Patient Review Instrument Form PDF Details

Understanding how your patients feel about the care they receive is essential for providing quality medical treatment. The Patient Review Instrument Form is a simple but powerful tool designed to help you get feedback from your patients on their experience at your office. This form helps gather information on patient satisfaction, allowing healthcare providers like yourself to apply improvements and stay informed of patient sentiment. Read on to learn more about what this review instrument can do for you and why it's such an important asset in the healthcare provider-patient relationship.

QuestionAnswer
Form NamePatient Review Instrument Form
Form Length19 pages
Fillable?No
Fillable fields0
Avg. time to fill out4 min 45 sec
Other namespatient review instrument form, new york patient review instrument, patient review instrument blank form for nys, patient review instrument forms

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NEW YORK STATE DEPARTMENT OF HEALTH

DI VI SI ON OF HEALTH CARE FI NANCI NG

I NSTRUCTI ONS: HOSPI TAL AND COMMUNI TY PATI ENT REVI EW I NSTRUMENT

GENERAL CONCEPTS:

1.PURPOSE: Pre-admission review to a Residential Health Care Facility (RHCF) from the hospital and community based residences and facilities, such as personal dwelling, domiciliary care facility/ adult home and congregate housing.

2.ASSESSORS: As qualified through the New York State Department of Health PRI Training Program - hospital discharge planners, certified home health care agency registered nurses, RHCF registered nurses, county public health nurses and other utilization review personnel as designated.

3.USI NG THESE I NSTRUCTI ONS: These instructions should be read before completing the H/ C PRI and should be kept with the H/ C PRI s as they are being completed. FREQUENT REFERENCE TO THE I NSTRUCTI ONS WI LL BE NEEDED I N ORDER TO COMPLETE THE H/ C PRI ACCURATELY.

4.ANSWER ALL QUESTI ONS: Answer all questions using the numeric codes provided. DO NOT LEAVE ANY QUESTI ONS TOTALLY BLANK. UNUSED BOXES FOR A QUESTI ON SHOULD REMAI N BLANK. For example, Medical Record Number: / _ / 9 / 6 / 2 / 1 / 0 / . I f there are unused boxes, they should be the left side of the number as shown in the example.

5.QUALI FI ERS: Many of the PRI questions contain multiple criteria which are labeled qualifiers. All qualifiers must be met for a question to be answered “yes.” These qualifiers take the following forms.

Time Period: The time period for the questions is the past week. For the patients who have been in the hospital for less than one week use the time from admission to H/ C PRI

completion as the time frame. I f the community assessor (e.g. certified home health care agency, RHCF assessor) does not have any history on the patient, then the day of the H/ C PRI assessment is the timeframe. See “Sources of I nformation” below.

Frequency – The frequency specifies how often something needs to occur to meet the qualifier. For example. Suctioning needs to occur daily for at least one week or the PRI cannot be checked for this patient as receiving this care.

Documentation. Some of the questions require specific medical record documentation to be present. Otherwise, the question cannot be answered “yes” for the patient.

Exclusions - Some of the questions specifically state to omit certain types of care or behavior when answering the question. For example, inhalators are excluded from oxygen therapy.

6.SOURCES OF I NFORMATI ON: For community based referred patients, the sources of information may not be as accessible as in the hospital. Discussion with the patient’s family members, other caregivers and personal physician(s) will help provide more accurate information. The patient may be receiving community services or may have in the past .

7.ACTI VI TI ES OF DAI LY LI VI NG (ADLs): The approach to measuring ADLs is slightly different from other PRI questions. Measure how capable the patient is in completing each ADL sixty percent (60% ) or more of the time that it needs to be performed. CAPABI LI TY: Reviewing the patient’s

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physical and mental status, measure the present capability of the patient to perform each ADL. This is in contrast to how the patient may be actually performing the ADLs in the hospital/ facility or in the community. Read the specific instructions on ADLs to understand the CHANGED CONDI TI ON RULE, the specific ADL definitions and the measurement of capability.

8.CORRECTI ONS: Cross out any response which you wish to change and reenter clearly to the

right of the original response. Example: / 3/ 4

3

I NSTRUCTI ONS: H/ C- PRI QUESTI ONS

I . ADMI NI STRATI VE DATA

1.OPERATI NG CERTI FI CATE NUMBER:

Enter the seven (7) or eight (8) character identifier stated on the facility’s / agency operating certificate. For a hospital there will always be seven (7) numbers followed by an “H” in the eighth box. For a certified home health agency and a county Department of Health, there will only be seven (7) numbers with no letters. This means that the first answer box to the left will remain blank. For a residential health care facility, there will be seven (7) numbers followed by a “P”, for a health related facility (HRF) or an “N” for a skilled nursing facility (SNF).

2.

SOCI AL SECURI TY

Do not leave blank; enter zero in far right hand box if

 

NUMBER:

patient does not have a number

3.OFFI CI AL FACI LI TY NAME: Print the formal name of the hospital/ community agency, etc.

4.

PATI ENT NAME:

When completing the H/ C PRI do not use nicknames.

