Data Collection For Developing Outpatient Therapy Payment Alternatives (dotpa) (cms-10298)

Data Collection for Developing Outpatient Therapy Payment Alternatives (DOTPA)

Appendix A CARE-F_Discharge_4-14-2010

DATA COLLECTION FOR DEVELOPING OUTPATIENT THERAPY PAYMENT ALTERNATIVES (DOTPA) (CMS-10298)

OMB: 0938-1096

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1096 can be found here:

2010-12-06 - No material or nonsubstantive change to a currently approved collection

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CARE-F
Discharge
This instrument uses the phrase
“2-day assessment period” to refer to the day of
discharge and the calendar day before the day of
discharge (beginning at 12:00 AM).

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid
OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is estimated to average 35 minutes per response,
including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.
i

Signatures of Clinicians 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 Developing
Outpatient Therapy Payment Alternatives project,
• 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 Developing Outpatient Therapy Payment Alternatives project 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.

Name/Signature
(Joe Smith)

Credential
(RN)

NPI
(if applicable)
1234567890

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Sections Worked On
Medical Information

Date(s) of
Data collection
(MM/DD/YYYY)

I. Administrative Items
A.

Assessment Type

A.3 Assessment Reference Date
______/______/______
MM

YYYY

(The last day of the admission assessment period.)

•

If the patient is admitted before noon, it is the
second calendar day of the admission.

• If the patient is admitted after noon, it is the
third calendar day of the admission.

Provider Information

B.1 Provider’s Name

Patient Information

C.1 Patient’s First Name

______________________
____________
C.2 Patient’s Middle Initial or Name

C.6 Patient’s Medicare Health Insurance Claim Number

|___|___|___|___|___|___|___|___|___|___|___|___|
C.7 Admission Date (Note: the admission date is the first day
the patient was covered by Medicare Part B)
______/______/______

________________________
___________
C.3 Patient’s Last Name

YYYY

C.8 Birth Date
______/______/______

________________________
___________
C.4 Patient’s Gender
Male
Female

YYYY

C.11 Discharge Date (Note: the discharge date is the last day
the patient was covered by Medicare Part B)
______/______/______
MM

YYYY

III. Current Medical Information
A. Primary Reason for Therapy
Please indicate the primary body function(s), body structure(s), and activity & participation reason(s) for which you are treating
this patient using the categories below. Check all primary reasons for therapy that apply.
A.1 Body Functions (Check at least one)
a. Global Mental Functions (consciousness, orientation,
intellectual function, energy & drive, sleep,
temperament, personality)
b. Specific Mental Functions (attention, memory,
psychomotor, emotional, perceptual, higher level
cognition, sequencing of complex tasks, calculation,
mental functions of language)
c. Seeing & Related Functions
d. Hearing
e. Vestibular Functions
f. Proprioceptive & Touch Functons
g. Other Sensory Functions (taste, smell)
h. Pain
i. Voice & Speech Functions (articulation, speech,
fluency & rhythm, alternative vocalization)
j. Functions of the Cardiovascular System
k. Functions of the Immunological & Hematological
Systems
l. Functions of the Respiratory System
m. Functions of the Digestive System
n. Functions Related to Metabolism & Endocrine
System
o. Urinary Functions
p. Genital & Reproductive Functions
q. Functions of the Joints & Bones
r. Muscle Functions (muscle power, tone, endurance)
s. Movement Functions (motor reflexes, involuntary
movements, control of movements, gait patterns,
neuromuscular functions)
t. Functions of the Skin
u. Functions of the Hair & Nails

A.2 Body Structures (Check at least one)
Structures Related to Movement
a. General/No Specific Body Location
b. Head
c. Cervical Spine
d. Thoracic Spine
e. Lumbar Spine
f. Pelvic Girdle
L: Left Side; R: Right Side
L R
g. Hip
h. Thigh
i. Knee
j. Calf
k. Foot/Ankle
l. Toes
m. Shoulder
n. Arm
o. Elbow
p. Wrist
q. Hand
r. Fingers
Structures Involved in Voice & Speech
s. Nose
t. Mouth
u. Tongue
v. Pharynx
w. Larynx
Other Structures
x. Eye & Related Structures
y. Ear & Related Structures
z. Structures of the Central Nervous System
aa. Structures of the Peripheral Nervous System
bb. Structures of the Cardiovascular, Immunological, &
Respiratory Systems
cc. Structures Related to the Digestive, Metabolic, &
Endocrine Systems
dd. Structures Related to the Genitourinary &
Reproductive Systems
ee. Skin & Related Structures

A.3 Activities and Participation
(Check at least one)
a. Purposeful Sensory Experiences (watching, listening)
b. Basic Learning (copying, rehearsing, learning to
read, write, acquiring skills)
c. Applying Knowledge (focusing attention, thinking,
reading, writing, calculating, solving problems,
making decisions)
d. General Tasks & Demands (simple and multiple
tasks, carrying out daily routine, handling stress)
e. Communication: Receiving (spoken, non verbal, sign
language, written)
f. Communication: Producing (speaking, nonverbal,
sign language, writing)
g. Conversation & Use of Communication Devices
(conversation, discussion, using devices and
techniques)
h. Changing & Maintaining Body Position
i. Carrying, Moving & Handling Objects
j. Walking & Moving
k. Moving Around Using Transportation
l. Self Care (washing oneself, toileting, dressing,
eating, drinking)
m. Acquisition of Necessities (a place to live, goods and
services)
n. Household Tasks (preparing meals, doing
housework)
o. Caring for Household Objects & Assisting Others
p. General Interpersonal Interactions
q. Particular Interpersonal Interactions (relating with
strangers, formal and informal relationships, family
and intimate relationships)
r. Education
s. Work & Employment
t. Economic Life
u. Community, Social & Civic Life

