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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

 

 


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