PROBLEM BEHAVIORS RATING SCALE (PBRS)

Code:__________ Rater Initials: _______ Facility ___________

Name: (first)___________________ (mi) ___ (last ) _________________________

Date: m____/___/____

Physician Initials __________ Signature ____________

( ) NURSING HOME

( ) INPATIENT

( ) AMBULATORY CLINIC

( ) IN HOME

SCORING: Circle problem behaviors based on direct observation of behaviors by you and coworkers only.

SEVERITY: (in the past week): 0=within normal limits 1=severity mild and/or no intervention needed 2=severity moderate and/ or intervention needed 3=severity marked and/or urgent intervention needed U=Unknown ?=Uncertain

FREQUENCY: 0=no occurrences / within normal limits 1=less than once weekly 2=between one and six occurrences per week 3=at least once per day U=Unknown ?=Uncertain.

In the severity (SEV) and frequency (FRQ) column, enter the highest ratings obtained by any of the problem behaviors circled for that category. You may use the same or different symptoms for SEV and FRQ. Leave categories with 0 scores blank. Regard severity as the worst during the time period being measured usually the past week.

Example: Subject has three problem behaviors. Circle these three items. The greatest severity of any of these problem behaviors in the past week was moderate; the frequency was daily: Record SEV score 2, FRQ score 3.

SEV	FRQ	CATEGORY	PROBLEM BEHAVIOR
2	3	06 HALLUCINATIONS	Giggles, talks to self, Admits to: voices, visions, smells, tastes, sensations.

SEV	FRQ	CATEGORY	PROBLEM BEHAVIOR
		01 APPEARANCE	Unkempt appearance, Poor hygiene, Drooling, Poor care of own environment
		02 LEVEL OF AWARENESS	Poor attention, Distractible, Consciousness fluctuates, Perplexed
		03 ORIENTATION	Disoriented to: time / place / person, Loses way
		04 DAY-NIGHT INVERSION	Behavior worse at night, Becomes confused at night
		05 THOUGHT FORM	Evades questions, Content difficult to understand, Illogical
		06 HALLUCINATIONS	Giggles, talks, to self, Admits to: voices, visions, smells, tastes, sensations
		07 DELUSIONS	Others stealing, Grandiose, Persecutory, Sexual, Jealousy, Other
		08 OBSESSIONS and PHOBIAS	Obsessional thoughts, Compulsions, Rituals, Phobic behavior
		09 MEMORY	Needs reminding, Forgetful, Loses possessions
		10 COMMUNICATION	Mute, Has difficulty understanding, Repeats words and phrases, Screams_____________________________, Loud noises, Pronunciation difficult to understand
		11 DAILY LIVING SKILLS	Difficulty with: combing hair, brushing teeth, dressing, writing
		12 VISION PROBLEMS	Difficulty seeing, Double or blurred vision
		13 AUDITORY PROBLEMS	Hard of hearing
		14 ANXIETY	Looks anxious, Panic attacks
		15 DEPRESSION	Weeping, Crying, Looks depressed
		16 EXCITABILITY	Excitable, Irritable, Confrontative, Euphoric, Elated, Shouting
		17 MOOD VARIATIONS	Moaning, Variable mood (over minutes)
		18 SELF-AWARENESS	Does not perceive self as ill, Poor judgement
		19 MOTIVATION/ENERGY	Does not complete simple tasks, Lethargic, Not motivated, Unoccupied
		20 GAIT/BALANCE	Stiff, Slow, Ataxic, Shuffles, Requires prostheses/wheerchair, Poor balance, Needs help to transfer, Falls
		21 INVOLUNTARY MOVEMENTS	Tics, Tremor, Mouth movements, Other purposeless movements
		22 AGITATION/RETARDATION	Restless, Pacing, Wandering, Withdrawn, Reclusive, Catatonic, Disrobing
		23 SPHINCTER CONTROL	Urinary incontinence, Fecal incontinence, Fecal smearing, Inappropriate voiding
		24 POSITION DIFFICULTIES	Falls from bed/chair/upright stance, Requires physical restraints for safety
		25 COMPLIANCE	Noncompliant with: medications, tasks, activities, Won?t attend groups, Resistive
		26 PROPERTY/RULES	Stealing, Hoarding, Smoking violations, Destructive, Hiding
		27 SEXUAL BEHAVIOR	Sexually inappropriate touching: self, others. Exposing self. Sexual word usage.
		28 INTERPERSONAL	Bothersome, Intrusive, Complaining, Clinging/anxious attachment, Suspicious
		29 SLEEP BEHAVIOR	Sleeps too little, Sleeps too much, Difficulty falling asleep, Day time sleepiness
		30 EATING BEHAVIOR	Resists, Eats non-food items, Weight gain, Weight loss, Poor appetite
		31 COMPLAINING	Complains of pain, Preoccupied by bodily symptoms
		32 SUICIDAL BEHAVIOR	Suicide attempt, Wishes to be dead, Suicidal ideation, Self-mutilation _____________________________, Requires physical restraints, Requires close observation, Evasive about suicide
		33 DANGER TO OTHERS	Verbal abusiveness, Angry, Physically threatening, Assaultive Throwing objects _____________________________, Fire-setting, Requires close observation, Requires physical restraints
		Total score per column. Maximum is 99. Minimum is 0.
		Total number of "U=unknown " ratings
		Total number of "?=uncertain " ratings