SNF Resident Assessment MDS Data and Supporting Regulations at 42 CFR 413.337, 413.343 and 424.32, and 483.20

Resident Identifier
OTHER
CURRENT
DIAGNOSES
AND ICD-9
CODES
J1. PROBLEM
CONDITIONS

Numeric Identifier

I3.

M2.
a.

•
•

b.

a. Pressure ulcer—any lesion caused by pressure resulting in
damage of underlying tissue
b. Stasis ulcer—open lesion caused by poor circulation in the lower
extremities

(Check all problems present in last 7 days unless other time frame is
indicated)
OTHER
INDICATORS OF FLUID
STATUS
e. Delusions
g. Edema
a. Weight gain or loss of 3 or
more pounds within a 7h. Fever
day period
i. Hallucinations
b. Inability to lie flat due to
j. Internal bleeding
shortness of breath
k. Recurrent lung aspirations in
c. Dehydrated; output
last 90 days
exceeds input
l. Shortness of breath
d. Insufficient fluid; did NOT
n. Unsteady gait
consume all/almost all
o. Vomiting
liquids provided during last
3 days

M3. HISTORY OF
RESOLVED
ULCERS
M4. OTHER SKIN
PROBLEMS
OR LESIONS
PRESENT
(Check all that
apply during
last 7 days)

(Code the highest level of pain present in the last 7 days)
PAIN
SYMPTOMS a. FREQUENCY with which
b. INTENSITY of pain
resident complains or
1. Mild pain
shows evidence of pain
2. Moderate pain
0. No pain (skip to J4)
3. Times when pain is horrible
1. Pain less than daily
or excruciating
2. Pain daily
c. Hip fracture in last 180 days
J4. ACCIDENTS (Check all that apply)
a. Fell in past 30 days
d. Other fracture in last 180
days
b. Fell in past 31-180 days

J2.

e. NONE OF ABOVE
J5. STABILITY a. Conditions/diseases make resident's cognitive, ADL, mood or
behavior patterns unstable—(fluctuating, precarious, or deteriorating)
OF
CONDITIONS
b. Resident experiencing an acute episode or a flare-up of a recurrent
or chronic problem

a. HT (in.)

WEIGHT
CHANGE

0. No
1. Yes
(Check all that apply in last 7 days)
NUTRITIONAL
a. Parenteral/IV
APPROACHES
b. Feeding tube

SKIN
TREATMENTS
(Check all that
apply during
last 7 days)

Resident had an ulcer that was resolved or cured in LAST 90 DAYS
0. No
1. Yes
a. Abrasions, bruises
b. Burns (second or third degree)
c. Open lesions other than ulcers, rashes, cuts (e.g., cancer lesions)
d. Rashes—e.g., intertrigo, eczema, drug rash, heat rash, herpes
zoster
e. Skin desensitized to pain or pressure
f. Skin tears or cuts (other than surgery)
g. Surgical wounds
h. NONE OF ABOVE
a. Pressure relieving device(s) for chair
b. Pressure relieving device(s) for bed
c. Turning/repositioning program
d. Nutrition or hydration intervention to manage skin problems
e. Ulcer care
f. Surgical wound care
g. Application of dressings (with or without topical medications) other
than to feet
h. Application of ointments/medications (other than to feet)
i. Other preventative or protective skin care (other than to feet)
j. NONE OF ABOVE

N1.

a. Resident has one or more foot problems—e.g., corns, callouses,
FOOT
bunions, hammer toes, overlapping toes, pain, structural problems
PROBLEMS
AND CARE b. Infection of the foot—e.g., cellulitis, purulent drainage
(Check all that c. Open lesions on the foot
apply during d. Nails/calluses trimmed during last 90 days
last 7 days)
e. Received preventative or protective foot care (e.g., used special
shoes, inserts, pads, toe separators)

TIME
AWAKE

b. WT (lb.)

a. Weight loss—5 % or more in last 30 days; or 10 % or more in last
180 days

f. Application of dressings (with or without topical medications)
g. NONE OF ABOVE
(Check appropriate time periods over last 7 days)
Resident awake all or most of time (i.e., naps no more than one hour
per time period) in the:
a. Morning
c. Evening
b. Afternoon
d. NONE OF ABOVE

(If resident is comatose, skip to Section O)

0. No
1. Yes
b. Weight gain—5 % or more in last 30 days; or 10 % or more in last
180 days
K5.

M5.

