Nursing Home Problem Behaviors Rating Scale (PBRS)

Code:__________ Rater Initials: _______ Facility ___________

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

Date: m____/___/____

Physician Initials __________ Signature ____________

SCORING: Circle problem behaviors based on observation of behaviors 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

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

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 Severity and Frequency. Leave categories with 0 scores blank.

Example: Subject has three problem behaviors. Circle these three items: The greatest severity of any of these problem behaviors is moderate; the greatest frequency is daily; record SEV score 2, FRQ score 3.

SEV	FRQ	Category	Problem Behaviors
2	3	06 HALLUCINATIONS	Talks to someone not present. Appears to be hallucinating: voices; visions; smells; tastes; sensations

SEV	FRQ	Category	Problem Behaviors
		01 APPEARANCE	Unkempt appearance, Poor hygiene, Drools, Poor care of own environment
		02 AWARENESS	Poor attention, Easily distracted, Consciousness, fluctuates, Looks bewildered
		03 ORIENTATION	Disoriented to: person; time; place; person, Gets lost
		04 DAY-NIGHT INVERSION	Confused at night, Behavior worse at night
		05 SPEECH	Content is difficult to understand/illogical, Form of speech is difficult to understand, Rambling
		06 HALLUCINATIONS	Talks to someone not present, Appears to be hallucinating: voices; visions; smells; tastes; sensations
		07 DELUSIONS	Others stealing, Grandiose, Persecutory, Sexual, Jealousy, Other
		08 OBSESSIONS	Obsessive thoughts, Compulsions, Rituals, Phobic behavior
		09 MEMORY	Needs reminding, Forgetful of recent/past events, Loses possessions, Loses train of thought
		10 COMMUNICATION	Mute, Has difficulty understanding, Repeats words/phrases, Screams, Emits loud noises, Curses
		11 DAILY LIVING SKILLS	Has difficulty with: combing hair, brushing teeth, dressing, bathing, eating
		12 VISION	Has difficulty seeing, Blind
		13 AUDITORY	Hard of hearing
		14 ANXIETY	Looks anxious, Repeatedly calls for help, Looks afraid, Paces
		15 DEPRESSION	Looks depressed, sad, Tearful, Expresses hopelessness, Expresses remorse, Mood remains fixed
		16 EXCITABILITY	Excitable, Combative, Irritable, Elated
		17 MOOD VARIATIONS	Mood varies widely, Mood worse in AM/PM
		18 SELF-AWARENESS	Does not perceive self as ill, Poor judgment
		19 MOTIVATION/ENERGY	Does not complete simple tasks, Lethargic, Not Motivated, Unoccupied, Stares into space
		20 GAIT/BALANCE	Stiff,Slow, Ataxic, Shuffles, Requires prostheses/wheelchair, Poor balance, Needs help to transfer, Falls
		21 INVOLUNTARY MOVEMENTS	Tics, Tremor, Mouth movements, Other purposeless movements/mannerisms
		22 AGITATION/RETARDATION	Agitated, Paces, Wanders, Withdrawn, Reclusive, Catatonic, Disrobes, Picks at skin, Exit seeking
		23 SPHINCTER CONTROL	Urinary incontinence, Fecal incontinence, Fecal smearing, Inappropriate voiding Irregular bowel habits
		24 RESTRAINTS	Requires physical restraints for safety
		25 COMPLIANCE	Non-compliant with: medications; activities; care, Will not attend groups, Otherwise resistive
		26 PROPERTY/RULES	Steals, Hides, Hoards, Smoking violations, Destructive
		27 SEXUAL BEHAVIOR	Sexually inappropriate touching (of self or others), Exposes self, Sexually inappropriate verbally
		28 INTERPERSONAL	Bothersome, Intrusive, Clinging/anxious attachment, Suspicious
		29 SLEEP	Sleeps too little, Sleeps too much, Difficulty falling asleep, Day time sleepiness
		30 EATING/DRINKING	Resists, Eats non-food items, Weight gain, Weight loss, Poor appetite, Excessive drinking
		31 COMPLAINING	Complains of pain, Preoccupied by bodily symptoms, Other complaints, Voices multiple criticisms
		32 SUICIDALITY	Suicidal attempt, Voices suicidal ideation, Self-mutilates, Evasive about suicide, Requires close observation
		33 DANGER TO OTHERS	Verbally abusive, Angry, Physically threatening, Physically assaultive, Sets fires, Throws objects
		TOTAL SCORE