CMS-10387 Nursing Home OMRA-Discharge (NOD) Item Set

Resident

Identifier

Date

MINIMUM DATA SET (MDS) - Version 3.0.

RESIDENT ASSESSMENT AND CARE SCREENING.
Nursing Home OMRA-Discharge (NOD) Item Set.
Section A.

Identification Information.

A0050. Type of Record.
Enter Code

1. Add new record
Continue to A0100, Facility Provider Numbers.
2. Modify existing record
Continue to A0100, Facility Provider Numbers.
3. Inactivate existing record
Skip to X0150, Type of Provider.

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. None of the above.
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. None of the above.
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

Identifier

Section A.

Date

Identification Information.

A0310. Type of Assessment - Continued.
Enter Code

Enter Code

Enter Code

E. Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry?
0. No...
1. Yes.
F. Entry/discharge reporting
01. Entry tracking record.
10. Discharge assessment-return not anticipated.
11. Discharge assessment-return anticipated.
12. Death in facility tracking record.
99. None of the above.
G. Type of discharge. - Complete only if A0310F = 10 or 11.
1. Planned...
2. Unplanned.

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

Identifier

Section A.

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

1.
2.
3.
4.
5.

Never married.
Married.
Widowed.
Separated.
Divorced.

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:

A1500. Preadmission Screening and Resident Review (PASRR).
Complete only if A0310A = 01, 03, 04, or 05
Enter Code

Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability
("mental retardation" in federal regulation) or a related condition?
0. No
Skip to A1550, Conditions Related to ID/DD Status.
Continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.
1. Yes
9. Not a Medicaid-certified unit
Skip to A1550, Conditions Related to ID/DD Status.

A1510. Level II Preadmission Screening and Resident Review (PASRR) Conditions.
Complete only if A0310A = 01, 03, 04, or 05.
Check all that apply.
A. Serious mental illness.
B. Intellectual Disability ("mental retardation" in federal regulation).
C. Other related conditions.

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Resident

Identifier

Section A.

Date

Identification Information.

A1550. Conditions Related to ID/DD Status.
If the resident is 22 years of age or older, complete only if A0310A = 01.
If the resident is 21 years of age or younger, complete only if A0310A = 01, 03, 04, or 05.
Check all conditions that are related to ID/DD status that were manifested before age 22, and are likely to continue indefinitely.
ID/DD With Organic Condition.
A. Down syndrome.
B. Autism.
C. Epilepsy.
D. Other organic condition related to ID/DD.
ID/DD Without Organic Condition.
E. ID/DD with no organic condition.
No ID/DD.
Z. None of the above.

A1600. Entry Date (date of this admission/entry or 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.
09.
99.

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

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

_
Day

Year

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

01.
02.
03.
04.
05.
06.
07.
08.
09.
99.

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

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Resident

Identifier

Section A.

Date

Identification Information.

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

Identifier

Section C.

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

Identifier

Section C.

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 C1300, Signs and Symptoms of Delirium.
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.

Delirium.
C1300. Signs and Symptoms of Delirium (from CAM©).
Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical record.
Enter Codes in Boxes.
Coding:
0. Behavior not present .
1. Behavior continuously
present, does not
fluctuate.
2. Behavior present,
fluctuates (comes and
goes, changes in severity).

A. Inattention - Did the resident have difficulty focusing attention (easily distracted, out of touch or
difficulty following what was said)?
B. Disorganized thinking - Was the resident's thinking disorganized or incoherent (rambling or irrelevant
conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?
C. Altered level of consciousness - Did the resident have altered level of consciousness (e.g., vigilant startled easily to any sound or touch; lethargic - repeatedly dozed off when being asked questions, but
responded to voice or touch; stuporous - very difficult to arouse and keep aroused for the interview;
comatose - could not be aroused)?
D. Psychomotor retardation- Did the resident have an unusually decreased level of activity such as
sluggishness, staring into space, staying in one position, moving very slowly?

C1600. Acute Onset Mental Status Change.
Enter Code

Is there evidence of an acute change in mental status from the resident's baseline?
0. No...
1. Yes.

Copyright © 1990 Annals of Internal Medicine. All rights reserved. Adapted with permission.

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Resident

Identifier

Section D.

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

Identifier

Section D.

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

Identifier

Section E.

Date

Behavior.

