MISSISSIPPI DOCUMENT-BASED AND QUALITY REVIEW FORM
PROVIDERS ARE ASKED TO COMPLETE AND FAX THIS FORM TO ASCEND (1-877.431.9568) WHEN A DOCUMENT-BASED REVIEW OR QUALITY
STUDY IS REQUESTED.
Resident Name
Date of Birth
NF Name
SSN
NF City
A. DIAGNOSIS (COMPLETE ALL OF A)
Current psychiatric and/or MR/DD diagnosis:
Admit Date
Medical Diagnoses:
Medical rehabilitative prognosis:
good
B. PSYCHOTROPIC AND ANTIDEPRESSANT MEDICATIONS (INCLUDING PSYCHIATRIC MEDICATIONS, MEDS FOR DEMENTIA, SEIZURES,
Medication
Dose MG/Day
Date Started
poor
unknown
AND SLEEP DISORDERS) ALSO ATTACH MDS
Response Y/N + any description
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Y
N
Y
N
Hostile
Refuses Care
Resists Care
Withdrawn
Frequent Conflicts
Avoids social situations
Agitation
Suspicious without reason
Disruptive (yelling, throwing,
hitting)
D. ARE CONCENTRATION OR COGNITION ISSUES PRESENT?
Requires more assistance than
Y
N
s/he should with tasks
Y
N
Wanders
Y
N
Difficulty concentrating
Y
N
Confused
Y
N
Fluctuating orientation
Y
N
Short term memory loss
N
Present within
the past 6
Months?
If present now
or in the past 6
months, is this
typical for the
resident?
Behavior
present
currently?
Present within
the past 6
Months?
Behavior
present
currently?
For the following Sections C-G, CHECK SYMPTOMS PRESENT NOW OR IN THE PAST 6 MONTHS. IF PRESENT NOW OR WITHIN THE PAST 6 MONTHS, IDENTIFY
WHETHER THE BEHAVIOR OR SYMPTOM IS TYPICALLY PRESENT FOR THAT RESIDENT (WHETHER THE SYMPTOM REPRESENTS THE PERSON’S BASELINE)
C. ARE INTERPERSONAL AND/OR PERSONALITY DISORDER SYMPTOMS PRESENT? N
Y (if yes, complete below; if no, proceed to Section D)
If present now or in
the past 6 months,
is this typical for the
resident?
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Y
N
Y
N
Inappropriate
Anxiety/Fear of Others
Extreme hypersensitivity
Expresses feelings of extreme jealousy
Anxiety/Fear of Others
Unstable relationships with others
Frequent conflicts with others
Believes others are exploiting,
harming, deceiving, or betraying;
Other:
Y (IF YES, COMPLETE BELOW; IF NO, PROCEED TO SECTION E)
Unable to complete tasks s/he should
Y
N
medically be able to complete
Y
N
Problems finding/using right words
Y
N
Disoriented to person
Y
N
Disoriented to place
Y
N
Disoriented to time
Y
N
Long term memory loss
Please complete and fax to Ascend Mississippi Team at 877.431.9568
840 Crescent Centre Drive, Suite 400 / Franklin, TN 37067 / (877) 431-1388
©Ascend Management Innovations
MISSISSIPPI DOCUMENT-BASED AND QUALITY REVIEW FORM
Resident Name
Date of Birth
Y
N
Short term memory loss
Y
N
Y
N
Other:
Y
N
If yes to any questions within this section, does the individual have a diagnosis of dementia?
A) Was dementia diagnosis by:
Attending MD
Psychiatrist
B) Are symptoms worse in the late afternoon or evening?
No
Yes
C) Dementia diagnosis date:
D) Diagnostic Tests:
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Depressed Mood
Loss of interest in previously
enjoyed activities
Weight gain or loss
Changeable, unpredictable, and
rapidly switching emotions
Fatigue and loss of energy
Expresses hopelessness or
helplessness
Personality Changes
Other:
F. ARE ANXIETY/STRESS SYMPTOMS PRESENT?
N
Excessive anxiety, worry, or
Y
N
apprehension (not due to a
medical condition)
Y
N
Excessive nervousness
Persistent and unpleasant
Y
N
thoughts or ideas (obsessions)
Intense terror/fear that strikes
Y
N
without warning
G. ARE PSYCHOTIC SYMPTOMS PRESENT?
N
Behaviors or speech which may
Y
N
appear eccentric, silly, or unusual.