 

 

Print last name first (e.g., Brant, Diana C).

6.

MEDI CAL RECORD

Enter the unique number assigned by the hospital/ agency

 

NUMBER/ CASE NUMBER:

to identify each patient . I t is not the Medicaid, Medicare

 

 

or Social Security number, unless that is the number used

to identify patients. I f there is no assigned case number for the community based patient, leave this question blank.

7.HOSPI TAL ROOM NUMBER: Enter the numbers and/ or letters which identify the patient’s room in the hospital or other applicable community facility. I f the patient is residing in the community when the H/ C-PRI review is completed, then print the address in Question 4, “Patient Name.”

(Community is defined as a personal dwelling, Adult Home, congregate housing or other domiciliary type of facilities/ dwellings.)

8.

NAME OF HOSPI TAL

Print the name of the hospital unit, such as “med-

 

UNI T/ BUI LDI NG/ DI VI SI ON:

surgery,” where the patient was reviewed. I nclude any

 

 

other unique hospital location identifiers, such as specific

 

 

building names where the unit is located. However, if the

 

 

patient has changed units or buildings or will be moving,

 

 

then print instead where the patient can be located in the

 

 

future (if known) . I f the patient is reviewed in the

 

 

community, then this question is not applicable and can

 

 

be left blank.

11A.

DATE OF HOSPI TAL

Enter in numerical format the month, day and year the

 

ADMI SSI ON OR I NI TI AL

patient was admitted to this hospital for purposes of this

 

 

4

 

AGENCY VI SI T:

review. (Use most recent hospitalization date for multiple

 

 

hospitalizations.) Do not include the date of Alternate

 

 

Level of Care status, rather enter this date, if applicable,

 

 

in Question 11B.

 

 

I f the patient is being reviewed in the community, enter

 

 

the date of the initial patient visit by the certified home

 

 

health care agency, nursing home or any other qualified

 

 

agency/ organization. This visit may be a followup to a

 

 

referral made by the patient, the patient’s family, the

 

 

patient’s physician, etc.

11B.

DATE OF ALTERNATE

Enter in numerical format the day, month and year the

 

LEVEL OF CARE STATUS:

patient went onto Alternate Level of Care status (ALC) in

 

 

the hospital. I f the patient has entered ALC status more

 

 

than once during this hospital stay, enter the most recent

 

 

ALC admission date. (That is, this patient was on ALC

 

 

status, but was discharged because of an acute episode

 

 

and then went back to ALC status.) I f the patient is not

 

 

on ALC status or is in the community during this review,

 

 

enter a zero (0) in the far right hand box.

12.

MEDI CAI D NUMBER:

Enter these numbers if patient has such coverage

13.

MEDI CARE NUMBER:

Available, whether or not coverage is being used. I f not,

 

 

enter only one zero (0) in the far right hand box.

14.

PRI MARY PAYOR:

Enter the one source of coverage which pays for most of

 

 

the patient’s current hospitalized stay; for patients in the

 

 

community enter what is covering the patient’s community

 

 

health care needs. Code “other” only if the primary payor

 

 

is not Medicaid or Medicare. “Other” includes self-pay and

 

 

private insurance.

15.

REASON FOR PRI

Select the one reason why the PRI is being completed.

 

COMPLETI ON:

This is for preadmission review purposes.

#1 RHCF Application from Hospital means the patient resides in the hospital at the time of this H/ C-PRI review and is applying for admission into a residential health care facility (RHCF, HRF or SNF). This H/ C-PRI is being completed by a qualified hospital assessor or another qualified assessor (i.e. RHCF assessor, certified home health care assessor) who enters the hospital to review the patient.

#2 RHCF Application for Community means the patient resides in the community during this

H/ C-PRI review. I nclude Adult Homes and other domiciliary care facilities.

I I .

MEDI CAL EVENTS

 

16.

DECUBI TUS LEVEL:

Enter the level of skin breakdown (located at pressure

 

 

points) using the qualifiers stated below:

 

DOCUMENTATI ON -

For a patient to be cited as level 4, documentation by a

 

 

licensed clinician must exist which describes the following

 

 

three components:

5

 

A description of the patient’s decubitus.

 

Circumstances or medical condition which leads

 

decubitus.

 

An active treatment plan.

DEFI NI TI ON

 

LEVELS:

 

# 0

No reddened skin or breakdown.

# 1

Reddened skin, potential breakdown.

# 2

Blushed skin, dusty colored, superficial layer of broken or

 

blistered skin.

# 3

Subcutaneous skin is broken down.

# 4

Necrotic breakdown of skin and subcutaneous tissue which may

 

involve muscle, fascia and bone.

# 5

Patient is at a level 4, but the documentation qualifier has not

 

been met .

17. MEDI CAL CONDI TI ONS:

For a YES to be answered for any of these conditions, all

 

of the following qualifiers must be met:

Time Period - Condition must be existed during the past week.

Documentation -

Written support exists that the patient has the condition.

Definitions - See chart below. (Examples are for clarification and are not intended to be all-inclusive.)

