PASRR Level I and Level II Documentation
PASRR Level I and Level II Documentation captures the pre-admission screening needed before skilled nursing placement, including the Level I result, any Level II referral, and the final admission disposition.
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Built for: Skilled Nursing Facilities · Long Term Care · Healthcare Admissions
Overview
PASRR Level I and Level II Documentation is a pre-admission screening template for recording whether a resident has completed the required Level I review and, when indicated, been referred for Level II evaluation before skilled nursing placement. It gives admissions staff a single place to capture the resident’s screening status, the date the screening happened, the result, the reviewing entity, and the final admission disposition.
Use this template when a facility needs a clear audit trail for a new admission decision and must show how mental illness or intellectual disability concerns were handled. It is especially useful when multiple people touch the intake process, because the form separates who completed the screening, who reviewed the Level II referral, and what documents support the final decision.
Do not use this as a general intake form for every resident detail. It is not meant to collect broad clinical history, unnecessary PII, or unrelated operational notes. If your workflow does not involve PASRR screening, or if the resident is not being considered for skilled nursing placement, this template is the wrong fit. Keep the form focused on the screening outcome, the referral path, and the disposition so the record stays usable, reviewable, and aligned with minimum-necessary data collection.
Standards & compliance context
- The template supports data minimization by limiting resident fields to what is needed for PASRR screening and admission disposition.
- The consent_to_store_pii field helps document notice and acknowledgment when the form stores resident-level information.
- The structured fields create an audit trail that can support internal review of pre-admission screening decisions and referral handling.
- If the form is published for staff use, it should meet WCAG 2.1 AA accessibility expectations for labels, validation, and keyboard navigation.
- Use progressive disclosure for Level II follow-up so staff only see the additional fields when a referral is actually required.
General regulatory context for orientation only — verify current requirements with counsel or the relevant agency before relying on this template for compliance.
What's inside this template
Submission Overview
This section establishes who submitted the record, when it was created, and whether the entry is a new screening or an update.
- Submission Date
- Facility Name
- Completed By
- Role / Title
- Submission Type
Resident Screening Details
This section identifies the resident and the admission context while keeping the data set limited to what the screening needs.
- Resident Initials
-
Date of Birth
Collect only if needed to accurately match the resident record.
- Is the individual a Medicaid applicant or beneficiary?
- Planned or Actual Admission Date
- Admission Source
Level I Screening
This section records the initial PASRR result and the short summary that explains why the case did or did not move forward.
- Was Level I screening completed?
- Level I Completion Date
- Level I Result
-
Level I Summary / Basis for Determination
Briefly document the observable facts or record sources used to support the Level I result.
Level II Review
This section captures the referral path and the secondary determination when Level I indicates further review is required.
- Was Level II review referred?
- Referral Date
- Reviewing Entity
- Level II Determination
- Level II Summary / Outcome Notes
Admission Disposition
This section ties the screening outcome to the actual placement decision and preserves the documents that support it.
- Final Disposition
- Disposition Notes
-
Supporting Documents
Upload any supporting PASRR documentation, determinations, or referral records.
Attestation and Consent
This section confirms the record is accurate, documents consent to store PII, and creates a signed audit trail.
- I attest that the information provided is accurate and complete to the best of my knowledge.
- I understand this form may contain limited PII necessary for PASRR documentation and consent to its storage and processing for compliance purposes.
- Electronic Signature
- Signature Date
How to use this template
- 1. Enter the submission details, including the facility name, completed_by, role_title, submission_date, and whether this is a new screening or an update.
- 2. Record the resident screening details using the minimum necessary identifiers, then confirm the admission date and admission source from the intake record.
- 3. Complete the Level I Screening section by marking whether it was completed, entering the completion date, selecting the result, and summarizing the screening basis in a concise note.
- 4. If the Level I result indicates a referral, fill out the Level II Review section with the referral date, reviewing entity, determination, and a brief summary of the review outcome.
- 5. Set the final disposition, add any disposition notes, attach supporting documents, and capture the attestation, consent to store PII, signature, and signature date before filing the record.
Best practices
- Use resident initials instead of full identifiers unless your workflow requires more, and collect only the PII needed to complete the screening.
- Mark required and optional fields clearly so staff do not over-collect data or leave critical compliance fields blank.
- Use conditional logic to show Level II fields only when a referral is triggered, which keeps the form shorter and easier to complete.
- Keep the Level I summary factual and specific, and avoid vague language like reviewed or cleared without stating the actual result.
- Attach the supporting documents at the time of submission so the audit trail is complete and easy to verify later.
- Record the disposition immediately after the screening decision to avoid mismatches between the form and the admission workflow.
- Include a clear consent_to_store_pii acknowledgment and a what happens after I submit note so staff understand how the record will be used.
What this template typically catches
Issues teams running this template most often surface in practice:
Common use cases
Frequently asked questions
What is this template used for?
This template documents PASRR pre-admission screening for a resident being considered for skilled nursing placement. It captures the Level I screening, any Level II referral, the reviewing entity, and the final disposition. Use it to keep the screening record tied to the admission decision and supporting documents.
When should Level II review be triggered?
Level II review is typically triggered when the Level I screening indicates a possible mental illness or intellectual disability concern that requires further evaluation. This template includes a clear referral path so the team can record when the case moves beyond Level I. If no referral is needed, the form still preserves the Level I result and summary.
Who should complete this form?
The form is usually completed by the admissions coordinator, case manager, social worker, or other designated intake staff who handles pre-admission screening. The completed_by and role_title fields make ownership explicit for the audit trail. If a separate reviewing entity performs Level II, that can be recorded in the dedicated section.
How often is this form used?
Use it for each new skilled nursing admission that requires PASRR screening, not as a one-time facility policy document. It should be completed at the point of pre-admission review and updated if a Level II referral or determination changes the disposition. The submission_date and admission_date fields help show timing.
What common mistakes does this template help prevent?
A frequent mistake is documenting the admission without a clear Level I result or without noting whether Level II was required. Another is leaving the disposition disconnected from the supporting documents, which makes later review harder. This template also helps avoid vague notes by separating summary fields from the final disposition.
Does this template help with privacy and consent requirements?
Yes. It includes a consent_to_store_pii field and keeps resident data limited to what is needed for screening and admission decisions. That supports data minimization and makes the privacy acknowledgment explicit. If your workflow allows anonymous submission for internal routing, you would not use this form for that purpose because it is tied to resident-level compliance records.
Can this be customized for different facilities or states?
Yes. Facilities can adjust the admission_source options, the wording of the Level I summary, and the supporting_documents list to match local intake workflows. You can also add conditional logic for state-specific routing or internal approval steps. Keep the core PASRR fields intact so the record still supports the screening decision.
What should be attached as supporting documents?
Attach the documents that substantiate the screening and disposition, such as referral notes, assessment summaries, determination letters, or discharge planning records. The goal is to make the audit trail easy to follow without collecting unnecessary PII. Only include what is needed to explain why the resident was admitted, deferred, or referred.
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