6720FDG CMS802

User Manual: 6720FDG

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surveyor assigned

Resident Room

Resident Number

Phase 1 ____________________

Phase 2 ____________________
Individual Interview (I) ______
Family Interview (F) ________

Closed Record (CL) _________

Comprehensive (C) __________
total sample:_______________

Form CMS-802 (04/12)

Abuse/Neglect
Clean/Comfort/Homelike
moderate/severe pain (Constant or Frequent)
Hi-Risk pressure Ulcer (stage 2-4)
New/Worsened pressure Ulcers (stage 2-4)
physical Restraints

2
3
4
5
6
7
8
9

Behavior symptoms affecting others/Self
Depressive symptoms

Admittance/Transfer/Discharge
MI (Non-Dementia) or ID/DD
Language/Communication
Vision/Hearing/Other Assistive Devices

10 11 12
13
14 15 16 17 18 19 20 21 22
23
24
25 26 27 28 29 30 31 32 33 34

Specialized Rehab Services (OT, PT, Speech, etc.)

Infections

Hydration/Swallowing/Oral Health

Specialty Care (Tube Feeding, Central Lines, Ventilators, O2)

ROM/Contractures/Positioning

Dialysis

Hospice

Need for increased aDl Help

excessive Weight loss/Gain

lo-Risk Resident lose Bowel/Bladder Control

indwelling Urinary Catheter

Urinary tract infection

psychoactive meds with absence of Condition
antianxiety/Hypnotic medication Use

Falls including Falls with major injury

Social Services

1

Self-Determination/Accommodation of Needs

Privacy/Dignity Issues

Resident Name

Closed Record/Comprehensive/Focused

Focused Review (FO) ________

Interview: Individual/Family

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Offsite _____ Phase I _____ Phase 2 _____ Provider # __________________

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