Form CMS-10387 Nursing Home and Swing Bed OMRA (NO/SO) Item Set

**DRAFT**

Resident

Identifier

Date

MINIMUM DATA SET (MDS) - Version 3.0

RESIDENT ASSESSMENT AND CARE SCREENING

**DRAFT** Nursing Home and Swing Bed OMRA (NO/SO) Item Set **DRAFT**
Section A.

Identification Information.

A0100. Facility Provider Numbers.
A. National Provider Identifier (NPI):

B. CMS Certification Number (CCN):

C. State Provider Number:

A0200. Type of Provider.
Enter Code

Type of provider.
1. Nursing home (SNF/NF).
2. Swing Bed.

A0310. Type of Assessment.
Enter Code

Enter Code

Enter Code

Enter Code

A. Federal OBRA Reason for Assessment.
01. Admission assessment (required by day 14).
02. Quarterly review assessment.
03. Annual assessment.
04. Significant change in status assessment.
05. Significant correction to prior comprehensive assessment.
06. Significant correction to prior quarterly assessment.
99. Not OBRA required assessment.
B. PPS Assessment.
PPS Scheduled Assessments for a Medicare Part A Stay.
01. 5-day scheduled assessment.
02. 14-day scheduled assessment.
03. 30-day scheduled assessment.
04. 60-day scheduled assessment.
05. 90-day scheduled assessment.
06. Readmission/return assessment.
PPS Unscheduled Assessments for a Medicare Part A Stay.
07. Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment).
Not PPS Assessment.
99. Not PPS assessment.
C. PPS Other Medicare Required Assessment - OMRA.
0. No...
1. Start of therapy assessment.
2. End of therapy assessment.
3. Both Start and End of therapy assessment.
4. Change of therapy assessment.
D. Is this a Swing Bed clinical change assessment? Complete only if A0200 = 2.
0. No...
1. Yes.

A0310 continued on next page.

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Resident

Section A.

Identifier

Date

Identification Information.

A0310. Type of Assessment - Continued.
Enter Code

Enter Code

E. Is this assessment the first assessment (OBRA, PPS, or Discharge) since the most recent admission?
0. No...
1. Yes.
F. Entry/discharge reporting
01. Entry record.
10. Discharge assessment-return not anticipated.
11. Discharge assessment-return anticipated.
12. Death in facility record.
99. Not entry/discharge record.

A0410. Submission Requirement.
Enter Code

1. Neither federal nor state required submission.
2. State but not federal required submission (FOR NURSING HOMES ONLY).
3. Federal required submission.

A0500. Legal Name of Resident.
A. First name:

B. Middle initial:

C. Last name:

D. Suffix:

A0600. Social Security and Medicare Numbers.
A. Social Security Number:

_

_

B. Medicare number (or comparable railroad insurance number):

A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid recipient.

A0800. Gender.
Enter Code

1. Male.
2. Female.

A0900. Birth Date.
_
Month

_
Day

Year

A1000. Race/Ethnicity.
Check all that apply.
A. American Indian or Alaska Native.
B. Asian.
C. Black or African American.
D. Hispanic or Latino.
E. Native Hawaiian or Other Pacific Islander.
F. White.

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Resident

Section A.

Identifier

Date

Identification Information.

A1100. Language.
Enter Code

A. Does the resident need or want an interpreter to communicate with a doctor or health care staff?
0. No...
Specify in A1100B, Preferred language.
1. Yes
9. Unable to determine.
B. Preferred language:

A1200. Marital Status.
Enter Code

Never married.
Married.
Widowed.
Separated.
Divorced.

1.
2.
3.
4.
5.

A1300. Optional Resident Items.
A. Medical record number:

B. Room number:

C. Name by which resident prefers to be addressed:

D. Lifetime occupation(s) - put "/" between two occupations:

A1600. Entry Date (date of this admission/reentry into the facility).
_
Month

_
Day

Year

A1700. Type of Entry.
Enter Code

1. Admission.
2. Reentry.

A1800. Entered From.
Enter Code

01.
02.
03.
04.
05.
06.
07.
99.

