Form Cms-725 - Surveyor Worksheet For Psychiatric Hospital Review:two Special Conditions
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
OMB No. 0938-0378
CENTERS FOR MEDICARE & MEDICAID SERVICES
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
Patient’s level of
participation in the activity
Presence of disruptive behavior,
and staff’s 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?
Page 1
Form CMS-725 (09/94)
(OPTIONAL)
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