 

 

Definition

17A

COMATOSE:

Unconscious, cannot be

 

 

aroused, and at most can

 

 

respond only to powerful

 

 

stimuli. The coma must

 

 

be present for at least

 

 

four days.

17B

DEHYDRATI ON:

Excessive loss of body

 

 

fluids requiring immediate

 

 

medical treatment and

 

 

ADL care.

17C

I NTERNAL

Blood loss stemming from

 

BLEEDI NG:

a subacute or chronic

 

 

condition (e.g.,

 

 

gastrointestinal,

 

 

respiratory or genito-

 

 

urinary conditions) which

 

 

may result in low blood

 

 

pressure and hemoglobin,

 

 

pallor, dizziness, fatigue,

 

 

rapid respiration.

17D

STASI S ULCER:

Open lesion, usually in

 

 

lower extremities, caused

 

 

by decreased blood flow

from chronic venous insufficiency.

Examples of Causes

Examples of

 

Treatment

Brain insult

Total ADL

Hepatic encephalopathy

intake & output

Cardiovascular accident

Parenteral

 

feeding

Fever

I ntake & output

Acute urinary tract infections

Electrolyte lab

Pneumonia

tests

Vomiting

Parenteral

Unstable diabetes

hydration

 

Nasal feedings

Use only the causes presented in

Critical

the definition.

monitoring of

 

vital signs

Exclude external hemorrhoids

Transfusion

and other minor blood loss

Use of blood

which is not dangerous and

pressure

requires only minor intervention.

elevators

 

Plasma

 

expanders

 

Blood every 60

 

days likely to be

 

needed

Severe edema

Sterile dressing

Diabetes

Compresses

PVD

Whirlpool

 

Leg elevation

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17E TERMI NALLY I LL: Professional prognosis

End stages of: carcinoma, renal

(judgment) is that patient

disease, Cardiac disease

is rapidly deteriorating

 

and will likely die within

 

three (3) months.

 

ADL Care Social/ emotional support

17F

CONTRACTURES:

A shortening and

 

 

tightening of ligaments

 

 

and muscles resulting in

 

 

loss of joint movement .

 

 

Determine whether range

 

 

of motion loss is actually

 

 

due to contractures and

 

 

not only due to spasticity

 

 

paralysis or joint pain.

 

 

I t is important to observe

 

 

the patient to confirm

 

 

whether a contracture

 

 

exists and check the chart

 

 

for confirmatory

 

 

documentation.

 

 

To qualify as “ Yes” on the

 

 

H/ C PRI the following

 

 

qualifier must be met:

 

 

1. The contracture must

 

 

be documented by a

 

 

physician, physical

 

 

therapist or

 

 

occupational therapist .

 

 

2. The status of the

 

 

contracture must be

 

 

reevaluated and

 

 

documented by the

 

 

physician, physical

 

 

therapist or

 

 

occupational therapist

 

 

on an annual basis.

 

 

There does not need to

 

 

be an active treatment

 

 

plan to enter “Yes” to

 

 

contractures.

17G

DI ABETES

A metabolic disorder in

 

MELLI TUS:

which the ability to oxidize

 

 

carbohydrates is

 

 

compromised due to

 

 

inadequate pancreatic

 

 

activity resulting in

 

 

disturbance of normal

insulin production. This may or may not be the primary problem (Q.29) or primary diagnosis. I t should be diagnosed by a physician. I nclude any degree of diabetes, stable

Destruction/ malfunction of the pancreas

Exclude hypoglycemia or hyperglycemia which may be a diabetic condition, but by itself does not constitute diabetes mellitus.

Special diet Oral agents

Insulin Exercise

7

or unstable, and any manner it is controlled.

17H URI NARY TRACT

During the past week,

Exclude if symptoms are

Antibiotics

I NFECTI ON:

signs and symptoms of a

present, but the lab values are

Fluids

 

UTI have been exhibited

negative

 

 

or it has been diagnosed

 

 

 

by lab tests. Symptoms

 

 

 

may include frequent

 

 

 

avoiding, foul smelling

 

 

 

urine, voiding small

 

 

 

amounts, cloudy urine,

 

 

 

sediment and an elevated

 

 

 

temperature. May or may

 

 

 

not be the primary

 

 

 

problem under Q.29.

 

 

 

I nclude as a UTI if it has

 

 

 

not been confirmed yet by

 

 

 

lab tests, but the

 

 

 

symptoms are present .

 

 

 

I nclude patients who

 

 

 

appear asymptomatic, but

 

 

 

whose lab values are

 

 

 

positive (e.g., mentally

 

 

 

confused or incontinent

 

 

 

patients)

 

 

17I

HI V I NFECTI ON

 

SYMPTOMATI C:

HI V (Human

I mmunodeficiency Virus) I nfection, Symptomatic I ncludes: Acquired

Immunodeficiency Syndrome (AI DS) and HI V related illnesses. The patient has been tested for HI V infection and a positive finding is documented AND the patient has had symptoms, documented by a physician as related to the HI V infection.

