Form CMS-10036 IRF-PAI instrument

(CMS-10036) Inpatient Rehabilitation Assessment Instrument and Data Set for PPS for Inpatient Rehabilitation Facilities

Proposed IRF-PAI Version 2.0 - Effective October 1 2018

Inpatient Rehabilitation Facility - Patient Assessment Instrument

OMB: 0938-0842

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0842

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
OMB No. 0938-0842
____________________________________________________________________________________________________________________________________
CENTER
FOR MEDICARE & MEDICAID SERVICES

INPATIENT REHABILITATION FACILITY - PATIENT ASSESSMENT INSTRUMENT
Identification Information*
1.

Payer Information*
20. Payment Source
(02 - Medicare Fee For Service; 51- Medicare-Medicare Advantage;
99 - Not Listed)

Facility Information
A. Facility Name

_____________________________________________________________

A. Primary Source

_________

_____________________________________________________________

B. Secondary Source

_________

_____________________________________________________________
Medical Information*

_____________________________________________________________
_____________________________________________________________

21. Impairment Group

________
Admission

B. Facility Medicare Provider Number ________________________
2.

Patient Medicare Number ____________________________________

Patient Medicaid Number ____________________________________

Patient First Name _________________________________________

5A. Patient Last Name _________________________________________
5B. Patient Identification Number ________________________________
6.

Birth Date

____/____/_______
MM / DD / YYYY

Social Security Number _____________________________________

Gender (1 - Male; 2 - Female) ________________________________

Race/Ethnicity (Check all that apply)

________
Discharge

Condition requiring admission to rehabilitation; code according to Appendix
A.
A. ______
B. ______
C. ______

22. Etiologic Diagnosis
(Use ICD codes to indicate the etiologic problem
that led to the condition for which the patient is
receiving rehabilitation)
23. Date of Onset of Impairment

____/____/________
MM / DD / YYYY

24. Comorbid Conditions
Use ICD codes to enter comorbid medical conditions
A.

American Indian or Alaska Native

A. ________

Asian

B. ________

Black or African American

C. ________

Hispanic or Latino

D. ________

Native Hawaiian or Other Pacific Islander
White

E. ________
F. ________

10. Marital Status
(1 - Never Married; 2 - Married; 3 - Widowed;
4 - Separated; 5 - Divorced)

______________

11. Zip Code of Patient's Pre-Hospital Residence

_______________

12. Admission Date

____/____/_______
MM / DD / YYYY

13. Assessment Reference Date

____/____/_____
MM / DD / YYYY

24A. Are there any arthritis conditions recorded in items #21, #22, or #24 that meet
all of the regulatory requirements for IRF classification (in 42 CFR
412.29(b)(2)(x), (xi), and (xii))?
______ __________
(0 - No; 1 - Yes)
25.

Height and Weight

14. Admission Class
(1 - Initial Rehab; 2 - Evaluation; 3 - Readmission;
4 - Unplanned Discharge; 5 - Continuing Rehabilitation)
15A. Admit From
(01- Home (private home/apt., board/care, assisted living, group home,
transitional living); 02- Short-term General Hospital; 03 - Skilled Nursing
Facility (SNF); 04 - Intermediate care; 06 - Home under care of organized
home health service organization; 50 - Hospice (home);
51 - Hospice (institutional facility); 61 - Swing bed; 62 - Another Inpatient
Rehabilitation Facility; 63 - Long-Term Care Hospital (LTCH);
64 - Medicaid Nursing Facility; 65 - Inpatient Psychiatric Facility;
66 - Critical Access Hospital; 99 - Not Listed)
16A. Pre-hospital Living Setting
Use codes from 15A. Admit From

DELETED

26. DELETED
(While measuring if the number is X.1-X.4 round down, X.5 or greater round
up)
25A. Height on admission (in inches) _____________________________
26A. Weight on admission (in pounds) ____________________________
Measure weight consistently, according to standard facility practice (e.g., in
a.m. after voiding, with shoes off, etc.)
27.

DELETED

28. DELETED

_______________

17. Pre-hospital Living With
______________
(Code only if item 16A is 01- Home: Code using 01 - Alone;
02 - Family/Relatives; 03 - Friends; 04 - Attendant; 05 - Other)
18. DELETED
19. DELETED

Proposed IRF-PAI Version 2.0 - Effective October 1, 2018

Page 1

Function Modifiers*
Complete the following specific functional items prior to scoring the
FIMTM Instrument:

29. Bladder Level of Assistance
(Score using FIM Levels 1 - 7)
30. Bladder Frequency of Accidents
(Score as below)

31.

