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Use with separate Hospital and Community PRI Instructions

DOH-694 (12/05) Page 1 of 4 NEW YORK STATE DEPARTMENT OF HEALTHOHSM-Division of Quality and Surveillance for Nursing Homes and ICFs/MR Use with separate Hospital and Community PRI InstructionsI. ADMINISTRATIVE DATA1. OPERATING CERTIFICATE NUMBER(1-8) 2. SOCIAL SECURITY NUMBER(9-17) - - 3. OFFICIAL NAME OF Hospital OR OTHER AGENCY/FACILITY COMPLETING THIS REVIEW 4A. PATIENT NAME (AND Community ADDRESS IF REVIEWED INCOMMUNITY) 4 B.

III. ACTIVITIES OF DAILY LIVING (ADLs) Measure the capability of the patient to perform each ADL 60% or more of the time it is performed during the past week (7 days). Read the Instructions for the Changed Condition Rule and the definitions of the ADL terms. 19. EATING: PROCESS OF GETTING FOOD BY ANY MEANS FROM THE RECEPTACLE INTO THE BODY (FOR ...

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