Form CMS-10064 MINIMUM DATA SET (MDS) For Swing Bed Hospitals

MINIMUM DATA SET (MDS)
FOR SWING BED HOSPITALS
1. RESIDENT
NAME
AA1
2. GENDER
AA2
3. BIRTHDATE
AA3
4. MARITAL
STATUS
A5
5. RACE/
ETHNICITY

15. DISCHARGE
DATE
a. (First)

b. (Middle Initial)

1. Male

c. (Last)

-

16. REENTRY
DATE

-

1. Never Married
2. Married

3. Widowed
4. Separated

(Check all that apply)
a. American Indian/Alaskan Native
b. Asian
c. Black or African American
d. Hispanic or Latino

f. White

-

AA5
8. RESIDENT
Enter + if pending or N if not a Medicaid recipient in first digit
MEDICAID
followed by blanks
NUMBER

CLINICAL DATA
17. COMATOSE

Persistent vegetative state with no discernible consciousness
If yes, skip to Item 23

B1
18. SHORT TERM
MEMORY
B2a
19. COGNITIVE
SKILLS

0. No

1. Memory problem

b. Repetitive questions
a. State Medicaid Provider Number

-

AA6a
10. ASSESSMENT a. Last day of MDS observation period
REFERENCE
DATE

-

-

b. Original (00) or correction
(enter number of correction)
A3a
11. REASONS
a. Primary Reasons for Assessment
FOR
00. PPS assessment for Medicare Payment
ASSESSMENT 06. Discharged–Return Not Anticipated
07. Discharged–Return Anticipated
09. Reentry
11. Assessment–Not for Medicare payment
b.
1.
2.
3.

PPS Scheduled Assessments
5-day
4. 90-day
30-day
5. Readmission/Return
60-day
7. 14-day

9. Other

l. Sad, pained, worried
facial expression

e. Self deprecation

m. Crying,tearfulness

f. Expression of unrealistic
fears

n. Repetitive physical
movements

g. Recurrent statements
that something terrible
is about to happen.

o. Withdrawal from
activities of interest
p. Reduced social
interaction

E1
22. BEHAVIORAL Behavioral symptom frequency in last 7 days
SYMPTOMS
0. Behavior NOT exhibited in last 7 days
1. Behavior occurred 1 to 3 days in last 7 days
2. Behavior occurred 4 to 6 days, but less than daily
3. Behavior occurred daily

b. Verbally abusive behavioral symptoms (E4bA)
c. Physically abusive behavioral symptoms (E4cA)

-

Date of initial admission for extended care swing bed services

-

d. Persistent anger with
self/others

a. Wandering (E4aA)

f. Assessment Needed for Other Reasons
(e.g., HMOs, MSP, sanction situations, etc.)
1. Yes
AA8 0. No
12. PRIOR ACUTE Date of admission for prior qualifying hospital stay
CARE STAY

-

AB1
14. ADMISSION/ 01. Private Home/apt with
no home health care
DISCHARGE
02. Private Home/apt with
STATUS
home health care
CODE
03. Board and Care/assisted
living/group home
04. Another nursing facility
05. Acute unit at own hospital

k. Insomnia/change in
usual sleep pattern

i. Repetitive anxious
complaints/concerns

e. State-Required Assessment
0. No
1. Yes

-

j. Unpleasant mood in
morning

c. Repetitive verbalizations

h. Repetitive health
complaints

c. OMRA Assessment
0. No
1. Yes
d. Clinical Change Assessment
0. No
1. Yes

d. Socially inappropriate/disruptive behavioral symptom (E4dA)
E4
23. ADLs

e. Resists care (E4eA)
(A) ADL Self-Performance—Code for resident's performance over
all shifts during the last 7 days
0. Independent
3. Extensive assistance
1. Supervision
4. Total dependence
2. Limited assistance
8. Activity did not occur
(B) ADL support provided—Code for most support provided over all

06. Acute unit at another
hospital
07. Psychiatric hospital
08. Rehabilitation hospital
09. MR/DD facility
10. Hospice
11. Deceased
12. Other

a. Admitted From – Code with all records
b. Discharge Status – Complete if Item 11a = 06 or 07
c. Reentered From – Complete if Item 11a = 09
OMB 0938-0872

