CMS-10487 Medical Record Review Tools

ATTACHMENT D
MEDICAL RECORD REVIEW TOOLS

MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION (MEPD)
MEDICAL RECORD REVIEW: MEPD INSTITUTION OF MENTAL DISEASE (IMD)
Round of Site Visit:
Site Visit Dates:
IMD Name:
State:
IMD Point of Contact:
IMD Point of Contact Information:
Date of MEPD Implementation:
Type of Information System:
__ Electronic, __ Paper, __ Combination
Brief description of system: ______________________________________________
Name of Information System:
Site Visitor:
Record Review Date:

D-1

RECORD 1
Mathematica Patient ID: [attach label or enter number]
Description of patient characteristics:
A.

Access to Inpatient Psychiatric Care
1.

Source of referral to this IMD:

2.

Was the patient previously admitted to this IMD?
Yes  [Enter date of most recent prior admission]
No
Unable to determine

3.

Has the patient been hospitalized twice or more during the past year?
PROBE: During the 12 months prior to the date of this admission.
Yes
No
Unable to determine

Reviewer’s comments/notes about this section:

B.

Boarding Time in Emergency Room
4.

When was this IMD contacted about bed availability for the patient’s most recent visit?
a.
b.
c.

5.

When was the patient transferred to this IMD for the most recent admission?
a.
b.
c.

6.

Date hospital contacted:
Time hospital contacted: am/pm
Unable to determine
Date transferred to hospital:
Time transferred to hospital:
Unable to determine

am/pm

How was the patient transported to this hospital?
a.
b.
c.

Ambulance
Receiving hospital’s transportation
Other

d.

Specify:
Unable to determine

Reviewer’s comments/notes about this section:

D-2

C.

Admission to IMD
7.

When was the patient admitted to this hospital?
a.
b.
c.

8.

Date of admission:
Time of admission: am/pm
Unable to determine

Did patient exhibit signs and symptoms of intoxication and/or withdrawal from drugs or alcohol
upon admission?
Yes
No
Unable to determine
8a.

9.

If Yes, describe symptoms of withdrawal exhibited by patient.

When was the initial nursing assessment completed?
a.
b.
c.

Date of initial nursing assessment:
Time of initial nursing assessment:
Unable to determine

am/pm

10. When was the initial medical history and physical completed?
a.
b.
c.

Date of initial medical history and physical:
Time of initial medical history and physical:
Unable to determine

am/pm

11. When was the initial psychiatric evaluation completed?
a.
b.
c.

Date of initial psychiatric evaluation:
Time of initial psychiatric evaluation:
Unable to determine

am/pm

12. Which diagnoses were identified in the initial psychiatric evaluation completed at this hospital?
Dimension
1.

Axis I

2.

Axis II

3.

Axis III

4.

Axis IV

5.

Axis V

Diagnoses (Include DSM code and
description if provided.)

Reviewer’s comments/notes about this section:

D-3

Not
documented

D.

Stabilization
13. Does the medical record include documentation that the patient was assessed for stabilization (that
is, to determine whether they remained suicidal, homicidal, or a danger to themselves or others) by
the third day of IMD admission?
Yes
No  GO TO Q.15
Unable to determine  GO TO Q.15
14. Enter date(s) of stabilization assessment documentation provided in the medical record regarding
whether the patient was suicidal, homicidal, or a danger to themselves or others. [Interviewer: Ask
person assisting with chart review how the hospital defines stabilization assessment.]

Stabilization Assessment Date

Patient expressed suicidal or homicidal thoughts or
gestures, or is dangerous to self or others

a. MM/DD/YYYY

Yes No Not Documented

b. MM/DD/YYYY

Yes No Not Documented

c. MM/DD/YYYY

Yes No Not Documented

d. MM/DD/YYYY

Yes No Not Documented

e. MM/DD/YYYY

Yes No Not Documented

f. MM/DD/YYYY

Yes No Not Documented

15. Was the patient chemically restrained, that is given psycho-active medication to subdue behavior
while at this IMD?
Yes, patient requested medication
Yes, staff initiated medication
No GO TO Q.17
Unable to determine GO TO Q.17
16. Enter the date(s) and time(s) of chemical restraint, name of pharmacological agent(s) administered,
dosage, and mode of administration.

Date

Time

Name of Pharmacological Agent(s)

1.
2.
3.
4.
5.

