How to Complete the New York DOH-694 Patient Review Instrument (PRI)

The New York DOH-694 Patient Review Instrument, formally the Hospital and Community Patient Review Instrument (H/C PRI), is a four-page clinical assessment that a PRI-certified registered nurse must complete before anyone can be admitted to a nursing home in New York State. The nurse evaluates the patient’s medical conditions, treatments, activities of daily living, and behaviors based on the past week of clinical observations, then pairs the finished form with the SCREEN (DOH-695) so the receiving facility can decide whether it can meet the patient’s documented needs.¹

Who Is Allowed to Complete the Form

Only a registered nurse who has finished the New York State Department of Health’s PRI Training Program may sign a DOH-694. Eligible assessors include hospital discharge planners, certified home health agency RNs, nursing home RNs, county public health nurses, and utilization review staff, provided they hold current PRI certification.¹ Social workers and other clinicians cannot be certified as H/C PRI assessors, although they may take the training to understand the placement process.²

The training is a recorded webinar of roughly four hours with case studies. When you finish, you receive an Assessor Identification Number that must appear on every DOH-694 you sign. There is no expiration on PRI certification: it stays valid unless the Department of Health changes the instrument itself.³

What to Pull Together Before You Start

The lookback period is one week, not thirty days. Every clinical question on the form refers to the patient’s status during the seven days before the assessment date. For a patient hospitalized fewer than seven days, the window shrinks to the time from admission through the day of PRI completion. For a community assessor with no prior history on the patient, the lookback is simply the day of the assessment.¹

Have the patient’s recent nursing notes, physician orders, therapy logs, and medication records covering that window in front of you. Several questions require specific documentation in the medical record before you can answer “yes.” Without that documentation, the answer is “no” regardless of what your clinical judgment tells you. Keep the instructions manual open while you work.¹

Working Through the Seven Sections

The DOH-694 has seven sections, and no question may be left blank. If you need to change an answer, cross out the original and write the corrected response clearly to the right.¹

Section I — Administrative Data (Items 1–15)

Identifying information: the facility’s operating certificate number, the patient’s name, Social Security number, date of birth, county of residence, medical record number, and hospital room or unit. You also enter the date of hospital admission or initial agency visit, the date the patient was placed on alternate level of care status if applicable, Medicaid number, Medicare number, and primary payor. Item 15 asks the reason for completing this PRI, such as new admission or change of condition.⁴

Section II — Medical Events (Items 16–18)

Item 16 records the most severe decubitus ulcer on a 0-to-5 scale as defined in the instructions. Item 17 is eleven yes/no medical conditions: comatose, dehydration, internal bleeding, stasis ulcer, terminally ill, contractures, diabetes mellitus, urinary tract infection, symptomatic HIV infection, accident, and ventilator dependence. Item 18 is thirteen yes/no medical treatments: tracheostomy care or suctioning, general suctioning, oxygen, respiratory care, nasogastric feeding, parenteral feeding, wound care, chemotherapy, transfusion, dialysis, bowel and bladder rehabilitation, catheter (indwelling or external), and daytime physical restraints.⁴ Each treatment carries qualifiers in the instructions, typically a frequency requirement such as “daily.” All qualifiers must be met before you can answer “yes.”

Section III — Activities of Daily Living (Items 19–22)

The ADL section is where assessors most often go wrong, because the form asks about capability rather than what the patient is actually doing. The instructions are explicit: assess what the patient is physically and mentally able to do, setting aside environmental factors like staffing or equipment availability.¹

The 60 percent rule governs every ADL rating: score the patient based on how capable they are of completing the task 60 percent or more of the time it needs to be performed. The four categories are eating (Item 19), mobility (Item 20), transfer between bed and chair excluding bath and toilet (Item 21), and toileting (Item 22), which combines continence status with the level of help needed. A patient is coded incontinent if they lose bladder or bowel control 60 percent or more of the time. Two-person transfer assistance requires a documented medical reason in the record, such as obesity, contractures, fracture risk, or attached equipment.¹

