CARE TOOL Provider Breakdown

Item Number Item Description Common Items to All Settings1 Acute Hospital Discharge PAC Admission Discharge Interim Expired
Signatures of Persons Who
Completed a Portion of the Assessment
A-L X X X X X X
I. Administrative Items
A1. Assessment Type Reason for assessment X X X X X X
 
B. Provider Information
B1 Provider's Name X X X X X X
B2 Medicare Provider's Identification Number X X X X X X
B3 National Provider Identification Code (NPI) X X X X X X
 
C. Patient Information
C1 Patient's First Name X X X X X X
C2 Patient's Middle Name X X X X X X
C3 Patient's Last Name X X X X X X
C4 Patient's Nickname X X X X X X
C5 Patient's Medicare Health Insurance Number X X X X X X
C6 Patient's Medicaid Number X X X X X X
C7 Patient's Identification Number X X X      
C8 Birth Date X X X      
C9 Social Security Number X X X      
C10 Gender X X X      
C11a-C11g Race/Ethnicity X X X      
C12 Is English their Primary Language X X X      
C12a If not, is an interpreter available? X X X      
C12b If not, what is the patient's primary language? X X X      
C13a Patient's choices documented in medical record X X X X X  
C13b Medical record documents authority to make decisions X X X X X  
C13c Medical record documents whether to resuscitate X X X X X  
 
D. Payer Information
D1-D13 Current Payment Sources X X X   X  
 
T.I. How long did it take you to complete this section?
 
II. Admission Information: Health History
A. Pre-admission Service Use
A1 Admission Date X X X      
A2 Admisson From X X X      
A3a If admitted from other setting, Last Primary Diagnosis   X X      
A3b If admitted from other setting, Last ICD-9 CM   X X      
A4a-A4i Other Services in past 2 months X X X      
 
B. Patient History Prior To This Current Illness, Exacerbation, or Injury
B1 Type of Prior Residence X X X      
B2 If in community,Zip Code of Prior Residence   X X      
B3a-B3g If in community, Lived With:   X X      
B4a-B4f If in community, Structural Barriers   X X      
B5a-B5e Prior Functioning X X X      
B6a-B6f Mobility Devices X X X      
B7 History of Falls X X X      
B8 Prior Mental Status X X X      
 
T.II. How long did it take you to complete this section?
 
III. Current Medical Items
A. Primary Diagnosis
A1 Primary Diagnosis X X X X X X
A2 ICD-9 CM X X X X X X
A2a If primary is V-code, Medical Condition   X X X X X
A2b ICD-9 CM for A2a   X X X X X
 
B. Other Diagnoses, Comorbidities, and Complications
B1a-B15a Diagnosis X X X X X X
B1b-B15b ICD-9 Code X X X X X X
B16 If all boxes are used, is list complete?   X X X X X
 
C. Procedures
C1 Any therapeutic or major procedure? X X   X X X
C1a-C15a If yes, Procedure Name   X   X X X
C1b-C15b If yes, ICD-9 CM Procedure Code   X   X X X
C1c-C15c If yes, Bilateral Procedure?   X   X X X
C16 If all boxes are used, is list complete?   X   X X X
 
D. Treatments
D1a-D32a Treatment at admission (or discharge) X X X X X X
D1b-D32b Used at any time during stay   X   X X X
D9c Reason for continuous monitoring   X X X X X
D12c Frequency of suctioning   X X X X X
D23c Reason for 24-hour supervision   X X X X X
 
E. Medications
E1a-E30a Medication Name X X X X X X
E1b-E30b Dose X X X X X X
E1c-E30c Route X X X X X X
E1d-E30d Frequency X X X X X X
E1e-E30e Planned Stop Date X X X X X X
E31 If all boxes are used, is list complete?   X X X X X
 
F. Allergies and Adverse Drug Reactions
F1 Any Known Allergies or Reactions? X X X X    
F1a-F8a Allergy/Cause of Reaction   X X X    
F1b-F8b Patient Reactions   X X X    
F9 If all lines are used, is the list complete?   X X X    
 