Community (private home/apt., board/care, assisted living, group home).
Another nursing home or swing bed.
Acute hospital.
Psychiatric hospital.
Inpatient rehabilitation facility.
MR/DD facility.
Hospice.
Other.

A2000. Discharge Date.
Complete only if A0310F = 10, 11, or 12
_
Month

_
Day

Year

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Resident

Section A.

Identifier

Date

Identification Information.

A2100. Discharge Status.
Complete only if A0310F = 10, 11, or 12
Enter Code

01.
02.
03.
04.
05.
06.
07.
08.
99.

Community (private home/apt., board/care, assisted living, group home).
Another nursing home or swing bed.
Acute hospital.
Psychiatric hospital.
Inpatient rehabilitation facility.
MR/DD facility.
Hospice.
Deceased.
Other.

A2300. Assessment Reference Date.
Observation end date:

_
Month

_
Day

Year

A2400. Medicare Stay.
Enter Code

A. Has the resident had a Medicare-covered stay since the most recent entry?
0. No
Skip to B0100, Comatose.
1. Yes
Continue to A2400B, Start date of most recent Medicare stay.
B. Start date of most recent Medicare stay:

_
Month

_
Day

Year

C. End date of most recent Medicare stay - Enter dashes if stay is ongoing:

_

_
Month

Day

Year

Look back period for all items is 7 days unless another time frame is indicated.
Section B.

Hearing, Speech, and Vision.

B0100. Comatose.
Enter Code

Persistent vegetative state/no discernible consciousness.
0. No
Continue to B0700, Makes Self Understood.
1. Yes
Skip to G0110, Activities of Daily Living (ADL) Assistance.

B0700. Makes Self Understood.
Enter Code

Ability to express ideas and wants, consider both verbal and non-verbal expression.
0. Understood.
1. Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time.
2. Sometimes understood - ability is limited to making concrete requests.
3. Rarely/never understood.

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Resident

Section C.

Identifier

Date

Cognitive Patterns.

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
Attempt to conduct interview with all residents.
Enter Code

0. No (resident is rarely/never understood)
Skip to and complete C0700-C1000, Staff Assessment for Mental Status.
1. Yes
Continue to C0200, Repetition of Three Words.

Brief Interview for Mental Status (BIMS).
C0200. Repetition of Three Words.
Ask resident: “I am going to say three words for you to remember. Please repeat the words after I have said all three.
The words are: sock, blue, and bed. Now tell me the three words.”
Enter Code

Number of words repeated after first attempt.
0. None.
1. One.
2. Two.
3. Three.
After the resident's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece
of furniture"). You may repeat the words up to two more times.

C0300. Temporal Orientation (orientation to year, month, and day).
Ask resident: "Please tell me what year it is right now."
Enter Code

Enter Code

Enter Code

A. Able to report correct year.
0. Missed by > 5 years or no answer.
1. Missed by 2-5 years.
2. Missed by 1 year.
3. Correct.
Ask resident: "What month are we in right now?"
B. Able to report correct month.
0. Missed by > 1 month or no answer.
1. Missed by 6 days to 1 month.
2. Accurate within 5 days.
Ask resident: "What day of the week is today?"
C. Able to report correct day of the week.
0. Incorrect or no answer.
1. Correct.

C0400. Recall.

Enter Code

Enter Code

Enter Code

Ask resident: "Let's go back to an earlier question. What were those three words that I asked you to repeat?"
If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.
A. Able to recall "sock".
0. No - could not recall.
1. Yes, after cueing ("something to wear").
2. Yes, no cue required.
B. Able to recall "blue".
0. No - could not recall.
1. Yes, after cueing ("a color").
2. Yes, no cue required.
C. Able to recall "bed".
0. No - could not recall.
1. Yes, after cueing ("a piece of furniture").
2. Yes, no cue required.

