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pdfVariable Name
MR Screen Name
Question type
Question text/description
Code list
Routing
(01) CONSENT OBTAINED (CONTINUE INTERVIEW)
(02) FINAL CONSENT DENIED
(03) REFUSAL CONVERTED (CONTINUE
INTERVIEW)
(04) FINAL REFUSAL
(01) HSPRE - HSPRECT
(02) HSFINSCR2 - FINSCRN2
(03) HSPRE - HSPRECT
(04) HSFINSCR2 - FINSCRN2
(01) CONTINUE
(02) CONSENT REQUIRED
(03) INITIAL REFUSAL
(01) BOX HA1 BOX HA1B
(02) HSFINSCR2 - FINSCRN2
(03) HSFINSCR2 - FINSCRN2
HEALTH STATUS SECTION SPECIFICATIONS
CRITERIA
SAMPLE TYPE= CFR, CFC, FFC, FCF, IPR
SEASON
If SAMPLE_TYPE= CFR, then SEASON=FALL
If SAMPLE TYPE in (CFC, FFC, FCF), then SEASON= ALL
If SAMPLE TYPE= IPR, then SEASON= FALL
PLACEMENT
Administered in flexible order after FQ and RH sections are completed.
BOX HSBEG
CONREFFN
HSCONREF
routing
CODE ONE
IF HSDISP = 1/ConsentRequired OR HSDISP = 4/InitialRefusal, GO TO HSCONREF - CONREFFN.
ELSE GO TO HSPRE - HSPRECT.
PLEASE INDICATE THE FINAL (CONSENT/REFUAL) STATUS
FOR THIS SECTION.
THIS SCREEN BEGINS THE HEALTH STATUS SECTION FOR (SP).
HSPRECT
HSPRE
CODE ONE
IF THERE ARE NO CONSENT OR REFUSAL ISSUES FOR THIS SECTION, PRESS "1" TO CONTINUE.
BOX HA1B
routing
IF PLACTYP1= 1/Free Standing Nursing Home, 4/NursingHomeUnitCCRC, 7/HospitalBasedSNF, or
17/Rehabilitation Facility, AND (CAIDCERT=1 OR CARECERT=1 OR CAIDCERT1=1 OR CARECERT1=1)
AND CCN=MISSING, GO TO HS1-CCNINTRO.
ELSE GO TO BOX HA1.
A CMS Certification Number (CCN) has not yet been reported for this facility even though this facility is
certified by [Medicare/Medicaid/Medicare and Medicaid].
Please confirm, does [FACILITY) have a CMS Certification Number, also referred to as a
Medicare/Medicaid Provider Number, OSCAR Provider Number, or Medicare Identification Number?
CCNINTRO
HS1
yes/no
IF THERE IS A MDS IN THE CHART FOR THE CASE, THE CCN CAN BE FOUND IN SECTION A0100,
QUESTION B.
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX HA1
(01) HS2-CCNDOC
(-8) BOX HA1
(-9) FBOX HA1
[IF NEEDED: The CMS Certification Number is a unique number assigned to any facility certified to
participate in Medicare and/or Medicaid. The CMS Certification Number is not the same as the National
Provider Identifier (NPI), which is a unique 10-digit identification number issued to health care
providers.]
Do you have a document that shows (FACILITY'S) CMS Certification Number?
CCNDOC
HS2
yes/no
[IF NEEDED: The CMS Certification Number is also referred to as a Medicare/Medicaid Provider
Number, OSCAR Provider Number, or Medicare Identification Number.]
IF FACILITY RESPONDENT DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF FACILITY IS
CERTIFIED BY MEDICARE AND/OR MEDICAID.
(00) NO
(01) YES
(02) NO BUT FACILITY IS CERTIFIED BY MEDICARE
AND/OR MEDICAID
(-8) Don't Know
(-9) Refused
(00) BOX HA1
(01) CASPER_LU- CCN
(02) CASPER_LU- CCN
(-8) BOX HA1
(-9)BOX HA1
Please tell me the CMS Certification Number.
[If you don't know the CCN I can look up the number using your Facility name and address.]
START TYPING IN THE "CMS CERTIFICATION NUMBER" BOX TO LAUNCH THE LOOKUP.
CCN
CASPER_LU
lookup
IF THE FACILITY RESPONDENT DOES NOT KNOW THE CMS CERTIFICATION NUMBER, PROBE TO
CONFIRM THAT THE FACILITY IS CERTIFIED BY MEDICARE AND/OR MEDICAID. THEN, SELECT A
DIFFERENT KEY TYPE TO USE TO SEARCH THE LOOKUP, SUCH AS FACILITY NAME OR ADDRESS.
(01) (value selected from lookup)
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX HA1C
(-8) BOX HA1C
(-9) BOX HA1C
IF YOU SELECTED THE WRONG FACILITY FROM THE LOOKUP, CLICK IN THE "CMS CERTIFICATION
NUMBER" BOX TO RELAUNCH THE LOOKUP AND SELECT THE CORRECT FACILITY.
IF YOU CANNOT FIND THE FACILITY'S CCN THEN SELECT "NOT FOUND" FROM THE LOOKUP TO PROCEED
WITH THE INTERVIEW.
[CMS CERTIFICATION NUMBER]
BOX HA1C
routing
IF CCN= 'NOT FOUND' THEN GO TO FA11D-NOTFOUND. ELSE, GO TO FA11C-LU_CONFIRM.
LU_CONFIRM
HS3
yes/no
I'd like to verify the CMS Certification Number I have selected. I have selected (CCN). Is that correct?
