CMS-10243.Appendix A Master CARE Tool Item Matrix 30 Day Revisions_103107

CARE Tool Item Matrix

Item Number

Item Description

Attestation and Signatures of Persons who Completed a Portion of the Assessment
Signatures

Acute Hospital
Discharge

PAC
Admission

PAC
Discharge

Interim

Expired

C

C

C

C

C

I. Administrative Items
A. Assessment Type
A1
A2
A3
A4

Reason for Assessment
Admission Date
Assessment Reference Date
Expired Date

C
C
C

C
C
C

C
C
C

C
C
C

C
C
C
C

B. Provider Information
B1
B2
B3

Provider's Name
Medicare Provider's Identification Number
National Provider Identification Code (NPI)

C
C
C

C
C
C

C
C
C

C
C
C

C
C
C

C
C
C
C
C
C
C
C
C
C
C
C

C
C
C
C
C
C
C
C
C
C
C
C

C
C
C
C
C
C

C
C
C
C
C
C

C
C
C
C
C
C

C12a

Patient's First Name
Patient's Middle Initial or Name
Patient's Last Name
Patient's Nickname (optional)
Patient's Medicare Health Insurance Number
Patient's Medicaid Number
Patient's Identification Number/Provider Account Number
Birth Date
Social Security Number (optional)
Gender
Race/Ethnicity
Is English the patient's primary language?
If English is not the patient’s primary language, what is the
patient’s primary language?

C

C

C12b

Does the patient want or need an interpreter (language or sign
language) to communicate with a doctor or health care staff?

C

C

D. Payer Information
D1-D13

Current Payment Sources

C

C

C

C

T.I.

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C
C
C
C

C
C
C
C

C
C
C
C
C
C
C
C

C
C
C
C
C
C
C
C

III. Current Medical Information/Clinicans
A. Primary Diagnosis
A1
Primary Diagnosis at Assessment

C

C

C

C

C

B. Other Diagnoses, Comorbidites,
and Complications
B1-B15
Other Comorbidities
B16
Is this list complete?

C
C

C
C

C
C

C
C

C
C

C
S

C
S

C
S

C
S

C
S

C. Patient Information
C1
C2
C3
C4
C5
C6
C7
C8
C9
C10
C11a-C11g
C12

II. Admission Information
A. Pre-admission Service Use
A1
A2
A3
A4a-A4i

Admission Date
Admitted From
Primary diagnosis in previous setting
Other Services in past 2 months

B. Patient History Prior To This Current Illness, Exacerbation, or Injury
B1
Where did patient live
B2
If in community,Zip Code of Prior Residence
B3a-B3d
If in community, help used
B3aa-B3ad
If in the community,who did the patient live with?
B4a-B4f
Structural barriers
B5a-B5e
Prior Functioning
B6a-B6h
Mobility Devices
B7
History of Falls
T.II.

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C. Major Procedures (Diagnostic,
Surgical, and Therapeutic
Interventions)

C1
C1a-C15a

10/29/2007

Did the patient have one or more major procedures
(diagnostic, surgical, and therapeutic interventions) during this
admission?
Procedures

CARE Tool Item Matrix
Acute Hospital
Discharge

PAC
Admission

PAC
Discharge

Interim

Expired

Right
Left
Not applicable
Is list complete?

S
S
S
S

S
S
S
S

S
S
S
S

S
S
S
S

S
S
S
S

D. Major Treatments
D1a-D30a
D1b-D30b
D9c
D11c
D23c
D30c

Admitted/Discharged With
Used at Any Time During Stay
Specify reason for continuous monitoring
Specify most intensive frequency of suctioning during stay
Specify reason for 24-hour supervision
Other Major Treatments: Specify

C
C
S
S
S
S

C
S
S
S
S

C
C
S
S
S
S

C
C
S
S
S
S

C
C
S
S
S
S

E. Medications
E1a-E30a
E1b-E30b
E1c-E30c
E1d-E30d
E1e-E30e
E31

Medication Name
Dose
Route
Frequency
Planned Stop Date
Is list complete?

C
C
C
C
C
C

C
C
C
C
C
C

C
C
C
C
C
C

C
C
C
C
C
C

C
C
C
C
C
C

F. Allergies and Adverse Drug Reactions
F1
Any Known Allergies or Reactions?
F1a-F8a
Allergy/Cause of Reaction
F1b-F8b
Patient Reactions
F9
Is the list complete?