Symptoms include but are not limited to abnormal weight loss, respiratory abnormalities, anemia, persistent fever, fatigue and diarrhea. Symptoms need not have occurred in the past four weeks. Exclude patients who have tested positive for HI V infection and have not become symptomatic, and patients who have not received the results of the HI V test .

8

17J.

ACCI DENT:

An event resulting in

 

 

serious bodily harm, such

 

 

as, a fracture, a laceration

 

 

which requires closure, a

 

 

second or third degree

 

 

burn or any injury

 

 

requiring admission to a

 

 

hospital.

 

 

To qualify as “ YES” on the

 

 

H/ C PRI the following

 

 

qualifier must be met:

 

 

1. During the past six

 

 

(6) months serious

 

 

bodily harm

 

 

occurred as the

 

 

result of one (1) or

 

 

more accidents.

17K

VENTI LATOR

A patient who has been

 

DEPENDENT:

admitted to a skilled

 

 

nursing facility on a

 

 

ventilator or has been

 

 

ventilator dependent

 

 

within five (5) days prior

 

 

to admission to the skilled

 

 

nursing facility. Patients

 

 

who are in the process of

 

 

being weaned off of

 

 

ventilator support will

 

 

qualify for this category

 

 

for one month after

 

 

extubation if they are

 

 

receiving active

 

 

respiratory rehabilitation

 

 

services during that

 

 

period. Patients in the

 

 

facility who decompensate

 

 

and require intubation

 

 

also qualify for this

 

 

category.

 

 

All services shall be

 

 

provided in accordance

 

 

with Part 416.13, Part

 

 

711.5 and 713.21 of

 

 

Chapter V of Title 10 of

 

 

the Official Compilation of

 

 

Codes Rules and

 

 

Regulations of the State of

 

 

New York.

18.

MEDI CAL

For a “YES” to be

 

TREATMENTS:

answered for any of

 

 

these, the following

 

 

qualifiers must be met:

Time Period - Treatment must have been given during the past week and is still required.

9

Frequency - As specified in the chart below.

Documentation - Physician order specifies that treatment should be given and includes frequency as cited below, where appropriate.

Exclusions - See Chart on the below.

18A. TRACHEOSTOMY CARE:

18B. SUCTI ONI NG:

18C. OXYGEN THERAPY:

DEFI NI TI ON

Care for a tracheostomy, including suctioning. Exclude any self-care patents who do not need daily staff help.

Nasal or oral techniques for clearing away fluid or secretions. May be for a respiratory problem.

Administration of oxygen by nasal catheter, mask (nasal or oronasal), funnel/ cone, or oxygen tent for conditions resulting from oxygen deficiency (e.g., cardio- pulmonary condition).

SPECI FI C

EXCLUSI ONS

FREQUENCY

 

Daily for the past

Self-care patients

week (7 days) or will

 

continue to be

 

required for seven

 

days.

 

Daily for the past

Any tracheotomy

week (7 days) or will

suctioning

continue to be

 

required for seven

 

days.

 

Daily for the past

I nhalators

week (7 days) or will

Oxygen in room, but

continue to be

not in use

required for seven

 

days.

 

18D. RESPI RATORY

CARE:

18E. NASAL GASTRI C

FEEDI NG:

18F. PARENTERAL FEEDI NG:

Care for any portion of the respiratory tract, especially the lungs (for example COPD, pneumonia). This care many include one or more of the following: Percussion or cupping, postural drainage, positive pressure machine, possibly oxygen to administer drugs, etc.

Primary food intake is by a tube inserted into nasal passage; resorted to when it is the only route to the stomach

I ntravenous or subcutaneous route for the administration of fluids used to maintain fluid, nutritional intake, electrolyte balance (e.g., comatose, damaged stomach)

Daily for the past

Suctioning

week (7 days) or will

 

continue to be

 

required for seven

 

days.

 

NoneNone Gastrostomy not applicable

NoneNone Gastrostomy not applicable

18G. WOUND CARE:

Subcutaneous lesion(s)

Care has been

Decubiti

resulting from surgery,

provided or is

Stasis ulcers

trauma, or open cancerous

professionally judged

Skin tears

ulcers.

to be needed for at

Feeding Tubes

 

least three

 

 

consecutive weeks

 

18H. CHEMOTHERAPY:

18I . TRANSFUSI ONS:

18J. DI ALYSI S:

18K. BOWEL AND/ OR

BLADDER

REHABI LI TATI ON:

Bladder

Rehabilitation:

10

Treatment of carcinoma

None

None

through I V and/ or oral

 

 

chemical agents, as ordered by

 

 

a physician. (Community

 

 

based patient may have to go

 

 

to a hospital for treatment .)

 

 

I ntroduction of whole blood or

None

None

blood components directly into

 

 

the blood stream. (Community

 

 

based patients may have to go

 

 

to a hospital for treatment .)

 

 

The process of separating

None

None

components, as in kidney

 

 

dialysis (e.g., renal failures,

 

 

leukemia, blood dsyscrasia.

 

 

Community based patients

 

 

may have to go to a hospital

 

 

for treatment .)