C0500. Summary Score.
Enter Score

Add scores for questions C0200-C0400 and fill in total score (00-15).
Enter 99 if the resident was unable to complete the interview.

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Resident

Section C.

Identifier

Date

Cognitive Patterns.

C0600. Should the Staff Assessment for Mental Status (C0700 - C1000) be Conducted?
Enter Code

0. No (resident was able to complete interview )
Skip to D0100, Should Resident Mood Interview be Conducted?.
1. Yes (resident was unable to complete interview)
Continue to C0700, Short-term Memory OK.

Staff Assessment for Mental Status.
Do not conduct if Brief Interview for Mental Status (C0200-C0500) was completed.

C0700. Short-term Memory OK.
Enter Code

Seems or appears to recall after 5 minutes.
0. Memory OK.
1. Memory problem.

C1000. Cognitive Skills for Daily Decision Making.
Enter Code

Made decisions regarding tasks of daily life.
0. Independent - decisions consistent/reasonable.
1. Modified independence - some difficulty in new situations only.
2. Moderately impaired - decisions poor; cues/supervision required.
3. Severely impaired - never/rarely made decisions.

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Resident

Section D.

Identifier

Date

Mood.

D0100. Should Resident Mood Interview be Conducted? - Attempt to conduct interview with all residents.
Enter Code

0. No (resident is rarely/never understood)
Skip to and complete D0500-D0600, Staff Assessment of Resident Mood
(PHQ-9-OV).
1. Yes
Continue to D0200, Resident Mood Interview (PHQ-9©).

D0200. Resident Mood Interview (PHQ-9©).
Say to resident: "Over the last 2 weeks, have you been bothered by any of the following problems?"
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the resident: "About how often have you been bothered by this?"
Read and show the resident a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
1. Symptom Presence.
0. No (enter 0 in column 2).
1. Yes (enter 0-3 in column 2).
9. No response (leave column 2
blank).

2. Symptom Frequency.
0. Never or 1 day.
1. 2-6 days (several days).
2. 7-11 days (half or more of the days).
3. 12-14 days (nearly every day).

1.
Symptom
Presence.

2.
Symptom
Frequency.

Enter Scores in Boxes

A. Little interest or pleasure in doing things.
B. Feeling down, depressed, or hopeless.
C. Trouble falling or staying asleep, or sleeping too much.
D. Feeling tired or having little energy.
E. Poor appetite or overeating.
F. Feeling bad about yourself - or that you are a failure or have let yourself or your family
down.
G. Trouble concentrating on things, such as reading the newspaper or watching television.
H. Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual.
I.

Thoughts that you would be better off dead, or of hurting yourself in some way.

D0300. Total Severity Score.
Enter Score

Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more items).

D0350. Safety Notification - Complete only if D0200I1 = 1 indicating possibility of resident self harm.
Enter Code

Was responsible staff or provider informed that there is a potential for resident self harm?
0. No...
1. Yes.

Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.

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Resident

Section D.

Identifier

Date

Mood.

D0500. Staff Assessment of Resident Mood (PHQ-9-OV*).

Do not conduct if Resident Mood Interview (D0200-D0300) was completed.
Over the last 2 weeks, did the resident have any of the following problems or behaviors?
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
Then move to column 2, Symptom Frequency, and indicate symptom frequency.
1. Symptom Presence.
0. No (enter 0 in column 2).
1. Yes (enter 0-3 in column 2).

2. Symptom Frequency.
0. Never or 1 day.
1. 2-6 days (several days).
2. 7-11 days (half or more of the days).
3. 12-14 days (nearly every day).

1.
Symptom
Presence.

2.
Symptom
Frequency.

Enter Scores in Boxes

A. Little interest or pleasure in doing things.
B. Feeling or appearing down, depressed, or hopeless.
C. Trouble falling or staying asleep, or sleeping too much.
D. Feeling tired or having little energy.
E. Poor appetite or overeating.
F. Indicating that s/he feels bad about self, is a failure, or has let self or family down.
G. Trouble concentrating on things, such as reading the newspaper or watching television.
H. Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety
or restless that s/he has been moving around a lot more than usual.
I.