III. Current Medical Information (cont.)
B. Primary and Secondary Medical Diagnoses
Based on available medical information, please indicate the patient’s primary (1ary) and secondary (2ary) medical conditions.
The primary diagnosis should be related to the reason for therapy. Please check all that apply.
B.1 Musculoskeletal
1ary 2ary
a. Pain Syndrome (fibromyalgia, polymyalgia,
etc.)
b. Pain, Not Pain Syndrome
c. Osteoarthritis
d. Rheumatoid Arthritis
e. TMJ Disorder
f. Fracture
g. Sprain/Strain
h. Osteoporosis
i. Herniated Disc
j. Spinal Stenosis
k. Scoliosis
l. Torticolis
m. Contusion
n. Joint Replacement
o. Amputation
p. Bursitis
q. Tendonitis
r. Internal Derangement of Joint
s. Tendon Rupture
t. Nerve Entrapment
u. Contracture
v. Other __________
B.2 Circulatory
1ary 2ary
a. TIA
b. Stroke
c. Atrial Fibrillation & Other Dysrhythmia
(bradycardia, tachydardia)
d. Coronary Artery Disease (angina, myocardial
infarction)
e. Deep Vein Thrombosis (DVT)
f. Heart Failure (including pulmonary edema)
g. Hypertension
h. Peripheral Vascular Disease/Peripheral Arterial
Disease
i. Other __________
B.3 Lymphatic System
1ary 2ary
a. Lymphedema
b. Other __________
B.4 Pulmonary/Respiratory System
1ary 2ary
a. Asthma
b. Bronchitis
c. Pneumonia
d. Chronic Obstructive Pulmonary Disease (COPD)
e. Cystic Fibrosis
f. Other __________
B.5 Integumentary System
1ary 2ary
a. Skin Ulcer/Wound
b. Burn
c. Other __________

B.6 Genitourinary System
1ary 2ary
a. End Stage Renal Disease (ESRD)
b. Incontinence
c. Pelvic Pain
d. Other __________
B.7 Mental Health
1ary 2ary
a. Anxiety Disorder
b. Depression
c. Bipolar Disease
d. Attention Disorder
e. Schizophrenia
f. Alzheimer’s Disease
g. Other __________
B.8 Cancer/Other Neoplasms
1ary2ary
a. Please Specify
B.9 Metabolic System
1ary 2ary
a. Diabetes Mellitus
b. Obesity
c. Other __________
B.10 Generalized Weakness
1ary 2ary
a. Generalized Weakness
B.11 Infectious Diseases
1ary 2ary
a. Please Specify
B.12 HIV
1ary 2ary
a. HIV
B.13 Gastrointestinal Disorders
1ary 2ary
a. Please Specify
B.14 Immune Disorders
1ary 2ary
a. Immune Disorders
B.15 Anemias/Other Hematological
Disorders
1ary 2ary
a. Anemia
b. Other _________________
B.16 Congenital Abnormalities
1ary 2ary
a. Musculoskeletal Congenital Deformities/
Anomalies
b. Neurological Congenital/Developmental
Anomalies
c. Other _________________

B.17 Neurological Conditions
1ary 2ary
a. Specific Diseases of Central Nervous System
(CNS)
b. Cranial Neuralgia
c. Cranial Nerve Injury
d. Seizure Disorder
e. Paralysis
f. Peripheral Nervous System Disorder (including
neuropathy)
g. Complex Regional Syndrome
h. Vertigo
i. Multiple Sclerosis
j. Parkinson’s
k. Huntington’s Disease
l. Head Injury
m. Traumatic Brain Injury
n. Non-Traumatic Brain Injury
o. Encephalopathy
p. Retinopathy
q. Guillain-Barré Syndrome
r. Other __________
B.18 Cognition/Judgement
1ary 2ary
a. Executive Function Disorder
b. Memory Impairment
c. Pragmatics Disorder
d. Dementia
e. Other _________________
B.19 Communication, Voice, or Speech
Disorder
1ary 2ary
a. Aphasia
b. Apraxia of Speech
c. Reading or Writing Dysfunction
d. Voice Disorder (Dysphonia)
e. Speech Disorder
f. Cognitive-Communication Disorder
g. Other __________
B.20 Swallowing Disorder
1ary 2ary
a. Dysphagia
B.21 Sensory Disorders/Gait or Balance
Disorder
1ary 2ary
a. Hearing Impairment
b. Vision Impairment
c. Gait or Balance Disorder
d. Other _________________
B.22 Other Condition
1ary 2ary
a. Please Specify _________________

III. Current Medical Information (cont.)
C.1

For how long has the patient experienced the primary medical condition related to the reason they are receiving
therapy?
Less than 1 week
Between 1 week and 1 month
Between 1 month and 3 months
More than 3 months
Unknown
C.2.a How many surgeries has the patient had in the past
C.2.b If the patient has had 1 or more surgeries
associated with the primary medical condition related
associated with the primary medical condition
to the reason they are receiving therapy?
related to the reason they are receiving therapy,
None
Unknown
when was the most recent surgery?
1
Less than 1 week ago
2
Between 1 week and 1 month ago
3
Between 1 month and 3 months ago
4 or more
More than 3 months ago

Major Treatments (“Admitted With” refers to the 2-day admission assessment period.)