32.

Admission

Discharge

Eating



Grooming

Bathing

Dressing - Upper

Dressing - Lower

Toileting



7 - No accidents
6 - No accidents; uses device such as a catheter
5 - One accident in the past 7 days
4 - Two accidents in the past 7 days
3 - Three accidents in the past 7 days
2 - Four accidents in the past 7 days
1 - Five or more accidents in the past 7 days

SPHINCTER CONTROL

Enter in Item 39G (Bladder) the lower (more dependent) score from Items 29
and 30 above

TRANSFERS

Bowel Level of Assistance
(Score using FIM Levels 1 - 7)
Bowel Frequency of Accidents
(Score as below)

34.

Shower Transfer

Distance Walked

36. Distance Traveled in Wheelchair

38.

Wheelchair

Bowel

Bed, Chair, Wheelchair



Toilet

Tub, Shower



Discharge

Goal

















W - Walk
C - Wheelchair
B - Both

LOCOMOTION
L.

Walk/Wheelchair

Stairs




Admission

Discharge




Comprehension

Expression

Social Interaction

Problem Solving




Memory




(Score Items 37 and 38 using FIM Levels 1 - 7; 0 if activity does not occur)
See training manual for scoring of Item 39L (Walk/Wheelchair)
* The FIM data set, measurement scale and impairment codes incorporated or
referenced herein are the property of U B Foundation Activities, Inc. ©1993,
2001 U B Foundation Activities, Inc. The FIM mark is owned by UBFA, Inc.

Proposed IRF-PAI Version 2.0 - Effective October 1, 2018







SOCIAL COGNITION

Discharge




V - Vocal
N - Nonvocal
B - Both

Admission




A - Auditory
V - Visual
B - Both

COMMUNICATION

(Code items 35 and 36 using: 3 - 150 feet; 2 - 50 to 149 feet;
1 - Less than 50 feet; 0 – activity does not occur)

37. Walk

(Score Items 33 and 34 using FIM Levels 1 - 7; use 0 if activity does not
occur) See training manual for scoring of Item 39K (Tub/Shower Transfer)

35.

Bladder

Discharge

Enter in Item 39H (Bowel) the lower (more dependent) score of Items 31and 32
above.

Tub Transfer

Admission

7 - No accidents
6 - No accidents; uses device such as a ostomy
5 - One accident in the past 7 days
4 - Two accidents in the past 7 days
3 - Three accidents in the past 7 days
2 - Four accidents in the past 7 days
1 - Five or more accidents in the past 7 days

33.

Admission
SELF-CARE





FIM LEVELS
No Helper
7

Complete Independence (Timely, Safely)

Modified Independence (Device)

Helper - Modified Dependence
5

Supervision (Subject = 100%)

Minimal Assistance (Subject = 75% or more)

Moderate Assistance (Subject = 50% or more)

Helper - Complete Dependence
2

Maximal Assistance (Subject = 25% or more)

Total Assistance (Subject less than 25%)

Activity does not occur; Use this code only at admission

Page 2

Therapy Information

____/____/________
MM / DD / YYYY

41. Patient discharged against medical advice?
42. Program Interruption(s)

______________
(0 - No; 1 - Yes)
______________
(0 - No; 1 - Yes)

43. Program Interruption Dates
(Code only if item 42 is 1 - Yes)
A. 1st Interruption Date

C. 2 Interruption Date

O0401A: Physical Therapy
a. Total minutes of individual therapy

________

b. Total minutes of concurrent therapy
c. Total minutes of group therapy

________
________

d. Total minutes of co-treatment therapy

________

O0401B: Occupational Therapy
B. 1st Return Date

MM / DD / YYYY
nd

O0401. Week 1: Total Number of Minutes Provided

MM / DD / YYYY

a. Total minutes of individual therapy

________

b. Total minutes of concurrent therapy
c. Total minutes of group therapy

________
________

d. Total minutes of co-treatment therapy

________

D. 2 Return Date
O0401C: Speech-Language Pathology

MM / DD / YYYY
E. 3rd Interruption Date

MM / DD / YYYY
F. 3rd Return Date

MM / DD / YYYY

a. Total minutes of individual therapy

________

b. Total minutes of concurrent therapy
c. Total minutes of group therapy

________
________

d. Total minutes of co-treatment therapy

________

MM / DD / YYYY

44C. Was the patient discharged alive?

