Cost and Resource Utilization (CRU) Data Collection for the Medicare Post Acute Care Payment Reform Demonstration (Staff Time Logs)

Unit (Non-Therapist) Staff Activity Form Instructions
Medicare Post-Acute Care Study

The Staff Activity Form (SAF) collects information on the time that you spend with, or on behalf of, your unit’s patients. At the end of your shift, please be sure your form is complete and return to the Nurse Manager.

This form is designed to be machine-read. The following are examples of acceptable ways of writing numbers:

Please be sure your “1”s and “7”s look different and that your “4”s and “9”s look different (for both computer and human readers). If possible, please use black ink. However, blue and green are acceptable.

Who completes this form?

Any non-therapy staff assigned to the unit, or other professionals routinely providing care on the unit, should complete this form for each shift that they spend on the unit. If you work during more than one shift, please use two forms.

Please note that there are separate forms for therapy staff versus nursing and other staff. Be sure to pick up the correct version—it’s printed at the top, and check boxes for your position are different for each form.

What are the steps to complete this form?

1. Write your name, date, shift (day, evening, or night), and shift length (in hours, so report 8½ as 8.5) at the top of the form. Indicate your position and employment type (regular full/part time, per diem or agency) in the check boxes.

This form will only be used for this study. Your name will only be used by your facility’s Site Coordinator to track whether all forms have been returned. Your name will be removed before the forms leave the facility.

2. During and at the end of the shift you will complete the rest of the form. It is divided into two sections:

• The first three rows ask you for the total amount of time, in minutes, for your total shift; with, or for, patients on this unit; and time off the unit. Note that there is only 1 activity category for off-unit time.

• The rest of the rows ask you to report time spent on the unit in activities with, or for, specific patients versus those more general in nature (such as shift report, taking off physician orders, checking med carts).

• Feel free to use patient names—the Site Coordinator will add special study ID numbers and remove patient names. You do not need to write in the study ID numbers.

3. Each row is divided into 5 separate categories, plus a column to add up time in each row. The activities are:

• Administer Meds/Blood & Patient Education—Time spent administering meds or blood to each patient plus time spent educating that patient on their meds. Education can include family members.

• Personal Care/Nursing Interventions/Assessment & Patient Education—Time spent providing personal and nursing care to patients, including time for nursing assessments. Include education related to nursing care.

• Charting/Care Planning/Rounding/Family Meetings—Report time spent charting, in care planning meetings, shift report, and other activities related to patient care on the unit but not face-to-face with patients.

• Transporting Patients—Time spent transporting patients off the unit.

• Administrative/Inservices/Committees/Breaks/Other Off-Unit Time—Report time spent in activities not directly related to patient care on the unit. This includes time spent on breaks as well as time spent on another patient care unit.

4. During your shift, about every 2 hours, update the times spent with specific patients, time not specific to individual patients on the unit, and on administrative/breaks/off-unit activities.

5. At the end of your shift, add up the rows and columns and record the totals. Return the form to the Site Coordinator or your supervisor.

How Should I Report Time?

Please report time in 5-10 minute increments. It is not necessary to report time spent with a particular patient in some activity as 32, 67, or 99 minutes. Instead, report 30, 70, or 100 minutes, respectively.

Therapy Staff Activity Form Instructions
Medicare Post-Acute Care Study

The Staff Activity Form (SAF) collects information on the time that you spend with, or on behalf of, this unit’s patients. At the end of your day, please be sure your form is complete and return to the Site Coordinator or your manager.

This form is designed to be machine-read. The following are examples of acceptable ways of writing numbers:

Please be sure your “1”s and “7”s look different and that your “4”s and “9”s look different (for both computer and human readers). If possible, please use black ink. However, blue and green are acceptable.

Who completes this form?

Any therapy staff assigned to the unit or treating more than 1 or 2 unit patients should complete this form for each day that they spend on the unit. If you will only work with 1 or 2 patients on this unit, feel free to record your time in the Consultant Log, located in a binder at the nurses’ station or unit front desk.

Please note that there are separate forms for therapy staff versus nursing and other staff. Be sure to pick up the correct version—it’s printed at the top, and check boxes for your position are different for each form.

What are the steps to complete this form?

1. Write your name and date at the top of the form. Please indicate your position (indicate discipline and level) and employment type (regular full/part time, per diem or agency) in the check boxes.

