CMS-10243.Appendix B MASTER CARE Tool 30 Day Revisions 103107

CARE Tool

Master Document

(Core and Supplemental Items)

General Information: Please note that this instrument uses the term “2-day assessment period” to refer to the first 2 days of admission and the last 2 days prior-to-discharge for look-back periods.

Post OMB Version

10/29/07

Signatures of Persons who Completed a
Portion of the Accompanying Assessment

I certify, to the best of my knowledge, the information in this assessment is

• collected in accordance with the guidelines provided by CMS for participation in this Post Acute Care Payment Reform Demonstration,

• an accurate and truthful reflection of assessment information for this patient,

• based on data collection occurring on the dates specified, and

• data-entered accurately.

I understand the importance of submitting only accurate and truthful data.

• This facility’s participation in the Post Acute Care Payment Reform Demonstration is conditioned on the accuracy and truthfulness of the information provided.

• The information provided may be used as a basis for ensuring that the patient receives appropriate and quality care and for conveying information about the patient to a provider in a different setting at the time of transfer.

I am authorized to submit this information by this facility on its behalf.

[I agree]     [I do not agree]

	Name/Signature	Credential	License # (if required)	Sections Worked On	Date(s) of Data collection
	(Joe Smith)	(RN)	(MA000000)	III A2-6	(MM/DD/YYYY)
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				I. Administrative Items
A. Assessment Type						B. Provider Information
Enter Code		A1. Reason for assessment 1. Acute discharge 2. PAC admission 3. PAC discharge 4. Interim 5. Expired				B1. Provider’s Name
						_____________________
						B2. Medicare Provider’s Identification Number
						_____________________
A2. Admission Date ______/______/______ MM DD YYYY
A3. Assessment Reference Date ____/_____/_____ MM DD YYYY						B3. National Provider Identification Code (NPI)
A4. Expired Date (leave blank if not applicable) ______/______/______ MM DD YYYY						|___|___|___|___|___|___|___|___|___|___|
C. Patient Information
C1. Patient’s First Name						C4. Patient’s Nickname (optional)
______________________ _____________						________________________ ___________
C2. Patient’s Middle Initial or Name						C5. Patient’s Medicare Health Insurance Number
________________________ ___________						|___|___|___|___|___|___|___|___|___|___|___|___|
C3. Patient’s Last Name						C6. Patient’s Medicaid Number
________________________ ___________						|___|___|___|___|___|___|___|___|___|___|
C7. Patient’s Identification/Provider Account Number
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
C8. Birth Date						Enter Code	C12. Is English the patient’s primary language? 0. No 1. Yes (If Yes, skip to C13.)
______/______/______ MM DD YYYY
C9. Social Security Number (optional)						C12a. If English is not the patient’s primary language, what is the patient’s primary language? ___________________________
|___|___|___|-|___|___|-|___|___|___|___|
Enter Code			C10. Gender 1. Male 2. Female			Enter Code	C13. Does the patient want or need an interpreter (oral or sign language) to communicate with a doctor or health care staff? 0. No 1. Yes
Check all that apply					C11. Race/Ethnicity a. American Indian or Alaska Native b. Asian c. Black or African American d. Hispanic or Latino e. Native Hawaiian or Pacific Islander f. White g. Unknown

			I. Administrative Items (cont.)
D. Payer Information: Current Payment Source(s)
Check all that apply		D1. None (no charge for current services) D2. Medicare (traditional fee-for-service) D3. Medicare (HMO/managed care) D4. Medicaid (traditional fee-for-service) D5. Medicaid (HMO/managed care) D6. Workers’ compensation D7. Title programs (e.g., Title III, V, or XX)			D8. Other government (e.g., TRICARE, VA, etc.) D9. Private insurance/Medigap D10. Private HMO/managed care D11. Self-pay D12. Other (specify) ___________________ D13. Unknown

T.I How long did it take you to complete this section? ________________________ (minutes)

			II. Admission Information
A. Pre-admission Service Use
A1. Admission Date ______/______/______ MM DD YYYY				A3. If admitted from a medical setting, what was the primary diagnosis being treated in the previous setting?
				______________________________________________
Enter Code		A2. Admitted From. Immediately preceding this admission, where was the patient? 1. Directly from community (e.g., private home, assisted living, group home, adult foster care) 2. Long-term nursing facility 3. Skilled Nursing Facility (SNF/TCU) 4. Hospital emergency department 5. Short-stay acute hospital 6. Long-term care hospital (LTCH) 7 Inpatient rehabilitation hospital or unit (IRF) 8. Psychiatric hospital or unit 9. Other (specify)_________________			Check all that apply		A4. In the last 2 months, what medical services other than those identified in A2 has the patient received? a. Skilled Nursing Facility (SNF/TCU) b. Short-stay acute hospital (IPPS) c. Long-term care hospital (LTCH) d. Inpatient rehabilitation hospital or unit (IRF) e. Psychiatric hospital or unit f. Home health g. Hospice h. Outpatient i. None
B. Patient History Prior To This Current Illness, Exacerbation, or Injury
B1. Prior to this recent illness, where did the patient live?					Check all that apply		B3.  If the patient lived in the community prior to this illness, what help was used? a. No help received or no help necessary b. Unpaid Assistance c. Paid Assistance d. Unknown
Enter Code	1. Private residence 2. Community based residence (e.g., assisted living residence, group home, adult foster care) 3. Permanently in a long-term care facility (e.g., nursing home) 4. Other (e.g., shelter, jail, no known address) 9. Unknown
							B3a. If the patient lived in the community prior to this illness, who did the patient live with? (Check all that apply.) a.   Lives alone b.   Lives with paid helper c.   Lives with other(s) d.   Unknown
B2. If the patient lived in the community prior to this illness, please provide the patient’s ZIP Code (if patient’s residence was in U.S.).
|___|___|___|___|___| Lives Outside U.S. Unknown

		II. Admission Information (cont.)
B4. If the patient lived in the community prior to this current illness, exacerbation, or injury, are there any structural barriers in the patient’s prior residence that could interfere with the patient's discharge?
Check all that apply			a. Structural barriers are not an issue. b. Stairs inside the living setting that must be used by patient (e.g., to get to toileting, sleeping, eating areas). c. Stairs leading from inside to outside of living setting. d. Narrow or obstructed doorways for patients using wheelchairs or walkers. e. Insufficient space to accommodate extra equipment (e.g., hospital bed, vent equipment). f. Other (specify) ____________________________________. g. Unknown
B5. Prior Functioning. Indicate the patient’s usual ability with everyday activities prior to this current illness, exacerbation, or injury.
3. Independent – Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper. 2. Needed partial assistance – Patient needed partial assistance from another person to complete activities. 1. Dependent – A helper completed the activity for the patient. 8. Not Applicable 9. Unknown				Enter Code	B5a. Self Care: Did the patient need help bathing, dressing, using the toilet, or eating?
				Enter Code	B5b. Mobility (Ambulation): Did the patient need assistance with walking from room to room (with or without devices such as cane, crutch, or walker)?
				Enter Code	B5c. Stairs (Ambulation): Did the patient need assistance with stairs (with or without devices such as cane, crutch, or walker)?
				Enter Code	B5d. Mobility (Wheelchair): Did the patient need assistance with moving from room to room using a wheelchair, scooter, or other wheeled mobility device?
				Enter Code	B5e. Functional Cognition: Did the patient need help planning regular tasks, such as shopping or remembering to take medication?
B6. Mobility Devices and Aids Used Prior to Current Illness, Exacerbation, or Injury (Check all that apply.)
Check all that apply			a. Cane/crutch b. Walker c. Orthotics/Prosthetics d. Wheelchair/scooter full time e. Wheelchair/scooter part time f. Mechanical lift required g. Other (specify) ____________________________________ h. None apply i. Unknown
Enter Code	B7. History of Falls. Has the patient had two or more falls in the past year or any fall with injury in the past year? 0. No 1. Yes 9. Unknown