_____________
(0 - No; 1 - Yes)

44D. Patient’s discharge destination/living setting, using codes below: (answer
only if 44C = 1; if 44C = 0, skip to item 46)
(01- Home (private home/apt., board/care, assisted living, group home,
transitional living); 02- Short-term General Hospital; 03 - Skilled Nursing
Facility (SNF); 04 - Intermediate care; 06 - Home under care of
organized home health service organization; 50 - Hospice (home);
51 - Hospice (institutional facility); 61 - Swing bed; 62 - Another
Inpatient Rehabilitation Facility; 63 - Long-Term Care Hospital (LTCH);
64 - Medicaid Nursing Facility; 65 - Inpatient Psychiatric Facility;
66 - Critical Access Hospital; 99 - Not Listed)
45. Discharge to Living With

O0402. Week 2: Total Number of Minutes Provided
O0402A: Physical Therapy
a. Total minutes of individual therapy

________

b. Total minutes of concurrent therapy
c. Total minutes of group therapy

________
________

d. Total minutes of co-treatment therapy

________

O0402B: Occupational Therapy
a. Total minutes of individual therapy

________

b. Total minutes of concurrent therapy
c. Total minutes of group therapy

________
________

d. Total minutes of co-treatment therapy

________

_____________

(Code only if item 44C is 1 - Yes and 44D is 01 - Home; Code using 1
Alone; 2 - Family / Relatives; 3 - Friends; 4 - Attendant;

5 - Other)

46. Diagnosis for Interruption or Death

_____________

(Code using ICD code)

O0402C: Speech-Language Pathology
a. Total minutes of individual therapy

________

b. Total minutes of concurrent therapy
c. Total minutes of group therapy

________
________

d. Total minutes of co-treatment therapy

________

47. Complications during rehabilitation stay
(Use ICD codes to specify up to six conditions that

began with this rehabilitation stay)

A. ____________

B. ____________

C. ____________

D. ____________

E. ____________

F. ____________

* The FIM data set, measurement scale and impairment codes incorporated or
referenced herein are the property of U B Foundation Activities, Inc. © 1993,
2001 U B Foundation Activities, Inc. The FIM mark is owned by UBFA, Inc.

Proposed IRF-PAI Version 2.0 - Effective October 1, 2018

Page 3

OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section B

Hearing, Speech, and Vision

B0100. Comatose.
Enter Code

Persistent vegetative state/no discernible consciousness .
0. No
Continue to B0200, Hearing
Skip to GG0100, Prior Functioning: Everyday Activities
1. Yes

B0200. Hearing (3-day assessment period)
Enter Code

Ability to Hear (with hearing aid or hearing appliances if normally used)
0. Adequate: No difficulty in normal conversation, social interaction, listening to TV
1. Minimal difficulty: Difficulty in some environments (e.g., when person speaks softly or setting is noisy)
2. Moderate difficulty: Speaker has to increase volume and speak distinctly
3. Highly impaired: Absence of useful hearing

B1000. Vision (3-day assessment period)
Enter Code

Ability to See in Adequate Light (with glasses or other visual appliances)
0. Adequate: Sees fine detail, such as regular print in newspapers/books
1. Impaired: Sees large print, but not regular print in newspapers/books
2. Moderately impaired: Limited vision; not able to see newspaper headlines but can identify objects
3. Highly impaired: Object identification in question, but eyes appear to follow objects
4. Severely impaired: No vision or sees only light, colors or shapes; eyes do not appear to follow objects

BB0700. Expression of Ideas and Wants (3-day assessment period)
Enter Code

Expression of Ideas and Wants (consider both verbal and non-verbal expression and excluding language barriers)
4. Expresses complex messages without difficulty and with speech that is clear and easy to understand
3. Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear
2. Frequently exhibits difficulty with expressing needs and ideas
1. Rarely/Never expresses self or speech is very difficult to understand.

