Definitions:
BALANCE
Difficult or unable to move to a standing position unassisted
Difficult or unable to turn self around and face the opposite direction when standing
Dizziness — The person experiences the sensation of unsteadiness, that he or she is turning, or that the surroundings are whirling around.
Unsteady gait — A gait that places the person at risk of falling. Unsteady gaits take many forms. The person may appear unbalanced or walk with a sway. Other gaits may have uncoordinated or jerking movements. Examples of unsteady gaits may include fast gaits with large, careless movements; abnormally slow gaits with small shuffling steps; or wide-based gaits with halting, tentative steps.
CARDIAC OR PULMONARY
Chest pain — The person experiences any type of pain in the chest area, which may be described as burning, pressure, stabbing, vague discomfort, etc.
Difficulty clearing airway secretions — In the last 3 days the person re-ports or has been observed to be unable to cough effectively to expel respiratory secretions (e.g. secondary to weakness or pain) or is unable to mobilize secretions or sputum from mouth (e.g. secondary to dysphagia or pain) or tracheostomy (e.g. secondary to viscosity of sputum; inability to physically remove secretions from tracheostomy entrance). Examples include a person with pneumonia who is too weak to cough and expel sputum or someone with ALS who requires suctioning to manage secretions.
PSYCHIATRIC
Abnormal thought process (e.g. loosening of associations, blocking, flight of ideas, tangentiality, circumstantiality) — Objective observation of the person indicates abnormalities in the form or way in which the person is expressing thoughts. Included are indicators such as loosening of associations, thought blocking, flight of ideas, tangentiality, circumstantiality, clang association, incoherence, neologisms, punning, etc.
Loose associations: The person jumps from one topic to another without an apparent connection between the topics.
Thought blocking: The person suddenly stops in the middle of a sentence, and is unable to recover what he or she said or complete other thoughts.
Flight of ideas: The person’s thoughts are expressed so quickly that the listener has difficulty keeping up.
Tangentiality: A thought process whereby the person digresses from the subject under discussion and introduces thoughts that seem unrelated, oblique, or irrelevant.
Circumstantiality: The person exhibits lack of goal directedness, incorporates unnecessary details, and has difficulty getting to an end point in the conversation.
Clang Association: The connection between the person’s thoughts is tenuous. The person may use rhyming and punning in their speech.
Incoherence: The person’s speech is unclear or confused. The communication does not make sense to the intended listener.
Neologism: A word made up by the person that is often condensed from several words. Neologisms are unintelligible to the listener.
Punning: The person uses words that are similar in sound, but different in meaning.
NEUROLOGICAL
Aphasia — A speech or language disorder caused by disease or injury to the brain resulting in difficulty expressing thoughts
(i.e. speaking, writing), or understanding spoken or written language.
GI STATUS
Acid Reflux — The regurgitation of small amounts of acid from the stomach to the throat.
Constipation — No bowel movement in 3 days or difficult passage of hard stool.
Diarrhea — The frequent elimination of watery stools caused by any etiology.
Vomiting — Regurgitation of stomach contents, regardless of etiology (e.g. drug toxicity, influenza, psychogenic).
SLEEP PROBLEMS
Difficulty falling asleep or staying asleep; waking up too early; restlessness; non-restful sleep — e.g., the person:
experiences an extended time gap between the point at which he/she at-tempted to fall asleep and the time at which sleep was actually initiated;
wakes up well before the desired time due to some factor inherent to him/her (exclude situations in which the person is awakened by some external source);
experiences sleep that is accompanied by repeated tossing and turning, or dreaming that causes motion or wakefulness, etc. such that the person does not feel relaxed when sleeping or rested when awake;
is easily awakened during sleep by sounds or movements and experiences one or more periods of awakening after sleep is initiated.
Too much sleep — An excessive amount of sleep that interferes with the person’s normal functioning.
OTHER
Aspiration — The inhalation of food or fluid into the person’s lungs.
Fever — A rise in the person’s body temperature, frequently as a result of infection.
GI or GU bleeding -
Gastrointestinal (GI) Bleeding — Any documented bleeding as diagnosed by a gastrointestinal evaluation or any evidence of current bleeding through rectal exam or guaiac testing. Bleeding may be frank (such as bright red blood) or occult (such as black, guaiac-positive stools).
Genitourinary (GU) Bleeding — Bleeding that occurs anywhere along the genitourinary tract. Urine that is dark or cloudy should be tested for the presence of blood. There may also be visible blood in the person’s urine, or frank (bright red blood) coming from the urethral opening.
Peripheral
edema — The person has an abnormal buildup of fluid in foot/ankle/leg
tissues.
Process:
Ask the person — he or she may not have told others of his or her symptoms. Ask family members or caregivers. Review any available clinical records.
Coding:
0. Not present
1. Present but not exhibited in last 3 days
2 Exhibited on 1 of last 3 days
3. Exhibited on 2 of last 3 days
4. Exhibited daily in last 3 days