T.II How long did it take you to complete this section? ________________________ (minutes)

		III. Current Medical Information Informationampra
Clinicians: For this section, please provide a listing of medical diagnoses, comorbid diseases and complications, and procedures based on a review of the patient’s clinical records available at the time of assessment. This information is intended to enhance continuity of care. For discharge only, these lists can be added to throughout the stay and will be specific to each setting.
A. Primary and Other Diagnoses, Comorbidities, and Complications
Indicate the primary diagnosis and up to 14 other diagnoses being treated, managed, or monitored in this setting. Please include all diagnoses (e.g., depression, schizophrenia, dementia, protein calorie malnutrition).
A1. Primary Diagnosis at Assessment _______________________________________________________
B. Other Diagnoses, Comorbidities, and Complications
B1. ______________ ________________________ __ _______________________ __ _ _
B2. ______________ ________________________ __ _______________________ __ _ _
B3. ______________ ________________________ __ _______________________ __ _ _
B4. ______________ ________________________ __ _______________________ __ _ _
B5. ______________ ________________________ __ _______________________ __ _ _
B6. ______________ ________________________ __ _______________________ __ _ _
B7. ______________ ________________________ __ _______________________ __ _ _
B8. ______________ ________________________ __ _______________________ __ _ _
B9. ______________ ________________________ __ _______________________ __ _ _
B10. ______________ ________________________ __ _______________________ __ _ _
B11. ______________ ________________________ __ _______________________ __ _ _
B12. ______________ ________________________ __ _______________________ __ _ _
B13. ______________ ________________________ __ _______________________ __ _ _
B14. ______________ ________________________ __ _______________________ __ _ _
Enter Code	B15. Is this list complete? 0. No 1. Yes

			III. Current Medical Information (cont.) (cont.)
C. Major Procedures (Diagnostic, Surgical, and Therapeutic Interventions)
Enter Code		C1. Did the patient have one or more major procedures (diagnostic, surgical, and therapeutic interventions) during this admission? 0. No (If No, skip to Section D. Treatments.) 1. Yes
List up to 15 procedures (diagnostic, surgical and therapeutic interventions). Indicate if a procedure was left, right, or not applicable (N/A). If procedure was bilateral (e.g., bilateral knee replacement), check both left and right boxes.
Procedure				Left	Right	N/A
C1a. ________________________ __________________________				C1b.	C1c.	C1d.
C2a. ________________________ __________________________				C2b.	C2c.	C2d.
C3a. ________________________ __________________________				C3b.	C3c.	C3d.
C4a. ________________________ __________________________				C4b.	C4c.	C4d.
C5a. ________________________ __________________________				C5b.	C5c.	C5d.
C6a. ________________________ __________________________				C6b.	C6c.	C6d.
C7a. ________________________ __________________________				C7b.	C7c.	C7d.
C8a. ________________________ __________________________				C8b.	C8c.	C8d.
C9a. ________________________ __________________________				C9b.	C9c.	C9d.
C10a. ________________________ __________________________				C10b.	C10c.	C10d.
C11a. ________________________ __________________________				C11b.	C11c.	C11d.
C12a. ________________________ __________________________				C12b.	C12c.	C12d.
C13a. ________________________ __________________________				C13b.	C13c.	C13d.
C14a. ________________________ __________________________				C14b.	C14c.	C14d.
C15a. ________________________ __________________________				C15b.	C15c.	C15d.
Enter Code	C16. Is this list complete? 0. No 1. Yes

		III. Current Medical Information (cont.) Items (cont.)
D. Major Treatments
Which of the following treatments did the patient receive? (Please note: “Used at any time during stay” is only necessary at discharge.)
Check all that apply	Admitted/Discharged With: D1a. D2a. D3a. D4a. D5a. D6a. D7a. D8a. D9a. D10a. D11a. D12a. D13a. D14a. D15a. D16a. D17a. D18a. D19a. D20a. D21a. D22a. D23a. D24a. D25a. D26a. D27a. D28a. D29a. D30a.		Used at Any Time During Stay D1b. D2b. D3b. D4b. D5b. D6b. D7b. D8b. D9b. D10b. D11b. D12b. D13b. D14b. D15b. D16b. D17b. D18b. D19b. D20b. D21b. D22b. D23b. D24b. D25b. D26b. D27b. D28b. D29b. D30b.	D1. None D2. Insulin Drip D3. Total Parenteral Nutrition D4. Central Line Management D5. Blood Transfusion(s) D6. Controlled Parenteral Analgesia – Peripheral D7. Controlled Parenteral Analgesia – Epidural D8. Left Ventricular Assistive Device (LVAD) D9. Continuous Cardiac Monitoring D9c. Specify reason for continuous monitoring: ___________________ D10. Chest Tube(s) D11. Trach Tube with Suctioning D11c. Specify most intensive frequency of suctioning during stay: Every____ hours D12. High O2 Concentration Delivery System with FiO2 > 40% D13. Non-invasive ventilation D14. Ventilator – Weaning D15. Ventilator – Non-Weaning D16. Hemodialysis D17. Peritoneal Dialysis D18. Fistula or Other Drain Management D19. Negative Pressure Wound Therapy D20. Complex Wound Management with positioning and skin separation/traction that requires at least two persons D21. Halo D22. Complex External Fixators (e.g., Ilizarov) D23. One-on-One 24-Hour Supervision D23c. Specify reason for 24-hour supervision: ______________________ D24. Specialty Surface or Bed (i.e., air fluidized, bariatric, low air loss, or rotation bed) D25. Multiple IV Antibiotic Administration D26. IV Vaso-actors (e.g., pressors, dilators, medication for pulmonary edema) D27. IV Anti-coagulants D28. IV Chemotherapy D29. Indwelling Bowel Catheter Management System D30. Other Major Treatments D30c. Specify_____________________________________________

		III. Current Medical Information (cont.)
E. Medications
List all current medications for the patient during the 2-day assessment period. These can be exported to an electronic file for merging with the assessment data.
Medication Name E1a._______________________ E2a._______________________ E3a._______________________ E4a._______________________ E5a._______________________ E6a._______________________ E7a._______________________ E8a._______________________ E9a._______________________ E10a.______________________ E11a.______________________ E12a.______________________ E13a.______________________ E14a.______________________ E15a.______________________ E16a.______________________ E17a.______________________ E18a.______________________ E19a.______________________ E20a.______________________ E21a.______________________ E22a.______________________ E23a.______________________ E24a.______________________ E25a.______________________ E26a.______________________ E27a.______________________ E28a.______________________ E29a.______________________ E30a.______________________			Dose E1b.___________ E2b.___________ E3b.___________ E4b.___________ E5b.___________ E6b.___________ E7b.___________ E8b.___________ E9b.___________ E10b.__________ E11b.__________ E12b.__________ E13b.__________ E14b.__________ E15b.__________ E16b.__________ E17b.__________ E18b.__________ E19b.__________ E20b.__________ E21b.__________ E22b.__________ E23b.__________ E24b.__________ E25b.__________ E26b.__________ E27b.__________ E28b.__________ E29b.__________ E30b.__________	Route E1c._____________ E2c._____________ E3c._____________ E4c._____________ E5c._____________ E6c._____________ E7c._____________ E8c._____________ E9c._____________ E10c.____________ E11c.____________ E12c.____________ E13c.____________ E14c.____________ E15c.____________ E16c.____________ E17c.____________ E18c.____________ E19c.____________ E20c.____________ E21c.____________ E22c.____________ E23c.____________ E24c.____________ E25c.____________ E26c.____________ E27c.____________ E28c.____________ E29c.____________ E30c.____________	Frequency E1d.__________ E2d.__________ E3d.__________ E4d.__________ E5d.__________ E6d.__________ E7d.__________ E8d.__________ E9d.__________ E10d._________ E11d._________ E12d._________ E13d._________ E14d._________ E15d._________ E16d._________ E17d._________ E18d._________ E19d._________ E20d._________ E21d._________ E22d._________ E23d._________ E24d._________ E25d._________ E26d._________ E27d._________ E28d._________ E29d._________ E30d._________	Planned Stop Date (if applicable) E1e.___/____/____ E2e.___/____/____ E3e.___/____/____ E4e.___/____/____ E5e.___/____/____ E6e.___/____/____ E7e.___/____/____ E8e.___/____/____ E9e.___/____/____ E10e.___/____/____ E11e.___/____/____ E12e.___/____/____ E13e.___/____/____ E14e.___/____/____ E15e.___/____/____ E16e.___/____/____ E17e.___/____/____ E18e.___/____/____ E19e.___/____/____ E20e.___/____/____ E21e.___/____/____ E22e.___/____/____ E23e.___/____/____ E24e.___/____/____ E25e.___/____/____ E26e.___/____/____ E27e.___/____/____ E28e.___/____/____ E29e.___/____/____ E30e.___/____/____
Enter Code	E31. Is this list complete? 0. No 1. Yes

