Form CMS-10246 CMS-10246.revised_cru_forms

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Overview

General SAF
Therapist SAF
HH Patient Time Log
Ancillary Log
Consult Log
Patient Tracking Form

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Sheet 1: General SAF

Unit (Non-Therapist) Staff Activity Form

Medicare Post-Acute Care Study

[Provider Name & Unit]

Staff Name

Date

/

/

Form

SFU-20071116

Shift Length (Hours)

.

Day

Evening

Night

Position

Employment Type

RN

Social Worker

Physician Assistant

Other

Reg. Full/Part Time

LPN/LVN

Case Mgr./Dis. Planner/Util. Rev.

Discharge Planning Mgr.

Per Diem

Nursing Assistant/Aide

PPS Coordinator

Nurse Manager

Contract/Agency

Adv. Practice RN/NP

Pharmacist

Physician (Administrative Activities Only)

PLEASE COMPLETE THIS FORM FOR ALL PATIENTS

Time (in Minutes) Spent in Each Activity

Personal

Care/

Administrative/

Nursing

Charting/

Inservice/

Administer

Care/

Care

Commit-

Meds/

Assess-

Planning/

tees/

Blood/

ments/

Rounding/

Breaks/

Total

Patient

Patient

Family

Transport

Other Off-

Time

Educ.

Educ.

Meetings

Patients

Unit Time

(min.)

Notes

Total Time in Shift

Patient ID #

On-Unit Activities

(Completed by

Off-Unit Activities

Site Coordinator)

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A

L

L

Not Patient-Specific

Patient Name↴

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Sheet 2: Therapist SAF

Therapy Staff Activity Form

Medicare Post-Acute Care Study

[Provider Name & Unit]

Staff Name

Date

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Form

SFT-20071116

Therapy Discipline

Therapy Position

Employment Type

Physical Therapy

Speech Therapy

Licensed Therapist

Therapy Manager

Regular Full/Part Time

Occupational Therapy

Recreation Therapy

Per Diem

Respiratory Therapy

Other

Therapy Assistant

Therapy Aide

Contract/Agency

PLEASE COMPLETE THIS FORM FOR ALL PATIENTS

Time (in Minutes) Spent in Each Type of Activity

Administrative/

Therapy Sessions for Unit Patients

Charting/

Individual

Care

Total

Therapy/

Group

Group

Group

Group

Group

Group

Planning/

Time

Assessment

#1

#2

#3

#4

#5

#6

Breaks

(min.)

Total Time in All Activities

Activities With Unit Patients

Other Activities

Time (in Minutes) Each Patient Spent in Your Therapy Sessions

“Groups” Are Any Therapy Sessions With 2 or More Patients.

Patient ID #

Individual

(Completed by

Therapy/

Group

Group

Group

Group

Group

Group

Site Coordinator)

Patient Name

Assessment

#1

#2

#3

#4

#5

#6

Notes

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Sheet 3: HH Patient Time Log

Home Health Patient Time Log

Medicare Post-Acute Care Study

[Provider Name & Office/Service]

Staff Name

Date

/

/

Form

HHL-20071116

Position (Check One)

RN

Occupational Therapy Assisant

Social Worker

LPN/LVN

Occupational Therapy Aide

Case Mgr./Dis. Planner/Util. Rev.

Nursing Asst./Aide

Respiratory Therapist

Nursing Manager

Adv. Prac. RN/NP

Respiratory Therapy Assistant

Therapy Manager

Physical Therapist

Respiratory Therapy Aide

Case/Discharge Plan. Manager

Physical Therapy Assistant

Speech Therapist

Administrative/Secretary/Clerk

Physical Therapy Aide

Speech Therapy Assistant

Other

Occupational Therapist

Speech Therapy Aide

Employment Type (Check One)

Regular Full/Part Time

Per Visit

Contract/Agency

PLEASE COMPLETE THIS FORM FOR ALL PATIENTS

Patient ID #

Time Spent on

(Completed by

Face-to-Face Visit

Patient Outside

Site Coordinator)

Patient Name

Time (minutes)

of Visit (minutes)

P

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V

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Note:

Time spent on patient outside of visit includes travel, telephone calls, meetings, charting, OASIS

completion, wound care consult calls, and other tasks related to patient care but not in a visit.

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Sheet 4: Ancillary Log

Patient Ancillary Service Log Form

Medicare Post-Acute Care Study

[Provider Name & Unit]

Date

/

/

Form

ANC-20071116

PLEASE COMPLETE THIS FORM FOR ALL PATIENTS

Check Imaging/Radiology, Other Diagnostic, or Complex Treatment Received

Patient ID # (Completed by Site Coordinator)

Patient Name

Angiogram

Aortogram

Arthrography

Bone Densitometry

Cholangiography

Cisternography

Diskography

Echocardiogram

EKG

GI Series (Upper or Lower)

Lymphangiography

Mammary Ductogram

Modified Barium Swallow

MRI

Myelography

Ultrasound ____________________________

Ultrasound ____________________________

Ultrasound ____________________________

Urethrocystography

Urography

Venography

X-Ray

Other Imaging _________________________

Other Imaging _________________________

Other Imaging _________________________

Arterial Blood Gas (ABG)

Bedside Bronchoscopy

Complex Pharyngeal & Speech Evaluation

Other Complex Diagnostics _______________

Other Complex Diagnostics _______________

Other Complex Diagnostics _______________

Complex Bowel Management _____________

Complex Bowel Management _____________

Continuous Cardiac Monitoring/Telemetry

Hemodialysis

Intermittent Bladder Catheterization

Multiple IV Antibiotic Administration

Negative Pressure Wound Therapy

Peritoneal Dialysis

Total Parenteral Nutrition

Ventilator Management (Weaning Only)

Other Complex Treatment ________________

Other Complex Treatment ________________

Other Complex Treatment ________________

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Sheet 5: Consult Log

Non-Physician Consult Log Form

Medicare Post-Acute Care Study

[Provider Name & Unit]

Date

/

/

Form

CON-20071116

PLEASE COMPLETE THIS FORM FOR ALL PATIENTS

Consultation Time (minutes)

Patient ID #

Wound/

(Completed by

Physical

Occ.

Resp.

Speech

Dietician/

Infection

Discharge

Social

PPS

Phlebotomist/

Other

Other Consult

Site Coordinator)

Patient Name

Therapist

Therapist

Therapist

Pathologist

Nutritionist

Nurse

Planner

Worker

Coordinator

Lab Tech

Consult

Description

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Sheet 6: Patient Tracking Form

Patient Tracking Form

Medicare Post-Acute Care Study

[Provider Name & Unit]

Data Collection Period Begin Date

/

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Data Collection Period End Date

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Form

PTF-20071116

Medicare

Patient?

Medicare Health Insurance

Interim CARE Tool

Sex

Patient ID #

Patient Name

Y

N

Claim (HIC) Number

Assessment Date

Admission Date

Discharge Date

Age

M

F

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