NOTFOUND
HS4
yes/no
YOU SELECTED 'CCN NOT FOUND'. SELECT 01 TO CONTINUE WITHOUT A CCN. SELECT 02 TO RETURN TO (01) CONTINUE WITHOUT CCN
THE LOOKUP AND SELECT ANOTHER CCN.
(02) NO, GO BACK TO LOOKUP TO CHANGE
BOX HA1D
routing
BOX HA1
routing
HA1PRE1C
HA1PRE1
CODE ONE
(01) YES
(02) NO, GO BACK TO LOOKUP TO CHANGE
(01) BOX HA1
(02) CASPER_LU-CCN
(01) BOX HA1C
(02) CASPER_LU-CCN
IF CCN IN ('NOT FOUND', MISSING, DK, RF), GO TO FA12-BEDSNUM.
ELSE GO TO BOX FA8.
IF ONLY TIME 2, GO TO BOX HAT2BEG.
ELSE IF FACR.HAINTFLG <> 1/Indicated , GO TO HA1PRE1 - HA1PRE1C.
ELSE GO TO HA1PRE2 - HA1PRE2C.
RECORD IDENTIFICATION
The next questions are about (SP)'s health status on or around (HS REF DATE). We have found that
much of the data we are collecting is usually located in the resident's full Minimum Data Set (MDS)
assessments, the Quarterly Review forms, and other medical chart notes. Please take a moment to
locate the records now and confirm they are the records closest to (HS REF DATE).
(01) CONTINUE
HA1PRE2 - HA1PRE2C
(01) CONTINUE
BOX HA2
(0) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA1B - HSCONTN1
(01) BOX HA2A
(-8)HA1B - HSCONTN1
(-9) HA9PREB - HA9PRBC
(00) NO, RETURN TO NAVIGATE SCREEN
(01) YES, CONTINUE WITHOUT MEDICAL
RECORDS
(00) BOX HCEND
(01) HA9PREB - HA9PRBC
PRESS "1" TO CONTINUE.
RECORD IDENTIFICATION
HA1PRE2C
HA1PRE2
BOX HA2
CODE ONE
routing
The following questions are about (SP)'s health status on or around (HS REF DATE).
PRESS "1" TO CONTINUE.
IF BASELINE INTERVIEW OR (CORE AND NO MDS AT PREVIOUS HS) GO TO HA1 - RECHAVE.
ELSE IF CORE AND SP HAD A MDS AT LAST HS APPLICATION ADMINISTERED FOR THIS SP, GO TO HA2 RECFORMS.
RECORD IDENTIFCATION
RECHAVE
HA1
YES/NO
Do you have (SP)'s medical records for the (admission) period on or around (HS REF DATE)?
Is there someone else I should speak with, or do the records exist elsewhere?
HSCONTN1
HA1B
CODE ONE
BOX HA2A
routing
DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT THE
MEDICAL RECORDS?
GO TO HA2 - RECFORMS.
RECORD IDENTIFICATION
[The last MDS form we collected was dated (LAST MDS DATE).]
RECFORMS
HA2
YES/NO
Do (SP)'s medical records contain (a full./another) MDS assessment (or Quarterly Review) form dated
[on or around [HSREFDATE)/after (LAST MDS DATE)].
(00) NO
(01) YES
(00) HA2B1 - HSCONTN2
(01) BOX HA3
(00) NO, RETURN TO NAVIGATE SCREEN
(01) YES, CONTINUE WITHOUT MDS
(00) BOX HCEND
(01) HA9PREB - HA9PRBC
[A MDS for on or around (HS REF DATE) is preferable.]
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
Is there someone else I should speak with, or do the records exist elsewhere?
HSCONTN2
ASSESDT1
HA2B1
CODE ONE
BOX HA3
routing
HA3A
DATE
DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT ANY
MDS FORMS?
GO TO HA3A - ASSESDT1.
RECORD IDENTIFICATION
[What is the assessment date on the full MDS assessment that was completed for (SP) on or around (HS
REF DATE)/What is the assessment date on the full MDS assessment that was completed for (SP) at
(01) CONTINUOUS ANSWER
admission, that is, on or around (HS REF DATE)/What is the assessment date on the full MDS
(-8) DON'T KNOW
assessment or Quarterly Review that was completed for (SP) closest to (HS REF DATE) after (HA3A
(-9) REFUSED
DISPLAY DATE/LAST HS REF DATE)/What is the assessment date on that form]?
BOX HA4
ENTER DATE IN "MM DD YY" FORMAT.
FORMTYPE1
CLOSFORM
BOX HA4
routing
BOX HA5
routing
HA4
CODE ONE
BOX HA7
routing
HA5
YES/NO
BOX HA8
routing
BOX HA9AA
routing
BOX HA9BB
routing
BOX HA9CC
routing
(IF NO MDS AVAILABLE, BACK UP AND CHANGE THE RESPONSE.)
IF HA3A - ASSESDT1 = DK, RF AND FIRST TIME AT HA3A - ASSESDT1, GO TO HA9PREB - HA9PRBC.
ELSE, GO TO BOX HA5.
IF LAST ASSESSMENT DATE ENTRY COLLECTED IN HA3A - ASSESDT1 IS VALID, SET A FLAG AND GO TO
HA4 - FORMTYPE1.
ELSE GO TO HA5 - CLOSFORM.
RECORD IDENTIFICATION
Please tell me if the form with the assessment date of (LAST ASSESSMENT DATE) is a full MDS or a
quarterly review.
IF MOST RECENT ASSESSMENT DATE IS COMPLETE THEN COMPARE WITH HS REF DATE. IF NUMBER OF
DAYS BETWEEN ASSESSMENT DATE AND HS REF DATE MORE THAN +/- 7, OR IF HA3A - ASSESDT1 IS DK
OR RF, GO TO HA5 - CLOSFORM.
