July 8, 2018

For a variety of reasons, including the availability of evaluators, it may not always be possible to perform a complete psychiatric evaluation on an individual before they are admitted to a nursing facility (NF). In these cases, it is possible to rely instead on information in the individual's medical record and/or psychosocial history.

The Code of Federal Regulations provides no specific guidance as to when information becomes "too old" to be usable. An evaluation done a year or more ago is more likely to be inaccurate than one done six months ago. Even if the evaluation is recent, one should not simply assume it is still accurate. There should be no information in the individual's record to suggest that his or her condition has changed markedly – for better or for worse – since the last evaluation was conducted. In person-centered terms, the evaluation should be sufficient to a) give an accurate Level II determination; and b) help to develop an effective plan of care.

Please see FAQ “How long should PASRR records be maintained?” for additional information.