 

 

The goal of this treatment to

Very specific and

Maintenance toileting

gain or regain optimal bowel

unique for each

schedule.

and/ or bladder function and to

patient .

 

re-establish a pattern. I t is

 

Restorative toileting

much more than just a

 

program but does not

toileting schedule or a

 

meet the treatment

maintenance/ conditioning

 

requirements

program. Rather it is an

 

specified in the

intense treatment which is

 

definition.

very specific and unique for

 

 

each patient and is of short

 

 

term duration. (i.e., usually not

 

 

longer than six weeks). NOT

 

 

all patients at level five under

 

 

toileting Q.22 may be a “ Yes”

 

 

with this question. The

 

 

specific definition for bladder

 

 

rehabilitation differs from

 

 

bowel rehabilitation; refer

 

 

below:

 

 

Will generally include these step-by-step procedures which are closely monitored, evaluated and documented:

(1)mental & physical assessment of the patient to determine training capacity;

(2)a 24 hour flow sheet or chart documenting voiding progress;

(3)possibly increased fluid intake during the daytime;

(4)careful attention to skin care;

(5)prevention of constipation;

(6)in the beginning may be

Bowel rehabilit at ion:

18L. CATHETER:

18M. PHYSI CAL RESTRAI NTS:

11

toileted 8 to 12 times per day with decreased frequency with progress.

A program to prevent chronic

 

Exclude a bowel

constipation/ impaction. The

 

maintenance

plan will generally include:

 

program which

(1) assessment of bowel

 

controls bowels

movements, relevant medical

 

incontinence by

problems, medication use;

 

development of a

(2) a dietary regimen of

 

routine bowel

increased fluids & bulk (e.g.,

 

schedule

bran, fruits);

 

 

(3) regular toileting for

 

 

purposes of bowel evacuation;

 

 

(4) use of glycerine

 

 

suppositories or laxatives;

 

 

(5) documentation on a

 

 

worksheet or Kardex.

 

 

During the past week an

 

Exclude catheters

indwelling or external catheter

 

used to empty the

has been needed. The

 

bladder once, secure

indwelling catheter has been

 

a specimen or instill

used for any duration during

 

medication.

the past week; a physician

 

 

order is present . The external

 

 

catheter was used on a

 

 

continuous basis (with proper

 

 

removal and replacement

 

 

during this period) for one or

 

 

more days during the past

 

 

week; a physician order is not

 

 

required.

 

 

A physical device used to

At least two (2)

Exclude all of the

restrict patient movement .

continuous daytime

following:

Physical restraints include

hours anytime during

Medication used for

belts, vests, cuffs, mitts,

the past week, (7

the sole purpose of

jackets, harnesses, and

days).

modifying patient

geriatric chairs.

 

behavior

 

 

Application only at

 

 

night

To Qualify as “Yes” on the H/ C

 

Application for less

PRI the following qualifiers

 

than two (2)

must be met:

 

continuous

1. The restraint must have

 

daytime hours

been applied for at least

 

Devices which the

two continuous daytime

 

patient can

hours anytime during the

 

release/ remove

past week, seven (7

 

such as velcro

days). Daytime includes

 

seatbelts on

the time from when the

 

wheelchairs

patient gets up in the

 

Patients who are bed

morning to when the

 

bound

patient goes to bed at

 

Siderails, locked

night .

 

doors/ gates, domes

12

2.An assessment of need for the physical restraint must be written by M.D. or R.N.

3.The comprehensive care plan based on the assessment must include a written physician’s order and specific nursing interventions regarding use of the physical restraint .

I I I . ACTI VI TI ES OF DAI LY LI VI NG: EATI NG, MOBI LI TY, TRANSFER, TOI LETI NG

Use the following qualifiers in answering each ADL question:

Time Period - Past week (7 days).

Frequency - Assess the capability level of the patient to perform each ADL 60% or more of the time performed since the ADL status may fluctuate during a 24 period.

CHANGED CONDI TI ON RULE: When a patient’s ADL has improved or deteriorated during the past week (7 days) and this course is unlikely to change, measure the ADL according to its present status.

MEASUREMENT APPROACH: Measure the present capability of the patient to complete each ADL. This may be in contrast to what the patient may actually be doing. The reason why you area assessing capacity, rather than actual performance, is so that only patient characteristics are taken into account when measuring ADLs. Omit nonpatient considerations when assessing ADLs. For example, physical barriers, such as stairs or no ramps, may prevent the patient from performing ADLs at the level s/ he is actually capable. Or facility safety policy or clinical order, such as bedrest, may prevent the patient from performing ADLs. Or informal supports in the community or hospital staff may be providing more assistance with ADLs (e.g., toileting) than the patient actually needs.

Definitions - SUPERVI SI ON: means verbal encouragement and observation, not physical hands on care.

ASSI STANCE: means physical hands-on care.

I NTERMI TTENT: means that a staff person does not have to be present during the entire activity, nor does the help have to be on a one-to-one basis

CONSTANT: means one-to-one care that requires a staff person to be present during the entire activity. I f the staff person is not present, the patient will not complete the activity.

