Patient Review Instrument Form – Fill Out and Use This PDF

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

#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.

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

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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.

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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.

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).

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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

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

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