UTILIZATION REVIEW

PART I: SERVICE OR SEVERITY OF ILLNESS CRITERIA

Instructions: Carefully read through the Intensity of Service and Severity of Illness criteria
provided. Also, read the policy criteria used to indicate medical necessity and continued stay
at the hospital. Then, in the table that follows, list the policy criteria in the appropriate
column based upon whether they are Intensity of Service or Severity of Illness criteria.

IS Criteria: Intensity of Service

Measures the level of intensity of treatment needed or resources used - "How much
care do they need?"

SI Criteria: Severity of Illness

A measure of how serious is the patient's illness or condition - "How sick are they?"

Policy:

The following criteria indicate medical necessity and continued hospital stay:

1. IV pain medications 3 or more times daily

2. White blood count >15,000/cu.mm.
3. Special neurological monitoring every 2 hours or more
4. Oral temperature > or equal to 101 degrees
5. Uncontrolled active bleeding at present time
6. Sudden onset of unconsciousness
7. Blood culture positive for pathogens
8. Respiratory assistance required
9. Surgery performed
10. Acute onset of chest pain/pressure

INTENSITY OF SERVICE SEVERITY OF ILLNESS

IV pain medications 3 or more times White blood count >15,000/cu.mm.

daily

Special neurological monitoring every 2 Oral temperature > or equal to 101

hours or more degrees

Blood culture positive for pathogens Uncontrolled active bleeding at present

time

Respiratory assistance required Sudden onset of unconsciousness

Surgery performed Acute onset of chest pain/pressure

PART II - UTILIZATION REVIEW FOR 3 PATIENTS

Instructions: Perform a Utilization Review on 3 patients. Below are notes from 3 patients
who are currently inpatients at the hospital. Based on the notes provided, complete the
Utilization Review Form that follows. Be sure to indicate if the documentation supports
continued stay or if you believe the patient should be discharged.

Patient 1:

8/16/xx
0200 Sleeping in bed, breathing easily.
0115 SVN with albuterol 0.5 cc given.
0130 Breathing easy, good air exchange. Lungs fields with only minor crackles. No
c/o at
this time.
0640 Feels better after treatment. Improving air flow in all lung fields. Foley catheter
removed.
IV discontinued.
0700 Up to BR, voids well.
0800 Dr. Wainwright visits. Patient resting well. Blood sugar 130, vital signs stable.
Ext. no edema. VS stable. Patient alert & oriented.

Patient 2:

3/29/xx
Afebrile, VSS
Drainage minimal
Continue present treatment.
IV Percocet every 4 hours
3-30-xx
Afebrile
VSS
Vitals stable
Drainage minimal
Drains removed.
IV Percocet every 6 hours
Patient 3:

1-23-xx 7-3pm Tylenol #3 given for incisional pain. Has been ambulating well in
hallway without assistance. Up to bathroom ad lib. Dressing dry. Staples removed,
Steri-Strips applied. Taking diet well. Continues to complain of abdominal pain,
possible gas.
Showered. Temp 101.9 degrees. Patient feeling dizzy on ambulation.

Utilization Review Form

Reminder: Complete this Utilization Review Form indicating if the documentation supports
continued stay or if you believe the patient should be discharged.

SAMPLE PATIENT 1 PATIENT 2 PATIENT 3

Criteria Indicator Onset of Patient alert & Drainage minimal Dressing dry
chest pain oriented.This Staples removed,
patient is Drains removed Steri-Strips
breathing Vitals stable applied.
easier with
good air Patient feeling
exchange. dizzy on
Lungs have ambulation.
minor Temp 101.9
crackles. degrees. Can
Patient resting walk without
well. Blood assistance. Can
sugar 130, go to the
vital signs bathroom ad lib.
stable. Foley Taking diet well
catheter
removed.

IV
discontinued.
No edema.

Decision Continued discharge Continued stay Continued stay

(Continued stay stay
or discharge)

Action None None IV Percocet every 7-3pm Tylenol

6 hours #3 given for
incisional pain.