States that life isn't worth living, wishes for death, or attempts to harm self.

J.

Being short-tempered, easily annoyed.

D0600. Total Severity Score.
Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 30.
Enter Score

D0650. Safety Notification - Complete only if D0500I1 = 1 indicating possibility of resident self harm.
Enter Code

Was responsible staff or provider informed that there is a potential for resident self harm?
0. No...
1. Yes.

* Copyright © Pfizer Inc. All rights reserved.
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Resident

Section E.

Identifier

Date

Behavior.

E0100. Psychosis.
Check all that apply
A. Hallucinations (perceptual experiences in the absence of real external sensory stimuli).
B. Delusions (misconceptions or beliefs that are firmly held, contrary to reality).
Z. None of the above.

Behavioral Symptoms.
E0200. Behavioral Symptom - Presence & Frequency.
Note presence of symptoms and their frequency.
Enter Codes in Boxes.
Coding:
0. Behavior not exhibited.
1. Behavior of this type occurred 1 to 3 days.
2. Behavior of this type occurred 4 to 6 days,
but less than daily.
3. Behavior of this type occurred daily.

A.

Physical behavioral symptoms directed toward others (e.g., hitting,
kicking, pushing, scratching, grabbing, abusing others sexually).

B.

Verbal behavioral symptoms directed toward others (e.g., threatening
others, screaming at others, cursing at others).

C.

Other behavioral symptoms not directed toward others (e.g., physical
symptoms such as hitting or scratching self, pacing, rummaging, public
sexual acts, disrobing in public, throwing or smearing food or bodily wastes,
or verbal/vocal symptoms like screaming, disruptive sounds).

E0800. Rejection of Care - Presence & Frequency.

Enter Code

Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the
resident's goals for health and well-being? Do not include behaviors that have already been addressed (e.g., by discussion or care
planning with the resident or family), and/or determined to be consistent with resident values, preferences, or goals.
0. Behavior not exhibited.
1. Behavior of this type occurred 1 to 3 days.
2. Behavior of this type occurred 4 to 6 days, but less than daily.
3. Behavior of this type occurred daily.

E0900. Wandering - Presence & Frequency.
Enter Code

Has the resident wandered?
0. Behavior not exhibited
1. Behavior of this type occurred 1 to 3 days.
2. Behavior of this type occurred 4 to 6 days, but less than daily.
3. Behavior of this type occurred daily.

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Resident

Section G.

Identifier

Date

Functional Status.

G0110. Activities of Daily Living (ADL) Assistance.
Refer to the ADL flow chart in the RAI manual to facilitate accurate coding.
Instructions for Rule of 3
￭ When an activity occurs three times at any one given level, code that level.
￭ When an activity occurs three times at multiple levels, code the most dependent, exceptions are total dependence (4), activity must require full assist
every time, and activity did not occur (8), activity must not have occurred at all. Example, three times extensive assistance (3) and three times limited
assistance (2), code extensive assistance (3).
￭ When an activity occurs at various levels, but not three times at any given level, apply the following:
￮ When there is a combination of full staff performance, and extensive assistance, code extensive assistance.
￮ When there is a combination of full staff performance, weight bearing assistance and/or non-weight bearing assistance code limited assistance (2).
If none of the above are met, code supervision.
1. ADL Self-Performance.
Code for resident's performance over all shifts - not including setup. If the ADL activity
occurred 3 or more times at various levels of assistance, code the most dependent - except for
total dependence, which requires full staff performance every time.

2. ADL Support Provided.
Code for most support provided over all
shifts; code regardless of resident's selfperformance classification.