E0100. Potential Indicators of 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 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 or family
and/or non-facility staff provided care
100% of the time for that activity over the
entire 7-day 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 did not occur or family and/or non-facility staff provided
care 100% of the time for that activity 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).
C. Walk in room - how resident walks between locations in his/her room.
D. Walk in corridor - how resident walks in corridor on unit.
E. Locomotion 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.
F. Locomotion off unit - 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 a prosthesis or TED hose. Dressing includes putting on and changing
pajamas and housedresses.
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.
J. Personal hygiene - how resident maintains personal hygiene, including combing hair,
brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths
and showers).

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Resident

Identifier

Section G.

Date

Functional Status.

G0120. Bathing.
How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair). Code for most
dependent in self-performance and support.
Enter Code A. Self-performance.
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 or family and/or non-facility staff provided care 100% of the time for that activity over the entire
7-day period.

Section H.

Bladder and Bowel.

H0100. Appliances.
Check all that apply.
A. Indwelling catheter (including suprapubic catheter and nephrostomy tube).
B. External catheter.
C. Ostomy (including urostomy, ileostomy, and colostomy).
D. Intermittent catheterization.
Z. None of the above.

H0200. Urinary Toileting Program.
Enter Code

Enter Code

A. Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on
admission/entry or reentry or since urinary incontinence was noted in this facility?
0. No
Skip to H0300, Urinary Continence.
1. Yes
Continue to H0200C, Current toileting program or trial.
9. Unable to determine
Continue to H0200C, Current toileting program or trial.
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.

H0300. Urinary Continence.
Enter Code

Urinary continence - Select the one category that best describes the resident.
0. Always continent.
1. Occasionally incontinent (less than 7 episodes of incontinence).
2. Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding).
3. Always incontinent (no episodes of continent voiding).
9. Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days.

H0400. Bowel Continence.
Enter Code

Bowel continence - Select the one category that best describes the resident.
0. Always continent.
1. Occasionally incontinent (one episode of bowel incontinence).
2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement).
3. Always incontinent (no episodes of continent bowel movements).
9. Not rated, resident had an ostomy or did not have a bowel movement for the entire 7 days.

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

Identifier

Section I.

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.
Heart/Circulation.
I0900. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD).
Genitourinary.
I1550. Neurogenic Bladder.
I1650. Obstructive Uropathy.
Infections.
I2000. Pneumonia.
I2100. Septicemia.
I2300. Urinary Tract Infection (UTI) (LAST 30 DAYS).
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).
I5250. Huntington's Disease.
I5300. Parkinson's Disease.
I5350. Tourette's Syndrome.
Nutritional.
I5600. Malnutrition (protein or calorie) or at risk for malnutrition.
Psychiatric/Mood Disorder.
I5700. Anxiety Disorder.
I5900. Manic Depression (bipolar disease).
I5950. Psychotic Disorder (other than schizophrenia).
I6000. Schizophrenia (e.g., schizoaffective and schizophreniform disorders).
I6100. Post Traumatic Stress Disorder (PTSD).
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

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Resident

Identifier

Section I.

Date

Active Diagnoses.

Active Diagnoses in the last 7 days - Continued.
Other.
I8000. Additional active diagnoses.
Enter diagnosis on line and ICD code in boxes. Include the decimal for the code in the appropriate box.

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.

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Resident

Identifier

Section J.

Date

Health Conditions.

J0100. Pain Management - Complete for all residents, regardless of current pain level.
At any time in the last 5 days, has the resident:
Enter Code A. Received scheduled pain medication regimen?
0. No...
1. Yes.
Enter Code B. Received PRN pain medications OR was offered and declined?
0. No...
1. Yes.
Enter Code C. Received non-medication intervention for pain?
0. No...
1. Yes.

J0200. Should Pain Assessment Interview be Conducted?
Attempt to conduct interview with all residents. If resident is comatose, skip to J1100, Shortness of Breath (dyspnea).
Enter Code

0. No (resident is rarely/never understood)
1. Yes
Continue to J0300, Pain Presence.

Skip to J1100, Shortness of Breath.

Pain Assessment Interview.
J0300. Pain Presence.
Enter Code Ask resident: "Have you had pain or hurting at any time in the last 5 days?"
0. No
Skip to J1100, Shortness of Breath.
1. Yes
Continue to J0400, Pain Frequency.
9. Unable to answer
Skip to J1100, Shortness of Breath.

