MPAF Data and Supporting Regulations in 42 CFR Sections 413.337, 413.343, 424.32 and 483.20

Resident Identifier

Numeric Identifier

E4. BEHAVIORAL (A) Behavioral symptom frequency in last 7 days
SYMPTOMS
0. Behavior not exhibited in last 7 days
1. Behavior of this type occurred 1 to 3 days in last 7 days
2. Behavior of this type occurred 4 to 6 days, but less than daily
3. Behavior of this type occurred daily
(B) Behavioral symptom alterability in last 7 days
0. Behavior not present OR behavior was easily altered
1. Behavior was not easily altered

(A) (B)

a. WANDERING (moved with no rational purpose, seemingly
oblivious to needs or safety)
b. VERBALLY ABUSIVE BEHAVIORAL SYMPTOMS (others
were threatened, screamed at, cursed at)
c. PHYSICALLY ABUSIVE BEHAVIORAL SYMPTOMS (others
were hit, shoved, scratched, sexually abused)
d. SOCIALLY INAPPROPRIATE/DISRUPTIVE BEHAVIORAL
SYMPTOMS (made disruptive sounds, noisiness, screaming,
self-abusive acts, sexual behavior or disrobing in public,
smeared/threw food/feces, hoarding, rummaged through others'
belongings)
e. RESISTS CARE (resisted taking medications/injections, ADL
assistance, or eating)
G1. (A) ADL SELF-PERFORMANCE—(Code for resident's PERFORMANCE OVER ALL
SHIFTS during last 7 days—Not including setup)
0. INDEPENDENT—No help or oversight —OR— Help/oversight provided only 1 or 2
times during last 7 days

G6. MODES OF (Check all that apply during last 7 days)
TRANSFER a. Bedfast all or most of time

1. SUPERVISION—Oversight, encouragement or cueing provided 3 or more times during
last 7 days —OR— Supervision (3 or more times) plus physical assistance provided only
1 or 2 times during last 7 days
2. LIMITED ASSISTANCE—Resident highly involved in activity; received physical help
in guided maneuvering of limbs or other nonweight bearing assistance 3 or more times
—OR—More help provided only 1 or 2 times during last 7 days

0. CONTINENT—Complete control [includes use of indwelling urinary catheter or ostomy
device that does not leak urine or stool]
1. USUALLY CONTINENT—BLADDER, incontinent episodes once a week or less;
BOWEL, less than weekly

4. TOTAL DEPENDENCE—Full staff performance of activity during entire 7 days

2. OCCASIONALLY INCONTINENT—BLADDER, 2 or more times a week but not daily;
BOWEL, once a week

BED
MOBILITY

3. FREQUENTLY INCONTINENT—BLADDER, tended to be incontinent daily, but some
control present (e.g., on day shift); BOWEL, 2-3 times a week
SUPPORT

(A) (B)

SELF-PERF

(B) ADL SUPPORT PROVIDED—(Code for MOST SUPPORT PROVIDED OVER ALL
SHIFTS during last 7 days; code regardless of resident's self-performance
classification)
0. No setup or physical help from staff
1. Setup help only
2. One person physical assist
8. ADL activity itself did not
3. Two+ persons physical assist
occur during entire 7days
How resident moves to and from lying position, turns side to side,
and positions body while in bed

b. TRANSFER How resident moves between surfaces—to/from: bed, chair,
wheelchair, standing position (EXCLUDE to/from bath/toilet)
WALK IN
ROOM
d. WALK IN
CORRIDOR
e. LOCOMOTION
ON UNIT
f. LOCOMOTION
OFF UNIT
c.

How resident walks between locations in his/her room
How resident walks in corridor on unit

How resident moves between locations in his/her room and
adjacent corridor on same floor. If in wheelchair, self-sufficiency
once in chair
How resident moves to and returns from off unit locations (e.g.,
areas set aside for dining, activities, or treatments). If facility has
only one floor, how resident moves to and from distant areas on
the floor. If in wheelchair, self-sufficiency once in chair
g. DRESSING How resident puts on, fastens, and takes off all items of clothing,
including donning/removing prosthesis
h.

b. Bed rails used for bed
mobility or transfer
Some or all of ADL activities were broken into subtasks during last 7
G7.
TASK
SEGMENTA- days so that resident could perform them
TION
0. No
1. Yes
H1. CONTINENCE SELF-CONTROL CATEGORIES
(Code for resident's PERFORMANCE OVER ALL SHIFTS)

3. EXTENSIVE ASSISTANCE—While resident performed part of activity, over last 7-day
period, help of following type(s) provided 3 or more times:
— Weight-bearing support
— Full staff performance during part (but not all) of last 7 days
8. ACTIVITY DID NOT OCCUR during entire 7 days

a.