0. Memory okay

Makes decisions regarding tasks of daily life

a. Negative statements

b. Medicare Provider Number

13. ADMISSION
DATE

1. Yes

Seems/appears to recall after 5 minutes

21. INDICATORS Code for indicators observed in the last 30 days,
OF
regardless of the assumed cause
DEPRESSION 0. Indicator not exhibited in last 30 days
1. Indicator exhibited up to five days a week
2. Indicator exhibited daily or almost daily (6 or 7 days a week)

AA7
9. FACILITY
PROVIDER
NUMBER

-

0. Independent
2. Moderately impaired
3. Severely impaired
B4 1. Modified independence
20. MAKING SELF Expressing information content – (however able)
UNDERSTOOD 0. Understood
2. Sometimes understood
3. Rarely/never understood
C4 1. Usually understood

AB4
a. Social Security Number
7. RESIDENT
SSN and
MEDICARE
NUMBERS
b. Medicare or Railroad Insurance Number

-

-

5. Divorced

e. Native Hawaiian or
other Pacific Islander

-

Complete if Item 11a = 09

A4

Enter code for the pre-hospital residence

6. ZIP CODE

-

R4

d. (Suffix)

2. Female

Complete if Item 11a = 06 or 07

shifts during last 7 days
0. No setup or physical help 3. Two + persons physical assist
1. Setup help only
8. Activity did not occur
2. One person assist
A

B

a. Bed Mobility (G1a)
b. Transfer (G1b)
c. Eating (G1h)
G1 d. Toilet Use (G1i)
SB-MDS 7/1/02

Resident Name
24. TOILETING
PROGRAMS

25. DISEASES

Numeric Identifier

Check any that apply during the last 14 days
a. Any scheduled toileting plan
H3 b. Bladder retraining program
Check only those conditions/diseases that have a
relationship to current ADL status, medical treatments, nursing
monitoring or risk of death. Do not code inactive diagnoses.
a. Diabetes mellitus (I1a)

d. Hemiplegia/hemiparesis (I1v)

b. Aphasia (I1r)

e. Multiple sclerosis (I1w)

I1 c. Cerebral palsy (I1s)
26. INFECTIONS
Check any that apply

f. Quadriplegia (I1z)

36. TIME
AWAKE

Check appropriate time periods over the last 7 days the
Resident was awake all or most of time (i.e., naps no more
than one hour per time period) in the:
a. Morning

N1
37. INJECTIONS
O3
38. SPECIAL
TREATMENTS
AND
PROCEDURES

b. Septicemia (I2g)
I2 a. Pneumonia (I2e)
Check all problems present in the last 7 days
27. PROBLEM
CONDITIONS
a. Dehydrated, output
d. Hallucinations (J1i)
exceeds input (J1c)
e. Internal bleeding (J1j)
b. Delusions (J1e)
f. Vomiting (J1o)
J1
28. WEIGHT
LOSS

c. Fever (J1h)

b. Code the average fluid intake per day by IV or tube
feedings in last 7 days
0. None
3. 1001 to 1500 cc/day
1. 1 to 500 cc/day
4. 1501 to 2000 cc/day
K6 2. 501 to 1000 cc/day
5. 2001 or more cc/day
31. ULCERS

(A) = # of days administered for 15 minutes or more
(B) = total # of minutes provided in the last 7 days

1. Yes

K3a
29. NUTRITIONAL Check all that apply in last 7 days
APPROACHES
a. Parenteral/IV
b. Feeding tube
K5
30. PARENTERAL Skip to item 31 if neither 29a nor 29b is coded
OR ENTERAL
a. Code the proportion of total calories the resident received
INTAKE
through parenteral or tube feedings in the last 7 days
0. None
3. 51% to 75%
1. 1% to 25%
4. 76% to 100%
2. 26% to 50%