This form will only be used for this study. Your name will only be used by your facility’s Site Coordinator to track whether all forms have been returned. Your name will be removed before the forms leave the facility.

2. During and at the end of your day you will complete the rest of the form. It is divided into two sections:

• The first three rows ask you for the total amount of time, in minutes, for your total shift; with, or for, patients on this unit; and time off the unit.

• The rest of the rows ask you to report time that patients on this unit spent with you in groups as well as in individual therapy. So, for a 1-hour group, you may spend 90 minutes preparing for and conducting the group, but each participating patient may spend from 1 to 60 minutes in that group. For the purposes of this data collection, a “group” is any therapy session with 2 or more patients. There is space to record on up to 6 groups—please record time in each group separately in the columns labeled “Group #1”, …, “Group #6”.

• Feel free to use patient names—the Site Coordinator will add special study ID numbers and remove patient names. You do not need to write in the study ID numbers.

3. Each row is divided into group therapies, individual therapy, and (for your time) time spent charting, on breaks, etc.

• Group Therapy—Please record time spent in each group separately. For the purposes of this data collection, a “group” is any therapy session with 2 or more patients. For reporting on your time, include preparation and charting time. For reporting patients’ times, only record face-to-face time.

• Individual Therapy/Assessment—Please record time spent in individual (one-on-one) therapy or time spent assessing patients individually. For reporting on your time, include preparation and charting time. For patients’ time, only record face-to-face time.

• Administrative/Charting/Care Planning/Breaks—Report time spent in any time not specific to a particular patient. On-unit examples include general charting, rounds, etc. Off-unit examples include time spent on breaks as well as time spent on another patient care unit.

4. During your shift, about every 2 hours, update the times spent with specific patients, time not specific to individual patients on the unit, and on administrative/breaks/off-unit activities.

5. At the end of your shift, add up the rows and columns in the top three rows only and record the totals. Return the form to the Site Coordinator or your manager.

How Should I Report Time?

Please report time in 5-10 minute increments. It is not necessary to report time spent with a particular patient in some activity as 32, 67, or 99 minutes. Instead, report 30, 70, or 100 minutes, respectively.

Home Health Patient Time Log Instructions
Medicare Post-Acute Care Study

The Home Health Patient Time Log collects information on the time that you spend with, or on behalf of, your patients. This includes face-to-face time as well as time spent on the patient outside of the visit. At the end of your day, or the next time you are in the office, please be sure your form is complete and return to the Site Coordinator or your manager.

This form is designed to be machine-read. The following are examples of acceptable ways of writing numbers:

Please be sure your “1”s and “7”s look different and that your “4”s and “9”s look different (for both computer and human readers). If possible, please use black ink. However, blue and green are acceptable.

Who completes this form?

All staff providing home health care or performing administrative duties in any of the participating offices/divisions/services should complete this form for each day.

Your Site Coordinator or manager will let you know if and on what day(s) to complete a form.

What are the steps to complete this form?

1. Write your name and date at the top of the form. Please indicate your position and employment type (regular full/part time, per diem or agency) in the check boxes.

Your name will only be used by your facility’s Site Coordinator to track whether all forms have been returned. The form will only be used for the study. Your name will be removed before the forms are sent to RTI.

2. During and at the end of your day you will complete the rest of the form:

• Each row corresponds to time spent with or for a particular patient.

• Feel free to use patient names—the Site Coordinator will add special study ID numbers and remove patient names. You do not need to write in the study ID numbers.

3. Each row is divided into two columns, one for face-to-face time and the other for time spent outside of visits.

• Face-to-Face Visit Time—Please record time spent in a visit with the particular patient. This is for face-to-face time.

• Time Spent Outside of Visits—Please record time you spend on the patient outside the visit. This includes travel time, charting, completing the OASIS instrument, taking wound care consult telephones calls, contacting physicians and other caregivers, etc.

4. At the end of each visit, or at least every two hours, update the times spent with, or for, specific patients.

5. At the end of your day, or the next time you are in the office, return the form to the Site Coordinator or your manager.

How Should I Report Time?

Please report time in 5-10 minute increments. It is not necessary to report time spent with a particular patient as 32, 67, or 99 minutes. Instead, report 30, 70, or 100 minutes, respectively.