Coding:
Activity Occurred 3 or More Times.
0. Independent - no help or staff oversight at any time.
1. Supervision - oversight, encouragement or cueing.
2. Limited assistance - resident highly involved in activity; staff provide guided maneuvering
of limbs or other non-weight-bearing assistance.
3. Extensive assistance - resident involved in activity, staff provide weight-bearing support.
4. Total dependence - full staff performance every time during entire 7-day period.

Coding:
0. No setup or physical help from staff.
1. Setup help only.
2. One person physical assist.
3. Two+ persons physical assist.
8. ADL activity itself did not occur during
entire period.

Activity Occurred 2 or Fewer Times.
7. Activity occurred only once or twice - activity did occur but only once or twice.
8. Activity did not occur - activity (or any part of the ADL) was not performed by resident or
staff at all over the entire 7-day period.

1.
Self-Performance.

2.
Support.

Enter Codes in Boxes

A. Bed mobility - how resident moves to and from lying position, turns side to side, and
positions body while in bed or alternate sleep furniture.
B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair,
standing position (excludes to/from bath/toilet).
H. Eating - how resident eats and drinks, regardless of skill. Do not include eating/drinking
during medication pass. Includes intake of nourishment by other means (e.g., tube feeding,
total parenteral nutrition, IV fluids administered for nutrition or hydration).
I. Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off
toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts
clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag or
ostomy bag.

Section H.

Bladder and Bowel.

H0200. Urinary Toileting Program.
Enter Code

C. Current toileting program or trial - Is a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) currently
being used to manage the resident's urinary continence?
0. No...
1. Yes.

H0500. Bowel Toileting Program.
Enter Code

Is a toileting program currently being used to manage the resident's bowel continence?
0. No...
1. Yes.

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Resident

Section I.

Identifier

Date

Active Diagnoses.

Active Diagnoses in the last 7 days - Check all that apply.

Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.
Infections.
I2000. Pneumonia.
I2100. Septicemia.
Metabolic.
I2900. Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy).
Neurological.
I4400. Cerebral Palsy.
I4900. Hemiplegia or Hemiparesis.
I5100. Quadriplegia.
I5200. Multiple Sclerosis (MS).
I5300. Parkinson's Disease.
Pulmonary.
I6200. Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease (e.g., chronic bronchitis and restrictive lung
diseases such as asbestosis).
I6300. Respiratory Failure

Section J.

Health Conditions.

Other Health Conditions.
J1100. Shortness of Breath (dyspnea).
Check all that apply.
C. Shortness of breath or trouble breathing when lying flat.

J1550. Problem Conditions.
Check all that apply.
A. Fever.
B. Vomiting.

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Section K.

Identifier

Date

Swallowing/Nutritional Status.

K0300. Weight Loss.
Enter Code

Loss of 5% or more in the last month or loss of 10% or more in last 6 months.
0. No or unknown.
1. Yes, on physician-prescribed weight-loss regimen.
2. Yes, not on physician-prescribed weight-loss regimen.

K0500. Nutritional Approaches.
Check all that apply.
A. Parenteral/IV feeding.
B. Feeding tube - nasogastric or abdominal (PEG).

K0700. Percent Intake by Artificial Route - Complete K0700 only if K0500A or K0500B is checked.
Enter Code

Enter Code

A. Proportion of total calories the resident received through parenteral or tube feeding.
1. 25% or less.
2. 26-50%.
3. 51% or more.
B. Average fluid intake per day by IV or tube feeding.
1. 500 cc/day or less.
2. 501 cc/day or more.

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Section M.

Identifier

Date

Skin Conditions.

Report based on highest stage of existing ulcer(s) at its worst; do not "reverse" stage.
M0300. Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Each Stage.

Enter Number

B. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also
present as an intact or open/ruptured blister.
1. Number of Stage 2 pressure ulcers.

Enter Number

C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be
present but does not obscure the depth of tissue loss. May include undermining and tunneling.
1. Number of Stage 3 pressure ulcers.

Enter Number

D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the
wound bed. Often includes undermining and tunneling.
1. Number of Stage 4 pressure ulcers.