Note how these terms are used together in the ADLs. For example, there is intermittent supervision and intermittent assistance.

13

CLARI FI CATI ON OF ADL RESPONSES

19. EATI NG:# 3 “Requires continual help...” means that the patient requires a staff person’s continual presence and help for reasons such as: patient tends to choke, has a swallowing problem, is learning to feed self, or is quite confused and forgets to eat .

#5 “Tube or parenteral feeding...” means that all food and drink is given by nursing staff through the means specified.

20.

MOBI LI TY:

# 3

“Walks with constant supervision and/ or assistance...” may be

 

 

 

required if the patient cannot maintain balance, has a history of falls,

 

 

 

has stress fracture potential, or is relearning to ambulate.

21.

TRANSFER:

# 4

“Requires two people...” may be required for reasons such as: the

 

Exclude

 

patient is obese, has contractures, has fracture (or stress fracture

 

transfers to

 

potential), has attached equipment that makes transfer difficult (for

 

bath or toilet

 

example, tubes). There must be logical medical reasons why the

 

 

 

patient needs the help of two (2) people to transfer. This reason

 

 

 

should be documented in the medical record.

 

 

# 5 “Bedfast ...” may refer to a patient with acute dehydration, severe

 

 

 

decubitus, or terminal illness.

22.

TOI LETI NG:

 

Definition- I NCONTI NENT - 60% or more of the time, the patient

 

 

 

loses control of his/ her bladder or bowel functions, with or without

 

 

 

equipment .

 

 

# 1

“Continent ...Requires no or intermittent supervision” and # 2

 

 

 

“ ...and/ or assistance” can refer to the continent patient or the

 

 

 

incontinent patient who needs no/ little help with his/ her toileting

 

 

 

equipment (for example, catheter).

 

 

# 3

“Continent ... Requires constant supervision/ total assistance...” refers

 

 

 

to a patient who may not be able to balance him/ herself and transfer,

 

 

 

has contractures, has a fracture, is confused or is on a rehabilitation

 

 

 

program. I n addition this level refers to the patient who needs

 

 

 

constant help with elimination/ incontinence appliances (for example,

 

 

 

colostomy, ileostomy).

 

 

# 4

“ I ncontinent ... Does not use a bathroom” refers to the patient who

 

 

 

does not go to a toilet room, but instead may use a bedpan or

 

 

 

continence pads. This patient may be bed-bound or is mentally

 

 

 

confused to the extent that a scheduled toileting program is not

 

 

 

beneficial.

 

 

# 5

“ I ncontinent ... Taken to a bathroom...” refers to the patient who is on

 

 

 

a formal toileting schedule, this should be documented in the medical

 

 

 

record. This patient may be on a formal bowel and bladder

rehabilitation program to regain or maintain control, or the toileting pattern is known and it is better psychologically and physically for the patent to be taken to the toilet (for example, to prevent decubiti).

14

A patient may have different levels of toileting capacity for bowel and bladder function. To determine the level of such a patient, note that level four and five refer to incontinence of either bladder or bowel.

Thus if a patient receives the type of care described in one of these levels for either type of incontinence, enter that level.

Example 1: A patient needs constant assistance with a catheter (level 3) and is incontinent of bowel and is taken to the bathroom every four hours (level 5). I n this instance, enter level 5 on the PRI because he is receiving the type of care described in this question for bowel incontinence.

Example 2: The patient requires intermittent supervision for bowel function (level 2), and is taken to the toilet every two hours to a bladder rehabilitation program. Enter level 5, as the patient is receiving this type of care for bladder incontinence

I V. BEHAVI ORS: VERBAL DI SRUPTI ON, PHYSI CAL AGGRESSI ON, DI SRUPTI VE, I NFANTI LE/ SOCI ALLY I NAPPROPRI ATE BEHAVI OR, AND HALLUCI NATI ONS

The following qualifiers must be met:

Time Period - Past week (7 days).

Frequency - As stated in the responses to each behavioral question.

Documentation - To qualify a patient as LEVEL 4 or to qualify the patient as a “YES” to HALLUCI NATI ONS, the following conditions must be met:

Active treatment plan for the behavioral problem must be in current use.

Psychiatric assessment by a recognized professional with psychiatric training/ education must exist to support the fact that the patient has a severe behavioral problem. This assessment must still be exhibited by the patient .

Definitions - The terms used on the PRI should be interpreted only as they are defined below:

PATI ENT’S BEHAVI OR: Measure it as displayed with the behavior modification and treatment plan in effect during the past week.

DI SRUPTI ON: Through verbal outbursts and/ or physical actions, the patient interferes with the staff and/ or other patients. This interference causes the staff to stop or change what they are doing immediately to control the situation. Without this staff assistance, the disruption would persist or a problem would occur.

NONDI SRUPTI ON: Verbal outbursts and/ or physical actions by the patient may be irritating, but do not create a need for immediate action by the staff.