Which of the following treatments did the patient receive a) at any time during their stay or b) at the time of discharge?
Check all that apply.
b. Used at
Any Time
During
c. Discharged
Stay
With

D.1
D.2
D.3
D.4
D.5
D.6
D.7
D.8
D.9
D.10
D.11
D.12
D.13
D.14
D.15
D.16
D.17
D.18
D.19
D.20
D.21
D.22
D.23
D.24
D.25
D.26
D.27
D.28
D.29
D.30

None
Insulin Drip
Total Parenteral Nutrition
Central Line Management
Blood Transfusion(s)
Controlled Parenteral Analgesia – Peripheral
Controlled Parenteral Analgesia – Epidural
Left Ventricular Assistive Device (LVAD)
Continuous Cardiac Monitoring: Specify reason for continuous monitoring:
Chest Tube(s)
Trach Tube with Suctioning: Specify most intensive frequency of suctioning during stay: Every____ hrs
High O2 Concentration Delivery System with FiO2 > 40%
Non-invasive ventilation
Ventilator – Weaning
Ventilator – Non-Weaning
Hemodialysis
Peritoneal Dialysis
Fistula or Other Drain Management
Negative Pressure Wound Therapy
Complex Wound Management with positioning and skin separation/traction that requires at least two
persons
Halo
Complex External Fixators (e.g., Ilizarov)
One-on-One 24-Hour Staff Supervision: Specify reason for 24-hour supervision: ______
Specialty Surface or Bed (i.e., air fluidized, bariatric, low air loss, or rotation bed)
Multiple Types of IV Antibiotic Administration
IV Vasoactive Medications (e.g., pressors, dilators, medication for pulmonary edema)
IV Anti-coagulants
IV Chemotherapy
Indwelling Bowel Catheter Management System
Other Major Treatments: Specify_____________________________________________

III. Current Medical Information (cont.)
E.

Skin Integrity (Complete during the 2-day assessment period.)

E.1-2 PRESENCE OF PRESSURE ULCERS
E.1

Is this patient at risk of developing pressure ulcers?
E.2 Does this patient have one or more unhealed
0. No
pressure ulcer(s) at stage 2 or higher or unstageable?
1. Yes, indicated by clinical judgment
0. No (If No, skip to E.6)
1. Yes
2. Yes, indicated high risk by formal assessment
2. Don’t Know
(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.
IF THE PATIENT HAS ONE OR MORE STAGE 2-4 OR UNSTAGEABLE PRESSURE ULCERS, indicate the number of unhealed
pressure ulcers at each stage.

Pressure ulcer at stage 2, stage 3, stage 4, or unstageable:
E.2.a Stage 2 – Partial thickness loss of dermis presenting as a shallow open

NUMBER OF PRESSURE ULCERS PRESENT AT
ASSESSMENT
1 2 3 4 5 6 7 8 + Unknown

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).

E.2.e Number of unhealed stage 2 ulcers known to be present for
more than 1 month.

Unknown

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.

E.2.b 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.

E.2.c 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.
E.2.d 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.

E.3 Measurements of LARGEST Unhealed Stage 3 or 4 Pressure Ulcer
If any unhealed pressure ulcer is stage 3 or 4 (or if eschar is present), record the most recent measurements for the
LARGEST ulcer (or eschar):
E.3.b Longest length in any dimension

|___|___|.|___| cm

E.3.c Width of SAME unhealed ulcer or eschar |___|___|.|___| cm
E.3.d Depth of SAME unhealed ulcer or eschar |___|___|.|___| cm
E.3.e Date of measurement

____/____/_____
MM

DD YYYY

III. Current Medical Information (cont.)
E.4 Indicate if any unhealed stage 3 or stage 4 pressure E6a-e. Number of Major Wounds
ulcer(s) has undermining and/or tunneling (sinus
Number of Major
tract) present.
Wounds
0. No
1. Yes
8. Unable to assess
0
1
2
3
4+
Type(s) of Major Wound(s)
E.5 Do the patient’s pressure ulcers interfere with
therapy treatments?
0. No
1. Yes
8. Don’t Know

E.6.a Delayed healing of surgical
wound

E.6.b Trauma-related wound (e.g.,
burns)

E.6 MAJOR WOUND (excluding pressure ulcers)

E.6.c Diabetic foot ulcer(s)

E.6.d Vascular ulcer (arterial or
venous including diabetic
ulcers not located on the
foot)

E.6.e Other (e.g., incontinence
associated dermatitis, normal
surgical wound healing).
Please specify:
________________________

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 E7)

1. Yes

Check all that
apply.

E.7 TURNING SURFACES NOT INTACT
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

IV. Cognitive Status, Mood, & Pain
A.

Comatose (Complete during the 2-day assessment period.)

A.1

Persistent vegetative state/no discernible consciousness at time of admission
0. No
1. Yes (If Yes, skip to G8)

Temporal Orientation/Mental Status (Complete during the 2-day assessment period.)

B.1

Interview Attempted

B.1.a Interview Attempted?
0. No
1. Yes (If Yes, skip to B2)

B.2

B.1.b Indicate reason that the interview was not attempted

and then skip to Section C.
1. Unresponsive or minimally conscious
2. Communication disorder
3. No interpreter available

Brief Interview for Mental Status: Any score with an asterisk will require completion of Section C.

B.2.a 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.
B.2.b Year, Month, Day
B.2.b.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
B.2.b.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
B.2.b.3 Ask patient: “What day of the week is today?”
Patient’s answer is:
2. Accurate
1. Incorrect or no answer

IV. Cognitive Status, Mood, & Pain (cont.)
B.2

Brief Interview for Mental Status (cont.)

B.2.c 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.

B.2.c.2 Recalls "blue?"
2. Yes, no cue required
1. Yes, after cueing (“a color”)
0. No, could not recall

B.2.c.1 Recalls “sock?”
2. Yes, no cue required
1. Yes, after cueing ("something to wear")
0. No, could not recall

B.2.c.3 Recalls "bed?"
2. Yes, no cue required
1. Yes, after cueing ("a piece of furniture")
0. No, could not recall

B.3

Does the patient have any problems with memory, attention, problem solving, planning, organizing, or
judgment?
0. No
1. Yes
8. Don’t Know

B.3.a Cognitive Status
Answer only if you answered “Yes” to B.3
1. Current season
2. Location of own room (nursing home only)
Please indicate all of the following that the
patient is able to recall.