1.
Y
N
Delusions - Erroneous beliefs or
misinterpretations (e.g., that s/he
has certain powers or someone is
attempting to cause harm
Y
N
Paranoia, such as feeling that
others are trying to cause harm
Other:
No
Yes, If yes:
Y (IF YES, COMPLETE BELOW; IF NO, PROCEED TO SECTION F)
If present now
or in the past 6
months, is this
typical for the
resident?
Behavior
present
currently?
Present
within the
past 6
Months?
Behavior
present
currently?
Present
within the
past 6
Months?
E. ARE MOOD ISSUES PRESENT?
SSN
Long term memory loss
If present now or in
the past 6 months,
is this typical for the
resident?
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Changes in sleep patterns
Feelings of worthlessness, helplessness,
or guilt
Difficulty concentrating
Mania (persistently elevated or irritable
moods, reduced sleep, increased
talkativeness, or inflated self-esteem)
Suicidal thoughts or feelings
Frequent refusal to eat (or significant
weight loss) and/or refuses medications
Homicidal behaviors or history
Other:
Y (IF YES, COMPLETE BELOW; IF NO, PROCEED TO SECTION G)
Persistent thoughts or memories
Y
N
prompting re-experiencing of a
traumatic event.
Y
N
Extreme and irrational fear of things
Repetitive actions (compulsions)
Y
N
believed to prevent a threatening event
Y
N
Other:
Y (IF YES, COMPLETE BELOW; IF NO, PROCEED TO SECTION H)
Incoherent, nonsensical, or loosely
Y
N
associated speech
Hallucinations - seeing, hearing, or
sensing presence of others not there;
Y
N
may mumble or speak to no one in
particular or become upset without
reason
Y
N
Other:
H. PROVIDER TREATMENTS AND SERVICES (PLEASE RESPOND TO ALL QUESTIONS IN THIS SECTION)
How would you characterize the individual’s current psychiatric status?
Stable/baseline Symptomatic but Stable
Unstable
If unstable, explain:
2.
Has the individual had any significant status change on the MDS in regards to his/her mental health condition since the PASRR
evaluation? N Y If yes, explain:
3.
Are behaviors/behavioral health symptoms manageable?
Resident Name
NA-there are no symptoms
Yes
Date of Birth
SSN
Please complete and fax to Ascend Mississippi Team at 877.431.9568
840 Crescent Centre Drive / Suite 400 / Franklin, TN 37067 / www.ascendami.com
©Ascend Management Innovations
No
MISSISSIPPI DOCUMENT-BASED AND QUALITY REVIEW FORM
If no, explain:
4.
How do symptoms affect the individual’s ability to complete Activities of Daily Living?
Psychiatric symptoms do not impact patient’s ability to participate in ADLs
Psychiatric symptoms marginally impact patient’s ability to participate in ADLs
Psychiatric symptoms significantly impair patient’s ability to participate in ADLs
5.
What services are being provided to (or planned for) the individual by an outside provider not on staff or a consultant of the
facility (such as a community mental health center provider)?
Service provided by an outside
provider that is not on staff or
a consultant of the facility
(such as a mental health
center)
Frequency (approximate);
Legend:
Currently
receiving
Psychiatric medication
monitoring
Individual therapy
Family Therapy
A= Every 4-6 months as needed
B= Every 2-3 months as needed
C= Every month as needed
D= 2-3 times monthly
E= Once weekly
F= 2-3 times weekly
G= 4-5 times weekly
A
B
C
E
F
G
A
B
C
E
F
G
A
B
C
E
F
G
Group Therapy by non-NF
entity
Psychosocial Rehabilitation
Services
A
B
C
E
F
G
A
B
C
E
F
G
Other (identify):
A
B
C
E
F
G
6.