BB0800. Understanding Verbal and Non-Verbal Content (3-day assessment period)
Enter Code

Understanding Verbal and Non-Verbal Content (with hearing aid or device, if used, and excluding language barriers)
4. Understands: Clear comprehension without cues or repetitions
3. Usually Understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to
understand
2. Sometimes Understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand
1. Rarely/Never Understands

Section C

Cognitive Patterns

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted? (3-day assessment period)
Attempt to conduct interview with all patients.
Enter Code

0. No (patient is rarely/never understood)
Skip to C0900, Memory/Recall Ability
1. Yes
Continue to C0200, Repetition of Three Words

Brief Interview for Mental Status (BIMS)
C0200. Repetition of Three Words
Ask patient: “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
3. Three
2. Two
1. One
0. None
After the patient'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.

Quality Indicators - Admission
Proposed IRF-PAI Version 2.0 - Effective October 1, 2018

Page 4

OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section C

Cognitive Patterns

Brief Interview for Mental Status (BIMS) - Continued
C0300. Temporal Orientation (orientation to year, month, and day)
Ask patient: “Please tell me what year it is right now.”
Enter Code

A. Able to report correct year
3. Correct
2. Missed by 1 year
1. Missed by 2 - 5 years
0. Missed by > 5 years or no answer
Ask patient: “What month are we in right now?”

Enter Code

B. Able to report correct month
2. Accurate within 5 days
1. Missed by 6 days to 1 month
0. Missed by > 1 month or no answer
Ask patient: “What day of the week is today?”
C. Able to report correct day of the week
1. Correct
0. Incorrect or no answer

C0400. Recall
Ask patient: “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.
Enter Code

Enter Code

A. Able to recall “sock”
2. Yes, no cue required
1. Yes, after cueing ("something to wear")
0. No - could not recall
B. Able to recall “blue”
2. Yes, no cue required
1. Yes, after cueing ("a color")
0. No - could not recall
C. Able to recall “bed”
2. Yes, no cue required
1. Yes, after cueing ("a piece of furniture")
0. No - could not recall

C0500. BIMS Summary Score.
Enter Score

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

C0600. Should the Staff Assessment for Mental Status (C0900) be Conducted?
Enter Code

0. No (patient was able to complete Brief Interview for Mental Status)
Skip to C1310, Signs and Symptoms of Delirium.
1. Yes (patient was unable to complete Brief Interview for Mental Status)
Continue to C0900, Memory/Recall Ability.

Quality Indicators - Admission
Proposed IRF-PAI Version 2.0 - Effective October 1, 2018

Page 5

OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section C

Cognitive Patterns

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

C0900. Memory/Recall Ability (3-day assessment period)
Check all that the patient was normally able to recall.
A. Current season.
B. Location of own room.
C. Staff names and faces.
E. That he or she is in a hospital/hospital unit.
Z. None of the above were recalled.

C1310. Signs and Symptoms of Delirium (from CAM©)
Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical record (3-day assessment period).
A. Acute Onset Mental Status Change
Enter Code

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

Coding:
0. Behavior not present
1. Behavior continuously
present, does not
fluctuate
2. Behavior present,
fluctuates (comes and
goes, changes in
severity)

B. Inattention - Did the patient have difficulty focusing attention, for example, being easily distractible
or having difficulty keeping track of what was being said?
C. Disorganized Thinking - Was the patient's thinking disorganized or incoherent (rambling
or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject
to subject)?
D. Altered Level of Consciousness - Did the patient have altered level of consciousness as indicated
by any of the following criteria?
■ 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

Section D

Mood

D0150. Patient Health Questionnaire 2 (PHQ-2©)
Say to patient: “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 patient: "About how often have you been bothered by this?"
Read and show the patient 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?
Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.

Quality Indicators - Admission
Proposed IRF-PAI Version 2.0 - Effective October 1, 2018

Page 6

OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section E

Behavioral Symptoms

E0200. Behavioral Symptom - Presence & Frequency
Note presence of symptoms and their frequency.
Enter Code 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

Section GG

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)

Functional Abilities and Goals

GG0100. Prior Functioning: Everyday Activities. Indicate the patient's usual ability with everyday activities prior to the current
illness, exacerbation, or injury.
Enter Codes in Boxes.
Coding:
3. Independent - Patient completed the activities
by him/herself, with or without an assistive
device, with no assistance from a helper.
2. Needed Some Help - Patient needed partial
assistance from another person to complete
activities.
1. Dependent - A helper completed the activities
for the patient.
8. Unknown
9. Not Applicable