Section IV — Behaviors (Items 23–26)

Four yes/no behavioral items: verbal disruption, physical aggression, disruptive or socially inappropriate behavior, and hallucinations. These flag patients who may need higher staffing or specialized behavioral support.⁴

Section V — Specialized Services (Items 27–28)

Item 27 rates physical therapy and occupational therapy separately on a four-level scale. Level 1 means no therapy. Level 2 is a maintenance program aimed at stabilizing or slowing decline. Level 3 is active restorative therapy received during the past week. Level 4 means the patient receives therapy but does not meet the full qualifiers, for example therapy provided on only two days when more are required. Record the number of days and total hours and minutes per week for each therapy type. Item 28 captures the number of physician visits.⁴

Sections VI and VII — Diagnosis, Plan of Care, and Signature (Items 29–35)

Item 29 is the primary medical problem with its ICD code. Items 30 through 33 form the plan of care summary: diagnoses and prognoses in narrative form, rehabilitation potential, a full medication list (name, dose, frequency, route, and the diagnosis requiring each medication), and a description of all treatments, including dressings, wound care, oxygen, special diets, allergies, abnormal lab values, and pacemakers. Item 34 records race or ethnic group. Item 35 is where you sign, print your name, and enter your Assessor Identification Number to validate the form.⁴

The completed form also carries a RUG-II (Resource Utilization Group) classification field, printed on the form itself, which categorizes the patient by expected care intensity based on the ADL, medical, and behavioral data you entered.⁴

The DOH-694 Alone Will Not Admit a Patient

A finished PRI is not sufficient for nursing home admission. New York regulation 10 NYCRR 415.26 requires a SCREEN form (DOH-695) for every nursing home admission regardless of reason or expected length of stay, and the PRI must be finished first because the SCREEN draws on its ADL and medical condition data to determine whether the patient could instead be served in the community.⁵

A different professional completes the SCREEN. Qualified screeners include social workers and discharge planners who have finished a separate DOH-approved SCREEN training program and hold their own ten-digit identification number. If any of the Direct Referral Factors for Community Based Assessment (items 8–12) is answered yes, the patient must be referred for a community-based assessment by a certified home health agency, long-term home health care program, or similar authorized organization before nursing home placement can move forward. The SCREEN also incorporates the federal Preadmission Screening and Resident Review (PASRR) Level I review for possible mental illness, intellectual disability, or developmental disability.⁵

How Long a Completed PRI Stays Valid

Validity depends on where the patient was assessed. A PRI completed on a hospitalized patient is valid for 30 days. A PRI completed on someone in any other setting, including their home, an adult home, or congregate housing, is valid for 90 days.⁶ If placement does not happen inside that window, a new PRI is required. A significant change in the patient’s medical condition triggers a reassessment even when the validity period has not expired, because the PRI used with the SCREEN must reflect the person’s current condition.⁵

Where to Get the Form, Instructions, and Certification

The form is at health.ny.gov/forms/doh-694.pdf. The instructions manual, which you should read before your first assessment and keep on hand for every one after that, is at health.ny.gov/forms/instructions/doh-694_instructions.pdf. The SCREEN form (DOH-695) is available separately through the same site. Nurses seeking initial PRI certification can access the training through the Public Health Training Center at the University at Albany.²

1
New York State Department of Health. Hospital and Community Patient Review Instrument Instructions
2
PHTC Online. Hospital and Community Patient Review Instrument (H/C PRI)
3
PHTC Online. H/C PRI Frequently Asked Questions
4
New York State Department of Health. Hospital and Community Patient Review Instrument (HC-PRI)
5
New York State Department of Health. SCREEN/PASRR Frequently Asked Questions (FAQ)
6
New York State Department of Health. Selecting a Nursing Home in New York State – A Guide for Consumers