M6.

c. End-stage disease, 6 or fewer months to live
d. NONE OF ABOVE
a. Chewing problem
ORAL
K1.
PROBLEMS b. Swallowing problem
K2.
HEIGHT
Record (a.) height in inches and (b.) weight in pounds. Base weight on most
recent measure in last 30 days; measure weight consistently in accord with
AND
standard facility practice—e.g., in a.m. after voiding, before meal, with shoes
WEIGHT
off, and in nightclothes
K3.

TYPE OF
ULCER

(For each type of ulcer, code for the highest stage in12the last 7 days using
scale in item M1—i.e., 0=none; stages 1, 2, 3, 4)

N2.

AVERAGE
TIME
INVOLVED IN
ACTIVITIES
O1. NUMBER OF
MEDICATIONS

h. On a planned weight
change program

(When awake and not receiving treatments or ADL care)
0. Most—more than 2/3 of time
2. Little—less than 1/3 of time
1. Some—from 1/3 to 2/3 of time
3. None
(Record the number of different medications used in the last 7 days; enter
"0" if none used)

O3. INJECTIONS (Record the number of DAYS injections of any type received during the
last 7 days; enter "0" if none used)
O4.

b. Code the average fluid intake per day by IV or tube in last 7 days
0. None
3. 1001 to 1500 cc/day
1. 1 to 500 cc/day
4. 1501 to 2000 cc/day
2. 501 to 1000 cc/day
5. 2001 or more cc/day
M1. ULCERS (Record the number of ulcers at each ulcer stage—regardless of
cause. If none present at a stage, record "0" (zero). Code all that apply
(Due to any during last 7 days. Code 9 = 9 or more.) [Requires full body exam.]
cause)
a. Stage 1. A persistent area of skin redness (without a break in the
skin) that
12 does not disappear when pressure is relieved.

P1.

Number
at Stage

K6. PARENTERAL (Skip to Section M if neither 5a nor 5b is checked)
OR ENTERAL a. Code the proportion of total calories the resident received through
INTAKE
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%

DAYS
RECEIVED
THE
FOLLOWING
MEDICATION

(Record the number of DAYS during last 7 days; enter "0" if not used.
Note—enter "1" for long-acting meds used less than weekly)
a. Antipsychotic
b. Antianxiety
c. Antidepressant

d. Hypnotic
e. Diuretic

SPECIAL a. SPECIAL CARE—Check treatments or programs received
during the last 14 days
TREATMENTS,
PROCETREATMENTS
PROGRAMS
DURES, AND
PROGRAMS a. Chemotherapy
m. Alcohol/drug treatment
b. Dialysis
c. IV medication
d. Intake/output

program
n. Alzheimer’s/dementia special
care unit

b. Stage 2. A partial thickness loss of skin layers that presents
clinically as an abrasion, blister, or shallow crater.

e. Monitoring acute medical
condition

o. Hospice care

c. Stage 3. A full thickness of skin is lost, exposing the subcutaneous
tissues - presents as a deep crater with or without
undermining adjacent tissue.

f. Ostomy care

q. Respite care
r. Training in skills required to
return to the community
(e.g., taking medications,
house work, shopping,
transportation, ADLs)

12

d. Stage 4. A full thickness of skin and subcutaneous tissue is lost,
exposing muscle or bone.
12

g. Oxygen therapy
h. Radiation
i. Suctioning

p. Pediatric unit

j. Tracheostomy care
k. Transfusions

s. NONE OF THE ABOVE

l. Ventilator or respirator
12

OMB 0938-0739 expiration date 12/31/2011

MDS 2.0 PPS July 2002