J0400. Pain Frequency.
Ask resident: "How much of the time have you experienced pain or hurting over the last 5 days?"
Enter Code

1.
2.
3.
4.
9.

Almost constantly.
Frequently.
Occasionally.
Rarely.
Unable to answer.

J0500. Pain Effect on Function.
A. Ask resident: "Over the past 5 days, has pain made it hard for you to sleep at night?"
Enter Code

Enter Code

0. No...
1. Yes.
9. Unable to answer.
B. Ask resident: "Over the past 5 days, have you limited your day-to-day activities because of pain?"
0. No...
1. Yes.
9. Unable to answer.

J0600. Pain Intensity - Administer ONLY ONE of the following pain intensity questions (A or B).
Enter Rating

Enter Code

A. Numeric Rating Scale (00-10).
Ask resident: "Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten
as the worst pain you can imagine." (Show resident 00 -10 pain scale)
Enter two-digit response. Enter 99 if unable to answer.
B. Verbal Descriptor Scale.
Ask resident: "Please rate the intensity of your worst pain over the last 5 days." (Show resident verbal scale)
1. Mild.
2. Moderate.
3. Severe.
4. Very severe, horrible.
9. Unable to answer.

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Resident

Identifier

Section J.

Date

Health Conditions.

Other Health Conditions.
J1100. Shortness of Breath (dyspnea).
Check all that apply.
A. Shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring).
B. Shortness of breath or trouble breathing when sitting at rest.
C. Shortness of breath or trouble breathing when lying flat.
Z. None of the above.

J1400. Prognosis.
Enter Code

Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? (Requires physician
documentation).
0. No...
1. Yes.

J1550. Problem Conditions.
Check all that apply.
A. Fever.
B. Vomiting.
C. Dehydrated.
D. Internal bleeding.
Z. None of the above.

J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent.
Enter Code

Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or scheduled PPS), whichever is more
recent?
Skip to K0200, Height and Weight.
0. No
1. Yes
Continue to J1900, Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS)

J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent.
Enter Codes in Boxes

Coding:
0. None
1. One
2. Two or more

A. No injury - no evidence of any injury is noted on physical assessment by the nurse or primary
care clinician; no complaints of pain or injury by the resident; no change in the resident's
behavior is noted after the fall.
B. Injury (except major) - skin tears, abrasions, lacerations, superficial bruises, hematomas and
sprains; or any fall-related injury that causes the resident to complain of pain.
C. Major injury - bone fractures, joint dislocations, closed head injuries with altered
consciousness, subdural hematoma.

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Resident

Identifier

Section K.

Date

Swallowing/Nutritional Status.

K0200. Height and Weight - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up.
A. Height (in inches). Record most recent height measure since admission/entry or reentry.
inches

pounds

B. Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight consistently, according to standard
facility practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.).

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.

K0310. Weight Gain.
Enter Code

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

K0510. Nutritional Approaches.
Check all of the following nutritional approaches that were performed during the last 7 days.
1. While NOT a Resident.
Performed while NOT a resident of this facility and within the last 7 days. Only check column 1 if
resident entered (admission or reentry) IN THE LAST 7 DAYS. If resident last entered 7 or more days
ago, leave column 1 blank.
2. While a Resident.
Performed while a resident of this facility and within the last 7 days.

1.
While NOT a
Resident.

2.
While a
Resident.

Check all that apply

A. Parenteral/IV feeding.
B. Feeding tube - nasogastric or abdominal (PEG).
C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food,
thickened liquids).
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol) .
Z. None of the above.

K0710. Percent Intake by Artificial Route - Complete K0710 only if Column 1 and/or Column 2 are checked for K0510A and/or K0510B.
1. While NOT a Resident.
Performed while NOT a resident of this facility and within the last 7 days. Only enter a
code in column 1 if resident entered (admission or reentry) IN THE LAST 7 DAYS. If
resident last entered 7 or more days ago, leave column 1 blank.
2. While a Resident.
Performed while a resident of this facility and within the last 7 days.
3. During Entire 7 Days.
Performed during the entire last 7 days.

1.
While NOT a
Resident.

2.
While a
Resident.

3.
During Entire
7 Days.

Enter Codes

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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Resident

Identifier

Section M.

Date

Skin Conditions.

Report based on highest stage of existing ulcer(s) at its worst; do not "reverse" stage.
M0100. Determination of Pressure Ulcer Risk.
Check all that apply.
A. Resident has a stage 1 or greater, a scar over bony prominence, or a non-removable dressing/device.