ELSE, GO TO BOX HA9AA.
Besides the form you just told me about, does (SP)'s medical record contain any other (full) MDS form
(or Quarterly Review form) dated closer to (HS REF DATE)?
HA6
CODE ONE
ASSESSMENT DATE: {ASSESSMENT DATE)
What was the primary reason for the assessment on the full MDS assessment dated (BCVAD/CCVAD)?
FORMREOS
HA6
VERBATIM TEXT
RECMDS
HA7A
YES/NO
(00) BOX HA7
(01) BOX HA7
(-8) BOX HA7
(-9) BOX HA7
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX HA8
(01) BOX HA8
(-8) BOX HA8
(-9) BOX HA8
(01) ADMISSION
(02) ANNUAL
(03) SIGNIFICANT CHANGE IN STATUS
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) HA7C - MDSINT1
(02) HA7C - MDSINT1
(03) HA7C - MDSINT1
(91) HA6 - FORMREOS
(-8) HA7C - MDSINT1
(-9) HA7C - MDSINT1
(01) CONTINUOUS ANSWER
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
HA7C - MDSINT1
(00) HA7C - MDSINT1
(01) HA7B - ASSESDT2
(-8) HA7C - MDSINT1
(-9) HA7C - MDSINT1
IF HA5 - CLOSFORM = 1/Yes, GO TO HA3A - ASSESDT1.
ELSE, GO TO BOX HA9AA.
IF HSTOT = 1 AND FORMTYPE = DK, RF, OR EMPTY, GO TO HA9PREB - HA9PRBC.
ELSE GO TO BOX HA9BB.
GO TO BOX HA9CC.
IF CVATYPE = 1/FulllMDS, GO TO HA6 - FORMREAS.
ELSE IF CVATYPE = 0/QuarterlyReview AND XBACKUP = EMPTY, GO TO HA7A - RECMDS.
ELSE GO TO HA7C - MDSINT1.
RECORD IDENTIIFCATION
3.0, A0310A
FORMREAS
(00) QUARTERLY REVIEW
(01) FULL MDS
(-8) Don't Know
(-9) Refused
OTHER (SPECIFY)
Does (SP)'s medical record contain a full MDS assessment dated between (HS DATE RANGE)?
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
What is the date of the full MDS assessment closest to (HS REF DATE)?
ASSESDT2
HA7B
date
BOX HA10
routing
IF NO MDS AVAILABLE, BACK UP AND CHANGE THE RESPONSE.
GO TO HA7C - MDSINT1.
RECORD IDENTIFICATION
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
(01) BOX HA10
(-8) BOX HA10
(-9) BOX HA10
(01) CONTINUE
BOX HA19A
(01) CONTINUE
HA47B - HCAIDNUM
Now I have some questions concerning (SP)'s health on or around [(HS REF DATE)/(his/her) admission
to the (facility/home). Please refer to (SP)'s medical record.]
MDSINT1
HA44PRBC
HCAIDNUM
HA7C
CODE ONE
BOX HA19A
routing
BOX HA22B
routing
HA44PREB
CODE ONE
HA47B
TEXT
[Please refer to the (FORM TYPE) with the assessment date of (CLOSEST VALID ASSESSMENT DATE)
when answering the following questions. [If the information is not found on the Quarterly Review,
(please refer to the full MDS form with the assessment date of (BACKUP MDS ASSESSMENT
DATE)/please refer to (SP)'s medical record) to answer the questions.]]
PRESS "1" TO CONTINUE.
IF BASELINE INTERVIEW AND CCN='NOT FOUND', MISSING, DK, RF, GO TO BOX HA22B HA9PREB HA9PRBC.
ELSE IF CCN='NOT FOUND', MISSING, DK, RF, GO TO HA11B - COMATOSE.
ELSE IF CCN=NON-MISSING AND PreloadSP.CURELAGE <= 65 AND SP IS Incoming Panel Respondent
(IPR), GO TO HA9B-MENTAL.
ELSE IF CCN=NON-MISSING, GO TO HA10B-HA10BCOD.
IF ((PERS.INCAID = EMPTY OR (PERS.INCAID = 1 AND PERS.ICAIDNM = DK, RF, OR EMPTY)) AND
PERS.CAIDECO <> 0/No OR 2/Pending) OR HSMCDFLG = 1/Indicated, GO TO HA44PREB - HA44PRBC.
ELSE, GO TO HA9PREB - HA9PRBC.
This next section asks for (SP)'s Medicaid number as recorded on the MDS assessment form.
PRESS "1" TO CONTINUE.
Please read me (SP)'s [(PREFERRED NAME FOR MEDICAID)/MEDICAID] ID number from the MDS
assessment form.
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
IF NO MEDICAID NUMBER, ENTER 96.
HCAIDVER
HA48B
YES/NO
(00) NO
I'd like to verify the [(PREFERRED NAME FOR MEDICAID)/MEDICAID] ID number that I have recorded. I
(01) YES
have entered (MEDICAID NUMBER). Is this correct?
(01) HA48B - HCAIDVER
(-8) HA9PREB - HA9PRBC
(-9) HA9PREB - HA9PRBC
(00) HA47B - HCAIDNUM
(01) HA9PREB - HA9PRBC
MENTAL HEALTH (MR/DD)
HA9PRBC
HA9PREB
BOX HA9B
CODE ONE
routing
Now I have some questions concerning (SP)'s health on or around [(HS REF DATE)/(his/her) admission
to the (facility/home)]. [(Please refer to (SP)'s medical record/Since I will be collecting information
about (SP) on or around (HS REF DATE) and there is no MDS or Quarterly Review available close to that
(01) CONTINUE
date, please refer to (SP)'s medical record for the information/Since you do not have a medical record
at hand for reference, please think about the information found in (SP)'s medical record) to answer
these questions.]