P1
39. NURSING
REHABILITATION/
RESTORATIVE
CARE

Record the number of days each of the following was provided to
the resident for more than or equal to 15 minutes per day in the
last 7 days. (Enter 0 if none or less than 15 minutes per day.)
a. Range of motion(passive)
b. Range of motion(active)
c. Splint/Brace assistance

f. Walking
g. Dressing or grooming
h. Eating or swallowing

d. Bed mobility
e. Transfer

i. Amputation/
Prosthesis Care
j. Communication

P3

In the last 14 days (or since swing bed admission/
readmission if less than 14 days in facility) how many
days has the physician (or authorized assistant or
P7 practitioner) examined the resident. (Enter 0 if none.)
In the last 14 days (or since swing bed admission/
41. PHYSICIAN
readmission if less than 14 days in facility) how many
ORDERS
days has the physician (or authorized assistant or
practitioner) changed the resident’s orders? Do not
P8 include order renewals without change. (Enter 0 if none).

42. ORDERED
THERAPIES

Skip unless this is a PPS 5 day or PPS
Readmission/Return assessment.
a. Ordered Therapies: Has physician ordered any of the
following therapy services to begin in the FIRST 14 days
of stay — physical therapy, occupational therapy or
speech pathology services. (T1b)
0. No
1. Yes
If No, skip to item 45.
b. Through day 15, provide an estimate of the number of
days when at least 1 therapy can be expected to be
delivered. (T1c)

a. Pressure relieving device(s) for chair
b. Pressure relieving device(s) for bed

c. Through day 15, provide an estimate of the
number of therapy minutes (across the therapies)
that can be expected to be delivered. (T1d)
T1

c. Turning/repositioning program
43. CASE MIX
GROUP

e. Ulcer Care

g. Application of dressings (with or without topical medications)
other than to feet.

d. Respiratory therapy

40. PHYSICIAN
VISITS

Check all that apply in last 7 days

f. Surgical wound care

(B)

c. Physical therapy

c. Surgical Wounds (M4g)

d. Nutrition or hydration intervention to manage skin problems

MIN

(A)

b. Occupational therapy

M4
34. SKIN
TREATMENTS

DAYS

a. Speech language pathology and audiology

Record the number of ulcers at each ulcer stage — regardless of cause. If none present at a stage, record "0".
Code all that apply during last 7 days. Code 9 for 9 or
more.

a. Stage 1 A persistent area of skin redness
b. Stage 2 A partial thickness loss of skin layers that
presents clinically as an abrasion, blister, or
shallow crater
c. Stage 3 A full thickness of skin is lost, exposing the
subcutaneous tissues
d. Stage 4 A full thickness of skin and subcutaneous
tissue is lost, exposing muscle or bone.
M1
Code pressure ulcers for the highest stage in the last
32. PRESSURE
7 days (0=None, stages =1, 2, 3, or 4)
ULCERS
M2a
33. OTHER SKIN
Check all that apply in last 7 days
PROBLEMS
a. Burns (second or third degree) (M4b)
OR
LESIONS
b. Open lesions other than ulcers, rashes, cuts (M4c)

Record the number of days injections of any type received
in last 7 days. If none, enter "0".
a. SPECIAL CARE – Check treatments received during the
the last 14 days
a. Chemotherapy (P1aa)
f. Suctioning (P1ai)
b. Dialysis (P1ab)
g. Tracheostomy care (P1aj)
c. IV medication (P1ac)
h. Transfusions (P1ak)
d. Oxygen therapy (P1ag)
i. Ventilator or respirator (P1al)
e. Radiation (P1ah)
b. THERAPIES – Record the number of days and total minutes
each of the following therapies was administered (for at
least 15 minutes a day) in the last 7 calendar days.
Note: Count only therapies provided after admission for
extended care swing bed services.

Weight loss - 5% or more in last 30 days or 10% or
more in the last 180 days
0. No

c. Evening

b. Afternoon

Medicare

State

T3
44. HIPPS Code
45. SIGNATURE

a. Name/Signature of RN Coordinating Assessment

M5 h. Application of ointments/medications (other than to feet)
35. FOOT
CARE
PROBLEMS

Check all that apply in last 7 days
a. Infection of the foot – e.g., cellulitis, purulent drainage (M6b)

-

b. Open lesions on the foot (M6c)
M6 c. Application of dressings (with or without topical medications) (M6f)

OMB 0938-0872

b. Date RN Assessment Coordinator signed as complete

-

R2
SB-MDS 7/1/02