M0210. Unhealed Pressure Ulcer(s).
Enter Code

Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher?
0. No
Skip to M0900, Healed Pressure Ulcers.
1. Yes
Continue to M0300, Current Number of Unhealed Pressure Ulcers at Each Stage.

M0300. Current Number of Unhealed 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.
E. Unstageable - Non-removable dressing: Known but not stageable due to non-removable dressing/device.

Enter Number

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

Enter Number

1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar.
G. Unstageable - Deep tissue: Suspected deep tissue injury in evolution.

Enter Number

1. Number of unstageable pressure ulcers with suspected deep tissue injury in evolution - If 0
of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar.

Enter Number

Skip to M0610, Dimension

2. Number of these unstageable pressure ulcers that were present at time of admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry.

M0610. Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar.
Complete only if M0300C1, M0300D1 or M0300F1 is greater than 0.
If the resident has one or more unhealed Stage 3 or 4 pressure ulcers or an unstageable pressure ulcer due to slough or eschar, identify the pressure
ulcer with the largest surface area (length x width) and record in centimeters:

.

cm

.

cm

.

cm

A. Pressure ulcer length: Longest length from head to toe.

B. Pressure ulcer width: Widest width of the same pressure ulcer, side-to-side perpendicular (90-degree angle) to length.
C. Pressure ulcer depth: Depth of the same pressure ulcer from the visible surface to the deepest area (if depth is unknown,
enter a dash in each box).

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Resident

Identifier

Section M.

Date

Skin Conditions.

M0800. Worsening in Pressure Ulcer Status Since Prior Assessment (OBRA or Scheduled PPS) or Last Admission/Entry or Reentry.
Complete only if A0310E = 0.
Indicate the number of current pressure ulcers that were not present or were at a lesser stage on prior assessment (OBRA or scheduled PPS) or last
admission/entry or reentry. If no current pressure ulcer at a given stage, enter 0.
Enter Number

Enter Number

Enter Number

A. Stage 2.

B. Stage 3.

C. Stage 4.

M0900. Healed Pressure Ulcers.
Complete only if A0310E = 0.
Enter Code

Enter Number

Enter Number

Enter Number

A. Were pressure ulcers present on the prior assessment (OBRA or scheduled PPS)?
0. No
Skip to M1030, Number of Venous and Arterial Ulcers.
1. Yes
Continue to M0900B, Stage 2.
Indicate the number of pressure ulcers that were noted on the prior assessment (OBRA or scheduled PPS) that have completely closed
(resurfaced with epithelium). If no healed pressure ulcer at a given stage since the prior assessment (OBRA or scheduled PPS), enter 0.
B. Stage 2.
C. Stage 3.
D. Stage 4.

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).
G. Skin tear(s).
H. Moisture Associated Skin Damage (MASD) (i.e. incontinence (IAD), perspiration, drainage).
None of the Above.
Z. None of the above were present.

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Resident

Identifier

Section M.

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. Pressure 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.

N0300. Injections.
Enter Days

Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less
than 7 days. If 0
Skip to N0410, Medications Received.

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/entry
or 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/entry or reentry if less than 7 days.

N0410. Medications Received.
Indicate the number of DAYS the resident received the following medications during the last 7 days or since admission/entry or reentry if less
than 7 days. Enter "0" if medication was not received by the resident during the last 7 days..
Enter Days

Enter Days

Enter Days

Enter Days

Enter Days

Enter Days

Enter Days

A. Antipsychotic.
B. Antianxiety.
C. Antidepressant.
D. Hypnotic.
E. Anticoagulant (warfarin, heparin, or low-molecular weight heparin).
F. Antibiotic.
G. Diuretic.

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Resident

Identifier

Section O.

Date

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
1.
2.
resident entered (admission or reentry) IN THE LAST 14 DAYS. If resident last entered 14 or more days
While NOT a
While a
ago, leave column 1 blank.
Resident.
Resident.
2. While a Resident.
Performed while a resident of this facility and within the last 14 days.
Check all that apply
Cancer Treatments.
A. Chemotherapy.
B. Radiation.
Respiratory Treatments.
C. Oxygen therapy.
E. Tracheostomy care.
F. Ventilator or respirator.
Other.
H. IV medications.
I. Transfusions.
J. Dialysis.
K. Hospice care.
M. Isolation or quarantine for active infectious disease (does not include standard body/fluid
precautions).