PRESS "1" TO CONTINUE.
IF BASELINE INTERVIEW AND CCN=MISSING, DK, RF, GO TO HA9B - MENTAL.
ELSE IF CCN='NOT FOUND', MISSING, DK, RF, GO TO HA11B - COMATOSE.
ELSE IF CCN=NON-MISSING AND PreloadSP.CURELAGE <= 65 AND SP is Incoming Panel Respondent
(IPR), GO TO HA9B-MENTAL.
ELSE IF CCN=NON-MISSING, GO TO HA10B-HA10BCOD.
MENTAL HEALTH (ID/DD)
[3.0, A1550]
MENTAL
HA9B
YES/NO CODE ALL
BOX HA9B
Did (SP)'s record indicate any history of mental retardation intellectual disability, mental illness, or
developmental disability problems?
Exclude diagnoses of organic brain syndrome, Alzheimer's disease, and related dementia.
SELECT ALL THAT APPLY.
IF SP HAS NO ID/DD PROBLEMS, SELECT NONE OF THE ABOVE
(01) DOWN SYNDROME
(02) AUTISM
(03) EPILEPSY
(04) OTHER ORGANIC CONDITION RELATED TO
ID/DD
(05) ID/DD WITH NO ORGANIC CONDITION
(96) NONE OF THE ABOVE
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA11B - COMATOSE HA10
(01) HA11B - COMATOSE HA10
(-8) HA11B - COMATOSE HA10
(-9) HA11B - COMATOSE HA10
BOX HA10
COMATOSE
HCHECOND
HCHEAID
HA11B
HA16B
HA17B
ROUTING
CODE ONE
CODE ONE
YES/NO
IF CCN=NON-MISSING AND PreloadSP.CURELAGE <= 65 AND SP is Incoming Panel Respondent (IPR), GO
TO HA28PREB-HA28PRBC.
ELSE GO TO HA1B- COMATOSE.
COMATOSE
(00) NO (NOT COMATOSE)
[3.0, B01000]
(01) YES (COMATOSE)
(-8) Don't Know
Was (SP) in a persistent vegetative state with no discernible consciousness on (HS REF
(-9) Refused
DATE)?
HEARING/COMMUNICATION
(00) HEARS ADEQUATELY
[3.0, B0200]
(01) HEARS WITH MINIMAL DIFFICULTY
What was the condition of (SP)'s hearing, with a hearing appliance, if used, on or around (HS REF DATE)? (02) HEARS WITH MODERATE DIFFICULTY
(03) HEARING HIGHLY IMPAIRED
Did (she/he) hear adequately, did (she/he) have minimal difficulty, did (she/he) have moderate
(-8) Don't Know
difficulty, or was (her/his) hearing highly impaired?
(-9) Refused
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
(00) NO
HEARING/COMMUNICATION
(01) YES
[3.0, B0300]
(-8) Don't Know
(-9) Refused
Did (she/he) have a hearing aid?
(00) HA16B - HCHECOND
(01) HA28PREB - HA28PRBC
(-8) HA16B - HCHECOND
(-9) HA16B - HCHECOND
(00) HA17B - HCHEAID
(01) HA17B - HCHEAID
(02) HA17B - HCHEAID
(03) HA17B - HCHEAID
(-8) HA17B - HCHEAID
(-9) HA17B - HCHEAID
(00) HA18PREB - HA18PRBC
(01) HA18PREB - HA18PRBC
(-8) HA18PREB - HA18PRBC
(-9) HA18PREB - HA18PRBC
HEARING/COMMUICATION
HA18PRBC
HA18PREB
CODE ONE
The next section deals with how (SP) communicated with others and how well (she/he) was understood
(01) CONTINUE
by others.
PRESS "1" TO CONTINUE.
HEARING/COMMUNICATION
[3.0, B0700]
HCUNCOND
HA18B
CODE ONE
HCUNDOTH
HA19B
CODE ONE
HA20PRBC
HA20PREB
CODE ONE
(00) UNDERSTOOD
(01) USUALLY UNDERSTOOD
Which statement best describes how effective (SP) was at making (herself/himself) understood on or
(02) SOMETIMES UNDERSTOOD
around (HS REF DATE)? Was (she/he) always understood, usually understood, sometimes understood, (03) RARELY/NEVER UNDERSTOOD
or rarely or never understood?
(-8) Don't Know
(-9) Refused
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
HEARING/COMMUNICATION
(00) UNDERSTAND
[3.0, B0800]
(01) USUALLY UNDERSTAND
(02) SOMETIMES UNDERSTAND
Which statement best describes how well (SP) understood others on or around (HS REF DATE)? Did (SP)
(03) RARELY/NEVER UNDERSTAND
always understand, usually understand, sometimes understand, or rarely or never understand?
(-8) Don't Know
(-9) Refused
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
VISION
Next is a question concerning (SP)'s vision on or around (HS REF DATE).
PRESS "1" TO CONTINUE.
VISION
[3.0, B1000]
VISION
HA20B
CODE ONE
VISAPPL
HA20AB
YES/NO
MENTCON
HA12AAB
YES/NO
(01) CONTINUE
(00) ADEQUATE
(01) IMPAIRED
(02) MODERATELY IMPAIRED
Which of the following statements best described (SP)'s ability to see in adequate light with visual aids,
(03) HIGHLY IMPAIRED
if used? Would you say (her/his) vision was adequate, impaired, moderately impaired, highly impaired,
(04) SEVERELY IMPAIRED
or severely impaired?