3. Staff names and faces
4. That s/he is in a hospital, nursing home, clinic, office, or home.
5. None of the above

Confusion Assessment Method: Code the following behaviors during the 2-day assessment period. Indicate
status regardless of cause.

C.1 Inattention: The patient has difficulty focusing
attention (e.g., easily distracted, out of touch, or
difficulty keeping track of what is said).
C.2 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).
C.3 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).
C.4 Psychomotor retardation: Patient has an
unusually decreased level of activity (e.g.,
sluggishness, staring into space, staying in one
position, moving very slowly).

Behavior not
present.

Behavior continuously
present, does not
fluctuate.

Behavior present,
fluctuates (e.g., comes and
goes, changes in severity).

IV. Cognitive Status, Mood, & Pain (cont.)
D.

Difficulty Remembering, Organizing, or Attending in Daily Life

D.1

Is the patient being treated or evaluated for difficulty remembering, organizing, or attending in daily life?
0. No (Please skip to Section E)
1. Yes (Please complete D.2 – D.4)

In Questions D.2 through D.4, please use the following definitions for the frequency with which the patient can perform the
indicated activity and for level of assistance:
Never:
Unable
Frequency Performing Activity

Level of Assistance

Rarely:
Sometimes:
Usually or Always:
Without Assistance:
With Assistance:

Less than 20% of the time
Between 20% and 49% of the time
At least 50% of the time
Patient performance without cueing, external guidance, assistive
device, or other compensatory augmentative intervention.
Patient performance with cueing, external guidance, assistive
device, or other compensatory augmentative intervention.

D.2
Problem Solving
The patient solves:
Simple Problems: Following
schedules; requesting assistance;
using a call bell; identifying basic
wants/needs; preparing a simple
cold meal.
Complex problems: Working on a
computer; managing personal,
medical, and financial affairs;
preparing a complex hot meal;
grocery shopping; route finding and
map reading.
D.3
Memory
The patient recalls:
Basic Information: Personal
information (e.g., family members,
biographical information, physical
location); schedules; names of
familiar staff; location of therapy
area.
Complex Information: Complex
and novel information (e.g., carry
out multiple-step activities, follow
a plan); anticipate future events
(e.g., keeping appointments).
D.4
Attention
The patient maintains attention
for:
Simple Activities: Following simple
directions; reading environmental
signs; eating a meal; completing
personal hygiene; dressing.
Complex Activities: Watching a
news program; reading a book;
planning and preparing a meal;
managing one’s own medical,
financial, and personal affairs.

Simple Problems

Complex Problems

D.2.a
Without
Assistance

D.2.b
With
Assistance

D.2.c
Without
Assistance

D.2d
With
Assistance

Never
Rarely
Sometimes
Usually or Always

Basic Information

Complex Information

D.3.a
Without
Assistance

D.3.b
With
Assistance

D.3.c
Without
Assistance

D.3.d
With
Assistance

Never
Rarely
Sometimes
Usually or Always

Simple Activities

Complex Activities

D.4.a
Without
Assistance

D.4.b
With
Assistance

D.4.c
Without
Assistance

D.4.d
With
Assistance

Never
Rarely
Sometimes
Usually or Always
9

IV. Cognitive Status, Mood, & Pain (cont.)
E.

Behavioral Signs & Symptoms (Complete during the 2-day assessment period.)

Has the patient exhibited any of the following behaviors during the 2-day assessment period?
E.1 Physical behavioral symptoms directed toward
others (e.g., hitting, kicking, pushing)?
0. No
1. Yes
E.2 Verbal behavioral symptoms directed towards
others (e.g., threatening, screaming at others)?
0. No
1. Yes

E.3 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

Mood (Complete during the 2-day assessment period.)

F.1 Mood Interview Attempted?
0. No (If No, skip to G1)
1. Yes
F.2 Patient Health Questionnaire (PHQ-2©)
Ask patient: “During the last 2 weeks, have you been bothered by any of the following problems?”
F.2.a Little interest or pleasure in doing things?
0. No (If No, skip to F2c)
1. Yes
8. Unable to respond (If Unable, skip to F2c)
F.2.b 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)
F.2.c Feeling down, depressed, or hopeless?
0. No (If No, skip to F3)
1. Yes
8. Unable to respond (If Unable, skip to F3)
F.2.d 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)
F.3

Feeling Sad

F.3

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

IV. Cognitive Status, Mood, & Pain (cont.)
G. Pain (Complete during the 2-day assessment period.)
G.2 Pain Presence
Ask patient: “Have you had pain or hurting at any time during

G.1 Pain Interview Attempted?
0. No Specify Reason: ___________________

the last 2 days?”
0. No (If No, skip to Section V. Impairments)

(If No, skip to G.8)
1. Yes

1. Yes
8. Unable to answer or no response

(skip to G.8)
G.3 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.”

0
1
2
3
4
5
6
7
8
9
10
No Pain
Moderate Pain
Worst Pain
G.4 Pain Effect on Sleep
G.5 Pain Effect on Activities
Ask patient: “During the past 2 days, has pain made it hard Ask patient: “During the past 2 days, have you limited your

for you to sleep?”

activities because of pain?”

0. No
1. Yes
8. Unable to answer or no response
G6.

0. No
1. Yes
8. Unable to answer or no response

How does the patient describe their pain? (Check all that apply.)

a. Constant
b. Intermittent

e. Burning
f. Pinching

i.
j.

c. Sharp
d. Dull

g. Numbness
h. Tingling

k. Pulling
l. Cramping

G7.

Ache/Throb
Stabbing

m. Tightness
n. Stiffness
o. Other: Please write in
____________________

Pain Location
R

Please ask the patient where they have pain
and mark with an X the indicated area(s).

