Instructions: Module 73A - TheMeasurementGroup.com

SPNS COOPERATIVE AGREEMENT EVALUATION

MODULE 73A: KARNOFSKY RATING SCALE INSTRUCTIONS

Citation: Huba, G. J., Melchior, L. A., Staff of The Measurement Group, Cherin, D., and HRSA/HAB's SPNS Cooperative Agreement Steering Committee (1996). Module 73A: Karnofsky Rating Scale. Available: www.TheMeasurementGroup.com. Culver City, California: The Measurement Group.

Source Citation: KARNOFSKY PERFORMANCE STATUS SCALE (KPS): Karnofsky, D. A., Abelmann, W. H., Craver, L. F., and Burchenal (1948). The use of nitrogen mustards in the palliative treatment of cancer. Cancer, 1, 634-656.

This module should be completed only by a knowledgeable health-care provider; it should not be distributed to nor filled in by the patient.

Answer questions by either filling in a circle, or writing a number or letter in a square box. If the answer goes in a square box, you must use a CAPITAL LETTER or number that does not touch the sides of the box. Print only one letter or number in each box. If the letters or numbers that you print touch the sides of the boxes, or if you do not clearly print the information, the computer will "kick out" the form and we will need to return it to you to be completed correctly. If the question asks for the answer to be filled in a circle, make sure that the circle is completely darkened. Only darken one circle for each question unless the instructions specifically tell you to darken as many as apply for that question.

Specific Parts of the Module 73A: Karnofsky Rating Scale

ID Letters/ID Numbers. These boxes are provided for entering the unique identifier your site is using to track client information. The four boxes on the left are to be used for letters, while the ten boxes on the right are reserved for numbers. You may use letters, numbers, or a combination of letters and numbers, for identification purposes. If you use a combination of letters and numbers, however, please use the letters first in your alphanumeric sequence (for example, if your unique identifier is MD-1479, the letters "M" and "D" would be entered in the first two of the four boxes reserved for letters and the numbers "1", "4", "7", and "9" would be entered into the first four of the ten boxes reserved for numbers). If you are unsure about a client’s unique identifier, check with your project director.

Site. This is a code to identify your project in the cross-cutting evaluation. It should be pre-printed on the form. Site codes are 3 letters.

Sub-Provider. This field may be used to designate specific sites or providers within your project. If appropriate, enter the code for the service provider agency doing the activity. Provider codes can be up to 3 letters.

Date. Enter the numbers representing today’s date (the date of the activity or on which services were provided) in these boxes. Enter the month as a number from 01 to 12 corresponding to January through December. Enter the day as a two-digit number (01 to 31). Enter the last two digits of the current year (for example, "96" for 1996). Make sure that if a month or day is less than 10, you place a "0" before the number.

Staff Code. Each staff member should be assigned a unique number code (up to 3 digits). Make sure that each new staff member has a unique code. Do not reassign any staff codes that have been previously assigned. Enter the 3-digit code for the staff who provided the services. If the staff code is less than 3 digits, place "0"s before the number. For example, 3 is "003."

Client Gender. Use your observations to determine if client is male or female. If the client is biologically male, darken the circle next to "Male." If the client is biologically female, darken the circle next to "Female." Ask him or her if necessary.

The Karnofsky Rating Scale. On this scale is recorded the client’s current performance status (or level of functioning) as indicated by the clients ability to perform common tasks. The scale ranges from 0 to 100% with a rating of 0% equal to the client being dead and a rating of 100% equal to the client being normal and manifesting no signs of disease. Darken the one bubble next to the description most suited to the client’s highest level of functioning.

CD4-Plus Lymphocyte Count. In the boxes provided, enter the person’s most recent CD4- (T4- or t-helper-) cell count per cubic millimeter of blood and CD4 %. The cell count must be entered into the boxes provided. Right justify the numbers you enter into the boxes using zeros to precede digits if necessary.

Module 73

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