A. Self-Care: Code the patient's need for assistance with bathing, dressing, using
the toilet, or eating prior to the current illness, exacerbation, or injury.
B. Indoor Mobility (Ambulation): Code the patient's need for assistance with
walking from room to room (with or without a device such as cane, crutch, or
walker) prior to the current illness, exacerbation, or injury.
C. Stairs: Code the patient's need for assistance with internal or external stairs (with
or without a device such as cane, crutch, or walker) prior to the current illness,
exacerbation, or injury.
D. Functional Cognition: Code the patient's need for assistance with planning
regular tasks, such as shopping or remembering to take medication prior to the
current illness, exacerbation, or injury.

GG0110. Prior Device Use. Indicate devices and aids used by the patient prior to the current illness, exacerbation, or injury.
Check all that apply.
A. Manual wheelchair.
B. Motorized wheelchair and/or scooter.
C. Mechanical lift.
D. Walker.
E. Orthotics/Prosthetics.
Z. None of the above.

Quality Indicators - Admission
Proposed IRF-PAI Version 2.0 - Effective October 1, 2018

Page 7

OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section GG

Functional Abilities and Goals

GG0130. Self-Care (3-day assessment period)
Code the patient's usual performance at admission for each activity using the 6-point scale. If activity was not attempted at
admission, code the reason. Code the patient's discharge goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is
permissible to code discharge goal(s).
Coding:
Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Patient completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns

1.
Admission
Performance.

2.
Discharge
Goal.

Enter Codes in Boxes
A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or
liquid once the meal is placed before the patient.

B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and
remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.

C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a
bowel movement. If managing an ostomy, include wiping the opening but not managing equipment.

E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of
back and hair). Does not include transferring in/out of tub/shower.

F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.
G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include
footwear.
H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is
appropriate for safe mobility; including fasteners, if applicable.

Quality Indicators - Admission
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Page 8

OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section GG

Functional Abilities and Goals

GG0170. Mobility (3-day assessment period)
Code the patient's usual performance at admission for each activity using the 6-point scale. If activity was not attempted at
admission, code the reason. Code the patient's discharge goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is
permissible to code discharge goal(s).
Coding:
Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Patient completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns

1.
Admission
Performance.

2.
Discharge
Goal.

Enter Codes in Boxes
A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the
bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with
feet flat on the floor, and with no back support.
D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the
bed.
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to get on and off a toilet or commode.
G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability
to open/close door or fasten seat belt.
I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space.
If admission performance is coded 07, 09, 10, or 88
Skip to GG0170M, 1 step (curb).
J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.
K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.

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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section GG

Functional Abilities and Goals

GG0170. Mobility (3-day assessment period) - Continued
Code the patient's usual performance at admission for each activity using the 6-point scale. If activity was not attempted at
admission, code the reason. Code the patient's discharge goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is
permissible to code discharge goal(s).
Coding:
Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Patient completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns
1.
Admission
Performance

2.
Discharge
Goal.

Enter Codes in Boxes
L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor),
such as turf or gravel.
M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
N. 4 steps: The ability to go up and down four steps with or without a rail.
O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon,
from the floor.
Q1. Does the patient use a wheelchair and/or scooter?
0. No
Skip to H0350, Bladder Continence
1. Yes
Continue to GG0170R, Wheel 50 feet with two turns
R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make
two turns.
RR1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized
S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar
space.
SS1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section H

Bladder and Bowel

H0350. Bladder Continence (3-day assessment period)
Enter Code

Bladder continence - Select the one category that best describes the patient..
0. Always continent (no documented incontinence)
1. Stress incontinence only
2. Incontinent less than daily (e.g., once or twice during the 3-day assessment period)
3. Incontinent daily (at least once a day)
4. Always incontinent
5. No urine output (e.g., renal failure)
9. Not applicable (e.g., indwelling catheter)

H0400. Bowel Continence (3-day assessment period)
Enter Code

Bowel continence - Select the one category that best describes the patient..
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, patient had an ostomy or did not have a bowel movement for the entire 3 days.