UNPREDI CTABLE BEHAVI OR: The staff cannot predict when (that is, under what circumstances) the patient will exhibit the behavioral problem. There is no evident pattern.

PREDI CTABLE BEHAVI OR: Based upon observations and experiences with the patient, the staff can discern when a patient will exhibit a

15

behavioral problem and plan appropriate responses in advance. The behavioral problem may occur during activities of daily living (for example, bathing), specific treatments (for example, contracture care, ambulation exercises), or when criticized, bumped into, etc.

CLARI FI CATI ON OF RESPONSES TO BEHAVI ORAL QUESTI ONS

23.

VERBAL DI SRUPTI ON:

Exclude verbal outbursts/ expressions/ utterances which do

 

 

not create disruption as defined by the PRI .

24.

PHYSI CAL AGGRESSI ON:

Note that the definition states “with intent for injury”

25.

DI SRUPTI VE, I NFANTI LE OR

Note that the definition states that this behavior is physical

 

SOCI ALLY I NAPPROPRI ATE

and creates disruption. EXCLUDE the following behaviors:

 

BEHAVI OR:

Verbal outbursts

 

 

Social Withdrawal

 

 

Hoarding

 

 

Paranoia

26.

HALLUCI NATI ONS:

For a “ YES” response, the hallucinations must have

 

 

occurred at least once during the past week (7 days) (in

 

 

addition to meeting the other qualifiers above for an active

 

 

treatment plan and psychiatric assessment).

V.

SPECI ALI ZED SERVI CES

 

 

27.

PHYSI CAL AND

For each therapy these three types of information will

 

OCCUPATI ONAL THERAPI ES:

 

be entered on the PRI : “Level”, “Days” and “Time”

(hours and minutes).

For a patient not receiving a therapy at all, the “Level” will always be entered in the answer key as # 1 (“does not receive”), the “Days” will be entered 0 (zero) and the “Time” will both be 0 (zero).

Use the chart below to understand the qualifiers for each of the three (3) types of information that will be entered. Whether a patient is receiving maintenance or restorative therapy will make a difference in terms of the qualifiers to be used. SEE CHART BELOW FOR THE SPECI FI C QUALI FI ERS.

QUALI FI ERS FOR LEVEL

MAI NTENANCE

 

THERAPY= LEVEL 2

DOCUMENTATI ON

No potential for

QUALI FI ERS:

increased functional

POTENTI AL FOR

ADL ability. Therapy is

I NCREASED

provided to maintain

FUNCTI ONAL/ ADL

and/ or retard

ABI LI TY

deterioration of current

 

functional/ ADL status.

 

Therapy plan of care

 

and progress notes

 

should support that

RESTORATI VE THERAPY

QUALI FI ERS

= LEVEL 3

NOT MET =

 

LEVEL 4

There I S positive

ENTER LEVEL 4

potential for improved

I F ANY ONE OF

functional status within

THE

a short and predictable

QUALI FI ERS

period of time. Therapy

UNDER

plan of care and

QUALI FI ERS

progress notes should

LEVELS 2 OR 3

support that patient has

I S NOT MET.

this potential/ is

 

improving.

 

16

patient has no potential for further or any significant improvement .

PHYSI CI AN ORDER

Yes

Yes, monthly

Enter Level 4 if

QUALI FI ER

 

 

 

PROGRAM DESI GN AND

Licensed professional

Licensed professional

 

EVALUATI ON

person with a 4 year,

person with a 4 year

any one (1) of

QUALI FI ER

specialized therapy

specialized therapy

 

 

degree evaluates

degree evaluates

 

 

program on a monthly

program on a monthly

the qualifiers

 

basis.

basis.

 

TI ME PERI OD

Treatments have been

Treatments have been

 

QUALI FI ER

provided during the past

provided during the past

under Levels 2

 

week.

week.

 

NEW ADMI SSI ON

Not Applicable

New admissions of less

 

QUALI FI ER

 

than one week can be

or 3 is not met .

 

 

marked for restorative

 

therapy if:

There is a physician order for therapy and patient is receiving it .

A new admission includes re- admissions to a residential health care facility.

27. DAYS AND TI ME PER WEEK QUESTI ON: QUALI FI ER

QUALI FI ERS FOR DAYS AND TI MES*

TYPE OF THERAPY SESSI ON

SPECI ALI ZED PROFESSI ONAL ON-SI TE (ON-SI TE MEANS I N WI THI N THE FACI LI TY)

MAI NTENANCE THERAPY (i.e, level 2 or 4 under “level” question)

Count only one-to-one care. Exclude group session (e.g., PT exercise session, OT cooking session).

A certified (2 year) or licensed (4 year) specialized professional is on-site supervising or providing therapy.

RESTORATI VE THERAPY (i.e., I f level 3 or 4 under “Level” question)

The licensed therapist has documented in the care/ plan that therapy is needed for at least one week.

Count only one-to-one care. Exclude group session (e.g., PT exercise session, OT cooking session).

A licensed (4 year) specialized professional is on-site supervising or providing care. (Do not include care provided by PT or OT aides.)