(-8) Don't Know
(-9) Refused
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
(00) NO
VISION
(01) YES
[3.0, B1200]
(-8) Don't Know
Does (SP) use a visual appliance such as glasses, contact lenses, or a magnifying glass?
(-9) Refused
COGNITIVE PATTERNS
(00) NO
[3.0, C0100]
(01) YES
(-8) Don't Know
Should a brief interview for Mental Status (C0200-C0500) be conducted?
(-9) Refused
HA18B - HCUNCOND
(00) HA19B - HCUNDOTH
(01) HA19B - HCUNDOTH
(02) HA19B - HCUNDOTH
(03) HA19B - HCUNDOTH
(-8) HA19B - HCUNDOTH
(-9) HA19B - HCUNDOTH
(00) HA20PREB - HA20PRBC
(01) HA20PREB - HA20PRBC
(02) HA20PREB - HA20PRBC
(03) HA20PREB - HA20PRBC
(-8) HA20PREB - HA20PRBC
(-9) HA20PREB - HA20PRBC
HA20B - VISION
(00) HA20AB - VISAPPL
(01) HA20AB - VISAPPL
(02) HA20AB - VISAPPL
(03) HA20AB - VISAPPL
(04) HA20AB - VISAPPL
(-8) HA20AB - VISAPPL
(-9) HA20AB - VISAPPL
(00) HA12AAB - MENTCON
(01) HA12AAB - MENTCON
(-8) HA12AAB - MENTCON
(-9) HA12AAB - MENTCON
(00) HA12PREB - HA12PRBC
(01) HA12AB - MENTSUM
(-8) HA12PREB - HA12PRBC
(-9) HA12PREB - HA12PRBC
BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) SUMMARY SCORE
[3.0, C0500]
MENTSUM
HA12AB
BOX HA12
HA12PRBC
HA12PREB
numeric
ENTER SUMMARY SCORE (0-15) FROM BIMS.
routing
ENTER ''99" IF THE RESIDENT WAS UNABLE TO COMPLETE THE INTERVIEW.
IF MENTSUM=99, GO TO HA12PREB-HA12PRBC.
ELSE GO TO HA36B-HALLUC.
MEMORY/COGNITIVE SKILLS
CODE ONE
[(Since (SP) was recorded as being unable to complete the Brief Interview for Mental Status, the next
series of questions deal with (SP)'s memory or recall ability./The next series of questions deal with
(SP)'s memory or recall ability.)]
PRESS "1" TO CONTINUE.
MEMORY/COGNITIVE SKILLS
[3.0, C0700]
CSMEMST
HA12B
CODE ONE
On or around (HS REF DATE), was (SP)'s short-term memory okay, that is, did (she/he) seem or appear
to recall things after 5 minutes?
MEMORY/COGNITIVE SKILLS
[3.0, C0800]
CSMEMLT
HA13B
CODE ONE
Was (SP)'s long-term memory okay; that is, did (she/he) seem or appear to recall events in the distant
past?
MEMORY/COGNITIVE SKILLS
[3.0, C0900]
HA14BCOD
HA14B
code all
On or around (HS REF DATE), was (SP) able to recall…
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
MEMORY/COGNITIVE SKILLS
[3.0, C1000]
CSDECIS
HA15B
CODE ONE
How skilled was (SP) in making daily decisions? Was (she/he) independent, did (she/he) exhibit
modified independence, was (she/he) moderately impaired, or was (she/he) severely impaired?
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
DEHYDRATION/DELUSIONS/HALLUCINATIONS
[3.0, E0100]
HALLUC
HA36B
YES/NO
Did (SP) experience hallucinations on or around (HS REF DATE)?
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
DEHYDRATION/DELUSIONS/HALLUCINATIONS
[3.0, E0100]
DELUS
HA35B
YES/NO
Did (SP) experience delusions on or around (HS REF DATE)?
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
BEHAVIORAL SYMPTOMS
[3.0, E0200]
BSAYSOT
HA21B
code one
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX HA12
(-8) HA36B - HALLUC
(-9) HA36B - HALLUC
(01) CONTINUE
HA12B - CSMEMST
(00) MEMORY OK
(01) MEMORY PROBLEM
(-8) Don't Know
(-9) Refused
(00) HA13B - CSMEMLT
(01) HA13B - CSMEMLT
(-8) HA13B - CSMEMLT
(-9) HA13B - CSMEMLT
(00) MEMORY OK
(01) MEMORY PROBLEM
(-8) Don't Know
(-9) Refused
(00) HA14B - HA14BCOD
(01) HA14B - HA14BCOD
(-8) HA14B - HA14BCOD
(-9) HA14B - HA14BCOD
(01) the current season?
(02) the location of (her/his) own room?
(03) staff names or faces?
(04) the fact that (she/he) was in a nursing home?