Patient Ancillary Service Log Instructions
Medicare Post-Acute Care Study

Imaging/Radiology	Other Diagnostics	Complex Treatments
Angiogram	Arterial Blood Gas	Complex Bowel
Aortogram	(ABG)	Management (specify)
Arthrography	Bedside Bronchoscopy	Continuous Cardiac
Bone Densitometry	Complex Pharyngeal &	Monitoring/Telemetry
Cholangiography	Speech Evaluation	Hemodialysis
Cisternography	Other Diagnostics	Intermittent Bladder
Diskography	(specify)	Catheterization
Echocardiogram		Multiple IV Antibiotic
EKG		Administration
GI Series (Upper or		Negative Pressure
Lower)		Wound Therapy
Lymphangiography		Peritoneal Dialysis
Mammary Ductogram		Total Parenteral Nutrition
Modified Barium		Ventilator Management
Swallow		(Weaning Only)
MRI		Other Complex
Myelography		Treatment (specify)
Ultrasound (specify)
Urethrocystography
Urography
Venography
X-Ray
Other Imaging (specify)

Please complete this form for ALL patients.

Who Completes This Form?

The Site Coordinator or Nursing/Unit Manager will assign one staff person to have primary responsibility for ensuring this form is completed and will notify all staff of who has primary responsibility. However, all other unit staff should assist this person by checking that the log is completed for patients who they know have received an ancillary service.

What Are the Steps to Complete This Form?

1. Please fill in the patient’s name in a blank row—you may reuse a row if a patient’s name is already listed.

2. Then, check the box in the column for the service you are logging. Services are grouped by general type (imaging/ radiology, other diagnostics, and complex treatments). These are listed in the table on the right. Within each of the three main groups, the services are listed in alphabetically .

3. The items in the table on the right marked with a star (★) and that say “(specify)” have a blank in the form for you to indicate the body part or the type of service.

Please keep these forms inside this binder.

The Patient Ancillary Service Log collects information on the imaging/radiology, other diagnostic, and complex treatment ancillary services that patients may receive during their stay. The focus is on those services that are particularly costly and that do not generally occur on a daily basis or that may only be provided during a portion of a patient’s stay.

Non-Physician Consult Log Instructions
Medicare Post-Acute Care Study

Please complete this form for ALL patients.

Who Completes This Form?

This form is intended for facility staff who either:

• do not regularly work on this unit;

• only provide care to one or two patients on the unit; or

• who otherwise serve in a consult capacity.

• Physicians do not need to complete this form.

If you have any questions about whether you should complete this log or if you should instead complete a Staff Activity Form, please ask the Site Coordinator or nurse/unit manager.

What Are the Steps to Complete This Form?

This form is designed to be machine-read. The following are examples of acceptable ways of writing numbers:

Please be sure your “1”s and “7”s look different and that your “4”s and “9”s look different (for both computer and human readers). If possible, please use black ink. However, blue and green are acceptable.

1. Please fill in the patient’s name in a blank row—you may reuse a row if a patient’s name is already listed and if someone has not already recorded time in the space you intend to fill out.

2. Then, indicate the time you spent, in minutes, with that patient in the column corresponding to your discipline. There are pre-printed columns for:

• Physical therapists

• Occupational therapists

• Respiratory therapists

• Speech pathologists

• Dieticians/nutritionists—dietary aides do not need to complete this form

• Wound/infection nurses—this category includes wound care nurses, infection control nurses, ostomy nurses, and other specialty care nurses who provide consult services to units rather than routine patient care.

• Discharge planners

• Social workers

• PPS coordinators—this category includes staff coordinating assessment instruments (e.g., IRF-PAI, MDS).

• Phlebotomists/other lab techs

• Other non-physician consult staff—clergy and other pastoral caregivers and volunteers do not need to complete this form

3. If you used the “Other Consult” category, please also write in the type of consult you provided.

Please keep these forms inside this binder.

The Non-Physician Consult Log tracks whether a patient received a visit from a physical, occupational, or respiratory therapist; speech pathologist; nutritionist/dietary consultant; wound or infection care nurse; discharge planner; social worker; PPS coordinator; phlebotomist or other lab tech; or another other non-physician consult. The time spent in each consult is recorded. We are excluding consulting physicians from this form because they bill their visit separately.

Form SFU-20071116