*QUALI FI ERS NOT MET: DO NOT ENTER ON THE PRI ANY DAYS AND TI ME OF THERAPY WHI CH DO NOT MEET BOTH THESE QUALI FI ERS UNDER EACH TYPE OF THERAPY.

 

17

28. NUMBER OF PHYSI CI AN VI SI TS:

Enter “0” (zero) unless the patient need qualifiers

 

stated below are met . I f and ONLY if, the patient

 

meets all the patient need qualifiers, then enter the

 

number of physician visits that meet the physician

 

visit qualifiers.

 

Do not answer this question for hospitalized

 

patients, unless on Alternate Level of Care

 

status. Enter “ 0” (zero) .

 

PATI ENT TYPE/ NEED QUALI FI ERS: The

 

patient has a medical condition that is (1)

 

unstable and changing; or (2) is stable, but

 

there is high risk of instability. I f this patient is

 

not closely monitored and treated by medical

 

staff, an acute episode or severe deterioration

 

can result . Documentation must support that

 

the patient is of this type (for example,

 

terminally ill, acute episode, recent

 

hospitalization, post -operative) .

 

PHYSI CI AN VI SI T QUALI FI ER: I f, and only if,

 

the patient meets the PATI ENT TYPE/ NEED

 

QUALI FI ER, then enter the number of

 

physician visits during the past week that

 

meets the following qualifications:

 

A visit qualifies only if there is physician

 

documentation that s/ he has personally

 

examined the patient to address the

 

pertinent medical problem. The physician

 

must make a notation or documentation

 

in the medical record as to the result of

 

the visit for the unstable medical condition

 

(e.g., change medications, renew

 

treatment orders, nursing orders, order

 

lab tests).

 

Do not include phone calls as a visit nor

 

visits which could be accomplished over

 

the telephone.

 

For community based patient, the

 

physician visit may occur in the patient’s

 

own home, physician’s office, outpatient

 

clinic or hospital.

DI AGNOSI S

29. PRI MARY MEDI CAL PROBLEMS: Follow the guidelines stated below when answering this question.

NURSI NG TI ME: The primary medical problem should be selected based on the condition that has created the most need for nursing time during the past week (7 days). A review of the medical record for nursing and physician notes during the past week may be necessary. For community

18

based patients review what is requiring the most care time from informal supports and health care professionals if any.

JUDGMENT: This decision may require the assessor to use her/ his own professional judgment in deciding upon the primary problem.

I CD-9: Refer to the I CD-9 codes for common diagnoses (attached at the end of these instructions) for easy access to most frequently used numbers. An I CD-9 code book containing the

complete I CD-9 listing should be available in the nursing and/ or medical records office of a facility.

NO I CD-9 NUMBER: Enter “0” (zero) in the far right box if no I CD-9 number can be found for the patient’s primary problem (or if the patient does not have a primary medical problem). I f you cannot locate the I CD-9 code for the primary medical problem, PRI NT THE NAME OF THE

PRI MARY MEDI CAL PROBLEM in the space provided on the PRI .

NOTE: I f the patient has AI DS or HI V related illnesses, indicate this in Section I I , Medical Events, I tem 17F. Do not use AI DS or HI V specific I CD codes (042-044). I nstead, use the code of the specific problem requiring the most caregiver time. For example, for all patients for whom viral pneumonia (NOS) is the condition requiring the most caregiver time, enter 480.9. Do not enter 042.1 for patients with HI V I nfection.

34.RACE/ ETHNI C GROUP:

The following definitions are to be utilized in determining race and ethnic groups:

1. WHI TE:

A person having origins in any of the original peoples of Europe, North

 

Africa or the Middle East .

2.WHI TE/ HI SPANI C: A person who meets the definition of both White and Hispanic. (see Hispanic below)

3. BLACK:

A person having origins in any of the Black racial groups of Africa.

4.BLACK/ HI SPANI C: A person who meets the definition of both Black and Hispanic (see below)

5.ASI AN or PACI FI C A person having origins in any of the original people of the Far East,

I SLANDER:

Southeast Asia, the I ndian Subcontinent, or the Pacific I slands. This

 

includes, for example, China, Japan, Korea, the Philippine I slands and

 

Samoa.

6.ASI AN or PACI FI C I SLAND/ HI SPANI C:

7.AMERI CAN I NDI AN or ALASKAN

NATI VE:

8.AMERI CAN I NDI AN or ALASKAN

NATI VE/ HI SPANI C:

A person who meets the definition of both Asian or Pacific I slander and Hispanic (see below).

A person having origins, in any of the original people of North America and who maintains tribal affiliation or community recognition.

A person who meets the definition of both American I ndian or Alaskan Native and Hispanic (see below).

19

9. OTHER:

Other groups not include in previous categories.

HI SPANI C:A person having origins of Puerto Rican, Mexican, Cuban, Dominican, Central or South American, or other Spanish Culture or origins.

35. QUALI FI ED

The individual who has completed and/ or reviewed the PRI . To be

ASSESSOR:

complete, each assessment must be signed by the qualified nurse

 

assessor.