(96) NONE CHECKED
(-8) Don't Know
(01) HA15B - CSDECIS
(02) HA15B - CSDECIS
(03) HA15B - CSDECIS
(04) HA15B - CSDECIS
(96) HA15B - CSDECIS
(-8) HA15B - CSDECIS
(00) INDEPENDENT
(01) MODIFIED INDEPENDENCE
(02) MODERATELY IMPAIRED
(03) SEVERELY IMPAIRED
(-8) Don't Know
(-9) Refused
(00 HA36B - HALLUC
(01) HA36B - HALLUC
(02) HA36B - HALLUC
(03) HA36B - HALLUC
(-8) HA36B - HALLUC
(-9) HA36B - HALLUC
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA35B - DELUS
(01) HA35B - DELUS
(-8) HA35B - DELUS
(-9) HA35B - DELUS
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA21B - BSAYSOT
(01) HA21B - BSAYSOT
(-8) HA21B - BSAYSOT
(-9) HA21B - BSAYSOT
(00) BEHAVIOR NOT EXHIBITED
(01) BEHAVIOR OCCURRED 1 TO 3 DAYS
How often did the following behavioral problems occur on or around (HS REF DATE)? Would you say the (02) BEHAVIOR OCCURRED 4 TO 6 DAYS
behavior was not exhibited, occurred 1 to 3 days, occurred 4 to 6 days, but less than daily, or occurred (03) BEHAVIOR OCCURRED DAILY
daily?
(-8) Don't Know
(-9) Refused
Physical behavior symptoms directed toward others.
(00) HA21B - BSVERBOT
(01) HA21B - BSVERBOT
(02) HA21B - BSVERBOT
(03) HA21B - BSVERBOT
(-8) HA21B - BSVERBOT
(-9) HA21B - BSVERBOT
BSVERBOT
HA21B
code one
BEHAVIORAL SYMPTOMS
[3.0, E0200]
Verbal behavior symptoms directed toward others.
BSNOTOT
HA21B
code one
BEHAVIORAL SYMPTOMS
[3.0, E0200]
Other behavioral symptoms not directed toward others.
BOX HA21B
routing
BSELFCAR
BSELFACT
HA21AB
HA21AB
HA21AB
Yes/No
Yes/No
YES/NO
Did any of (SP)'s behavior…
put the resident at significant risk for physical illness or injury?
BEHAVIORAL SYMPTOMS
[3.0, E0500]
significantly interfere with the resident's care?
BEHAVIORAL SYMPTOMS
[3.0, E0500]
significantly interfere with the resident's participation in activities or social interactions?
BEHAVIORAL SYMPTOMS
[3.0, E0600]
BSOTHILL
BSOTHACT
BSOTHENV
HA21BB
HA21BB
HA21BB
YES/NO
YES/NO
YES/NO
Did any of (SP)'s behavior…
put others at significant risk for physical illness or injury?
BEHAVIORAL SYMPTOMS
[3.0, E0600]
significantly intrude on the privacy or activities of others?
BEHAVIORAL SYMPTOMS
[3.0, E0600]
significantly disrupt care or living environment?
BEHAVIORAL SYMPTOMS
[3.0, E0800]
BSNOEVAL
HA21CB
CODE ONE
BSOFTWAN
HA21DB
CODE ONE
BSWDANGR
HA21EB
YES/NO
(00) HA21B - BSNOTOT
(01) HA21B - BSNOTOT
(02) HA21B - BSNOTOT
(03) HA21B - BSNOTOT
(-8) HA21B - BSNOTOT
(-9) HA21B - BSNOTOT
(00) BOX HA21B
(01) BOX HA21B
(02) BOX HA21B
(03) BOX HA21B
(-8) BOX HA21B
(-9) BOX HA21B
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA21AB - BSELFCAR
(01) HA21AB - BSELFCAR
(-8) HA21AB - BSELFCAR
(-9) HA21AB - BSELFCAR
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA21AB - BSELFACT
(01) HA21AB - BSELFACT
(-8) HA21AB - BSELFACT
(-9) HA21AB - BSELFACT
(00) HA21BB - BSOTHILL
(01) HA21BB - BSOTHILL
(-8) HA21BB - BSOTHILL
(-9) HHA21BB - BSOTHILL
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA21BB - BSOTHACT
(01) HA21BB - BSOTHACT
(-8) HA21BB - BSOTHACT
(-9) HA21BB - BSOTHACT
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BEHAVIOR NOT EXHIBITED
(01) BEHAVIOR OCCURRED 1 TO 3 DAYS
(02) BEHAVIOR OCCURRED 4 TO 6 DAYS
(03) BEHAVIOR OCCURRED DAILY
(-8) Don't Know
(-9) Refused
(00) BEHAVIOR NOT EXHIBITED
(01) BEHAVIOR OCCURRED 1 TO 3 DAYS
(02) BEHAVIOR OCCURRED 4 TO 6 DAYS
(03) BEHAVIOR OCCURRED DAILY
(-8) Don't Know
(-9) Refused
(00) HA21BB - BSOTHENV
(01) HA21BB - BSOTHENV
(-8) HA21BB - BSOTHENV
(-9) HA21BB - BSOTHENV
(00) HA21CB - BSNOEVAL
(01) HA21CB - BSNOEVAL
(-8) HA21CB - BSNOEVAL
(-9) HA21CB - BSNOEVAL
(00) HA21DB - BSOFTWAN
(01) HA21DB - BSOFTWAN
(02) HA21DB - BSOFTWAN
(03) HA21DB - BSOFTWAN
(-8) HA21DB - BSOFTWAN
(-9) HA21DB - BSOFTWAN
(00) HA22PREB - HA22PRBC
(01) HA21EB - BSWDANGR
(02) HA21EB - BSWDANGR
(03) HA21EB - BSWDANGR
(-8) HA21EB - BSWDANGR
(-9) HA21EB - BSWDANGR
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
HA21EB - BSWOTACT
IF HA21B - BSAYSOT and HA21B - BSVERBOT and HA21B - BSNOTOT = 0/BehaviorNotExhibited, GO TO
HA21CB - BSNOEVAL.
ELSE GO TO HA21AB - BSELFILL.