Enter Number

F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar.
1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar.

M1030. Number of Venous and Arterial Ulcers.
Enter Number

Enter the total number of venous and arterial ulcers present.

M1040. Other Ulcers, Wounds and Skin Problems.
Check all that apply.
Foot Problems.
A. Infection of the foot (e.g., cellulitis, purulent drainage).
B. Diabetic foot ulcer(s).
C. Other open lesion(s) on the foot.
Other Problems.
D. Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion).
E. Surgical wound(s).
F. Burn(s) (second or third degree).
None of the Above.
Z. None of the above were present.

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Section M.

Identifier

Date

Skin Conditions.

M1200. Skin and Ulcer Treatments.
Check all that apply.
A. Pressure reducing device for chair.
B. Pressure reducing device 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 nonsurgical dressings (with or without topical medications) other than to feet.
H. Applications of ointments/medications other than to feet.
I. Application of dressings to feet (with or without topical medications).
Z. None of the above were provided.

Section N.

Medications.

N0350. Insulin.
Enter Days

A. Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/
reentry if less than 7 days.

Enter Days

B. Orders for insulin - Record the number of days the physician (or authorized assistant or practitioner) changed the resident's
insulin orders during the last 7 days or since admission/reentry if less than 7 days.

Section O.

Special Treatments, Procedures, and Programs.

O0100. Special Treatments, Procedures, and Programs.
Check all of the following treatments, procedures and programs that were performed during the last 14 days.
1. While NOT a Resident.
Performed while NOT a resident of this facility and within the last 14 days. Only check column 1 if
resident entered (admission or reentry) IN THE LAST 14 DAYS. If resident last entered 14 or more days
ago, leave column 1 blank.
2. While a Resident.
Performed while a resident of this facility and within the last 14 days.
Cancer Treatments.

1.
While NOT a
Resident.

2.
While a
Resident.

Check all that apply

A. Chemotherapy.
B. Radiation.
Respiratory Treatments.
C. Oxygen therapy.
E. Tracheostomy care.
F. Ventilator or respirator.
Other.
H. IV medications.
I. Transfusions.
J. Dialysis.
M. Isolation or quarantine for active infectious disease (does not include standard body/fluid
precautions).

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Section O.

**DRAFT**

Identifier

Date

Special Treatments, Procedures, and Programs.

O0400. Therapies.
A. Speech-Language Pathology and Audiology Services.
Enter Number of Minutes

1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually
in the last 7 days.

Enter Number of Minutes

2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident
concurrently with one other resident in the last 7 days.

Enter Number of Minutes

3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group
of residents in the last 7 days.
If the sum of individual, concurrent, and group minutes is zero,

Enter Number of Days

skip to O0400B, Occupational Therapy

4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
5. Therapy start date - record the date the most recent
therapy regimen (since the most recent entry) started.

_
Month

6. Therapy end date - record the date the most recent
therapy regimen (since the most recent entry) ended
- enter dashes if therapy is ongoing.

_
Day

_
Year

Month

_
Day

Year

B. Occupational Therapy.
Enter Number of Minutes

1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually
in the last 7 days.

Enter Number of Minutes

2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident
concurrently with one other resident in the last 7 days.

Enter Number of Minutes

3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group
of residents in the last 7 days.
If the sum of individual, concurrent, and group minutes is zero,

Enter Number of Days

skip to O0400C, Physical Therapy

4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
5. Therapy start date - record the date the most recent
therapy regimen (since the most recent entry) started.

_
Month

6. Therapy end date - record the date the most recent
therapy regimen (since the most recent entry) ended
- enter dashes if therapy is ongoing.

_
Day

_
Year

Month

_
Day

Year

C. Physical Therapy.
Enter Number of Minutes

1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually
in the last 7 days.

Enter Number of Minutes

2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident
concurrently with one other resident in the last 7 days.

