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pdfResident
Identifier
Date
MINIMUM DATA SET (MDS) - Version 3.0
RESIDENT ASSESSMENT AND CARE SCREENING
Nursing Home and Swing Bed OMRA-Start of Therapy (NS/SS) 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.
MDS 3.0 OMRA-Start of Therapy (NS/SS) Version 1.11.1 Effective 10/01/2013
Page 1 of 13
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.
MDS 3.0 OMRA-Start of Therapy (NS/SS) Version 1.11.1 Effective 10/01/2013
Page 2 of 13
Resident
Identifier
Section A.
Date
Identification Information.
A1200. Marital Status.
Enter Code
Never married.
Married.
Widowed.
Separated.
Divorced.
1.
2.
3.
4.
5.
A1300. Optional Resident Items.
A. Medical record number:
B. Room number:
C. Name by which resident prefers to be addressed:
D. Lifetime occupation(s) - put "/" between two occupations:
A1600. Entry Date (date of this admission/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.
MDS 3.0 OMRA-Start of Therapy (NS/SS) Version 1.11.1 Effective 10/01/2013
Page 3 of 13
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 G0110, Activities of Daily Living (ADL) Assistance.
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
MDS 3.0 OMRA-Start of Therapy (NS/SS) Version 1.11.1 Effective 10/01/2013
Page 4 of 13
Resident
Identifier
Section G.
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).
H. Eating - how resident eats and drinks, regardless of skill. Do not include eating/drinking
during medication pass. Includes intake of nourishment by other means (e.g., tube feeding,
total parenteral nutrition, IV fluids administered for nutrition or hydration).
I. Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off
toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts
clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag or
ostomy bag.
Section H.
Bladder and Bowel.
H0200. Urinary Toileting Program.
Enter Code
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 H0500, Bowel Toileting Program.
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.
H0500. Bowel Toileting Program.
Enter Code
Is a toileting program currently being used to manage the resident's bowel continence?
0. No...
1. Yes.
MDS 3.0 OMRA-Start of Therapy (NS/SS) Version 1.11.1 Effective 10/01/2013
Page 5 of 13
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
Respiratory Treatments.
E. Tracheostomy care.
F. Ventilator or respirator.
Other.
M. Isolation or quarantine for active infectious disease (does not include standard body/fluid
precautions).
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
MDS 3.0 OMRA-Start of Therapy (NS/SS) Version 1.11.1 Effective 10/01/2013
Page 6 of 13
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,
Enter Number of Minutes
Enter Number of Days
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.
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
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
MDS 3.0 OMRA-Start of Therapy (NS/SS) Version 1.11.1 Effective 10/01/2013
Page 7 of 13
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 Q.
Participation in Assessment and Goal Setting.
Q0100. Participation in Assessment.
Enter Code
Enter Code
Enter Code
A. Resident participated in assessment.
0. No...
1. Yes.
B. Family or significant other participated in assessment.
0. No...
1. Yes.
9. 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.
MDS 3.0 OMRA-Start of Therapy (NS/SS) Version 1.11.1 Effective 10/01/2013
Page 8 of 13
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.
MDS 3.0 OMRA-Start of Therapy (NS/SS) Version 1.11.1 Effective 10/01/2013
Page 9 of 13
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:
MDS 3.0 OMRA-Start of Therapy (NS/SS) Version 1.11.1 Effective 10/01/2013
Page 10 of 13
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
MDS 3.0 OMRA-Start of Therapy (NS/SS) Version 1.11.1 Effective 10/01/2013
Page 11 of 13
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:
MDS 3.0 OMRA-Start of Therapy (NS/SS) Version 1.11.1 Effective 10/01/2013
Page 12 of 13
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 OMRA-Start of Therapy (NS/SS) Version 1.11.1 Effective 10/01/2013
Page 13 of 13
File Type | application/pdf |
File Title | MDS 3.0 Item Set |
Subject | All MDS 3.0 assessment items |
Author | CMS |
File Modified | 2018-04-26 |
File Created | 2009-09-17 |