			III. Current Medical Information (cont.)
F. Allergies & Adverse Drug Reactions
Enter Code	F1. Does patient have allergies or any known adverse drug reactions? 0. None known (If Unknown, skip to Section G. Skin Integrity.) 1. Yes (If Yes, list all allergies/causes of reaction [e.g., food, medications, other] and describe the adverse reactions.)
Allergies/Causes of Reaction F1a. _________________________________________ F2a. _________________________________________ F3a. _________________________________________ F4a. _________________________________________ F5a. _________________________________________ F6a. _________________________________________ F7a. _________________________________________ F8a. _________________________________________						Patient Reaction F1b. _________________________________________ F2b. _________________________________________ F3b. _________________________________________ F4b _________________________________________ F5b. _________________________________________ F6b. _________________________________________ F7b. _________________________________________ F8b. _________________________________________
Enter Code	F9. Is the list complete? 0. No 1. Yes
G. Skin Integrity
G1-2. PRESENCE OF PRESSURE ULCERS
Enter Code		G1. Is this patient at risk of developing pressure ulcers? 0. No 1. Yes, indicated by clinical judgment 2. Yes, indicated high risk by formal assessment (e.g., on Braden or Norton tools) or the patient has a stage 1 or greater ulcer, a scar over a bony prominence, or a non-removable dressing, device, or cast.					Enter Code		G2. Does this patient have one or more unhealed pressure ulcer(s) at stage 2 or higher? 0. No (If No, skip to Section G5. Major Wounds.) 1. Yes
IF THE PATIENT HAS ONE OR MORE STAGE 2-4 Pressure Ulcers, indicate the number of unhealed pressure ulcers at each stage.
CODING: Please specify the number of ulcers at each stage: 0 = 0 ulcers 1 = 1 ulcer 2 = 2 ulcers 3 = 3 ulcers 4 = 4 ulcers 5 = 5 ulcers 6 = 6 ulcers 7 = 7 ulcers 8 = 8 or more ulcers 9 = Unknown				Number present at assessment	Number with onset during this service			Pressure ulcer at stage 2, stage 3, or stage 4 only:
				Stage 2 Enter Code	Stage 2 Enter Code			G2a. Stage 2 – Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister (excludes those resulting from skin tears, tape stripping, or incontinence associated dermatitis).
				Stage 3 Enter Code	Stage 3 Enter Code			G2b. Stage 3 – Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
				Stage 4 Enter Code	Stage 4 Enter Code			G2c. Stage 4 – Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
				Unstageable Enter Code	Unstageable Enter Code			G2d. Unstageable – Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, gray, green, or brown) or eschar (tan, brown, or black) in the wound bed. Include ulcers that are known or likely, but are not stageable due to non-removable dressing, device, cast or suspected deep tissue injury in evolution.

		III. Current Medical Information (cont.) Items (cont.)
G. Skin Integrity (cont.)
Number of Unhealed Stage 2 Ulcers		G2e. Number of unhealed stage 2 ulcers known to be present for more than 1 month. If the patient has one or more unhealed stage 2 pressure ulcers, record the number present today that were first observed more than 1 month ago, according to the best available records. If the patient has no unhealed stage 2 pressure ulcers, record “0.”		G5. MAJOR WOUND (excluding pressure ulcers)
				Enter Code		Does the patient have one or more major wound(s) that require ongoing care because of draining, infection, or delayed healing? 0. No (If No, skip to Section G6. Turning Surfaces Not Intact.) 1. Yes
Enter Length |___|___|.|___|cm Enter Width |___|___|.|___|cm Date Measured __ _/_ __/ ___ MM DD YYYY			G3. If any pressure ulcer is stage 3 or 4 (or if eschar is present) during the 2-day assessment period, please record the most recent measurements for the LARGEST ulcer (or eschar): a. Longest length in any direction b. Width of SAME unhealed ulcer or eschar c. Date of measurement	G5a–e. NUMBER OF MAJOR WOUNDS
				Number of Major Wounds			Type(s) of Major Wound(s)
							G5a. Delayed healing of surgical wound
							G5b. Trauma-related wound
							G5c. Diabetic foot ulcer(s)
							G5d. Vascular ulcer (arterial or venous including diabetic ulcers not located on the foot)
							G5e. Other (e.g., incontinence associated dermatitis, normal surgical wound healing). Please specify. ________________________________
Enter Code	G4. Indicate if any unhealed stage 3 or stage 4 pressure ulcer(s) has undermining and/or tunneling (sinus tract) present. 0. No 1. Yes 8. Unable to assess			G6. TURNING SURFACES NOT INTACT
				Check All That Apply	Turning Surface		Indicate which of the following turning surfaces have either a pressure ulcer or major wound. a. Skin for all turning surfaces is intact b. Right hip not intact c. Left hip not intact d. Back/buttocks not intact e. Other turning surface(s) not intact