BEHAVIORAL SYMPTOMS
[3.0, E0500]
BSELFILL
(00) BEHAVIOR NOT EXHIBITED
(01) BEHAVIOR OCCURRED 1 TO 3 DAYS
(02) BEHAVIOR OCCURRED 4 TO 6 DAYS
(03) BEHAVIOR OCCURRED DAILY
(-8) Don't Know
(-9) Refused
(00) BEHAVIOR NOT EXHIBITED
(01) BEHAVIOR OCCURRED 1 TO 3 DAYS
(02) BEHAVIOR OCCURRED 4 TO 6 DAYS
(03) BEHAVIOR OCCURRED DAILY
(-8) Don't Know
(-9) Refused
How often did (SP) reject evaluation or care that is necessary to achieve (his/her) goals for
health and well-being on or around (HS REF DATE)? Would you say the behavior was not
exhibited, occurred 1 to 3 days, occurred 4 to 6 days, but less than daily, or occurred daily?
BEHAVIORAL SYMPTOMS
[3.0, E0900]
How often did (SP) wander on or around (HS REF DATE)? Would you say the behavior was
not exhibited, occurred 1 to 3 days, occurred 4 to 6 days, but less than daily, or occurred
daily?
BEHAVIORAL SYMPTOMS
[3.0, E1000]
Did any of (SP)'s wandering…
place the resident at significant risk of getting to a potentially dangerous place?
BSWOTACT
HA21EB
YES/NO
BEHAVIORAL SYMPTOMS
[3.0, E1000]
significantly intrude on the privacy or activities of others?
ADLS/PHYSICAL FUNCTIONING
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
HA22PREB - HA22PRBC
(01) CONTINUE
HA22B - PFTRNSFR
(00) INDEPENDENT
(01) SUPERVISION
(02) LIMITED ASSISTANCE
(03) EXTENSIVE ASSISTANCE
(04) TOTAL DEPENDENCE
(07) ACTIVITY OCCURRED ONLY ONCE OR TWICE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
HA22B - PFLOCOMO
(00) INDEPENDENT
(01) SUPERVISION
(02) LIMITED ASSISTANCE
(03) EXTENSIVE ASSISTANCE
(04) TOTAL DEPENDENCE
(07) ACTIVITY OCCURRED ONLY ONCE OR TWICE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
HA22B - PFDRSSNG
(00) INDEPENDENT
(01) SUPERVISION
(02) LIMITED ASSISTANCE
(03) EXTENSIVE ASSISTANCE
(04) TOTAL DEPENDENCE
(07) ACTIVITY OCCURRED ONLY ONCE OR TWICE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
HA22B - PFEATING
(00) INDEPENDENT
(01) SUPERVISION
(02) LIMITED ASSISTANCE
(03) EXTENSIVE ASSISTANCE
(04) TOTAL DEPENDENCE
(07) ACTIVITY OCCURRED ONLY ONCE OR TWICE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
HA22B - PFTOILET
The next questions are about (SP)'s ability to perform Activities of Daily Living or ADLs, on or around (HS
REF DATE).
HA22PRBC
HA22PREB
CODE ONE
I will read you a list of activities and would like you to tell me if (SP)'s self-performance was
independent, required supervision, required limited assistance, required extensive assistance, was
totally dependent, or if the activity did not occur. [By self-performance I mean what (SP) actually did
for (himself/herself) and how much help was required by staff members.]
PRESS "1" TO CONTINUE.
ADLS/PHYSICAL FUNCTIONING
[3.0, G0110]
[SHOW CARD HA1]
PFTRNSFR
HA22B
CODE ONE
Please tell me (SP)'s level of self-performance in…
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
transferring (for example, in and out of bed).
PFLOCOMO
HA22B
CODE ONE
ADLS/PHYSICAL FUNCTIONING
[3.0, G0110]
[SHOW CARD HA1]
locomotion on unit.
PFDRSSNG
HA22B
CODE ONE
ADLS/PHYSICAL FUNCTIONING
[3.0, G0110]
[SHOW CARD HA1]
dressing.
PFEATING
HA22B
CODE ONE
ADLS/PHYSICAL FUNCTIONING
[3.0, G0110]
[SHOW CARD HA1]
eating.
PFTOILET
HA22B
CODE ONE
ADLS/PHYSICAL FUNCTIONING
[3.0, G0110]
[SHOW CARD HA1]
using the toilet.
(00) INDEPENDENT
(01) SUPERVISION
(02) LIMITED ASSISTANCE
(03) EXTENSIVE ASSISTANCE
(04) TOTAL DEPENDENCE
(07) ACTIVITY OCCURRED ONLY ONCE OR TWICE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
ADLS/PHYSICAL FUNCTIONING
[3.0, G0120]
PFBATHNG
HA23B
CODE ONE
(00) INDEPENDENT
(01) SUPERVISION
(02)PHYSICAL HELP LIMITED TO TRANSFER ONLY
Again referring to the time on or around (HS REF DATE), what was (SP)'s level of self-performance when (03) PHYSICAL HELP IN PART OF BATHING
bathing: was (she/he) independent, did (she/he) require supervision, require physical help limited to
ACTIVITY
transfer only, require physical help in part of the bathing activity, was (she/he) totally dependent, or did (04) TOTAL DEPENDENCE
the activity not occur?
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
(-9) Refused
HA23B - PFBATHNG
HA24PREB - HA24PRBC
MODES OF LOCMOTION
HA24PRBC
HA24PREB
CODE ONE
The next questions are about modes of locomotion and appliances or devices (SP) might have used on
or around (HS REF DATE).
PRESS "1" TO CONTINUE.