G. Skin Integrity
G1 Pressure Ulcer Risk X X X X X  
G2 Any Stage 2+ Pressure Ulcers? X X X X X  
G2a-G2d Number of Pressure Ulcers/Stage 2+   X X X X  
G2e If Stage 2 :Number of Older Unhealed   X X X X  
G3a Largest stage 3 or 4 or eshcar length in any direction   X X X X  
G3b Width of SAME unhealed ulcer or eschar   X X X X  
G3c Most recent measurement date of SAME ulcer or eschar   X X X X  
G4 If Stage 3 or 4, Tunneling   X X X X  
G5 Any Major Wounds (non-pressure ulcer) X X X X X  
G5a-G5e Number of Major Wounds   X X X X  
G6a-G6d Turning surfaces not intact   X X X X  
 
H. Physiologic Factors
H1a-H28a Date X X X X X  
H1b-H28b Value X X X X X  
H1c-H28c Check if NOT tested   X X X X  
H1c-H4c Estimated value   X X X X  
 
T.III. How long did it take you to complete this section?
 
IV. Cognitive Status
A. Comatose
A1 Persistent vegetative state X X X X X  
 
B. Brief Interview for Mental Status
B1 Interview Attempted X X X X X  
B1a If no, reason interview not attempted   X X X X  
B2 Repetition of Three Words X X X X X  
B3a-B3b Temporal Orientation X X X X X  
B4a-B4c Recall X X X X X  
 
C. Observational of Cognitive Status
C1 Short Term Memory X X X X X  
C2 Long Term Memory X X X X X  
C3a-C3e Memory/Recall Ability X X X X X  
C4 Cognitive Reasoning X X X X X  
 
D. Confusion Assessment Method
D1 Inattention X X X X X  
D2 Disorganized thinking X X X X X  
D3 Altered level of consciousness/alertness X X X X X  
D4 Psychomotor retardation X X X X X  
 
E. Behavorial Signs and Symptoms
E1 Physical X X X X X  
E2 Verbal X X X X X  
E3 Other X X X X X  
 
F. Mood
F1 Interview attempted X X X X X  
F2a-F2d PHQ2 X X X X X  
F3 Feeling Sad X X X X X  
 
G. Pain
G1 Interview attempted? X X X X X  
G2 Pain presence X X X X X  
G3 Pain severity 0-10   X X X X  
G4 Pain severity verbal descriptor   X X X X  
G5a-G5b Pain effect on function   X X X X  
G6a-G6e Observed Pain   X X X X  
 
T.IV. How long did it take you to complete this section?
 
V. Impairments
A1 Any Impairment? X X X X X  
 
B. Bladder and Bowel Management
B1a-B1b Use of external or indwelling device   X X X X  
B2a-B2b Frequency of incontinence   X X X X  
B3a-B3b Assistance managing bowel/bladder   X X X X  
B4 If incontinent, history of incontinence   X X X X  
 
C. Swallowing
C1a-C1g Swallowing disorder (1)   X X X X  
C2a-C2c Swallowing disorder (2)   X X X X  
 
D. Hearing, Vision, and Communication Comprehension
D1 Understanding verbal content   X X X X  
D2 Expression of ideas and wants   X X X X  
D3 Ability to see in adequate light   X X X X  
D4 Ability to hear   X X X X  
 
E. Upper Extremity Range of Motion
E1a-E1d Range of motion   X X X X  
 
F. Weight-bearing Restrictions
F1a-F1d Weight bearing restriction   X X X X  
 
G. Grip Strength
G1a-G1b Grip Strength   X X X X  
 
H. Respiratory Status
H1 Respiratory status   X X X X  
 
I. Endurance
I1 Mobility Endurance   X X X X  
I2 Sitting Endurance   X X X X  
 
J. Mobility and Aides Needed
Ja-Jf Indicate all mobility and aides needed   X X X X  
 
T.V. How long did it take you to complete this section?
 