D-4

Dose

Mode of
Administration
(IM, IV, PO, or SQ)

17. Was the patient physically restrained while at this IMD?
Yes
No GO TO Q.19
Unable to determine  GO TO Q.19
18. Enter the date(s), time(s), and mode of physical restraint.
Date

Time

Mode of Restraint
(Four point leather or cloth restraint, physical hold, hand mitts, other)

1.
2.
3.
4.
5.
6.
19. Was consultation ordered for evaluation of an active or chronic medical condition?
Yes
No  GO TO Q.21
Unable to determine  GO TO Q.21
20. Was treatment provided for an active or chronic medical condition as a result of the consultation?
Yes, treatment provided at this facility
Yes, treatment provided at a different facility
No
21. Did an injury or infection occur during the patient’s stay in this hospital?
Yes
No  GO TO Q.23
Unable to determine GO TO Q.23
22. What type of injury or infection did the patient have?
a.
b.
c.
d.

Self-inflicted injury
Nosocomial injury only
Nosocomial infection only
Both nosocomial injury and infection

Reviewer’s comments/notes about this section (describe the stabilization process):

D-5

E.

Discharge Planning
23. What was the earliest date discharge plans, or a patient meeting with a discharge planner, was
documented?
Date:
Not documented  GO TO Q25
24. Does the discharge plan include documentation of patient’s preferences after discharge?
Yes
Not documented
25. When was the patient discharged from this IMD?
a.
b.

Date of discharge:
Time of discharge:

am/pm

26. Does the medical record include documentation that IMD staff contacted the patient’s other
providers for input into the discharge plan?
Yes
No
Unable to determine
27. Does the discharge plan include a follow-up aftercare appointment scheduled within 7 days of the
discharge date?
Yes
Yes, but not scheduled for within 7 days of the discharge date
No  GO TO Q.29
Unable to determine  GO TO Q.29
28. Record date of appointment and provider.
a.
b.

Appointment date:
Provider’s name:

29. Does the medical record include documentation that medication reconciliation was conducted upon
discharge?
Yes
No
Unable to determine
30. Does the discharge plan include discharge medications?
Yes
No
Unable to determine
31. Does the discharge plan include the reason for hospitalization?
Yes
No
Unable to determine
32. Does the discharge plan include the principal discharge diagnosis?
Yes
No
Unable to determine

D-6

33. Does the discharge plan include the next level of care recommendations?
Yes
No
Unable to determine
34. Does the discharge plan include documentation that the discharge plan was sent to patient’s
aftercare provider?
Yes
No
Unable to determine
35. Does the discharge plan include the patient’s signature?
Yes
No
Unable to determine
Reviewer’s comments/notes about this section:

END

D-7

MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION (MEPD)
MEDICAL RECORD REVIEW: MEPD GENERAL HOSPITAL (GH)
Round of Site Visit:
Site Visit Dates:
GH Name:
State:
GH Point of Contact:
GH Point of Contact Information:
Date of MEPD Implementation:
Type of Information System:
__ Electronic, __ Paper, __ Combination):
Brief description of system:_____________________________________________
Name of Information System:
Site Visitor:
Record Review Date:

D-8

RECORD 1
Mathematica Patient ID: [attach label or enter number]
Description of patient characteristics:
A.

Access to Inpatient Psychiatric Care
1.

Source of referral to this general hospital:

2.

Was the patient previously admitted to this general hospital for psychiatric treatment in a nonpsychiatric unit?
Yes  [Enter date of most recent prior admission]
No
Unable to determine

3.

Has the patient been hospitalized twice or more during the past year?
PROBE:

During the 12 months prior to the date of this admission.

Yes
No
Unable to determine
Reviewer’s comments/notes about this section:

B.

Boarding Time in Emergency Room
4.

When was this general hospital contacted about bed availability for the patient’s most recent visit?
a.
b.
c.

5.

When was the patient transferred to this general hospital for the most recent admission?
a.
b.
c.

6.

Date hospital contacted:
Time hospital contacted: am/pm
Unable to determine
Date transferred to hospital:
Time transferred to hospital:
Unable to determine

am/pm

How was the patient transported to this general hospital?
a.
b.
c.
d.

Ambulance
Receiving hospital’s transportation
Other
Specify:
Unable to determine

Reviewer’s comments/notes about this section:

D-9

C.

Admission to GH
7.

When was the patient admitted to this general hospital?
a.
b.
c.

8.

Date of admission:
Time of admission: am/pm
Unable to determine

Did patient exhibit signs and symptoms of intoxication and/or withdrawal from drugs or alcohol
upon admission?
Yes
No
Unable to determine
8a.

9.

If Yes, describe symptoms of withdrawal exhibited by patient.

When was the initial nursing assessment completed?
a.
b.
c.

Date of initial nursing assessment:
Time of initial nursing assessment:
Unable to determine

am/pm

10. When was the initial medical history and physical completed?
a.
b.
c.

Date of initial medical history and physical:
Time of initial medical history and physical:
Unable to determine

am/pm

11. When was the initial psychiatric evaluation completed?
a.
b.
c.

Date of initial psychiatric evaluation:
Time of initial psychiatric evaluation:
Unable to determine

am/pm

12. Which diagnoses were identified in the initial psychiatric evaluation completed at this hospital?
Dimension
1.

Axis I

2.