Enter Number of Minutes

3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group
of residents in the last 7 days.
If the sum of individual, concurrent, and group minutes is zero,

Enter Number of Days

skip to O0400D, Respiratory Therapy

4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
5. Therapy start date - record the date the most recent
therapy regimen (since the most recent entry) started.

_
Month

6. Therapy end date - record the date the most recent
therapy regimen (since the most recent entry) ended
- enter dashes if therapy is ongoing.

_
Day

_
Year

Month

_
Day

Year

O0400 continued on next page

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Resident

Section O.

Identifier

Date

Special Treatments, Procedures, and Programs.

O0400. Therapies - Continued.
D. Respiratory Therapy.
Enter Number of Days

2. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.

O0450. Resumption of Therapy - Complete only if A0310C = 2 or 3 and A0310F = 99.
Enter Code

A. Has a previous rehabilitation therapy regimen (speech, occupational, and/or physical therapy) ended, as reported on this End of
Therapy OMRA, and has this regimen now resumed at exactly the same level for each discipline?
0. No
Skip to O0500, Restorative Nursing Programs.
1. Yes
B. Date on which therapy regimen resumed:

_
Month

_
Day

Year

O0500. Restorative Nursing Programs.
Record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days
(enter 0 if none or less than 15 minutes daily).
Number
of Days.

Technique.
A. Range of motion (passive).
B. Range of motion (active).
C. Splint or brace assistance.

Number
of Days.

Training and Skill Practice In:
D. Bed mobility.
E. Transfer.
F. Walking.
G. Dressing and/or grooming.
H. Eating and/or swallowing.
I. Amputation/prostheses care.
J. Communication.

Section Q.

Participation in Assessment and Goal Setting.

Q0100. Participation in Assessment.
Enter Code

Enter Code

Enter Code

A. Resident participated in assessment.
0. No.
1. Yes.
B. Family or significant other participated in assessment.
0. No.
1. Yes.
9. No family or significant other.
C. Guardian or legally authorized representative participated in assessment.
0. No.
1. Yes.
9. No guardian or legally authorized representative.

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Resident

Section X.

Identifier

Date

Correction Request.

X0100. Type of Record.
1. Add new record
Skip to Z0100, Medicare Part A Billing
2. Modify existing record
Continue to X0150, Type of Provider.
3. Inactivate existing record
Continue to X0150, Type of Provider.
Identification of Record to be Modified/Inactivated - The following items identify the existing assessment record that is in error. In this
section, reproduce the information EXACTLY as it appeared on the existing erroneous record, even if the information is incorrect.
This information is necessary to locate the existing record in the National MDS Database.
Enter Code

X0150. Type of Provider.
Enter Code

Type of provider.
1. Nursing home (SNF/NF).
2. Swing Bed.

X0200. Name of Resident on existing record to be modified/inactivated.
A. First name:

C. Last name:

X0300. Gender on existing record to be modified/inactivated.
Enter Code

1. Male
2. Female

X0400. Birth Date on existing record to be modified/inactivated.
_
Month

_
Day

Year

X0500. Social Security Number on existing record to be modified/inactivated.
_

_

X0600. Type of Assessment on existing record to be modified/inactivated.
Enter Code

Enter Code

A. Federal OBRA Reason for Assessment
01. Admission assessment (required by day 14)
02. Quarterly review assessment
03. Annual assessment
04. Significant change in status assessment
05. Significant correction to prior comprehensive assessment
06. Significant correction to prior quarterly assessment
99. Not OBRA required assessment
B. PPS Assessment
PPS Scheduled Assessments for a Medicare Part A Stay
01. 5-day scheduled assessment
02. 14-day scheduled assessment
03. 30-day scheduled assessment
04. 60-day scheduled assessment
05. 90-day scheduled assessment
06. Readmission/return assessment
PPS Unscheduled Assessments for a Medicare Part A Stay
07. Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment)
Not PPS Assessment
99. Not PPS assessment

X0600 continued on next page.