VI. Functional Status
A. Self Care
A1 Eating X X X X X  
A2 Tube Feeding X X X X X  
A3 Oral Hygiene X X X X X  
A4 Toilet Hygiene X X X X X  
A5 Upper Body Dressing X X X X X  
A6 Lower Body dressing X X X X X  
 
B. Core Functional Mobility
B1 Lying to Sitting on Side of Bed X X X X X  
B2 Sit to Stand X X X X X  
B3 Chair/Bed-to-Chair Transfer X X X X X  
B4 Toilet Transfer X X X X X  
B5 Mode of Mobility X X X X X  
B5a Longest distance patient can walk   X X X X  
B5b Longest distance patient can wheel   X X X X  
 
C. Supplemental Functional Ability: Code patient on all activities that the patient can participate in and which you can observe.
C1 Sponge Bath     X X X  
C2 Shower/Bathe Self     X X X  
C3 Roll Left or Right     X X X  
C4 Sit to Lying     X X X  
C5 Picking up object     X X X  
C6 Mode of Mobility: Wheelchair?     X X X  
C6a One Step (curb)     X X X  
C6b Walk 50 feet with 2 turns     X X X  
C6c 12 steps-interior     X X X  
C6d 4 steps-exterior     X X X  
C6e Wheelchair Users Only: Short ramp     X X X  
C6f Wheelchair Users Only: Long ramp     X X X  
C7 Telephone-Answering X X X X X  
C8 Telephone-Placing Call X X X X X  
C9 Medication Management-Oral Medications     X X X  
C10 Medication Management-Inhalant/Mist Medications     X X X  
C11 Medication Management-Injectable Medications     X X X  
C12 Make light meal     X X X  
C13 Wipe down surface     X X X  
C14 Light shopping     X X X  
C15 Laundry     X X X  
C16 Get in/out of car     X X X  
C17 Drive a car     X X X  
C18 Use Public Transportation     X X X  
 
T.VI. How long did it take you to complete this section?
 
VII. Engagement
A1 Indicate level of engagment: 0-6 scale X X X X X  
 
T.VII. How long did it take you to complete this section?
 
VIII. Frailty/Life Expectancy
A1 Surprise if patient was readmitted in the next 6 months X X   X X  
A2 Surprise if patient died in the next 12 months X X   X X  
 
T.VIII. How long did it take you to complete this section?
 
IX. Discharge Status
A1 Discharge date X X   X    
A2 Discharge location X X   X    
A3 Frequency of Assistance at Discharge   X   X    
 
B.Caregiver Information: If discharged to non-institutional community setting              
B1a-B1f Patient Lives with at Discharge   X   X    
B2 Caregiver Availability   X   X    
B3a-B3d Types of Caregivers   X   X    
 
C. Other Discharge Needs              
C1 Ability to pay for medications   X   X    
C2 Ability to manage medications   X        
C3 Patient Transportation   X   X    
C4. Does availability of caregivers affect discharge options   X   X    
 
D. Discharge Care Options              
D1a-D1j Deemed Appropriate by the Provider X X   X    
D2a-D2j Bed/Services Available X X   X    
D3a-D3j Refused by Patient/Family X X   X    
D4a-D4j Not Covered by Insurance X X   X    
 
E. Discharge Information     X   X    
E1 Provider Name X X   X    
E2 Provider Type X X   X    
E3 Provider City X X   X    
E4 Provider State X X   X    
E5 Medicare Provider Identification Number X X   X    
E6 Patient requests that information not be shared X X   X    
E7 Discharge delay X X   X    
E8 Reason for Discharge Delay   X   X    
 
T.IX. How long did it take you to complete this section?
 
X. Other Useful Information
A1 Other useful information about this patient X X X X X X
 
XI. Feedback
A1 Notes X X X X X X
 
Note:
1 These items are collected regardless of site of care. Discharge items are collected only on discharge assessments. Admission are collected only on admission assessments.