Form DOH-694 "Hospital and Community Patient Review Instrument (Hc-Pri)" - New York

What Is Form DOH-694?

This is a legal form that was released by the New York State Department of Health - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2005;
  • The latest edition provided by the New York State Department of Health;
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  • Fill out the form in our online filing application.

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Download Form DOH-694 "Hospital and Community Patient Review Instrument (Hc-Pri)" - New York

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Hospital and Community
NEW YORK STATE DEPARTMENT OF HEALTH
Patient Review Instrument (HC-PRI)
OHSM-Division of Quality and Surveillance for Nursing Homes and ICFs/MR
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
11A. DATE OF HOSPITAL ADMISSION OR INITIAL AGENCY VISIT
COMMUNITY)
-
-
(49-56)
4B. COUNTY OF RESIDENCE
MO DAY YEAR
5. DATE OF PRI COMPLETION
11B. DATE OF ALTERNATE LEVEL OF CARE STATUS IN HOSPITAL
(IF APPLICABLE)
-
-
(18-25)
-
-
(57-64)
MO DAY YEAR
MO DAY YEAR
6.
MEDICAL RECORD NUMBER/CASE NUMBER
12. MEDICAID NUMBER
(65-75)
(26-34)
7.
HOSPITAL ROOM NUMBER
13. MEDICARE NUMBER
(35-39)
(76-85)
8.
NAME OF HOSPITAL UNIT/DIVISION/BUILDING
14. PRIMARY PAYOR
(86)
1=Medicaid
2=Medicare
3= Other
9.
DATE OF BIRTH
15. REASON FOR PRI COMPLETION
(87)
-
-
1.
RHCF Application from Hospital
(40-47)
MO DAY YEAR
2.
RHCF Application from Community
3.
Other (Specify:
)
10. SEX
1=Male
(48)
2=Female
II. MEDICAL EVENTS
16. DECUBITUS LEVEL: ENTER THE MOST SEVERE
18. MEDICAL TREATEMENTS: READ THE INSTRUCTIONS FOR
LEVEL (0-5) AS DEFINED IN THE INSTRUCTIONS.
THE QUALIFIERS.
1=YES
2=NO
17. MEDICAL CONDITIONS: DURING THE PAST WEEK. READ THE
A. Trachesotomy Care/Suctioning
INSTRUCTIONS FOR SPECIFIC DEFINITIONS
(Daily—Exclude self-care)
1=YES
2=NO
A. Comatose
B. Suctioning-General (Daily)
B. Dehydration
C. Oxygen (Daily)
C. Internal Bleeding
D. Respiratory Care (Daily)
D. Stasis Ulcer
E. Nasal Gastric Feeding
E. Terminally Ill
F. Parenteral Feeding
F. Contractures
G. Wound Care
G. Diabetes Mellitus
H. Chemotherapy
H. Urinary Tract Infection
I. Transfusion
I. HIV Infection Symptomatic
J. Dialysis
J. Accident
K. Bowel and Bladder Rehabilitation (SEE INSTRUCTIONS)
K. Ventilator Dependent
L. Catheter (Indwelling or External)
M. Physical Restraints (Daytime Only)
DOH-694 (12/05) Page 1 of 4
Hospital and Community
NEW YORK STATE DEPARTMENT OF HEALTH
Patient Review Instrument (HC-PRI)
OHSM-Division of Quality and Surveillance for Nursing Homes and ICFs/MR
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
11A. DATE OF HOSPITAL ADMISSION OR INITIAL AGENCY VISIT
COMMUNITY)
-
-
(49-56)
4B. COUNTY OF RESIDENCE
MO DAY YEAR
5. DATE OF PRI COMPLETION
11B. DATE OF ALTERNATE LEVEL OF CARE STATUS IN HOSPITAL
(IF APPLICABLE)
-
-
(18-25)
-
-
(57-64)
MO DAY YEAR
MO DAY YEAR
6.
MEDICAL RECORD NUMBER/CASE NUMBER
12. MEDICAID NUMBER
(65-75)
(26-34)
7.
HOSPITAL ROOM NUMBER
13. MEDICARE NUMBER
(35-39)
(76-85)
8.
NAME OF HOSPITAL UNIT/DIVISION/BUILDING
14. PRIMARY PAYOR
(86)
1=Medicaid
2=Medicare
3= Other
9.
DATE OF BIRTH
15. REASON FOR PRI COMPLETION
(87)
-
-
1.
RHCF Application from Hospital
(40-47)
MO DAY YEAR
2.
RHCF Application from Community
3.
Other (Specify:
)
10. SEX
1=Male
(48)
2=Female
II. MEDICAL EVENTS
16. DECUBITUS LEVEL: ENTER THE MOST SEVERE
18. MEDICAL TREATEMENTS: READ THE INSTRUCTIONS FOR
LEVEL (0-5) AS DEFINED IN THE INSTRUCTIONS.
THE QUALIFIERS.
1=YES
2=NO
17. MEDICAL CONDITIONS: DURING THE PAST WEEK. READ THE
A. Trachesotomy Care/Suctioning
INSTRUCTIONS FOR SPECIFIC DEFINITIONS
(Daily—Exclude self-care)
1=YES
2=NO
A. Comatose
B. Suctioning-General (Daily)
B. Dehydration
C. Oxygen (Daily)
C. Internal Bleeding
D. Respiratory Care (Daily)
D. Stasis Ulcer
E. Nasal Gastric Feeding
E. Terminally Ill
F. Parenteral Feeding
F. Contractures
G. Wound Care
G. Diabetes Mellitus
H. Chemotherapy
H. Urinary Tract Infection
I. Transfusion
I. HIV Infection Symptomatic
J. Dialysis
J. Accident
K. Bowel and Bladder Rehabilitation (SEE INSTRUCTIONS)
K. Ventilator Dependent
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
3= Walks with constant one-to-one supervision and/or constant physical
mechanical device (for example, a walker), but not a wheelchair.
assistance.
2=Walks with intermittent supervision (that is, verbal cueing and
4= Wheels with no supervision or assistance, except for difficult maneuvers
observation). May require human assistance for difficult parts of
(for example, elevators, ramps). May actually be able to walk, but generally
walking (for example, stairs, ramps).
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),
28.
(133-134)
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.
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 problem
29.
-
(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
1.
Secondary (Include Sensory Impairments)
1.
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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