| Name: | Patient Strengths | ||||||
|---|---|---|---|---|---|---|---|
| Collected For: | HBIPS-1 | ||||||
| Definition: | Documentation in the medical record that an admission screening for a minimum of two patient strengths was performed within the first three days of admission. | ||||||
| Question: | Is there documentation in the medical record that the patient was screened for a minimum of two patient strengths within the first three days of admission? | ||||||
| Format: |
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| Allowable Values: | Y (Yes) Documentation in the medical record includes a screening for a minimum of two patient strengths performed within the first three days of admission. N (No) Documentation in the medical record does not include a screening for a minimum of two patient strengths OR the screening was not performed within the first three days of admission OR unable to determine from medical record documentation. X (Unable to complete admission screening) Documentation in the medical record that a screening for a minimum of two patient strengths cannot be completed due to the patient's inability or unwillingness to answer screening questions within the first three days of admission OR patient has a previous admission to the psychiatric unit during a single hospitalization. | ||||||
| Notes for Abstraction: | A screening for patient strengths must be completed by a qualified psychiatric practitioner, e.g., psychiatrist, psychologist, registered nurse (RN), physician's assistant (PA) or Master of Social Work (MSW) within the first three days of admission. The titles of qualified psychiatric practitioners may vary from state to state.
If the patient was in an acute-care hospital and had multiple admissions to the psychiatric unit during his or her hospitalization, select the first admission to the psychiatric unit. The admission screening timeframe must have occurred within the first three days of admission for psychiatric care. The day after admission is defined as the first day. An admission screen performed in an ambulatory setting, i.e. emergency department, crisis center which results in an admission to an inpatient psychiatric care setting can be used if the screen becomes a permanent part of the medical record. If there is documentation that the patient is not a reliable historian, a relative or guardian if available, may answer the screening questions on behalf of the patient. | ||||||
| Suggested Data Sources: |
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| Additional Notes: | |||||||
| Guidelines for Abstraction: | |||||||
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