Patient Review Instrument Form PDF Details

In today's healthcare landscape, the New York State Department of Health has established a comprehensive Patient Review Instrument (PRI) tailored for those transitioning from hospitals and community-based residences to Residential Health Care Facilities (RHCFs). This PRI, essential for pre-admission reviews, emphasizes a thorough assessment process entrusted to a range of qualified assessors including hospital discharge planners and certified home health care agency nurses. With a structured set of instructions, the form ensures no question is left unanswered, utilizing numeric codes for responses and specific criteria—qualifiers—that must be met for an accurate evaluation. Assessors are advised to frequently consult these instructions for precision in completion. Information about the patient, sourced from family discussions, caregiver input, and medical records, feeds into a detailed exploration of the patient's ability to carry out Activities of Daily Living (ADLs). These ADLs, measured differently than other sections, focus on the patient’s capability rather than current performance. Corrections to responses are easily made, allowing for dynamic updates during the assessment process. Administrative details, such as facility identification and patient information, are meticulously captured alongside medical conditions, underpinned by defined criteria and documentation requirements. The PRI not only delineates the patient's medical and physical needs but also frames the necessity for specific care levels, providing a structured pathway for admission into suitable healthcare facilities, ensuring individual healthcare needs are recognized and accurately addressed.

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

Form Preview Example

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

2

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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