Axis II

3.

Axis III

4.

Axis IV

5.

Axis V

Diagnoses
(Include DSM code and description if provided.)

Reviewer’s comments/notes about this section:

D-10

Not
documented

D.

Stabilization
13. Does the medical record include documentation that the patient was assessed for stabilization (that
is, to determine whether they remained suicidal, homicidal, or a danger to themselves or others) by
the third day of admission?
Yes
No  GO TO Q.15
Unable to determine  GO TO Q.15
14. Enter date(s) of stabilization assessment documentation provided in the medical record regarding
whether the patient was suicidal, homicidal, or a danger to themselves or others. [Note: Site visitor
will need to ask person assisting with chart review how the hospital defines stabilization assessment]

Stabilization Assessment Date

Patient expressed suicidal or homicidal thoughts
or gestures, or is dangerous to self or others

a. MM/DD/YYYY

Yes No Not Documented

b. MM/DD/YYYY

Yes No Not Documented

c. MM/DD/YYYY

Yes No Not Documented

d. MM/DD/YYYY

Yes No Not Documented

e. MM/DD/YYYY

Yes No Not Documented

f. MM/DD/YYYY

Yes No Not Documented

15. Was the patient chemically restrained, that is given psycho-active medication to subdue behavior
while at this general hospital?
Yes, patient requested medication
Yes, staff initiated medication
No GO TO Q.17
Unable to determine GO TO Q.17
16. Enter the date(s) and time(s) of chemical restraint, name of pharmacological agent(s) administered,
dosage, and mode of administration.

Date

Time

Name of Pharmacological Agent(s)

1.
2.
3.
4.
5.
6.

D-11

Dose

Mode of
Administration
(IM, IV, PO, or SQ)

17. Was the patient physically restrained while at this general hospital?
Yes
No GO TO Q.19
Unable to determine  GO TO Q.19
18. Enter the date(s), time(s), and mode of physical restraint.
Date

Time

Mode of Restraint
(Four point leather or cloth restraint, physical hold, hand mitts, other)

1.
2.
3.
4.
5.
6.
19. Was consultation ordered for evaluation of an active or chronic medical condition?
Yes
No  GO TO Q.21
Unable to determine  GO TO Q.21
20. Was treatment provided for an active or chronic medical condition as a result of the consultation?
Yes, treatment provided at this facility
Yes, treatment provided at a different facility
No
21. Did an injury or infection occur during the patient’s stay in this hospital?
Yes
No  GO TO Q.23
Unable to determine GO TO Q.23
22. What type of injury or infection did the patient have?
a.
b.
c.
d.

Self-inflicted injury
Nosocomial injury only
Nosocomial infection only
Both nosocomial injury and infection

Reviewer’s comments/notes about this section (describe the stabilization process):

D-12

E.

Discharge Planning
23. What was the earliest date discharge plans, or a patient meeting with a discharge planner, was
documented?
Date:
Not documented  GO TO Q25
24. Does the discharge plan include documentation of patient’s preferences after discharge?
Yes
Not documented
25. When was the patient discharged from this general hospital?
a.
b.

Date of discharge:
Time of discharge:

am/pm

26. Does the medical record include documentation that general hospital staff contacted the patient’s
other providers for input into the discharge plan?
Yes
No
Unable to determine
27. Does the discharge plan include a follow-up aftercare appointment scheduled within 7 days of the
discharge date?
Yes
Yes, but not scheduled for within 7 days of the discharge date
No  GO TO Q.29
Unable to determine  GO TO Q.29
28. Record date of appointment and provider.
a.
b.

Appointment date:
Provider’s name:

29. Does the medical record include documentation that medication reconciliation was conducted upon
discharge?
Yes
No
Unable to determine
30. Does the discharge plan include discharge medications?
Yes
No
Unable to determine
31. Does the discharge plan include the reason for hospitalization?
Yes
No
Unable to determine
32. Does the discharge plan include the principal discharge diagnosis?
Yes
No
Unable to determine

D-13

33. Does the discharge plan include the next level of care recommendations?
Yes
No
Unable to determine
34. Does the discharge plan include documentation that the discharge plan was sent to patient’s
aftercare provider?
Yes
No
Unable to determine
35. Does the discharge plan include the patient’s signature?
Yes
No
Unable to determine
Reviewer’s comments/notes about this section:

END

D-14

MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION (MEPD)
MEDICAL RECORD REVIEW: MEPD EMERGENCY ROOM (ER)
Round of Site Visit:
Site Visit Dates:
ER Hospital Name:
State:
ER Point of Contact:
ER Point of Contact Information
Date of MEPD Implementation:
Type of Information System:
__ Electronic, __ Paper, __ Combination
Brief description of System:
___________________________________________________________
Name of Information System:
Site Visitor:
Record Review Date:

D-15

RECORD 1
Mathematica Patient ID: [attach label or enter number]
Description of patient characteristics:
A.