IV. Cognitive Status, Mood, & Pain (cont.)
Check all that apply.

G.8.

Pain Observational Assessment. If patient could not be interviewed for pain assessment, check all indicators of
pain or possible pain.
G.8.a Non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning)
G.8.b Vocal complaints of pain (e.g., “that hurts, ouch, stop”)
G.8.c Facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw)
G.8.d Protective body movements or postures (e.g., bracing, guarding, rubbing or massaging a body part/area,
clutching or holding a body part during movement)
G.8.e None of these signs observed or documented

V. Impairments
A.

Bladder and Bowel Management: Use of Device(s) and Incontinence
(Complete during the 2-day assessment period.)

A.1

Does the patient have any impairments with bladder or bowel management (e.g., use of a device or
incontinence)?
No (If No impairments, skip to Section B)
Yes (If Yes, please complete this section)
A.2.a Bladder
A.2.b Bowel
Does this patient use an external or indwelling device or
0. No
0. No
require intermittent catheterization?
1. Yes
1. Yes
Indicate the frequency of incontinence. Please check one
option under both Bladder and Bowel.
A.3.a Bladder
A.3.b Bowel

A.2

A.3

Continent (no documented incontinence)

Stress incontinence only (bladder only)

Incontinent less than daily (only once during the 2-day
assessment period)

Incontinent daily (at least once a day)

Always incontinent

No urine/bowel output (e.g., renal failure)

Not applicable (e.g., indwelling catheter)

A.4

Does the incontinence interfere with therapy treatments?

A.4.a Bladder
0. No
1. Yes
9. Unknown

A.4.b Bowel
0. No
1. Yes
9. Unknown

V. Impairments (cont.)
B. Swallowing (Complete during the 2-day assessment period.)
Check all that apply.

B.1

Does the patient have any signs or symptoms of a possible swallowing disorder?
B.1.a History of dysphagia/aspiration pneumonia
B.1.b Complaints of difficulty or pain with swallowing
B.1.c Coughing or choking during meals or when swallowing medications
B.1.d Holding food in mouth/cheeks or residual food in mouth after meals
B.1.e Loss of liquids/solids from mouth when eating or drinking
B.1.f NPO: intake not by mouth
B.1.g Other (specify) _______________________________________________________
B.1.h None

B.2

Describe the patient’s usual ability with swallowing. (Check one option ONLY.)
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.

B.3 For safety and maximal nutritional intake, the
patient requires:
Liquid Diet Modification: Thickened liquids (e.g.,
consistency of syrup, honey, or pudding)
Solid Diet Modification: Cooked until soft; chopped,
ground, mashed; or pureed
Maximal Cueing: Multiple cues that are obvious to
nonclinicians, including any combination of auditory, visual,
pictorial, tactile, or written cues
Minimal Cueing: Subtle and only one type of cueing

B.3.a
Diet Modification

B.3.b
Level of Cueing or
Assistance

Both Liquids & Solids

Maximal

Either Liquids or Solids

Minimal

None

C. Hearing, Vision, and Communication (Complete during the 2-day assessment period.)
C.1

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

C.1.a Ability to See in Adequate Light (with glasses or
other visual appliances)
3. Adequate: Sees fine detail, including regular
print in newspapers/books

C.1.b Ability to Hear (with hearing aid or hearing
appliance, if normally used)
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

2. Mildly to Moderately Impaired: Can identify
objects; may see large print
1. Severely Impaired: No vision or object
identification questionable

1. Severely Impaired: Absence of useful hearing
8. Unable to assess
9. Unknown

8. Unable to assess
9. Unknown

V. Impairments (cont.)
C.1.c Understanding Verbal Content (excluding language
C.1.d Expression of Ideas and Wants
barriers)
4. Expresses complex messages without difficulty
4. Understands: Clear comprehension without cues
and with speech that is clear and easy to
or repetitions
understand
3. Usually Understands: Understands most
3. Exhibits some difficulty with expressing needs and
conversations, but misses some part/intent of
ideas (e.g., some words or finishing thoughts) or
message. Requires cues at times to understand
speech is not clear
2. Sometimes Understands: Understands only
2. Frequently exhibits difficulty with expressing
basic conversations or simple, direct phrases.
needs and ideas
Frequently requires cues to understand
1. Rarely/Never expresses self or speech is very
1. Rarely/Never Understands
difficult to understand.
8. Unable to assess
8. Unable to assess
9. Unknown
9. Unknown

Difficulty Communicating in Daily Life

D.1 Is the patient being treated or evaluated for difficulty communicating in daily life?
0. No (If No, skip to Section E)
1. Yes (If Yes, please complete D.2 – D.5)
In Questions D.2 through D.5, please use the following definitions for the frequency with which the patient can perform
the indicated activity and level of assistance:
Frequency Performing Activity

Level of Assistance

Never:
Rarely:
Sometimes:

Unable
Less than 20% of the time
Between 20% and 49% of the time

Usually or Always:

At least 50% of the time

Without Assistance:

Patient performance without cueing, external guidance,
assistive device, or other compensatory augmentative
intervention.
Patient performance with cueing, external guidance, assistive
device, or other compensatory augmentative intervention.

With Assistance:
D.2 Language Comprehension
The patient comprehends:

Basic Information

Basic Information: Simple
directions; simple yes/no questions;
simple words or phrases.
Complex Information: Complex
sentences/directions/ messages;
conversations about routine daily
activities.

Complex Information

D.2.a
Without
Assistance

D.2.b
With
Assistance

D.2.c
Without
Assistance

Never

D.2.d
With Assistance

Rarely

Sometimes

Usually or Always

D.3 Language Expression
The patient comprehends:
Basic Information: Simple
directions; simple yes/no questions;
simple words or phrases.
Complex Information: Complex
Never
sentences/ directions/messages;
Rarely
conversations about routine daily
Sometimes
activities.