O0250. Influenza Vaccine - Refer to current version of RAI manual for current flu season and reporting period.
Enter Code

Enter Code

A. Did the resident receive the Influenza vaccine in this facility for this year's Influenza season?
Continue to O0250C, If Influenza vaccine not received, state reason.
0. No
1. Yes
Skip to O0300, Pneumococcal Vaccine.
C. If Influenza vaccine not received, state reason:
1. Resident not in facility during this year's flu season.
2. Received outside of this facility.
3. Not eligible - medical contraindication.
4. Offered and declined.
5. Not offered.
6. Inability to obtain vaccine due to a declared shortage.
9. None of the above.

O0300. Pneumococcal Vaccine.
Enter Code

Enter Code

A. Is the resident's Pneumococcal vaccination up to date?
0. No
Continue to O0300B, If Pneumococcal vaccine not received, state reason.
1. Yes
Skip to O0400, Therapies.
B. If Pneumococcal vaccine not received, state reason:
1. Not eligible - medical contraindication.
2. Offered and declined.
3. Not offered.

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Resident

Section O.

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 Minutes

Enter Number of Days

skip to O0400A5, Therapy start date

3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in
co-treatment sessions in the last 7 days.
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 Minutes

Enter Number of Days

skip to O0400B5, Therapy start date

3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in
co-treatment sessions in the last 7 days.
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

Identifier

Section O.

Date

Special Treatments, Procedures, and Programs.

O0400. Therapies - Continued.
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,

skip to O0400C5, Therapy start date

3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in
co-treatment sessions in the last 7 days.

Enter Number of Minutes

Enter Number of Days

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

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.

O0420. Distinct Calendar Days of Therapy.
Enter Number of Days

Record the number of calendar days that the resident received Speech-Language Pathology and Audiology Services,
Occupational Therapy, or Physical Therapy for at least 15 minutes in the past 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

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Resident

Identifier

Section O.

Date

Special Treatments, Procedures, and Programs.

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 P.

Restraints.

P0100. Physical Restraints.
Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that
the individual cannot remove easily which restricts freedom of movement or normal access to one's body.

Enter Codes in Boxes.
Used in Bed.
A. Bed rail.
B. Trunk restraint.
C. Limb restraint.
Coding:
0. Not used.
1. Used less than daily.
2. Used daily.

D. Other.
Used in Chair or Out of Bed.
E. Trunk restraint.
F. Limb restraint.
G. Chair prevents rising.
H. Other.

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Resident

Identifier

Section Q.

Date

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

Q0400. Discharge Plan.
Enter Code

A. Is active discharge planning already occurring for the resident to return to the community?
0. No
1. Yes

Q0600. Referral.
Enter Code

Has a referral been made to the Local Contact Agency? (Document reasons in resident's clinical record)
0. No - referral not needed.
1. No - referral is or may be needed (For more information see Appendix C, Care Area Assessment Resources #20).
2. Yes - referral made.

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Resident

Identifier

Section X.

Date

Correction Request.

Complete Section X only if A0050 = 2 or 3.
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.
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

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. None of the above.
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. None of the above.
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.

X0600 continued on next page.

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Resident

Identifier

Section X.

Date

Correction Request.

X0600. Type of Assessment.- Continued
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 tracking record.
10. Discharge assessment-return not anticipated.
11. Discharge assessment-return anticipated.
12. Death in facility tracking record.
99. None of the above.

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 (A0050 = 2).
Check all that apply.
A. Transcription error.
B. Data entry error.
C. Software product error.
D. Item coding error.
E. End of Therapy - Resumption (EOT-R) 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 (A0050 = 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

Identifier

Section X.

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

Identifier

Section Z.

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 billing code:

B. RUG billing version:

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Resident

Section Z.

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

Year

Legal Notice Regarding MDS 3.0 - Copyright 2011 United States of America and InterRAI. This work may be freely used and
distributed solely within the United States. Portions of the MDS 3.0 are under separate copyright protections; Pfizer Inc. holds
the copyright for the PHQ-9 and the Annals of Internal Medicine holds the copyright for the CAM. Both Pfizer Inc. and the Annals
of Internal Medicine have granted permission to freely use these instruments in association with the MDS 3.0.
MDS 3.0 Nursing Home OMRA-Discharge (NOD) Version 1.11.1 Effective 10/01/2013

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