Admission to Emergency Room (ER)
1.

When was the patient admitted to the ER?
a.
b.

2.

Date of admission to ER:
Time of admission to ER: am/pm

Was the patient’s Medicaid number identified in the medical record?
Yes
No
Unable to determine

3.

When was the initial medical history and physical examination completed?
a.
b.
c.

4.

When was the patient medically cleared by a provider?
a.
b.
c.

5.

am/pm

Suicidal?
Homicidal?
Dangerous to themselves?
Dangerous to others?
Unable to determine

When was the patient assessed by a provider to determine whether inpatient psychiatric treatment
was necessary?
a.
b.
c.

7.

Date of medical clearance:
Time of medical clearance:
Unable to determine

Upon admission to the ER, was the patient identified as…
a.
b.
c.
d.
e.

6.

Date of initial medical history and physical examination:
Time of initial medical history and physical examination: am/pm
Unable to determine

Date psychiatric emergency determined:
Time psychiatric emergency was determined:
Unable to determine

am/pm

What type of provider determined the presence of a psychiatric emergency?
a.
b.
c.
d.
e.
f.
g.

MD/DO
NP/CNS/PA
RN
LCSW
Psychologist
Licensed mental health professional (e.g., licensed counselor or therapist)
Other

Specify:
h.

Unable to determine

D-16

8.

Was eligibility for the demonstration indicated in the ER medical record?
Yes, patient eligible
Yes, patient not eligible
Not documented
Not applicable, pre-demonstration

9.

Which diagnoses were identified in the initial psychiatric evaluation completed at this ER?
Dimension

1.

Axis I

2.

Axis II

3.

Axis III

4.

Axis IV

5.

Axis V

Diagnoses (Include DSM code and description if provided.)

Reviewer’s comments/notes about this section:

B.

Stabilization
10. Was the patient evaluated for active substance use while in the ER?
Yes
No  GO TO Q.12
Unable to determine  GO TO Q.12
11. What type of evaluation was conducted?
a.
b.
c.

Specialist consult
Laboratory diagnostics
Other

Specify:
d.
Unable to determine
12. Was the patient treated for active substance use while in the ER?
Yes
No  GO TO Q.14
Unable to determine  GO TO Q.14
13. What type of treatment was provided to the patient?
a.
b.

Pharmacologic treatment
Other

Specify:
c.
Unable to determine

D-17

Not documented

14. Was the patient evaluated for an active or chronic medical condition while in the ER?
Yes
No  GO TO Q.16
Unable to determine  GO TO Q.16
15. What type of evaluation was conducted?
a.
b.
c.
d.

Specialist consult
Laboratory diagnostics
Radiographic or ultrasonic diagnostics
Other

Specify:
e.
Unable to determine
16. Was the patient treated for an active or chronic medical condition while in the ER?
Yes
No  GO TO Q.18
Unable to determine  GO TO Q.18
17. What type of treatment was provided to the patient?
a.
b.
c.

Pharmacologic treatment
Education/support
Other

Specify:
18. Was the patient chemically restrained, that is, given psycho-active medication to subdue behavior
while at this ER?
Yes, patient requested medication
Yes, staff initiated medication
No  GO TO Q.20
Unable to determine  GO TO Q.20
19. Enter the date(s) and time(s) of chemical restraint, name of pharmacological agent(s) administered,
dosage, and mode of administration.
Date

Time

Name of Pharmacological
Agent(s)

1.
2.
3.
4.
5.
6.

D-18

Dose

Mode of Administration
(IM, IV, PO, or SQ)

20. Was the patient physically restrained while at this ER?
Yes
No  GO TO Q.22
Unable to determine  GO TO Q.22
21. Enter the date(s), time(s), and mode of physical restraint.
Date

Time

Mode of Restraint
(Four point leather or cloth restraints, physical hold, hand mitts, other)

1.
2.
3.
4.
5.
6.
Reviewer’s comments/notes about this section:

C.

Access to Inpatient Psychiatric Care
22. To where was the patient discharged or transferred from the ER?
Specify: __________________________________________
23. What facilities were contacted to see whether a bed was available for the patient?

Name of Facility

Date contacted
for bed
availability

1.
2.
3.
24. When was the patient discharged from the ER?
a.
b.

Date of discharge from ER:
Time of discharge from ER:

am/pm

D-19

Time contacted
for bed
availability

Date patient
accepted for
bed

Time patient
accepted for
bed

25. How was the patient transported to their discharge placement?
a.
b.
c.

Ambulance
Receiving facility transportation
Other

d.

Specify:
Unable to determine

Reviewer’s comments/notes about this section:

END

D-20