C
S
S
S

C
S
S
S

C
S
S
S

G. Skin Integrity
G1
G2

C
C

C
C

C
C

C
C

G2a-G2d
G2e
G3a
G3b
G3c
G4
G5
G5a-G5e
G6a-G6e

Pressure Ulcer Risk
Any Stage 2+ Pressure Ulcers?
Number present at assessment/
Number with onset during this service
If Stage 2 :Number of Unhealed
Longest length in any direction
Width of SAME unhealed ulcer or eschar
Date of measurement
If Stage 3 or 4, Tunneling
Any Major Wounds (excluding pressure ulcer)
Number and Type of Major Wounds
Turning surfaces not intact

S
S
S
S
S
S
C
S
C

S
S
S
S
S
S
C
S
C

S
S
S
S
S
S
C
S
C

S
S
S
S
S
S
C
S
C

H. Physiologic Factors
H1a-H23a, H30a
H1b-H22b, H24b-H29b, H31b-H42b
H1c-H42c
H1d-H4d
H10d
H23d

Date
Value
Check if NOT tested
Estimated value
Specify source and amount of supplemental O2
Specify source and amount of supplemental O2

C
C
C
C
C
C
C

C
C
C
C
C
C
C

C
C
C
C
C
C
C

C
C
C
C
C
C
C

T.III.

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IV. Cognitive Status
A. Comatose
A1

Persistent vegetative state

C

C

B. Temporal Orientation and BIMS
B1a
B1b
B2a
B2b
B3a
B3b.1.
B3b.2.
B3b.3.
B3c.1.
B3c.2.
B3c.3.

Interview attempted
Reason interview not attempted
Ask patient: “Please tell me what year it is right now.”
Ask patient: “What month are we in right now?
Repetition of three words
Ask patient: “Please tell me what year it is right now.”
Ask patient: “What month are we in right now?
Ask patient: “What day of the week is today?”
Recalls “sock?”
Recalls "blue?"
Recalls "bed?"

C
S
C
C

C
S

Item Number

Item Description

C1b-C15b
C1c-C15c
C1d-C15d
C16

C
C
C
C
C
C

C. Observational of Cognitive Status
C1a-C1f
Memory/Recall Ability

S

S

D. Confusion Assessment Method
D1
D2
D3
D4

S
S
S
S

S
S
S
S

10/29/2007

Inattention
Disorganized thinking
Altered level of consciousness/alertness
Psychomotor retardation

CARE Tool Item Matrix
PAC
Admission

PAC
Discharge

E. Behavorial Signs and Symptoms
E1
Physical
E2
Verbal
E3
Other

C
C
C

C
C
C

F. Mood
F1
F2a-F2d
F3

Interview attempted
PHQ2
Feeling Sad

C
C
C

C
C
C

G. Pain
G1
G2
G3
G4
G5
G6a-G6e

Interview attempted?
Pain presence
Pain severity 0-10
Pain effect on function
Limited activities because of pain
Observed Pain

C
C
S
S
S
S

C
C
S
S
S
S

C
C
S
S
S
S

C
C
S
S
S
S

T.IV.

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Item Number

Item Description

Acute Hospital
Discharge

Interim

V. Impairments
A. Bladder and Bowel Management
A1
A2a-A2b
A3a-A3b
A4a-A4b
A5a-A5b

Any impairments?
Use of external or indwelling device
Frequency of incontinence
Assistance managing bowel/bladder equipment
Incontinent prior to the current illness

C
S
S
S
S

C
S
S
S
S

C
S
S
S
S

C
S
S
S
S

B . Swallowing
B1
B1a-B1g
B2a-B2c

Any impairments?
Swallowing: signs and symptoms
Swallowing: usual ability

C
S
S

C
S
S

C
S
S

C
S
S

C. Hearing, Vision, Communication, & Comprehension
C1
C1a
C1b
C1c
C1d

Any impairments?
Understanding verbal content
Expression of ideas and wants
Ability to see in adequate light
Ability to hear

C
S
S
S
S

C
S
S
S
S

C
S
S
S
S

C
S
S
S
S

D. Weight-bearing
D1
D1a-D1d

Any impairments?
Weight-bearing upper and lower extremities

C
S

C
S

C
S

C
S

E. Grip Strength
E1
E1a-E1b

Any impairments?
Grip strength right and left hands

C
S

C
S

C
S

C
S

F. Respiratory Status
F1
F1a-F1b

Any impairments?
Respiratory Status

C
S

C
S

C
S

C
S

G. Endurance
G1
G1a
G1b

Any impairments?
Mobility Endurance
Sitting Endurance

C
S
S

C
S
S

C
S
S

C
S
S

C

C

C

C

H. Mobility Devices and Aids Needed
H1a-H1h
Indicate all mobility and aids needed
T.V.

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VI. Functional Status
A. Self Care
A1
A2
A3
A4
A5
A6

Eating
Tube Feeding
Oral Hygiene
Toilet Hygiene
Upper Body Dressing
Lower Body dressing