Basic Information

Complex Information

D.3.a
Without
Assistance

D.3.b
With
Assistance

D.3.c
Without
Assistance

D.3.d
With Assistance

Usually or Always
14

V. Impairments (cont.)
D.4 Motor Speech Production
The patient’s speech is:
Intelligible in Short Utterances: Short
consonant-vowel combinations;
automatic words; simple words or
predictable phrases.
Intelligible in Conversation: Long
utterances; low predictability sentences;
communication in vocational, avocational,
and social activities.
D.5 Voice
The patient’s voice is functional in the
following types of activities:
Low Vocal Demand: Speaking softly;
speaking in quiet environments; talking
for short periods of time.
High Vocal Demand: Speaking loudly;
speaking in noisy environments; talking
for extended periods of time.

Never
Rarely
Sometimes
Usually or
Always

Intelligible in Short
Utterances
D.4.a
D.4.b
Without
With
Assistance
Assistance

Intelligible in Conversation
D.4.c
Without
D.4.d
Assistance
With Assistance

Low Vocal Demand
D.5.a
D.5.b
Without
With
Assistance
Assistance

High Vocal Demand
D.5.c
Without
D.5.d
With Assistance
Assistance

E. Weight-bearing (Complete during the 2-day assessment period.)
E.1 Does the patient have any impairments with weight-bearing?
0. No (If No, skip to Section F)
1. Yes (If Yes, please complete this section)
CODING: Indicate all the patient’s weight-bearing restrictions.
Upper Extremity
E.1.a Left

1. Fully weight-bearing: No medical restrictions

0. Not fully weight-bearing: Patient has medical
restrictions or unable to bear weight (e.g.
amputation)

E.1.b Right

Lower Extremity
E.1.c Left

E.1.d Right

V. Impairments (cont.)
F.

Respiratory Status (Complete during the 2-day assessment period.)

F.1 Does the patient have any impairments with respiratory status?
0. No (If No, skip to Section G)
1. Yes (If Yes, please complete this section)
F.1.a

F.1.b

With
Without
Supplemental O2 Supplemental O2

Respiratory Status: Was the patient dyspneic or noticeably short of breath?

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

G. Endurance (Complete during the 2-day assessment period.)
G.1 Does the patient have any impairments with endurance?
0. No (If No, skip to Section H)
1. Yes (If Yes, please complete this section)
G.1.a Mobility Endurance: Was the patient able to walk or
wheel 50 feet (15 meters)?
0. No, could not do
1. Yes, can do with rest
2. Yes, can do without rest
8. Not assessed due to medical restriction

G.1.b Sitting Endurance: Was the patient able to tolerate
sitting for 15 minutes?
0. No
1. Yes, with support
2. Yes, without support
8. Not assessed due to medical restriction

H. Mobility Devices and Aids Needed (Complete during the 2-day assessment period.)
H.1 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
g. Other (specify) ______________________
h. None apply

VI. Functional Status: Usual Performance
A.

Core Self Care: The core self care items should be completed on ALL patients.
(Complete during the 2-day assessment period.)

Code the patient’s most usual performance 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.

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
Activities may be completed with or without assistive devices.
and provides more than half the effort.
6. Independent – Patient completes the activity by him/herself
1.
Dependent – Helper does ALL of the effort. Patient does
with no assistance from a helper.
none
of the effort to complete the task.
5. Setup or clean-up assistance – Helper SETS UP or CLEANS
UP; patient completes activity. Helper assists only prior to or If activity was not attempted code:
M. Not attempted due to medical condition
following the activity.
S. Not attempted due to safety concerns
4. Supervision or touching assistance –Helper provides
VERBAL CUES or TOUCHING/ STEADYING assistance as patient A. Task attempted but not completed
N. Not applicable
completes activity. Assistance may be provided throughout
P. Patient Refused
the activity or intermittently.
Patient’s Most Usual
Performance
6

Activity Not
Attempted Code
M

A.1 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.

A.2 Tube feeding: The ability to manage all equipment/supplies related to
obtaining nutrition.

A.3 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.

A.4 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.
A.5 Upper body dressing: The ability to put on and remove shirt or pajama top.
Includes buttoning three buttons.
A.6 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 during the 2-day assessment period.)

Code the patient’s most usual performance using the 6-point scale below.
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.

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
Activities may be completed with or without assistive devices.
THAN HALF the effort. Helper lifts or holds trunk or limbs
6. Independent – Patient completes the activity by him/herself
and provides more than half the effort.
with no assistance from a helper.
1. Dependent – Helper does ALL of the effort. Patient does
5. Setup or clean-up assistance – Helper SETS UP or CLEANS
none of the effort to complete the task.
UP; patient completes activity. Helper assists only prior to or
If activity was not attempted code:
following the activity.
M. Not attempted due to medical condition
4. Supervision or touching assistance –Helper provides
VERBAL CUES or TOUCHING/ STEADYING assistance as patient S. Not attempted due to safety concerns
A. Task attempted but not completed
completes activity. Assistance may be provided throughout
N. Not applicable
the activity or intermittently.
P. Patient Refused
Patient’s Most Usual
Activity Not
Performance
Attempted Code
6 5 4 3 2 1 M S A N P
B.1

B.4

Lying to sitting on side of bed: The ability to safely move from lying on the back
to sitting on the side of the bed with feet flat on the floor, no back support.
Sit to stand: The ability to safely come to a standing position from sitting in a
chair or on the side of the bed.
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.
Toilet transfer: The ability to safely get on and off a toilet or commode.

B.5

Does this patient primarily use a wheelchair for mobility?

B5a.