Section I

Active Diagnoses

Comorbidities and Co-existing Conditions
Check all that apply.
I0900. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD).
I2900. Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)
I7900. None of the above

Section J

Health Conditions

J1750. History of Falls
Enter Code

Has the patient had two or more falls in the past year or any fall with injury in the past year?
0. No
1. Yes
8. Unknown

J2000. Prior Surgery
Enter Code

Did the patient have major surgery during the 100 days prior to admission?
0. No
1. Yes
8. Unknown

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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section K

Swallowing/Nutritional Status

K0520. Nutritional Approaches
Check all of the following nutritional approaches that were performed during the first 3 days of admission.
1.
Performed
during the first 3
days of admission
Check all that apply
A. Parenteral/IV feeding
B. Feeding tube - nasogastric or abdominal (e.g., 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

Section M

Skin Conditions

Report based on highest stage of existing ulcers/injuries at their worst; do not "reverse" stage.
M0210. Unhealed Pressure Ulcers/Injuries
Enter Code

Does this patient have one or more unhealed pressure ulcers/injuries?
0. No
Skip to N2001, Drug Regimen Review
Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.
1. Yes

M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
Enter Number

A. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not
have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues..
1. Number of Stage 1 pressure injuries

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

E. Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device
1. Number of unstageable pressure ulcers/injuries due to non-removable dressing/device

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

Enter Number

G. Unstageable - Deep tissue injury
1. Number of unstageable pressure injuries presenting as deep tissue injury

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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section N

Medications

N2001. Drug Regimen Review
Enter Code

Did a complete drug regimen review identify potential clinically significant medication issues?
0. No - No issues found during review
Skip to O0110, Special Treatments, Procedures, and Programs
1. Yes - Issues found during review
Continue to N2003, Medication Follow-up
9. NA - Patient is not taking any medications
Skip to O0110, Special Treatments, Procedures, and Programs

N2003. Medication Follow-up
Enter Code

Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/
recommended actions in response to the identified potential clinically significant medication issues?
0. No
1. Yes

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 first 3 days of admission. For chemotherapy and
dialysis, check if it is part of the patient's treatment plan.
3.
Performed
during the first
3 days of admission
Check all that apply
Cancer Treatments
A. Chemotherapy (if checked, please specify below)
A2a.

A3a.

Oral

A10a. Other
B. Radiation.
Respiratory Treatments.
C. Oxygen Therapy (if checked, please specify below)
C2a. Continuous
C3a. Intermittent
D. Suctioning (if checked, please specify below)
D2a. Scheduled
D3a. As needed
E. Tracheostomy Care.
F. Invasive Mechanical Ventilator.
G. Non-invasive Mechanical Ventilator (BiPAP/CPAP) (if checked, please specify below)
G2a. BiPAP
G3a. CPAP

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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section O

Special Treatments, Procedures, and Programs

O0110. Special Treatments, Procedures, and Programs.
Check all of the following treatments, procedures, and programs that were performed during the first 3 days of admission. For chemotherapy and
dialysis, check if it is part of the patient's treatment plan.
3.
Performed
during the first
3 days of admission
Check all that apply
Other Treatments.
H. IV Medications (if checked, please specify below)
H3a. Antibiotics
H4a. Anticoagulation
H10a. Other
I. Transfusions
J. Dialysis (if checked, please specify below)
J2a. Hemodialysis
J3a. Peritoneal dialysis
O. IV Access (if checked, please specify below)
O2a. Peripheral IV
O3a. Midline
O4a. Central line (e.g., PICC, tunneled, port)
O10a. Other
None of the Above
Z. None of the above

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OMB No. 0938-0842
Patient

Identifier

Date

DISCHARGE
Section B

Hearing, Speech, and Vision

B0100. Comatose.
Enter Code

Persistent vegetative state/no discernible consciousness .
0. No
Continue to C1310, Signs and Symptoms of Delirium
Skip to GG0130, Self-Care
1. Yes

Section C

Cognitive Patterns

C1310. Signs and Symptoms of Delirium (from CAM©) (within the last 7 days)
A. Acute Onset Mental Status Change
Enter Code

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

Coding:
0. Behavior not present
1. Behavior continuously
present, does not
fluctuate
2. Behavior present,
fluctuates (comes and
goes, changes in
severity)

Enter Code in Boxes.
B. Inattention - Did the patient have difficulty focusing attention, for example, being easily distractible
or having difficulty keeping track of what was being said?
C. Disorganized Thinking - Was the patient's thinking disorganized or incoherent (rambling or irrelevant
conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?
D. Altered Level of Consciousness - Did the patient have altered level of consciousness as indicated
by any of the following criteria?
■ 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

