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Concurrent Review Guide

for COUNTY FUNDED SNF

|Review Date: | |

|Facility Name: | |

|Doctor’s Name: | |

|Client Name: | |

|Client DOB: | |

|Date Admitted: | |

Required attachments:

• Monthly Psychiatrist Notes for period being reviewed

1. Current ICD 10 diagnoses

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2. Medication changes (since admit or since last review)

|Name |From Dosage |To Dosage |Dosing Schedule |Date of Change |Reason for Change |

| | | |(am, bid, etc.) | | |

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3. Current medications not included above. Do not include PRNs.

|Name |Dosage |Dosing Schedule |Date started |Reason/ Symptom addressed |

| | |(am, bid, etc.) | | |

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3. Psychiatric PRN medications administered in review period

|Name |Dosage |Times taken per |Date started |Reason/Symptom addressed |

| | |month | | |

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4. High risk behaviors in review period

|Behavior Type |Number of Incidents since last review |Intervention applied and client response |

|Assault | | |

|Property Destruction | | |

|Threats | | |

|AWOL behavior | | |

|Sexual acting out | | |

|Use of seclusion | | |

|Use of restraints | | |

|Other | | |

5. High risk medical issues/ exacerbations of chronic medical issues

|Medical disorder |Number and type of incidents since last |Intervention applied and client response |

| |review | |

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6. Completion of ADLS/ showers/ bathing/ clothing/ meals

|Behavior |With or without assistance |Average completion per week |

|ADLS | | |

|Showers/Bathing | | |

|Clean appropriate clothing | | |

|Meals | | |

7. Participation in program activities/ groups

|Activity |Average number of times per week |Participation level |

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8. Summary of client’s presentation/progress/interventions used:

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9. Current discharge planning. Include any barriers to discharge.

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Please fax completed review to:

Optum

(888) 687-2515

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