Select the longest distance the patient walks and code his/her level of independence (Level 1-6) on that distance.
Observe performance. (Select only one.)
6 5 4 3 2 1 M S A N P

B.2
B.3

0. No (If No, code B.5.a for the longest distance completed)
1. Yes (If Yes, code B.5.b for the longest distance completed)

B.5.a.1 Walk 150 ft (45 m): Once standing, can walk at least150 feet (45 meters) in
corridor or similar space.
B.5.a.2 Walk 100 ft (30 m): Once standing, can walk at least 100 feet (30 meters) in
corridor or similar space.
B.5.a.3 Walk 50 ft (15 m): Once standing, can walk at least 50 feet (15 meters) in corridor
or similar space.
B.5.a.4 Walk in Room Once Standing: Once standing, can walk at least 10 feet (3 meters)
in room, corridor or similar space.

B.5.b Select the longest distance the patient wheels and code his/her level of independence (Level 1-6). Observe
performance. (Select only one.)
6 5 4 3 2 1 M S A N
B.5.b.1 Wheel 150 ft (45 m): Once standing, can wheel at least 150 feet (45 meters) in
corridor or similar space.
B.5.b.2 Wheel 100 ft (30 m): Once standing, can wheel at least 100 feet (30 meters) in
corridor or similar space.
B.5.b.3 Wheel 50 ft (15 m): Once standing, can wheel at least 50 feet (15 meters) in
corridor or similar space.
B.5.b.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 during the 2-day assessment period.)

Code the patient’s most usual performance using the 6-point scale below.
Safety and Quality of Performance – If helper assistance is
3. Partial/moderate assistance – Helper does LESS THAN
required because patient’s performance is unsafe or of poor
HALF the effort. Helper lifts, holds or supports trunk or
quality, score according to amount of assistance provided.
limbs, but provides less than half the effort.
Activities may be completed with or without assistive devices.
2. Substantial/maximal assistance – Helper does MORE
THAN HALF the effort. Helper lifts or holds trunk or limbs
6. Independent – Patient completes the activity by him/herself
and provides more than half the effort.
with no assistance from a helper.
1. Dependent – Helper does ALL of the effort. Patient does
5. Setup or clean-up assistance – Helper SETS UP or CLEANS
none of the effort to complete the task.
UP; patient completes activity. Helper assists only prior to or
If activity was not attempted code:
following the activity.
M. Not attempted due to medical condition
4. Supervision or touching assistance –Helper provides
VERBAL CUES or TOUCHING/ STEADYING assistance as patient S. Not attempted due to safety concerns
E. Not attempted due to environmental constraints
completes activity. Assistance may be provided throughout
A. Task attempted but not completed
the activity or intermittently.
N. Not applicable
P. Patient Refused
Patient’s Most Usual Activity Not Attempted
Performance
Code
6 5 4 3 2 1 M S E A N P
C.1
C.2

C.3
C.4
C.5
C.6
C.7

Wash upper body: The ability to wash, rinse, and dry the face, hands, chest,

and arms while sitting in a chair or bed.
Shower/bathe self: The ability to bathe self in shower or tub, including
washing, rinsing, and drying, self. Does not include transferring in/out of

tub/shower.
Roll left and right: The ability to roll from lying on back to left and right side,

and roll back to back.
Sit to lying: The ability to move from sitting on side of bed to lying flat on the

bed.
Picking up object: The ability to bend/stoop from a standing position to pick

up small object such as a spoon from the floor.
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.
Does this patient primarily use a wheelchair for mobility?
0. No (If No, code C.7.a–C.7.f)

1. Yes (If Yes, code C.7.f–C.7.h)
C.7.a 1 step (curb): The ability to step over a curb or up and down one step.
C.7.b Walk 50 feet with two turns: The ability to walk 50 feet and make two turns.
C.7.c 12 steps-interior: The ability to go up and down 12 interior steps with a rail.
C.7.d Four steps-exterior: The ability to go up and down 4 exterior steps with a rail.
C.7.e Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or
sloping surfaces, such as grass or gravel.
C.7.f 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.
C.7.g Wheel short ramp: Once seated in wheelchair, goes up and down a ramp of
less than 12 feet (4 meters).
C.7.h 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 (Complete during the 2-day assessment period.)

Code the patient’s most usual performance using the 6-point scale below.
Safety and Quality of Performance – If helper assistance is
3. Partial/moderate assistance – Helper does LESS THAN
required because patient’s performance is unsafe or of poor
HALF the effort. Helper lifts, holds or supports trunk or
quality, score according to amount of assistance provided.
limbs, but provides less than half the effort.
Activities may be completed with or without assistive devices.
2. Substantial/maximal assistance – Helper does MORE
THAN HALF the effort. Helper lifts or holds trunk or limbs
6. Independent – Patient completes the activity by him/herself
and provides more than half the effort.
with no assistance from a helper.
1. Dependent – Helper does ALL of the effort. Patient does
5. Setup or clean-up assistance – Helper SETS UP or CLEANS
none of the effort to complete the task.
UP; patient completes activity. Helper assists only prior to or
If activity was not attempted code:
following the activity.
M. Not attempted due to medical condition
4. Supervision or touching assistance –Helper provides
VERBAL CUES or TOUCHING/ STEADYING assistance as patient S. Not attempted due to safety concerns
A. Task attempted but not completed
completes activity. Assistance may be provided throughout
N. Not applicable
the activity or intermittently.
P. Patient Refused
Patient’s Most Usual Activity Not Attempted
Performance
Code
6 5 4 3 2 1 M S E A N P
C.8
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.
C.9
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.
C.10 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.
C.11. 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.
C.12 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.
C.13 Make light meal: The ability to plan and prepare all aspects of a light
meal such as a bowl of cereal or a sandwich and cold drink, or reheat
a prepared meal.
C.14 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.
C.15 Light shopping: Once at store, can locate and select up to five
needed goods, take to check out, and complete purchasing

transaction.
C.16 Laundry: Includes all aspects of completing a load of laundry using a
washer and dryer. Includes sorting, loading and unloading, and

adding laundry detergent.
C.17 Use public transportation: The ability to plan and use public
transportation. Includes boarding, riding, and alighting from

transportation.
20

VI. Functional Status (cont.)
D.

Participation

D.1 Social Participation
Ask patient: “Think about how you currently socialize with others, like going out or visiting with family and friends. Which of the

following best describes you?”
I do not have any difficulty doing things socially.
I maintain my usual pattern of social activities, despite some difficulties.
I am somewhat restricted in the amount or type of social activities I do.
I am very restricted in the amount or type of social activities I do.
I do not see family or friends, and I only see those who provide care to me.