	III. Current Medical Information (cont.)
H. Physiologic Factors
Record the most recent value for each of the following physiologic factors. Indicate the date (MM/DD/YYYY) that the value was collected. If the test was not provided during this admission, check “not tested.” If it is not possible to measure height and weight, check box if value is estimated (actual measurement is preferred).
Date		Complete using format below	Value	Check if NOT tested	Check here if value is estimated	Anthropometric Measures
H1a. ___/___/__ H2a. ___/___/__ H3a. ___/___/__ H4a. ___/___/__		__xxx.x__ __xxx.x__ __xxx.x__ __xxx.x__	H1b. ________ H2b. ________ H3b. ________ H4b. ________	H1c. H2c. H3c. H4c.	H1d. H2d. H3d. H4d.	H1. Height (inches) OR H2. Height (cm) H3. Weight (pounds) OR H4. Weight (Kg)
H5a. ___/___/__ H6a. ___/___/__ H7a. ___/___/__ H8a. ___/___/__ H9a. ___/___/__ H10a. ___/___/__ H11a. ___/___/__ H12a. ___/___/__ H13a. ___/___/__ H14a. ___/___/__ H15a. ___/___/__ H16a. ___/___/__ H17a. ___/___/__ H18a. ___/___/__ H19a. ___/___/__ H20a. ___/___/__ H21a. ___/___/__ H22a. ___/___/__ H23a. ___/___/__ H24. H25. H26. H27. H28. H29. H30a. ___/___/__ H31. H32. H33. H34. H35. H36. H37. H38. H39. H40. H41. H42.		__xxx.x__ __ xx.x__ __xxx __ __ xx __ _xxx/xxx_ _ _xxx __ _ _ xx.x _ __ xx.x _ __ xxx.x__ __ xx.x__ _ _xxx __ __ x.x_ _ __ xx __ __ x.x_ _ __ x.x_ _ __ xx.x__ __ x.x_ _ __ xx __ __ x.xx _ __ xxx __ _ _xxx __ _ _xxx __ __ xx __ __ xx __ __ xxxx __ __ xxx __ __ xxx __ __ xxx __ __ xxx __ _ xxx __ __xx,x _ _ xxxx __ _ xxxx __ _ xxxx __ _ xxxx __ _ xxxx __	H5b. ________ H6b. ________ H7b. ________ H8b. ________ H9b. ________ H10b. ________ H11b. ________ H12b. ________ H13b. ________ H14b. ________ H15b. ________ H16b. ________ H17b. ________ H18b. ________ H19b. ________ H20b. ________ H21b. ________ H22b. ________ H24b. ________ H25b. ________ H26b. ________ H27b. ________ H28b. ________ H29b. ________ H31b. ________ H32b. ________ H33b. ________ H34b. ________ H35b. ________ H36b. ________ H37b. ________ H38b. ________ H39b. ________ H40b. ________ H41b. ________ H42b. ________	H5c. H6c. H7c. H8c. H9c. H10c. H11c. H12c. H13c. H14c. H15c. H16c. H17c. H18c. H19c. H20c. H21c. H22c. H23c. H24c. H25c. H26c. H27c. H28c. H29c. H30c. H31c. H32c. H33c. H34c. H35c. H36c. H37c. H38c. H39c. H40c. H41c. H42c.	Vital Signs H5. Temperature (OF) OR H6. Temperature (OC) H7. Heart Rate (beats/min) H8. Respiratory Rate (breaths/min) H9. Blood Pressure mm/Hg H10. O2 saturation (Pulse Oximetry) % H10d. Please specify source and amount of supplemental O2 _________________ Laboratory H11. Hemoglobin (gm/dL) H12. Hematocrit (%) H13. WBC (K/mm3) H14. HbA1c (%) H15. Sodium (mEq/L) H16. Potassium (mEq/L) H17. BUN (mg/dL) H18. Creatinine (mg/dL) H19. Albumin (gm/dL) H20. Prealbumin (mg/dL) H21. INR Other H22. Left Ventricular Ejection Fraction (%) Arterial Blood Gases (ABGs) H23d. Please specify source and amount of supplemental O2 _________________ H24. pH H25. PaCO2 (mm/Hg) H26. HCO3 (mEq/L) H27. PaO2 (mm/Hg) H28. SaO2 (%) H29. B.E. (base excess) (mEq/L) Pulmonary Function Tests H31. FVC (cc’s) H32. FEV (% of FVC) H33. FEV1 (% of FVC in 1 second) H34. FEV2 (% of FVC in 2 seconds) H35. FEV3 (% of FVC in 3 seconds) H36. PEF (liters per minute) H37. MVV (liters per minute) H38. SVC (cc’s) H39. TLC (cc’s) H40. FRC (cc’s) H41. RV (cc’s) H42. ERV (cc’s)

T.III How long did it take you to complete this section? ________________________ (minutes)

		IV. Cognitive Status, Mood and Pain
A. Comatose
Enter Code	A1. Persistent vegetative state/no discernible consciousness at time of admission (discharge) 0. No 1. Yes (If Yes, skip to G6. Pain Observational Assessment.)
B. Temporal Orientation/Mental Status
B1. Interview Completed			Enter Code	B3b. Year, Month, Day B3b.1. Ask patient: “Please tell me what year it is right now.” Patient’s answer is: 3. Correct 2. Missed by 1 year 1. Missed by 2 to 5 years 0. Missed by more than 5 years or no answer
Enter Code	B1a. Interview Attempted? 0. No 1. Yes (If Yes, skip to B2a. [for acute care discharges] or B3. BIMS (for PAC admissions.)
Enter Code	B1b. Indicate reason that the interview was not attempted and then skip to Section C. Observational Assessment of Cognitive Status: 1. Unresponsive or minimally conscious 2. Communication disorder 3. No interpreter available		Enter Code	B3b.2. Ask patient: “What month are we in right now? Patient’s answer is: 2. Accurate within 5 days 1. Missed by 6 days to 1 month 0. Missed by more than 1 month or no answer
B2. Temporal Orientation Complete only for acute care discharges.			Enter Code	B3b.3. Ask patient: “What day of the week is today?” Patient’s answer is: 2. Accurate 1. Incorrect or no answer
Enter Code	B2a. Ask patient: “Please tell me what year it is right now.” Patient’s answer is: 3. Correct 2. Missed by 1 year 1. Missed by 2 to 5 years 0. Missed by more than 5 years or no answer
			Enter Code	B3c. Recall Ask patient: “Let’s go back to the first question. What were those three words that I asked you to repeat?” If unable to remember a word, give cue (i.e., something to wear; a color; a piece of furniture) for that word. B3c.1. Recalls “sock?” 2. Yes, no cue required 1. Yes, after cueing ("something to wear") 0. No, could not recall
Enter Code	B2b. Ask patient: “What month are we in right now? Patient’s answer is: 2. Accurate within 5 days 1. Missed by 6 days to 1 month 0. Missed by more than 1 month or no answer
B3. BIMS Complete only for PAC admission.			Enter Code	B3c.2. Recalls "blue?" 2. Yes, no cue required 1. Yes, after cueing (“a color”) 0. No, could not recall
Enter Code	B3a. Repetition of Three Words Ask patient: "I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue and bed. Now tell me the three words." Number of words repeated by patient after first attempt: 3. Three 2. Two 1. One 0. None
After the patient's first attempt say: "I will repeat each of the three words with a cue and ask you about them later: sock, something to wear; blue, a color; bed, a piece of furniture." You may repeat the words up to two more times.			Enter Code	B3c.3. Recalls "bed?" 2. Yes, no cue required 1. Yes, after cueing ("a piece of furniture") 0. No, could not recall

		IV. Cognitive Status, Mood & Pain (cont.)
C. Observational Assessment of Cognitive Status at 2-Day Assessment Period: Complete this section only if patient could not be interviewed.
Check all that apply			C1. Memory/recall ability: Check all that the patient normally recalled during the 2-day assessment period: C1a. Current season C1b. Location of own room C1c. Staff names and faces C1d. That he or she is in a hospital, nursing home, or home C1e. None of the above are recalled C1f. Unable to assess Specify reason ______________________________
D. Confusion Assessment Method: Complete this section only if patient scored 0 or 1 on B2a. or B2b. (for acute care discharges) or B3b.1., B3b.2., or B3b.3 (for PAC admissions).
Code the following behaviors during the 2-day assessment period.
CODING: 0. Behavior is not present. 1. Behavior continuously present does not fluctuate. 2. Behavior present, fluctuates (e.g., comes and goes, changes in severity).				 Enter Code in Boxes 	Enter Code	D1. Inattention: The patient has difficulty focusing attention (e.g., easily distracted, out of touch, or difficulty keeping track of what is said).
					Enter Code	D2. Disorganized thinking: The patient's thinking is disorganized or incoherent (e.g., rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching of topics or ideas).
					Enter Code	D3. Altered level of consciousness/alertness: The patient has an altered level of consciousness: vigilant (e.g., startles easily to any sound or touch), lethargic (e.g., repeatedly dozes off when asked questions, but responds to voice or touch), stuporous (e.g., very difficult to arouse and keep aroused for the interview), or comatose (e.g., cannot be aroused).
					Enter Code	D4. Psychomotor retardation: Patient has an unusually decreased level of activity (e.g., sluggishness, staring into space, staying in one position, moving very slowly).

