Appendices
50
Appendix F: Patient Health Questionnaire (PHQ-9)
D0300. Total Severity Score
Enter Score Add scores for all frequency responses in Column 2 – Symptom
Frequency. Total score must be between 00 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is
blank for 3 or more items).
D0350. Safety Notification - Complete only if D0200|1 = 1 indicating possibility of
resident self harm
Enter Code Was responsible staff or provider informed that there is a potential for
resident self harm?
0. No
1. Yes
(cont'd)
Appendix G: CMS Regulations Regarding PRN use of Psychotropic
Medications
The federal (CMS) definition of psychotropic agents include antipsychotic,
antidepressant, antianxiety, and hypnotic agents. State surveyors may include central
nervous system agents, mood stabilizers, anticonvulsants, muscle relaxants, anti-
cholinergic medications, antihistamines, NMDA receptor modulators and over-the-
counter natural or herbal products. Please check state regulations.
• PRN Psychotropics (excluding antipsychotics):
14 day limitation on all PRN orders. Order may be extended beyond 14 days if the
attending physician or prescribing practitioner:
1. Believes it is appropriate to extend the order AND
2. Documents clinical rationale for the extension AND
3. Provides a specific duration of use
* e above items may be documented upon initiation of the PRN psychotropic order, thus
allowing use of the PRN beyond the 14 day limit.
• PRN Antipsychotics:
14 day limitation on all PRN orders. Order may NOT be extended beyond the
14 day limit. A NEW order for the PRN antipsychotic may be written if the
attending physician or prescribing practitioner:
1. DIRECTLY examines and assesses the resident. Evaluation by facility staff is
NOT permitted. AND
2. Documents the clinical rationale for the new order which includes:
a. What is the benefit of the medication to the resident? AND
b. Has the resident's expressions or indications of distress improved as a result of
the PRN medication?
* e above items must be completed every 14 days for a resident receiving a PRN antipsychotic.
ere are no exceptions for Hospice residents.
Federal guidance and interpretive Guideline F758: Free from Unnec Psychotropic
Meds/PRN Use
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/
som107ap_pp_guidelines_ltcf.pdf