(Code for ability during test in the last 7 days)
G3.
0. Maintained position as required in test
1. Unsteady, but able to rebalance self without physical support
(see training 2. Partial physical support during test;
manual)
or stands (sits) but does not follow directions for test
3. Not able to attempt test without physical help
a. Balance while standing
b. Balance while sitting—position, trunk control
G4. FUNCTIONAL (Code for limitations during last 7 days that interfered with daily functions or
LIMITATION placed residents at risk of injury)
(B) VOLUNTARY MOVEMENT
IN RANGE OF (A) RANGE OF MOTION
0. No limitation
0. No loss
MOTION
1. Limitation on one side
1. Partial loss
(A) (B)
2. Limitation on both sides
2. Full loss
a. Neck
b. Arm—Including shoulder or elbow
c. Hand—Including wrist or fingers
d. Leg—Including hip or knee
e. Foot—Including ankle or toes
f. Other limitation or loss
G5. MODES OF (Check if applied during last 7 days)
LOCOMOb. Wheeled self
TION
TEST FOR
BALANCE

EATING

For Section I : check only those diseases that have a relationship to current ADL status,
cognitive status, mood and behavior status, medical treatments, nursing monitoring, or risk of
death. (Do not list inactive diagnoses)
I1. DISEASES

v. Hemiplegia/Hemiparesis
w. Multiple sclerosis

j. Peripheral vascular
disease
m. Hip fracture

i. TOILET USE How resident uses the toilet room (or commode, bedpan, urinal);
transfer on/off toilet, cleanses, changes pad, manages ostomy or
catheter, adjusts clothes

OMB 0938-0739 expiration date 12/31/2011

a. Diabetes melitus
d. Arteriosclerotic heart
disease (ASHD)
f. Congestive heart failure

How resident eats and drinks (regardless of skill). Includes intake of
nourishment by other means (e.g., tube feeding, total parenteral
nutrition)

j. PERSONAL How resident maintains personal hygiene, including combing hair,
HYGIENE brushing teeth, shaving, applying makeup, washing/drying face,
hands, and perineum (EXCLUDE baths and showers)
G2. BATHING How resident takes full-body bath/shower, sponge bath, and
transfers in/out of tub/shower (EXCLUDE washing of back and
hair.) Code for most dependent in self-performance.
(A) BATHING SELF PERFORMANCE codes appear below
0. Independent—No help provided
1. Supervision—Oversight help only
2. Physical help limited to transfer only
3. Physical help in part of bathing activity
4. Total dependence
8. Activity itself did not occur during entire 7 days

4. INCONTINENT—Had inadequate control BLADDER, multiple daily episodes;
BOWEL, all (or almost all) of the time
a.
BOWEL
Control of bowel movement, with appliance or bowel continence
CONTIprograms, if employed
NENCE
b. BLADDER Control of urinary bladder function (if dribbles, volume insufficient to
soak through underpants), with appliances (e.g., foley) or continence
CONTIprograms, if employed
NENCE
H2.
BOWEL
c. Diarrhea
ELIMINATION
PATTERN d. Fecal impaction
H3. APPLIANCES a. Any scheduled toileting plan
d. Indwelling catheter
AND
i. Ostomy present
b. Bladder retraining program
PROGRAMS
c. External (condom) catheter

z. Quadriplegia
ee. Depression
ff. Manic depressive (bipolar
disease)

r. Aphasia

gg. Schizophrenia

s. Cerebral palsy

hh. Asthma

t. Cerebrovascular accident
(stroke)

(A)

x. Paraplegia

ii. Emphysema/COPD

I2. INFECTIONS (If none apply, CHECK the NONE OF ABOVE box)
g. Septicemia
a. Antibiotic resitant infection
(e.g. Methicillin resistant
h. Sexually transmitted
staph)
diseases
b. Clostridium difficile (c. diff.)
i. Tuberculosis
c. Conjunctivitis
j. Urinary tract infection in
last 30 days
d. HIV infection
k.
Viral hepatitis
e. Pneumonia
l. Wound infection
f. Respiratory infection
m. NONE OF ABOVE
MDS 2.0 PPS July 2002