			IV. Cognitive Status, Mood & Pain (cont.) (cont.)
E. Behavioral Signs & Symptoms: PAC Admission and Discharge				F2. Patient Health Questionnaire (PHQ2) (cont. )
Has the patient exhibited any of the following behaviors during the 2-day assessment period?				Enter Code	F2c. Feeling down, depressed, or hopeless? 0. No (If No, skip to question F3.) 1. Yes 8. Unable to respond (If Unable, skip to question F3.)
Enter Code	E1. Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing). 0. No 1. Yes
Enter Code	E2. Verbal behavioral symptoms directed towards others (e.g., threatening, screaming at others). 0. No 1. Yes			Enter Code	F2d. If Yes, how many days in the last 2 weeks? 0. Not at all (0 to 1 days) 1. Several days (2 to 6 days) 2. More than half of the days (7 to 11 days) 3. Nearly every day (12 to 14 days)
Enter Code	E3. Other disruptive or dangerous behavioral symptoms not directed towards others, including self-injurious behaviors (e.g., hitting or scratching self, attempts to pull out IVs, pacing). 0. No 1. Yes			F3. Feeling Sad: PAC Admission and Discharge
				Enter Code	F3a. Ask patient: “During the past 2 weeks, how often would you say, ‘I feel sad’?” 0. Never 1. Rarely 2. Sometimes 3. Often 4. Always 8. Unable to respond
F. Mood: PAC Admission and Discharge
Enter Code		F1. Mood Interview Attempted? 0. No (If No, skip to Section G1. Pain Interview.) 1. Yes
F2. Patient Health Questionnaire (PHQ2): PAC Admission and Discharge
Ask patient: “During the last 2 weeks, have you been bothered by any of the following problems?”
Enter Code		F2a. Little interest or pleasure in doing things? 0. No (If No, skip to question F2c.) 1. Yes 8. Unable to respond (If Unable, skip to question F2c.)
Enter Code		F2b. If Yes, how many days in the last 2 weeks? 0. Not at all (0 to 1 days) 1. Several days (2 to 6 days) 2. More than half of the days (7 to 11 days) 3. Nearly every day (12 to 14 days)

				IV. Cognitive Status, Mood & Pain (cont.) (cont.)
G. Pain
	Enter Code		G1. Pain Interview Attempted? 0. No (If No, skip to G6. Pain Observational Assessment.) 1. Yes			Enter Code	G4. Pain Effect on Function Ask patient: “During the past 2 days, has pain made it hard for you to sleep?” 0. No 1. Yes 8. Unable to answer or no response
	Enter Code		G2. Pain Presence Ask patient: “Have you had pain or hurting at any time during the last 2 days?” 0. No (If No, skip to Section V. Impairments.) 1. Yes 8. Unable to answer or no response (Skip to G6. Pain Observational Assessment.)
	Enter Code		G3. Pain Severity Ask patient: “Please rate your worst pain during the last 2 days on a zero to 10 scale, with zero being no pain and 10 as the worst pain you can imagine.” Enter 88 if patient does not answer or is unable to respond and skip to G6. Pain Observational Assessment.			Enter Code	G5. Ask patient: “During the past 2 days, have you limited your activities because of pain?” 0. No 1. Yes 8. Unable to answer or no response
	G6. Pain Observational Assessment. If patient could not be interviewed for pain assessment, check all indicators of pain or possible pain at the 2-day assessment period.
	Check all that apply				G6a. Non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning) G6b. Vocal complaints of pain (e.g., “that hurts, ouch, stop”) G6c. Facial Expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) G6d. Protective body movements or postures (e.g., bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement) G6e. None of these signs observed or documented

T.IV How long did it take you to complete this section? ________________________ (minutes)

			V. Impairments
A. Bladder and Bowel Management: Use of Device(s) and Incontinence
Enter Code	A1. Does the patient have any impairments with bladder or bowel management? 0. No (If No impairments, skip to Section B. Swallowing.) 1. Yes (If Yes, please complete this section.)
Bladder Enter Code A2a. Enter Code A3a. Enter Code A4a. Enter Code A5a.				Bowel Enter Code A2b. Enter Code A3b. Enter Code A4b. Enter Code A5b.	A2. Does this patient use an external or indwelling device or require intermittent catheterization? 0. No 1. Yes A3. Indicate the frequency of incontinence during the 2-day assessment period. 0. Continent (no documented incontinence) 1. Stress incontinence only (bladder only) 2. Incontinent less than daily (only once during the 2-day assessment period) 3. Incontinent daily (at least once a day) 4. Always incontinent 5. No urine/bowel output during the 2-day assessment period (e.g., renal failure) A4. Does the patient need assistance to manage equipment or devices related to bladder or bowel care (e.g., urinal, bedpan, indwelling catheter, intermittent catheterization, ostomy)? 0. No 1. Yes A5. If the patient is incontinent or has an indwelling device, was the patient incontinent (excluding stress incontinence) immediately prior to the current illness, exacerbation, or injury? 0. No 1. Yes 9. Unknown
B. Swallowing
Enter Code		B1. Does the patient have any impairments with swallowing? 0. No (If No impairments, skip to Section C. Hearing, Vision, and Communication.) 1. Yes (If Yes, please complete this section.)

Check all that apply		B1. Swallowing Disorder: Signs and symptoms of possible swallowing disorder. B1a. Complaints of difficulty or pain with swallowing B1b. Coughing or choking during meals or when swallowing medications B1c. Holding food in mouth/cheeks or residual food in mouth after meals B1d. Loss of liquids/solids from mouth when eating or drinking B1e. NPO: intake not by mouth B1f. Other (specify) ______________________________________
		B2. Swallowing: Describe the patient’s usual ability with swallowing. B2a. Regular food: Solids and liquids swallowed safely without supervision and without modified food or liquid consistency. B2b. Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety. B2c. Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance.

	V. Impairments (cont.)
C. Hearing, Vision, and Communication

Enter Code

C1. Does the patient have any impairments with hearing, vision, or communication? 0. No (If No impairments, skip to Section D. Weight-bearing.) 1. Yes (If Yes, please complete this section.)

C1a. Understanding Verbal Content		C1c. Ability to See in Adequate Light (with glasses or other visual appliances)
Enter Code	4. Understands: Clear comprehension without cues or repetitions 3. Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to understand 2. Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand 1. Rarely/Never Understands 8. Unable to assess 9. Unknown
		Enter Code	3. Adequate: Sees fine detail, including regular print in newspapers/books 2. Mildly to Moderately Impaired: Can identify objects; may see large print 1. Severely Impaired: No vision or object identification questionable 8. Unable to assess 9. Unknown
C1b. Expression of Ideas and Wants		C1d. Ability to Hear (with hearing aid or hearing appliance if normally used)
Enter Code	4. Expresses complex messages without difficulty and with speech that is clear and easy to understand 3. Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear 2. Frequently exhibits difficulty with expressing needs and ideas 1. Rarely/Never expresses self or speech is very difficult to understand. 8. Unable to assess 9. Unknown
		Enter Code	3. Adequate: Hears normal conversation and TV without difficulty 2. Mildly to Moderately Impaired: Difficulty hearing in some environments or speaker may need to increase volume or speak distinctly 1. Severely Impaired: Absence of useful hearing 8. Unable to assess 9. Unknown

		V. Impairments (cont.)
D. Weight-bearing
Enter Code	D1. Does the patient have any impairments with weight-bearing? 0. No (If No impairments, skip to Section E.. Grip Strength.) 1. Yes (If Yes, please complete this section.)
CODING: Indicate all the patient’s weight-bearing restrictions in the 2-day assessment period.
1. Fully weight-bearing: No medical restrictions 0. Not fully weight-bearing: Patient has medical restrictions or unable to bear weight (e.g. amputation)					Upper Extremity D1a. Left D1b. Right Enter Enter Code Code	Lower Extremity D1c. Left D1d. Right Enter Enter Code Code
E. Grip Strength
Enter Code	E1. Does the patient have any impairments with grip strength? 0. No (If No impairments, skip to Section F. Respiratory Status.) 1. Yes (If Yes, please complete this section.)
CODING: Indicate the patient’s ability to squeeze your hand in the 2-day assessment period.
2. Normal 1. Reduced/Limited 0. Absent					E1a. Left Hand E1b. Right Hand Enter Enter Code Code
F. Respiratory Status
Enter Code		F1. Does the patient have any impairments with respiratory status? 0. No (If No impairments, skip to Section G. Endurance.) 1. Yes (If Yes, please complete this section.)
With Supplemental O2 Enter Code F1a.			Without Supplemental O2 Enter Code F1b.	Respiratory Status: Was the patient dyspneic or noticeably Short of Breath in the 2-day assessment period? 5. Severe, with evidence the patient is struggling to breathe at rest 4. Mild at rest (during day or night) 3. With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation 2. With moderate exertion (e.g., while dressing, using commode or bedpan, walking between rooms) 1. When climbing stairs 0. Never, patient was not short of breath 8. Not assessed (e.g., on ventilator) 9. Not applicable