C
C
C
C
C
C

C
C
C
C
C
C

C
C
C
C
C
C

C
C
C
C
C
C

B. Core Functional Mobility
B1
B2

Lying to Sitting on Side of Bed
Sit to Stand

C
C

C
C

C
C

C
C

10/29/2007

Expired

CARE Tool Item Matrix
Acute Hospital
Discharge

PAC
Admission

PAC
Discharge

Interim

C
C
C
C
C

C
C
C
C
C

C
C
C
C
C

C
C
C
C
C

C. Supplemental Functional Ability: Code patient on all activities that the patient can participate in and which you can observe.
C1
Wash upper body
S
S
C2
Shower/bathe self
S
S
C3
Roll Left and Right
S
S
C4
Sit to Lying
S
S
C5
Picking up object
S
S
C6
Putting on/taking off footwear
S
S
C7
Mode of Mobility: Wheelchair?
S
S
C7a
One Step (curb)
S
S
C7b
Walk 50 feet with 2 turns
S
S
C7c
12 steps-interior
S
S
C7d
4 steps-exterior
S
S
C7e
Walking 10 feet on uneven surfaces
S
S
C7f
Car transfer
S
S
C7g
Wheel short ramp
S
S
C7h
Wheel long ramp
S
S
C8
Telephone-answering
S
S
C9
Telephone-Placing Call
S
S
C10
Medication Management-Oral Medications
S
S
C11
Medication Management-Inhalant/Mist Medications
S
S
C12
Medication Management-Injectable Medications
S
S
C13
Make light meal
S
S
C14
Wipe down surface
S
S
C15
Light shopping
S
S
C16
Laundry
S
S
C17
Use Public Transportation
S
S

S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S

S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S

C
C
C

C
C
C

C
C
C

C*

C
C
C
C
C
S
S

Item Number

Item Description

B3
B4
B5
B5a
B5b

Chair/Bed-to-Chair Transfer
Toilet Transfer
Mode of Mobility
Longest distance patient can walk
Longest distance patient can wheel

T.VI.

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VII. Overall Plan of Care/Advance Care Directives
A.Overall Plan of Care/Advance Care Directives
Documented agreed-upon care goals and expected dates of
A1
completion
A2
Description of overall status
A3
Documented care decisions
T.VII.

C
C
C

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VIII. Discharge Status
A. Discharge Information
A1
A2
A3
A4
A5
A6
A7

Discharge date
Attending Physician
Discharge location
Frequency of Assistance at Discharge
Caregiver Availability
Willing Caregiver(s)
Types of Caregiver(s)

C
C
C
C
C
S
S

B. Caregiver Information
B1

Patient lives with

S

C. Support Needs/Caregiver Assistance
C1a-C1h
Patient needs this
C2a-C2g
Caregiver able
C3a-C3g
Caregiver needs training or other supportive services
C4a-C4g
Caregiver not likely to be able
C5a-C5g
Caregiver ability unclear

S
S
S
S
S

D. Discharge Care Options
D1a-D1k
D2a-D2k
D3a-D3k
D4a-D4k

Deemed Appropriate by the Provider
Bed/Services Available
Refused by Patient/Family
Not Covered by Insurance

C
C
C
C

C
C
C
C

E. Discharge Location Information
E1
E2
E3
E4
E5

Discharged with referral
Provider Name
Provider Type
Provider City
Provider State

C
S
S
S
S

C
S
S
S
S

10/29/2007

C*
C*

S

C*
C*
C*
C*
C*

S
S
S
S
S

Expired

CARE Tool Item Matrix

Item Number

Item Description

E6
E7
E8
E9

Medicare Provider Identification Number
Discharge delay
Reason for Discharge Delay
Patient requests that information not be shared

T.IX.

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IX. Medical Coding Information
A. Principal Diagnosis
A1
A1a
A2

PAC
Admission

S
S
S
S

PAC
Discharge

Interim

Expired

S
S
S
S

C
C
S

C
C
S

C
C
S

C
C
S

C
C
S

S

S

S

S

S

B. Other Diagnoses, Combordities, and Complications
B1a-B15a
ICD-9 CM Code
B1b-B15b
Diagnosis
B16
Is this list complete?

C
C
C

C
C
C

C
C
C

C
C
C

C
C
C

C. Major Procedures (Diagnostic, Surgical, and Therapeutic Interventions)
C1
One or more major proecedure
C1a-C15a
ICD-9 CM Code
C1b-C15b
Procedure
C16
Is this list complete?

C
S
S
S

C
S
S
S

C
S
S
S

C
S
S
S

C
S
S
S

X. Other Useful Information
A1

Other useful information about this patient

S

S

S

S

S

XI. Feedback
A1

Notes

S

S

S

S

S

A2a

ICD-9 CM Code for Principal Diagnosis
Principal Diagnosis at Assessment
ICD-9 CM Code for Principal Diagnosis if it was a V-code
If principal diagnosis was a V-code was was the primary
medical condition or injury being treated

Acute Hospital
Discharge

Notes: *These items are included in home health admission assessments.

10/29/2007