D
D
D
D
D
D
Most recent date of
service; Legend:
A= Within the last week
B= >1 week but < 1 mo
C= > 1 mo but <2 mos
D= > 2 mos but <3 mos
E= >3 mos but <4 mos
F= > 4 mos but <5 mos
G= >5 mos but <6 mos
H= >6 months
A
B
C
D
E
F
G
H
A
B
C
D
E
F
G
H
A
B
C
D
E
F
G
H
A
B
C
D
E
F
G
H
A
B
C
D
E
F
G
H
A
B
C
D
E
F
G
H
Currently
receiving
Received over the
past 6 months but
not currently
Services are
planned but
have not begun
Psychiatric medication monitoring
Supportive counseling
Behavior plan
Other (identify):
Is the prior PASRR evaluation in the patient’s record (floor record)?
not be located.
8.
Are PASRR recommendations incorporated in Care Plan?
incorporated, but service needs have since changed No
COMMENTS:
1.
Name of mental health provider
agency (or community mental
health center)
Services
are
planned
but have
not begun
What behavioral health services is the NF providing currently or within the past 6 months:
Service provided by an NF provider or
consultant
7.
Received
over the
past 6
months but
not
currently
Yes
Are these
services
provided by an
employee of
the agency?
If services are being provided by an
outside provider that provides
consulting to the NF, name the
outside provider agency
Y
N
Y
N
Y
N
Y
N
No, but I was able to locate a copy
No, it could
Yes, they are currently incorporated
Yes, they were initially
Unknown because the document could not be located
I. PSYCHIATRIC SERVICES (PLEASE RESPOND TO ALL QUESTIONS IN THIS SECTION)
LIST ANY INPATIENT PSYCHIATRIC ADMISSIONS. IF THE INDIVIDUAL HAS BEEN A LONG-TERM RESIDENT, LIMIT THE RESPONSES TO THE PAST 2 YEARS:
DATE
CIRCUMSTANCES, IF KNOWN:
DATE
CIRCUMSTANCES, IF KNOWN:
DATE
CIRCUMSTANCES, IF KNOWN:
DATE
CIRCUMSTANCES, IF KNOWN:
Resident Name
Date of Birth
SSN
L. GUARDIANSHIP AND PHYSICIAN INFORMATION
Please complete and fax to Ascend Mississippi Team at 877.431.9568
840 Crescent Centre Drive / Suite 400 / Franklin, TN 37067 / www.ascendami.com
©Ascend Management Innovations
MISSISSIPPI DOCUMENT-BASED AND QUALITY REVIEW FORM
Does the individual have a legal guardian?
Legal Representative Last Name:
Street:
No
First Name:
City:
Primary Physician’s Name:
Street:
Yes, legal guardian information is below:
Phone:
State:
Zip:
Phone:
City:
Fax:
State:
Zip:
SECTION M: CHECK ALL APPLICABLE INFORMATION AND ATTACH RECORDS TO THIS SUBMISSION
Provide copies of any consultations or evaluations that support and/or substantiate the mental health, physical and/or behavioral
change(s) noted on this form. Select attachments included
Required Documents if NF resident:
MAR Plan of Care MDS
Preferred Documents if available and/or applicable:
Physician’s Notes
Nursing Notes/Summary
Medical Consultation(s)
Psychiatric Evaluation(s)
Intellectual Assessment(s) Other (List):
Signature: ____________________________________________
Printed Name:
Position:
Facility:
Phone:
Date form was submitted to Ascend:
Ascend use Only
Purpose:
Quality Study
Service Monitoring
Document-Based Review (requires new summary):
Approved NF
Rationale:
Requires onsite Level II evaluation
Date:
Quality Reviewer Name:
Quality Reviewer Comments:
Revised 4/15/2013
Please complete and fax to Ascend Mississippi Team at 877.431.9568
840 Crescent Centre Drive / Suite 400 / Franklin, TN 37067 / www.ascendami.com
©Ascend Management Innovations
Denied