				V. Impairments (cont.)
G. Endurance
Enter Code			G1. Does the patient have any impairments with endurance? 0. No (If No impairments, skip to Section H. Mobility Devices and Aids Needed.) 1. Yes (If Yes, please complete this section.)
Enter Code		G1a. Mobility Endurance: Was the patient able to walk or wheel 50 feet (15 meters) in the 2-day assessment period? 0. No, could not do 1. Yes, can do with rest 2. Yes, can do without rest 8. Not assessed due to medical counter indication
Enter Code		G1b. Sitting Endurance: Was the patient able to tolerate sitting for 15 minutes during the 2-day assessment period? 0. No 1. Yes, with support 2. Yes, without support 8. Not assessed due to medical counter indication
H. Mobility Devices and Aids Needed
Check all that apply					H1. Indicate all mobility devices and aids needed at time of assessment. (Check all that apply.) a. Canes/crutch b. Walker c. Orthotics/Prosthetics d. Wheelchair/scooter full time e. Wheelchair/scooter part time f. Mechanical lift required g. Other (specify) ______________________________ h. None apply

T.V How long did it take you to complete this section? ________________________ (minutes)

	VI. Functional Status: Usual Performance UsualUUsuUsperperformance .v lowest
A. Core Self Care: The core self care items should be completed on ALL patients.
Code the patient’s most usual performance for the 2-day assessment period using the 6-point scale below.
CODING: Safety and Quality of Performance – If helper assistance is required because patient’s performance is unsafe or of poor quality, score according to amount of assistance provided. Code for the most usual performance in the 2-day assessment period. Activities may be completed with or without assistive devices. 6. Independent – Patient completes the activity by him/herself with no assistance from a helper. 5. Setup or clean-up assistance – Helper SETS UP OR CLEANS UP; patient completes activity. Helper assists only prior to or following the activity. 4. Supervision or touching assistance –Helper provides VERBAL CUES or TOUCHING/ STEADYING assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 3. Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 2. Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 1. Dependent – Helper does ALL of the effort. Patient does none of the effort to complete the task. If activity was not attempted code: M. Not attempted due to medical condition S. Not attempted due to safety concerns A. Task attempted but not completed N. Not applicable P. Patient Refused		 Enter Code in Boxes 	Enter Code	A1. Eating: The ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on a table/tray. Includes modified food consistency.
			Enter Code	A2. Tube feeding: The ability to manage all equipment/supplies related to obtaining nutrition.
			Enter Code	A3. Oral hygiene: The ability to use suitable items to clean teeth. Dentures: The ability to remove and replace dentures from and to mouth, and manage equipment for soaking and rinsing.
			Enter Code	A4. Toilet hygiene: The ability to maintain perineal hygiene, adjust clothes before and after using toilet, commode, bedpan, urinal. If managing ostomy, include wiping opening but not managing equipment.
			Enter Code	A5. Upper body dressing: The ability to put on and remove shirt or pajama top. Includes buttoning three buttons.
			Enter Code	A6. Lower body dressing: The ability to dress and undress below the waist, including fasteners. Does not include footwear.

	VI. Functional Status (cont.)
B. Core Functional Mobility: The core functional mobility items should be completed on ALL patients.
Complete for ALL patients: Code the patient’s most usual performance for the 2-day assessment period using the 6-point scale below.
CODING: Safety and Quality of Performance – If helper assistance is required because patient’s performance is unsafe or of poor quality, score according to amount of assistance provided. Code for the most usual performance in the 2-day assessment period. Activities may be completed with or without assistive devices. 6. Independent – Patient completes the activity by him/herself with no assistance from a helper. 5. Setup or clean-up assistance – Helper SETS UP OR CLEANS UP; patient completes activity. Helper assists only prior to or following the activity. 4. Supervision or touching assistance –Helper provides VERBAL CUES or TOUCHING/ STEADYING assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 3. Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 2. Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 1. Dependent – Helper does ALL of the effort. Patient does none of the effort to complete the task. If activity was not attempted code: M. Not attempted due to medical condition S. Not attempted due to safety concerns A. Task attempted but not completed N. Not applicable P. Patient Refused		 Enter Code in Boxes 	Enter Code		B1. Lying to Sitting on Side of Bed: The ability to safely move from lying on the back to sitting on side of bed with feet flat on the floor, no back support.
			Enter Code		B2. Sit to Stand: The ability to safely come to a standing position from sitting in a chair or on the side of a bed.
			Enter Code		B3. Chair/Bed-to-Chair Transfer: The ability to safely transfer to and from a chair (or wheelchair). The chairs are placed at right angles to each other.
			Enter Code		B4. Toilet Transfer: The ability to safely get on and off a toilet or commode.
			MODE OF MOBILITY
			Enter Code	B5. Does this patient primarily use a wheelchair for mobility? 0. No (If No, code B5a for the longest distance completed.) 1. Yes (If Yes, code B5b for the longest distance completed.)
			E nter Code E nter Code E nter Code E nter Code	B5a. Select the longest distance the patient walks and code his/her level of independence (Level 16) on that distance (observe their performance): 1. Walk 150 ft (45 m): Once standing, can walk at least150 feet (45 meters) in corridor or similar space. 2. Walk 100 ft (30 m): Once standing, can walk at least 100 feet (30 meters) in corridor or similar space 3. Walk 50 ft (15 m): Once standing, can walk at least 50 feet (15 meters) in corridor or similar space 4. Walk in Room Once Standing: Once standing, can walk at least 10 feet (3 meters) in room, corridor or similar space.
			E nter Code E nter Code E nter Code E nter Code	B5b. Select the longest distance the patient wheels and code his/her level of independence (Level 16) (observe their performance): 1. Wheel 150 ft (45 m): Once sitting, can wheel at least 150 feet (45 meters) in corridor or similar space. 2. Wheel 100 ft (30 m): Once sitting, can wheel at least 100 feet (30 meters) in corridor or similar space 3. Wheel 50 ft (15 m): Once sitting, can wheel at least 50 feet (15 meters) in corridor or similar space 4. Wheel in Room Once Seated: Once seated, can wheel at least 10 feet (3 meters) in room, corridor, or similar space.

