is currently receiving physical and/or

1=Does not receive.

occupational therapy for the past week.

2= Maintenance program-Requires and is currently receiving

4=Receives therapy, but does not fulfill the qualifiers stated in the

physical and/or occupational therapy to help stabilize or slow

instructions. (For example, therapy provided for only two days).

functional deterioration.

 

DAYS AND TIME PER WEEK: ENTER THE CURRENT NUMBER OF DAYS AND TIME (HOURS AND MINUTES) DURING THE PAST WEEK (7 DAYS) THAT EACH THERAPY WAS PROVIDED. ENTER ZERO IF AT #1 LEVEL ABOVE. READ INSTRUCTIONS AS TO QUALIFIERS IN COUNTING DAYS AND TIME.

28.NUMBER OF PHYSICIAN VISITS: DO NOT ANSWER THIS QUESTION FOR HOSPITALIZED PATIENTS, (ENTER ZERO), UNLESS ON ALTERENATE LEVEL OF CARE STATUS. ENTER ONLY THE NUMBER OF VISITS DURING THE PAST WEEK THAT ADHERED TO THE PATIENT NEED AND DOCUMENTATION QUALIFIERS IN THE INSTRUCTIONS. THE PATIENT MUST BE MEDICALLY UNSTABLE TO ENTER ANY PHYSICIAN VISITS, OTHERWISE ENTER A ZERO.

28.

(133-134)

VI. DIAGNOSIS

29.PRIMARY PROBLEM: THE MEDICAL CONDITION REQUIRING THE LARGEST AMOUNT OF NURSING TIME IN THE HOSPITAL OR CARE TIME IF IN THE COMMUNITY. (FOR HOSPITALIZED PATIENTS THIS MAY OR MAY NOT BE THE ADMISSION DIAGNOSIS).

ICD-9 Code of medical problem29. -

(135-139)

If code cannot be located, print medical name here:

DOH-694 (12/05) Page 3 of 4

VII. PLAN OF CARE SUMMARY

This section is to communicate to providers any additional clinical information, which may be needed for their preadmission review of the patient. It does not have to be completed if the information below is already provided by your own form, which is attached to this H/C-PRI.

30.DIAGNOSES AND PROGNOSES: FOR EACH DIAGNOSIS, DESCRIBE THE PROGNOSIS AND CARE PLAN IMPLICATIONS. Primary Prognosis

Secondary (Include Sensory Impairments)

2.

3.

4.

31. REHABILITATION POTENTIAL (INFORMATION FROM THERAPISTS)

A.POTENTIAL DEGREE OF IMPROVEMENT WITH ADLs WITHIN SIX MONTHS (DESCRIBE IN TERMS OF ADL LEVELS ON THE HC-PRI):

B.CURRENT THERAPY CARE PLAN: DESCRIBE THE TREATMENTS (INCLUDING WHY) AND ANY SPECIAL EQUIPMENT REQUIRED.

32. MEDICATIONS

 

 

 

 

NAME

DOSE

FREQUENCY

ROUTE

DIAGNOSIS REQUIRING

 

 

 

 

EACH MEDICATION

33.TREATMENTS: INCLUDE ALL DRESSINGS, IRRIGATIONS, WOUND CARE, OXYGEN.

A. TREATMENTS

DESCRIBE WHY NEEDED

FREQUENCY

B. NARRATIVE: DESCRIBE SPECIAL DIET, ALLERGIES, ABNORMAL LAB VALUES, PACEMAKER.

34.RACE/ETHNIC GROUP: ENTER THE CODE WHICH BEST DESCRIBES THE PATIENT’S RACE OR ETHNIC GROUP 34.

1=White

4=Black/Hispanic

7=American Indian or Alaskan Native

2=White/Hispanic

5=Asian or Pacific Islander

8=American Indian or Alaskan Native/Hispanic

3=Black

6=Asian or Pacific Islander/Hispanic

9=Other

35.QUALIFIED ASSESSOR: I HAVE PERSONALLY OBSERVED/INTERVIEWED THIS PATIENT AND COMPLETED THIS H/C PRI. YES NO

I CERTIFY THAT THE INFORMATION CONTAINED HEREIN IS A TRUE ABSTRACT OF THE PATIENT’S CONDITION AND MEDICAL RECORD.

___________________________________

IDENTIFICATION NO.

SIGNATURE OF QUALIFIED ASSESSOR

DOH-694 (12/05) Page 4 of 4

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