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OMB No. 0938-0842
Patient

Identifier

Date

DISCHARGE
Section D

Mood

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

Section E

Behavioral Symptoms

E0200. Behavioral Symptom - Presence & Frequency
Note presence of symptoms and their frequency.
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

Enter Code in Boxes.
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)

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OMB No. 0938-0842
Patient

Identifier

Date

DISCHARGE
Section GG

Functional Abilities and Goals

GG0130. Self-Care (3-day assessment period)
Code the patient's usual performance at discharge for each activity using the 6-point scale. If activity was not attempted at
discharge, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Patient completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns

3.
Discharge.
Performance
Enter Codes in Boxes
A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once
the meal is placed before the patient.

B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove
dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.

C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel
movement. If managing an ostomy, include wiping the opening but not managing equipment.

E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and
hair). Does not include transferring in/out of tub/shower.

F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.

G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear.

H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate
for safe mobility; including fasteners, if applicable.

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OMB No. 0938-0842
Patient

Identifier

Date

DISCHARGE
Section GG

Functional Abilities and Goals

GG0170. Mobility (3-day assessment period)
Code the patient's usual performance at discharge for each activity using the 6-point scale. If activity was not attempted at
discharge, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Patient completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns

3.
Discharge.
Performance
Enter Codes in Boxes
A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with feet flat
on the floor, and with no back support.
D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to get on and off a toilet or commode.
G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/
close door or fasten seat belt.
I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space.
If discharge performance is coded 07, 09, 10, or 88
Skip to GG0170M, 1 step (curb).
J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.
K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.

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Page 18

OMB No. 0938-0842
Patient

Identifier

Date

DISCHARGE
Section GG

Functional Abilities and Goals

GG0170. Mobility (3-day assessment period) - Continued
Code the patient's usual performance at discharge for each activity using the 6-point scale. If activity was not attempted at
discharge, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because patient's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Patient completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns

3.
Discharge.
Performance
Enter Codes in Boxes
L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such
as turf or gravel.
M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
N. 4 steps: The ability to go up and down four steps with or without a rail.
O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from
the floor.
Q3. Does the patient use a wheelchair and/or scooter?
0. No
Skip to J1800, Any Falls Since Admission
1. Yes
Continue to GG0170R, Wheel 50 feet with two turns
R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two
turns.
RR3. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized
S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.
SS3. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

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OMB No. 0938-0842
Patient

Identifier

Date

DISCHARGE
Section J

Health Conditions

J1800. Any Falls Since Admission .
Enter Code

Has the patient had any falls since admission?
0. No
Skip to K0520, Nutritional Approaches
1. Yes
Continue to J1900, Number of Falls Since Admission .

J1900. Number of Falls Since Admission.
Coding:
0. None
1. One
2. Two or more

Enter Codes in Boxes.
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 patient; no change in the patient'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 patient to complain of pain
C. Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural
hematoma

Section K

Swallowing/Nutritional Status

K0520. Nutritional Approaches
Check all of the following nutritional approaches that were performed during the last 7 days.
2.
Performed
during the last
7 days
Check all that apply
A. Parenteral/IV feeding
B. Feeding tube - nasogastric or abdominal (e.g., 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

Section M

Skin Conditions

Report based on highest stage of existing ulcers/injuries at their worst; do not "reverse" stage.
M0210. Unhealed Pressure Ulcers/Injuries
Enter Code

Does this patient have one or more unhealed pressure ulcers/injuries?
0. No
Skip to N2005, Medication Intervention
1. Yes
Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.