	VI. Functional Status (cont.)
C. Supplemental Functional Ability: Complete only for patients who will need post-acute care to improve their functional ability or personal assistance following discharge.
Please code patient on all activities they are able to participate in and which you can observe, or have assessed by other means, using the 6-point scale below.
CODING: Safety and Quality of Performance – If helper assistance is required because patient’s performance is unsafe or of poor quality, score according to amount of assistance provided. Code for the most usual performance in the 2-day assessment period. Activities may be completed with or without assistive devices. 6. Independent – Patient completes the activity by him/herself with no assistance from a helper. 5. Setup or clean-up assistance – Helper SETS UP OR CLEANS UP; patient completes activity. Helper assists only prior to or following the activity. 4. Supervision or touching assistance –Helper provides VERBAL CUES or TOUCHING/ STEADYING assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 3. Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 2. Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 1. Dependent – Helper does ALL of the effort. Patient does none of the effort to complete the task. If activity was not attempted code: M. Not attempted due to medical condition S. Not attempted due to safety concerns E. Not attempted due to environmental constraints A. Task attempted but not completed N. Not applicable P. Patient Refused		 Enter Code in Boxes 	Enter Code	C1. Wash Upper Body: The ability to wash, rinse, and dry the face, hands, chest, and arms while sitting in a chair or bed.
			Enter Code	C2. Shower/bathe self: The ability to bathe self in shower or tub, including washing and drying self. Does not include transferring in/out of tub/shower.
			Enter Code	C3. Roll left and right: The ability to roll from lying on back to left and right side, and roll back to back.
			Enter Code	C4. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
			Enter Code	C5. Picking up object: The ability to bend/stoop from a standing position to pick up small object such as a spoon from the floor.
			Enter Code	C6. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that are appropriate for safe mobility.
			MODE OF MOBILITY
			Enter Code	C7. Does this patient primarily use a wheelchair for mobility? 0. No (If No, code C7a–C7f.) 1. Yes (If Yes, code C7f–C7h.)
			Enter Code	C7a. 1 step (curb): The ability to step over a curb or up and down one step.
			Enter Code	C7b. Walk 50 feet with two turns: The ability to walk 50 feet and make two turns.
			Enter Code	C7c. 12 steps-interior: The ability to go up and down 12 interior steps with a rail.
			Enter Code	C7d. Four steps-exterior: The ability to go up and down 4 exterior steps with a rail.
			Enter Code	C7e. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces, such as grass, gravel, ice or snow.
			Enter Code	C7f. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt.
			Enter Code	C7g. Wheel short ramp: Once seated in wheelchair, goes up and down a ramp of less than 12 feet (4 meters).
			Enter Code	C7h. Wheel long ramp: Once seated in wheelchair, goes up and down a ramp of more than 12 feet (4 meters).

	VI. Functional Status (cont.)
C. Supplemental Functional Ability (cont.): Complete only for patients who will need post-acute care to improve their functional ability or personal assistance following discharge.
Please code patient on all activities they are able to participate in and which you can observe, or have assessed by other means, using the 6-point scale below.
CODING: Safety and Quality of Performance – If helper assistance is required because patient’s performance is unsafe or of poor quality, score according to amount of assistance provided. Code for the most usual performance in the first 2-day assessment period. Activities may be completed with or without assistive devices. 6. Independent – Patient completes the activity by him/herself with no assistance from a helper. 5. Setup or clean-up assistance – Helper SETS UP OR CLEANS UP; patient completes activity. Helper assists only prior to or following the activity. 4. Supervision or touching assistance –Helper provides VERBAL CUES or TOUCHING/ STEADYING assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 3. Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 2. Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 1. Dependent – Helper does ALL of the effort. Patient does none of the effort to complete the task. If activity was not attempted code: M. Not attempted due to medical condition S. Not attempted due to safety concerns E. Not attempted due to environmental constraints A. Task attempted but not completed N. Not applicable P. Patient Refused		 Enter Code in Boxes 	Enter Code		C8. Telephone-answering: The ability to pick up call in patient’s customary manner and maintain for 3 minutes. Does not include getting to the phone.
			Enter Code		C9. Telephone-placing call: The ability to pick up and place call in patient’s customary manner and maintain for 3 minutes. Does not include getting to the phone.
			Enter Code		C10. Medication management-oral medications: The ability to prepare and take all prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals.
			Enter Code		C11. Medication management-inhalant/mist medications: The ability to prepare and take all prescribed inhalant/mist medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals.
			Enter Code		C12. Medication management-injectable medications: The ability to prepare and take all prescribed injectable medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals.
			Enter Code		C13. Make light meal: The ability to plan and prepare all aspects of a light meal such as bowl of cereal or sandwich and cold drink, or reheat a prepared meal.
			Enter Code		C14. Wipe down surface: The ability to use a damp cloth to wipe down surface such as table top or bench to remove small amounts of liquid or crumbs. Includes ability to clean cloth of debris in patient’s customary manner.
			Enter Code		C15. Light shopping: Once at store, can locate and select up to five needed goods, take to check out, and complete purchasing transaction.
			Enter Code		C16. Laundry: Includes all aspects of completing a load of laundry using a washer and dryer. Includes sorting, loading and unloading, and adding laundry detergent.
			Enter Code		C17. Use public transportation: The ability to plan and use public transportation. Includes boarding, riding, and alighting from transportation.

T.VI How long did it take you to complete this section? ________________________ (minutes)

		VII. Overall Plan of Care/Advance Care Directives
A. Overall Plan of Care/Advance Care Directives
Enter Code	A1. Have the patient (or representative) and the care team (or physician) documented agreed-upon care goals and expected dates of completion or re-evaluation? 0. No, but this work is in process 1. Yes 9. Unclear or unknown		Check all that apply		A3. In anticipation of serious clinical complications, has the patient made and documented care decisions? 1. The patient has designated and documented a decision-maker (if the patient is unable to make decisions). 2. The patient (or surrogate) has made and documented a decision to forgo resuscitation.
Enter Code	A2. Which description best fits the patient’s overall status? 1. The patient is stable with no risk for serious complications and death (beyond those typical of the patient’s age). 2. The patient is temporarily facing high health risks but likely to return to being stable without risk for serious complications and death (beyond those typical of the patient’s age). 3. The patient is likely to remain in fragile health and have ongoing high risks of serious complications and death. 4. The patient has serious progressive conditions that could lead to death within a year. 9. The patient’s situation is unknown or unclear to the respondent.

T.VIII How long did it take you to complete this section? ________________________ (minutes)

			VIII. Discharge Status
A. Discharge Information: Items with an asterisk (*) relating to assistance/support needs and caregiver availability are also included in home health admission assessments.
A1. Discharge Date ______/______/______ MM DD YYYY Y				A6. Willing Caregiver(s)*
A2. Attending Physician				Does the patient have one or more willing caregiver(s)?
___________ ___________				Enter Code		0. No (If No, skip to Section B. Residential Information.) 1. Yes, confirmed by caregiver 2. Yes, confirmed only by patient 9. Unclear from patient; no confirmation from caregiver
A3. Discharge Location
Where will the patient be discharged to?
Enter Code		1. Private residence 2. Other community-based residential setting (e.g., assisted living residents, group home, adult foster care) 3. Long-term care facility/nursing home 4. Skilled nursing facility (SNF/TCU) 5. Short-stay acute hospital (IPPS) 6. Long-term care hospital (LTCH) 7. Inpatient rehabilitation hospital or unit (IRF) 8. Psychiatric hospital or unit 9. Facility-based hospice 10. Other (e.g., shelter, jail, no known address) 11. Discharged against medical advice		A7. Types of Caregiver(s)*
				What is the relationship of the caregiver(s) to the patient?
				Check all that apply				a. Spouse or significant other b. Child c. Other unpaid family member or friend d. Paid help
A4. * Frequency of Assistance at Discharge (or admission for HH)				B. Residential Information: Complete only if patient is discharged to a private residence or other community-based setting.
How often will the patient require assistance (physical care or supervision) from a caregiver(s) or provider(s)?
Enter Code	1. Patient does not require assistance 2. Weekly or less (e.g., requires help with grocery shopping or errands, etc.) 3. Less than daily but more often than weekly 4. Intermittently and predictably during the day or night 5. All night but not during the day 6. All day but not at night 7. 24 hours per day, or standby services			B1. * Patient Lives With at Discharge (or admission for HH)
				Upon discharge (admission), who will the patient live with?
				Check all that apply					a. Lives alone b. Lives with paid helper c. Lives with other(s) d. Unknown
A5. Caregiver(s) Availability
Enter Code	Was the discharge destination decision influenced by the availability of a family member or friend to provide assistance? 0. No (If No, skip to Section B. Residential Information.) 1. Yes

