Form CMS-R-250 MDS Medicare PPS Assessment Form

MDS MEDICARE PPS ASSESSMENT FORM
(REVISED OCTOBER 2006)
AB5. RESIDENTIAL
HISTORY
5 YEARS
PRIOR TO
ENTRY

Numeric Identifier

(Check all settings resident lived in during 5 years prior to date of entry.)
a. Prior stay at this nursing home
b. Stay in other nursing home
c. Other residential facility—board and care home, assisted living,
group home
d. MH/psychiatric setting
e. MR/DD setting
f. NONE OF ABOVE

A1. RESIDENT
NAME
a. (First)
A2.

A3.

ASSESS- a. Last day of MDS observation period
MENT
REFERENCE
DATE
Day
Month

A4a. DATE OF
REENTRY

A5.
A6.

c. (Last)

b. (Middle Initial)

d. (Jr/Sr)

ROOM
NUMBER

MARITAL
STATUS
MEDICAL
RECORD
NO.

C4.

MAKING
SELF
UNDERSTOOD

Day
3. Widowed
4. Separated

0. ADEQUATE—sees fine detail, including regular print in
newspapers/books
1. IMPAIRED—sees large print, but not regular print in newspapers/
books
2. MODERATELY IMPAIRED—limited vision; not able to see
newspaper headlines, but can identify objects
3. HIGHLY IMPAIRED—object identification in question, but eyes
appear to follow objects
4. SEVERELY IMPAIRED—no vision or sees only light, colors, or
shapes; eyes do not appear to follow objects

Year

Year
5. Divorced

A10. ADVANCED (For those items with supporting documentation in the medical
DIRECTIVES record, check all that apply)
b. Do not resuscitate

E1. INDICATORS
OF
DEPRESSION,
ANXIETY,
SAD MOOD

c. Do not hospitalize

MEMORY

b. Repetitive questions—e.g.,
"Where do I go; What do I
do?"
c. Repetitive verbalizations—
e.g., calling out for help,
("God help me")
d. Persistent anger with self
or others—e.g., easily
annoyed, anger at
placement in nursing
home; anger at care
received
e. Self deprecation—e.g., "I
am nothing; I am of no use
to anyone"

(Code for behavior in the last 7 days.) [Note: Accurate assessment
requires conversations with staff and family who have direct knowledge
of resident's behavior over this time].
0. Behavior not present
1. Behavior present, not of recent onset
2. Behavior present, over last 7 days appears different from resident's usual
functioning (e.g., new onset or worsening)

f. Expressions of what
appear to be unrealistic
fears—e.g., fear of being
abandoned, left alone,
being with others
g. Recurrent statements that
something terrible is about
to happen—e.g., believes
he or she is about to die,
have a heart attack

a. EASILY DISTRACTED—(e.g., difficulty paying attention; gets
sidetracked)
b.PERIODS OF ALTERED PERCEPTION OR AWARENESS OF
SURROUNDINGS—(e.g., moves lips or talks to someone not
present; believes he/she is somewhere else; confuses night and
day)
c. EPISODES OF DISORGANIZED SPEECH—(e.g., speech is
incoherent, nonsensical, irrelevant, or rambling from subject to
subject; loses train of thought)

1. Indicator of this type exhibited up to five days a week
2. Indicator of this type exhibited daily or almost daily (6, 7 days a week)

a. Resident made negative
statements—e.g., "Nothing
matters; Would rather be
dead; What's the use;
Regrets having lived so
long; Let me die"

(Recall of what was learned or known)

a. Short-term memory OK—seems/appears to recall after 5 minutes
0. Memory OK
1. Memory problem
b. Long-term memory OK—seems/appears to recall long past
0. Memory OK
1. Memory problem
B3. MEMORY/ (Check all that resident was normally able to recall during last 7
days)
RECALL
ABILITY
d. That he/she is in a nursing home
a. Current season
b. Location of own room
e. NONE OF ABOVE are recalled
c. Staff names/faces
B4. COGNITIVE (Made decisions regarding tasks of daily life)
SKILLS FOR 0. INDEPENDENT—decisions consistent/reasonable
DAILY
DECISION- 1. MODIFIED INDEPENDENCE—some difficulty in new situations
only
MAKING
2. MODERATELY IMPAIRED—decisions poor; cues/supervision
required
3. SEVERELY IMPAIRED—never/rarely made decisions
B5. INDICATORS
OF
DELIRIUM—
PERIODIC
DISORDERED
THINKING/
AWARENESS

(Code for indicators observed in last 30 days, irrespective of the assumed cause)
0. Indicator not exhibited in last 30 days

VERBAL EXPRESSIONS
OF DISTRESS

B1. COMATOSE (Persistent vegetative state/no discernible consciousness)
0. No
1. Yes
(If Yes, skip to Section G)
B2.

0. UNDERSTOOD
1. USUALLY UNDERSTOOD—difficulty finding words or finishing
thoughts
2. SOMETIMES UNDERSTOOD—ability is limited to making
concrete requests
3. RARELY/NEVER UNDERSTOOD

C6. ABILITY TO (Understanding verbal information content—however able)
UNDER0.UNDERSTANDS
STAND
1.USUALLY UNDERSTANDS—may miss some part/intent of
OTHERS
message
2.SOMETIMES UNDERSTANDS—responds adequately to simple,
direct communication
3.RARELY/NEVER UNDERSTANDS
(Ability to see in adequate light and with glasses if used)
D1. VISION

Date of reentry from most recent temporary discharge to a hospital in
last 90 days (or since last assessment or admission if less than 90
days)

Month
1. Never married
2. Married

(Expressing information content—however able)

h. Repetitive health
complaints—e.g.,
persistently seeks medical
attention, obsessive
concern with body functions
i. Repetitive anxious
complaints/concerns
(non-health related) e.g.,
persistently seeks attention/
reassurance regarding
schedules, meals, laundry,
clothing, relationship issues
SLEEP-CYCLE ISSUES
j. Unpleasant mood in
morning
k. Insomnia/change in usual
sleep pattern
SAD, APATHETIC, ANXIOUS
APPEARANCE
l. Sad, pained, worried facial
expressions—e.g.,
furrowed brows
m. Crying, tearfulness
n. Repetitive physical
movements—e.g., pacing,
hand wringing, restlessness,
fidgeting, picking
LOSS OF INTEREST
o. Withdrawal from activities
of interest—e.g., no interest
in long standing activities or
being with family/friends
p. Reduced social interaction

E2.

MOOD
PERSISTENCE

One or more indicators of depressed, sad or anxious mood were
not easily altered by attempts to "cheer up", console, or reassure
the resident over last 7 days
0. No mood
1. Indicators present,
2.Indicators present,
indicators
easily altered
not easily altered

d.PERIODS OF RESTLESSNESS—(e.g., fidgeting or picking at skin,
clothing, napkins, etc; frequent position changes; repetitive physical
movements or calling out)
e.PERIODS OF LETHARGY—(e.g., sluggishness; staring into
space; difficult to arouse; little body movement)
f. MENTAL FUNCTION VARIES OVER THE COURSE OF THE
DAY—(e.g., sometimes better, sometimes worse; behaviors
sometimes present, sometimes not)
OMB 0938-0739 expiration date 12/31/2011

MDS 2.0 PPS July 2002