VII. Discharge Status
A.

Discharge Information

A.1 Discharge Location

A.4 Willing Caregiver(s)

Where will the patient be discharged to?

Does the patient have one or more willing caregiver(s)?

a. Private home/apartment
b. Assisted living, group home, adult foster care,
board/care
c. Long-term nursing facility
d. Skilled nursing facility (SNF/TCU)
e. MR/DD facility
f. Other facility (e.g., hospital)
g. Facility-based hospice
h. Other (specify)__________________
i. Discharged against medical advice

No (If No, skip to Section B)
Yes, confirmed by caregiver
Yes, confirmed only by patient
Unclear from patient; no confirmation from caregiver (If
Unclear, skip to Section B)

A.2 Frequency of Assistance at Discharge

A5. Types of Caregiver(s)

How often will the patient require assistance (physical
care or supervision) from a caregivers or providers?

What is the relationship of the caregiver(s) to the patient?

1. Patient does not require assistance (skip to

a. Spouse or significant other
Check all that apply.

Section B)
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

b. Child
c. Other unpaid family member or friend
d. Paid help

Residential Information: Complete only if patient
is discharged to a private residence or other
community-based setting.

B.1

Patient Lives With at Discharge

A.3 Caregiver(s) Availability
Was the discharge destination decision influenced by the
availability of a family member or friend to provide
assistance?

Upon discharge, who will the patient live with?
Check all
that apply.

0. No (If No, skip to B.1)
1. Yes

a.
b.
c.
d.

Lives alone
Lives with paid helper
Lives with other(s)
Unknown

VII. Discharge Status (cont.)
C. Support Needs/Caregiver (CG) 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 will need
training and/or
CG not likely to
other supportive
be able/CG
CG ability
not available
CG able
services
unclear

C.1.a

a. ADL assistance (e.g.,
transfer/ambulation, bathing,
dressing, toileting, eating/feeding)

C.2.a

C.3.a

C.4.a

C.5.a

C.1.b

b. IADL assistance (e.g., meals,
housekeeping, laundry, telephone,
shopping, finances)

C.2.b

C.3.b

C.4.b

C.5.b

C.1.c

c. Medication administration (e.g., oral,
inhaled, or injectable)

C.2.c

C.3.c

C.4.c

C.5.c

C.1.d

d. Medical procedures/treatments (e.g.,
changing wound dressing)

C.2.d

C.3.d

C.4.d

C.5.d

C.1.e

e. Management of equipment (includes
oxygen, IV/infusion equipment,
enteral/parenteral nutrition, ventilator
therapy equipment, or supplies)

C.2.e

C.3.e

C.4.e

C.5.e

C.1.f

C.2.f

C.3.f

C.4.f

C.5.f

C.1.g

g. Advocacy or facilitation of patient’s
participation in appropriate medical
care (includes transportation to or
from appointments)

C.2.g

C.3.g

C.4.g

C.5.g

C.1.h

h. None of the above or non-residential
setting

Supervision and safety

VIII. 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 assessment 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.
A.1

ICD-9 CM code for Principal Diagnosis at
Assessment

|___|___|___|.|___|___|

A.2 If Principal Diagnosis was a V-code, what was the ICD-9
CM code for the primary medical condition or injury
being treated? |___|___|___|.|___|___|
A.2.a If Principal Diagnosis was a V-code, what was the
primary medical condition or injury being treated?

A.1.a Principal Diagnosis at Assessment

_____________________________________

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

B.1.a

|___|___|___|.|___|___|

B.1.b

______________

__________________ __

___

B.2.a

|___|___|___|.|___|___|

B.2.b

______________

__________________ __

___

B.3.a

|___|___|___|.|___|___|

B.3.b

______________

__________________ __

___

B.4.a

|___|___|___|.|___|___|

B.4.b

______________

__________________ __

___

B.5.a

|___|___|___|.|___|___|

B.5.b

______________

__________________ __

___

B.6.a

|___|___|___|.|___|___|

B.6.b

______________

__________________ __

___

B.7.a

|___|___|___|.|___|___|

B.7.b

______________

__________________ __

___

B.8.a

|___|___|___|.|___|___|

B.8.b

______________

__________________ __

___

B.9.a

|___|___|___|.|___|___|

B.9.b

______________

__________________ __

___

B.10.a |___|___|___|.|___|___|

B.10.b ______________

__________________ __

___

B.11.a |___|___|___|.|___|___|

B.11.b ______________

__________________ __

___

B.12.a |___|___|___|.|___|___|

B.12.b ______________

__________________ __

___

B.13.a |___|___|___|.|___|___|

B.13.b ______________

__________________ __

___

B.14.a |___|___|___|.|___|___|

B.14.b ______________

__________________ __

___

B.15.a |___|___|___|.|___|___|

B.15.b ______________

__________________ __

___

IX. Other Useful Information
A.

Is there other useful information about this patient that you want to add?

X. 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.

File Type	application/pdf
File Title	Administrative Items
Author	dlee
File Modified	2010-04-14
File Created	2010-04-14