DEPARTMENT OF HEALTH AND HUMAN SERVICES Form ApprovedCENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0378 SURVEYOR WORKSHEET FOR PSYCHIATRIC HOSPITAL REVIEW: TWO SPECIAL CONDITIONS SECTION I:IDENTIFICATION Patient Number Surveyor Name Sex Date of Birth Hospital Name Date of Admission Unit or Ward Dates of Survey Diagnosis SECTION II:PATIENT OBSERVATION DOCUMENTATION OBSERVATION NO. 1 OBSERVATION NO. 2 OBSERVATION NO. 3 Date and location Beginning and ending times Number of patients present Number of staff/volunteers present Identify the modality in progress What the patient is doing (regardless of whether or not a scheduled treatment modality was in progress) If the modality or intervention is related to the specific treatment plan goals and objectives Patients level of participation in the activity Presence of disruptive behavior, and staffs interventions, if any Any other pertinent information Did the patient receive active treatment during this observation interval? Did the patient achieve desired outcomes during this observation interval? Form CMS-725 (09/94) Page 1(OPTIONAL)>>>> 2SECTION III:COMPONENTS OF THE PATIENTS TREATMENT PLAN AND SURVEYOR COMMENTS 1) Goals-long range short term Interventions Identified Problem(s) 2) Timeframes What? By Whom? Surveyors Comments projected outcome How will this effect outcome? Form CMS-725 (09/94) Page 2(OPTIONAL)>>>> 3SECTION IV: MEDICAL RECORD DOCUMENTATION CODE INFORMATION COMPLIANCE CODE INFORMATION COMPLIANCE B105 Legal Status B116 Estimates Memory Functioning B106 Admitting/Intercurrent Diagnosis B117 Inventory of Assets B107 Reasons for Admission B118 Treatment Plan B108 Social Services Reports B119 (Based on Inventory of Strengths and Disabilities) B109 Neurological Examination B120 Substantiated Diagnosis B110 Psychiatric Evaluation B121 Short/Long Term Goals B111 Completed Within 60 hrs. B122 Specific Treatment Modalities B112 Contains Medical History B123 Staff Responsibilities B113 Record of Mental Status B124 Adequate Documentation to Justify the Diagnosis and Treatment B114 Notes Onset of Illness B125 Treatment Notes B115 Describes Attitude/Behavior B126/132Progress Notes SECTION V: PATIENT INTERVIEW SAMPLE QUESTIONS A. Setting Context: 1. Requesting permission of the patient to talk. 2. Identifier Informationsurveyor name; what the survey process is about, why it is done, and why it is important to talk with patients during a survey. How long have you been here? What brought you here? B. Patients Awareness of Treatment: What is the staff doing for you? What is your treatment plan? Do you get to do activities?Exercises? Have you seen your doctor (nurse, social worker, activity therapist)? Taking any medications? How are you doing now? Plan for leaving the hospital? Form CMS-725 (09/94) Page 3(OPTIONAL)>>>> 4SECTION VI:STAFF INTERVIEW SAMPLE QUESTIONS A. Setting Context: Ask if this is a good time to talk with staff person. B. Staff Persons Awareness of Treatment: What is being done to help this PT? What brought the PThere? How long has the PTbeen here? Have you attended a treatment plan meeting regarding the PT? Has the PT attended the treatment plan meeting? What are the PTs goals? What changes have you noticed since the PTcame here? What are the DC plans for this PT? SECTION VII:OTHER PERTINENT INFORMATION (use this space for additional data from previous sections) Form CMS-725 (09/94) Page 4(OPTIONAL)>>>> 5OTHER PERTINENT INFORMATION (continued from previous page) 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 validOMB control number for this information collection is 0938-0378.The time required to complete this information collection is estimated to average 15 minutes per response,including the time to review instructions, search existing resources, gather the data needed, and complete and review the infor mation collection.If you have any commentsconcerning the accuracy of the time estimate(s), or suggestions for improving this form, write to:CMS, 7500 Security Blvd., N2- 14-26, Baltimore, Maryland 21244-1850.Form CMS-725 (09/94) (OPTIONAL) Page 5