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Run: PASRR Level I and Level II Documentation

PASRR Level I and Level II Documentation template for recording pre-admission screening, referral triggers, and admission disposition before skilled nursing ...

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Submission Overview

Submission Type (required)

Facility Name (required)

Screening Date (required)

Screening Completed By (required)

Anonymous submission

Select only if your workflow allows anonymous submission. Do not include patient-identifying details if anonymous is selected.

Yes No N/A

Resident Screening Details

Resident Initials (required)

Use initials or your facility-approved identifier if full name is not required.

Date of Birth

Collect only if required by your PASRR workflow or state process.

Medicaid ID Last 4 Digits

If needed, enter only the last 4 digits to minimize PII exposure.

Admission Type (required)

Planned Admission Date (required)

Level I Screening

Was Level I screening completed? (required)

Level I Completion Date

Suspected mental illness present? (required)

Suspected intellectual disability present? (required)

Basis for Level I determination

Select all that apply to support the screening decision.

Level II Review

Was Level II referral made? (required)

Referral Date

Reviewing Entity

Enter the state-designated review entity or contractor name if applicable.

Level II Review Status

Level II Outcome Summary

Summarize the outcome and any admission restrictions, recommendations, or next steps.

Admission Disposition

Admission Disposition (required)

Follow-up Actions

Select all actions that apply.

Next Review Date

Attestation and Consent

Attestation (required)

I attest that the information provided is accurate to the best of my knowledge and collected in accordance with applicable privacy and documentation requirements.

Yes No N/A

Signature (required)

Signature Date (required)

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Email (required)

Your name (optional)

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