M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
Enter Number

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OMB No. 0938-0842
Patient

Identifier

Date

DISCHARGE
Section M

Skin Conditions

Report based on highest stage of existing ulcers/injuries at their worst; do not "reverse" stage.
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage - Continued

Enter Number

2. Number of these Stage 2 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission
Number
these Stage
pressure
ulcers that
admission
- enter
how many
were noted
at themay
timebe
of
C. 2.
Stage
3: Fullof
thickness
tissue2loss.
Subcutaneous
fatwere
may present
be visibleupon
but bone,
tendon
or muscle
is not exposed.
Slough
admission
present but does not obscure the depth of tissue loss. May include undermining and tunneling.
1. Number of Stage 3 pressure ulcers
If 0
Skip to M0300D, Stage 4.
2. Number of these Stage 3 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission
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
If 0
Skip to M0300E, Unstageable - Non-removable dressing/device..
2. Number of these Stage 4 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission
E. Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device

Enter Number

1. Number of unstageable pressure ulcers/injuries due to non-removable dressing/device
If 0
Skip to M0300F, Unstageable - Slough and/or eschar.
Enter Number

Enter Number

2. Number of these unstageable pressure ulcers/injuries that were present upon admission - enter how many were noted at
the time of admission
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
If 0
Skip to M0300G, Unstageable - Deep tissue injury
2. Number of these unstageable pressure ulcers that were present upon admission - enter how many were noted at the time of
admission
G. Unstageable - Deep tissue injury
1. Number of unstageable pressure injuries presenting as deep tissue injury
If 0
Skip to N2005, Medication Intervention

Enter Number

2. Number of these unstageable pressure injuries that were present upon admission - enter how many were noted at the time
of admission

Section N

Medications

N2005. Medication Intervention
Enter Code

Did the facility contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next
calendar day each time potential clinically significant medication issues were identified since the admission?
0. No
1. Yes
9. NA - There were no potential clinically significant medication issues identified since admission or patient is not taking
any medications.

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OMB No. 0938-0842
Patient

Identifier

Date

DISCHARGE
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.
4.
Performed during
the last 14 days
Check all that apply
Cancer Treatments
A. Chemotherapy (if checked, please specify below)
A2a. IV
A3a. Oral
A10a. Other
B. Radiation.
Respiratory Treatments.
C. Oxygen Therapy (if checked, please specify below)
C2a. Continuous
C3a. Intermittent
D. Suctioning (if checked, please specify below)
D2a. Scheduled
D3a. As needed
E. Tracheostomy Care.
F. Invasive Mechanical Ventilator.
G. Non-invasive Mechanical Ventilator (BiPAP/CPAP) (if checked, please specify below)
G2a. BiPAP
G3a. CPAP
Other Treatments.
H. IV Medications (if checked, please specify below)
H3a. Antibiotics
H4a. Anticoagulation
H10a. Other
I. Transfusions
J. Dialysis (if checked, please specify below)
J2a. Hemodialysis
J3a. Peritoneal dialysis
O. IV Access (if checked, please specify below)
O2a. Peripheral IV
O3a. Midline
O4a. Central line (e.g., PICC, tunneled, port)
O10a. Other
None of the Above
Z. None of the above

Quality Indicators - Discharge
Proposed IRF-PAI Version 2.0 - Effective October 1, 2018

Page 22

OMB No. 0938-0842
Patient

Identifier

Date

DISCHARGE
Section O

Special Treatments, Procedures, and Programs

O0250. Influenza Vaccine - Refer to current version of IRF-PAI Training Manual for current influenza vaccination season and
reporting period.
Enter Code

A. Did the patient receive the influenza vaccine in this facility for this year's influenza vaccination season?
0. No
1. Yes

Skip to O0250C, If influenza vaccine not received, state reason
Continue to O0250B, Date influenza vaccine received

B. Date influenza vaccine received
M
Enter Code

Complete date and skip to Z0400A, Signature of Persons Completing the Assessment

C. If influenza vaccine not received, state reason:
1.
2.
3.
4.
5.
6.
9.

Patient not in this facility during this year's influenza vaccination season
Received outside of this facility
Not eligible - medical contraindication
Offered and declined
Not offered
Inability to obtain influenza vaccine due to a declared shortage
None of the above

Quality Indicators - Discharge
Proposed IRF-PAI Version 2.0 - Effective October 1, 2018

Page 23

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTER FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0842

Item Z0400A. Signature of Persons Completing the Assessment*
I certify that the accompanying information accurately reflects patient assessment information for this patient 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 patients 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.
Signature

Title

Date Information is Provided

Time

A.
B.

Proposed IRF-PAI Version 2.0 - Effective October 1, 2018

Page 24

File Type	application/pdf
File Title	IRF Patient Assessment Instrument
Subject	IRF Patient Assessment Instrument
Author	Centers for Medicare & Medicaid Services
File Modified	2017-05-31
File Created	2015-04-16