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Resident

Section X.

Identifier

Date

Correction Request.

X0600. Type of Assessment.- Continued
Enter Code

C. PPS Other Medicare Required Assessment - OMRA
0. No...
1. Start of therapy assessment.
2. End of therapy assessment.
3. Both Start and End of therapy assessment.
4. Change of therapy assessment.

Enter Code

D. Is this a Swing Bed clinical change assessment? Complete only if X0150 = 2.
0. No...
1. Yes.

Enter Code

F. Entry/discharge reporting
01. Entry record.
10. Discharge assessment-return not anticipated.
11. Discharge assessment-return anticipated.
12. Death in facility record.
99. Not entry/discharge record.

X0700. Date on existing record to be modified/inactivated - Complete one only.
A. Assessment Reference Date - Complete only if X0600F = 99.

_
Month

_
Day

Year

B. Discharge Date - Complete only if X0600F = 10, 11, or 12.

_
Month

_
Day

Year

C. Entry Date - Complete only if X0600F = 01.

_
Month

_
Day

Year

Correction Attestation Section.- Complete this section to explain and attest to the modification/inactivation request.
X0800. Correction Number.
Enter Number

Enter the number of correction requests to modify/inactivate the existing record, including the present one.

X0900. Reasons for Modification.- Complete only if Type of Record is to modify a record in error (X0100 = 2).
Check all that apply.
A. Transcription error.
B. Data entry error.
C. Software product error.
D. Item coding error.
E. Add resumption of therapy date.
Z. Other error requiring modification.
If "Other" checked, please specify:

X1050. Reasons for Inactivation.- Complete only if Type of Record is to inactivate a record in error (X0100 = 3).
Check all that apply.
A. Event did not occur.
Z. Other error requiring inactivation.
If "Other" checked, please specify:

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Resident

Section X.

Identifier

Date

Correction Request.

X1100. RN Assessment Coordinator Attestation of Completion.
A. Attesting individual's first name:

B. Attesting individual's last name:

C. Attesting individual's title:
D. Signature.
E. Attestation date.

_
Month

_
Day

Year

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Resident

Section Z.

Identifier

Date

Assessment Administration.

Z0100. Medicare Part A Billing.
A. Medicare Part A HIPPS code (RUG group followed by assessment type indicator):

B. RUG version code:

Enter Code

C. Is this a Medicare Short Stay assessment?
0. No...
1. Yes

Z0150. Medicare Part A Non-Therapy Billing.
A. Medicare Part A non-therapy HIPPS code (RUG group followed by assessment type indicator):

B. RUG version code:

Z0300. Insurance Billing.
A. RUG Case Mix group:

B. RUG version code:

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Resident

Section Z.

**DRAFT**

Identifier

Date

Assessment Administration.

Z0400. Signature of Persons Completing the Assessment or Entry/Death Reporting.
I certify that the accompanying information accurately reflects resident assessment information for this resident and that I collected or coordinated
collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable
Medicare and Medicaid requirements. I understand that this information is used as a basis for ensuring that residents receive appropriate and quality
care, and as a basis for payment from federal funds. I further understand that payment of such federal funds and continued participation in the
government-funded health care programs is conditioned on the accuracy and truthfulness of this information, and that I may be personally subject to
or may subject my organization to substantial criminal, civil, and/or administrative penalties for submitting false information. I also certify that I am
authorized to submit this information by this facility on its behalf.
Date Section
Signature.
Title.
Sections.
Completed.

A.
B.
C.

D.
E.
F.
G.
H.
I.
J.
K.
L.
Z0500. Signature of RN Assessment Coordinator Verifying Assessment Completion.
A. Signature:

B. Date RN Assessment Coordinator signed
assessment as complete:

_
Month

_
Day

MDS 3.0 OMRA (NO/SO) Proposed SNF Changes 10/01/2011 **DRAFT** **DRAFT** **DRAFT** **DRAFT**

Year

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