	VIII. Discharge Status (cont.)
C. Support Needs/Caregiver Assistance*
Type of Assistance Needed Patient needs assistance with (check all that apply)			Support Needs/Caregiver Assistance (If patient needs assistance, check one on each row)
			CG able	CG will need training and/or other supportive services	CG not likely to be able	CG ability unclear
C1a		a. ADL assistance (e.g., transfer/ambulation, bathing, dressing, toileting, eating/feeding)	C2a	C3a	C4a	C5a
C1b		b. IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)	C2b	C3b	C4b	C5b
C1c		c. Medication administration (e.g., oral, inhaled, or injectable)	C2c	C3c	C4c	C5c
C1d		d. Medical procedures/treatments (e.g., changing wound dressing)	C2d	C3d	C4d	C5d
C1e		e. Management of equipment (includes oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment, or supplies)	C2e	C3e	C4e	C5e
C1f		f. Supervision and safety	C2f	C3f	C4f	C5f
C1g		g. Advocacy or facilitation of patient’s participation in appropriate medical care (includes transportation to or from appointments)	C2g	C3g	C4g	C5g
C1h		h. None of the above

	VIII. Discharge Status (cont.)
D. Discharge Care Options
Please indicate whether the following services were considered appropriate for the patient at discharge; for those identified as potentially appropriate, were they: available, refused by family, or not covered by insurance. (Check all that apply.)
Type of Service		Considered Appropriate by the Provider	Bed/Services Available	Refused by Patient/Family	Not Covered by Insurance
a. Home Health Care (HHA)		D1a	D2a	D3a	D4a
b. Skilled Nursing Facility (SNF)		D1b	D2b	D3b	D4b
c. Inpatient Rehabilitation Hospital (IRF)		D1c	D2c	D3c	D4c
d. Long-Term Care Hospital (LTCH)		D1d	D2d	D3d	D4d
e. Psychiatric Hospital		D1e	D2e	D3e	D4e
f. Outpatient Services		D1f	D2f	D3f	D4f
g. Acute Hospital Admission		D1g	D2g	D3g	D4g
h. Hospice		D1h	D2h	D3h	D4h
i. Long-term personal care services		D1i	D2i	D3i	D4i
j. LTC Nursing Facility		D1j	D2j	D3j	D4j
k. Other (specify) ________________		D1k	D2k	D3k	D4k

		VIII. Discharge Status (cont.)
E. Discharge Location Information
Enter Code	E1. Is the patient being discharged with referral for additional services? 0. No (If No, skip to E7. Discharge Delay.) 1. Yes (If yes, please identify the name, location, and type of service to which the patient is discharged.)
E2. Provider’s Name			E4. Provider City
________________________ ___________			________________________ ___________
Enter Code	E3. Provider Type 1. Home Health Care (HHA) 2. Skilled Nursing Facility (SNF) 3. Inpatient Rehabilitation Hospital (IRF) 4. Long-Term Care Hospital (LTCH) 5. Psychiatric Hospital 6. Outpatient Services 7. Acute Hospital 8. Hospice 9. LTC Nursing Facility 10. Other (specify) ________________		E5. Provider State
			________________________ ___________
			E6. Medicare Provider’s Identification Number
			________________________ ___________
E7. Discharge Delay			E8. Reason for Discharge Delay
Enter Code	Was the patient’s discharge delayed for at least 24 hours? 0. No 1. Yes		Enter Code	1. No bed available 2. Services, equipment or medications not available (e.g., home health care, durable medical equipment, IV medications) 3. Family/support (e.g., family could not pick patient up) 4. Medical (patient condition changed) 5. Other (specify)_______________________
E9. In the situation that the patient or an authorized representative has requested this information not be shared with the next provider, check here:

T.IX How long did it take you to complete this section? ________________________ (minutes)

		IX. Medical Coding Information
Coders: For this section, please provide a listing of principal diagnosis, comorbid diseases and complications, and procedures based on a review of the patient’s clinical records at the time of discharge or at the time of a significant change in the patient’s status affecting Medicare payment.
A. Principal Diagnosis
Indicate the principal diagnosis for billing purposes. Indicate the ICD-9 CM code. For V-codes, also indicate the medical diagnosis and associated ICD-9 CM code. Be as specific as possible.
A1. ICD-9 CM code for Principal Diagnosis at Assessment				A2. If Principal Diagnosis was a V-code, what was the ICD-9 CM code for the primary medical condition or injury being treated? |___|___|___|.|___|___|
|___|___|___|.|___|___|
A1a. Principal Diagnosis at Assessment _____________________________________				A2a. If Principal Diagnosis was a V-code, what was the primary medical condition or injury being treated? _____________________________________
B. Other Diagnoses, Comorbidities, and Complications
List up to 15 ICD-9 CM codes and associated diagnoses being treated, managed, or monitored in this setting. Include all diagnoses (e.g., depression, schizophrenia, dementia, protein calorie malnutrition). If a V-code is listed, also provide the ICD-9 CM code for the medical diagnosis being treated.
ICD-9 CM code			Diagnosis
B1a. |___|___|___|.|___|___|			B1b. ______________ ________________________ __ ___
B2a. |___|___|___|.|___|___|			B2b. ______________ ________________________ ___ __
B3a. |___|___|___|.|___|___|			B3b. ______________ ________________________ __ ___
B4a. |___|___|___|.|___|___|			B4b. ______________ ________________________ _ ____
B5a. |___|___|___|.|___|___|			B5b. ______________ ________________________ _____
B6a. |___|___|___|.|___|___|			B6b. ______________ ________________________ _____
B7a. |___|___|___|.|___|___|			B7b. ______________ ________________________ _ ____
B8a. |___|___|___|.|___|___|			B8b. ______________ _________________________ ____
B9a. |___|___|___|.|___|___|			B9b. __________________ ______________________ ___
B10a. |___|___|___|.|___|___|			B10b. _____________ ____________________________ __
B11a. |___|___|___|.|___|___|			B11b. _____________ _________________________ _____
B12a. |___|___|___|.|___|___|			B12b. _____________ ________________________ ______
B13a. |___|___|___|.|___|___|			B13b. _____________ ________________________ ______
B14a. |___|___|___|.|___|___|			B14b. _____________ ________________________ ______
B15a. |___|___|___|.|___|___|			B15b. _____________ ________________________ ______
Enter Code	B16. Is this list complete? 0. No 1. Yes

			IX. Medical Coding Information (cont.)
C. Major Procedures (Diagnostic, Surgical, and Therapeutic Interventions)
Enter Code		C1. Did the patient have one or more major procedures (diagnostic, surgical, and therapeutic interventions) during this admission? 0. No (If No, skip section) 1. Yes
List up to 15 ICD-9 CM codes and associated procedures (diagnostic, surgical, and therapeutic interventions) performed during this admission.
ICD-9 CM code				Procedure
C1a. |___|___|.|___|___|				C1b. _____________ ________________________ ______
C2a. |___|___|.|___|___|				C2b. _____________ ________________________ ______
C3a. |___|___|.|___|___|				C3b. _____________ ________________________ ______
C4a. |___|___|.|___|___|				C4b. _____________ ________________________ ______
C5a. |___|___|.|___|___|				C5b. _____________ ________________________ ______
C6a. |___|___|.|___|___|				C6b. _____________ ________________________ ______
C7a. |___|___|.|___|___|				C7b. _____________ ________________________ ______
C8a. |___|___|.|___|___|				C8b. _____________ ________________________ ______
C9a. |___|___|.|___|___|				C9b. _____________ ________________________ ______
C10a. |___|___|.|___|___|				C10b. _____________ ________________________ ______
C11a. |___|___|.|___|___|				C11b. _____________ ________________________ ______
C12a. |___|___|.|___|___|				C12b. _____________ ________________________ ______
C13a. |___|___|.|___|___|				C13b. _____________ ________________________ ______
C14a. |___|___|.|___|___|				C14b. _____________ ________________________ ______
C15a. |___|___|.|___|___|				C15b. _____________ ________________________ ______
Enter Code	C16. Is this list complete? 0. No 1. Yes

	X. Other Useful Information
A1. Is there other useful information about this patient that you want to add?

	XI. Feedback
A. Notes
Thank you for your participation in this important project. So that we may improve the form for future use, please comment on any areas of concern or things you would change about the form.