MODES OF LOCOMOTION
[3.0, G0600]
On or around (HS REF DATE) did (he/she) use…
HA24BCOD
HA24B
CODE ALL
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
HA25PRBC
BOX HA14B
routing
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
GO TO HA25PREB - HA25PRBC.
CONTINENCE
HA25PREB
CODE ONE
The next questions are about (SP)'s bowel and bladder control on or around (HS REF DATE).
(01) CONTINUE
HA24B - HA24BCOD
(01) a cane or crutch?
(02) a walker?
(03) a manual or electric wheelchair?
(04) a limb prosthesis?
(96) NONE CHECKED
(-8) Don't Know
BOX HA14B
(01) CONTINUE
HA25B - CTBOWELC
PRESS "1" TO CONTINUE.
CONTINENCE
[3.0, H0400]
CTBOWELC
HA25B
CODE ONE
What was the level of (SP)'s bowel control on or around (HS REF DATE)? Was (she/he)
always continent, occasionally incontinent, frequently incontinent, always incontinent, or was
(she/he) not rated?
CONTINENCE
[3.0, H0300]
CTBLADDC
HA28PRBC
HA26B
CODE ONE
HA28PREB
CODE ONE
BOX HA28B
routing
What was the level of (SP)'s bladder control on or around (HS REF DATE)? Was (she/he) always
continent, occasionally incontinent, frequently incontinent, always incontinent, or was (she/he) not
rated?
(00) ALWAYS CONTINENT
(01) OCCASIONALLY INCONTINENT
(02) FREQUENTLY INCONTINENT
(03) ALWAYS INCONTINENT
(04) NOT RATED
(-8) Don't Know
(-9) Refused
(00) ALWAYS CONTINENT
(01) OCCASIONALLY INCONTINENT
(02) FREQUENTLY INCONTINENT
(03) ALWAYS INCONTINENT
(04) NOT RATED
(-8) Don't Know
(-9) Refused
The questions in the next section deal with (SP)'s active diagnoses or conditions during the time on or
around (HS REF DATE). [By active I mean those diseases associated with (her/his) ADL status, cognition,
behavior, medical treatments, or risk of death on or around (HS REF DATE). Please think about what is (01) CONTINUE
in (SP)'s medical record when answering the following questions.]
PRESS "1" TO CONTINUE.
IF XPRIMARY <> EMPTY OR CCN=NON-MISSING , GO TO HA28B - HA28BCD1.
ELSE GO TO HA28B2 - HA28BCD2.
HA26B - CTBLADDC
HA28PREB - HA28PRBC
BOX HA28B
DIAGNOSES/CONDITIONS
[3.0, Section I
MDS ASSESSMENT DATE: (ASSESSMENT DATE)]
HA28BCD1
HA28B
CODE ALL
What active diseases were checked on (SP)'s MDS assessment?
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
(01) ALZHEIMER'S DISEASE
(02) ANEMIA
(03) ANXIETY DISORDER
(04) APHASIA
(05) ARTHRITIS
(06) ASTHMA, COPD, OR CHRONIC LUNG DISEASE
(07) ATRIAL FIBRILLATION OR OTHER
DYSRHYTHMIAS
(08) BENIGN PROSTATIC HYPERPLASIA
(09) CANCER
(10) CATARACTS, GLAUCOMA, OR MACULAR
DEGENERATION
(11) CEREBRAL PALSY
(12) CEREBROVASCULAR ACCIDENT (CVA),
TRANSIENT ISCHEMIC ATTACK (TIA), OR STROKE
(13) CIRRHOSIS
(14) CORONARY ARTERY DISEASE (E.G., ANGINA,
MI, AND ASHD)
(15) DEEP VENOUS THROMBOSIS (DVT),
PULMONARY EMBOLUS (PE) OR PULMONARY
THROMBO-EMBOLISM (PTE)
(16) DEMENTIA, OTHER THAN ALZHEIMER'S
(17) DEPRESSION
(18) DIABETES MELLITUS (E.G., DIABETIC
RETINOPATHY, NEPHROPATHY, AND
NEUROPATHY)
(19) GASTROESOPHAGEAL REFLUX DISEASE
(GERD) OR ULCER
(20) HEART FAILURE (E.G., CONGESTIVE HEART
FAILURE (CHF) AND PULMONARY EDEMA)
(21) HEMIPLEGIA/HEMIPARESIS
(22) HIP FRACTURE
(23) HUNTINGTON'S DISEASE
(24) HYPERKALEMIA
(25) HYPERLIPIDEMIA (E.G.,
HYPERCHOLESTEROLEMIA)
(26) HYPERTENSION
(27) HYPONATREMIA
(28) MALNUTRITION OR AT RISK FOR
MALNUTRITION
(29) MANIC DEPRESSION (BIPOLAR DISEASE)
(30) MULTIPLE SCLEROSIS
(31) NEUROGENIC BLADDER
(32) OBSTRUCTIVE UROPATHY
(33) ORTHOSTATIC HYPOTENSION
(34) OSTEOPOROSIS
(35) OTHER FRACTURE
(36) PARAPLEGIA
(37) PARKINSON'S DISEASE
(38) PERIPHERAL VASCULAR DISEASE (PVD) OR
PERIPHERAL ARTERIAL DISEASE (PAD)
(39) POST TRAUMATIC STRESS DISORDER (PTSD)
(40) PSYCHOTIC DISORDER (OTHER THAN
SCHIZOPHRENIA)
(41) QUADRIPLEGIA
(42) RENAL INSUFFICIENCY, RENAL FAILURE, OR
(01) HA29B - HA29BCOD
(02) HA29B - HA29BCOD
(03) HA29B - HA29BCOD
(04) HA29B - HA29BCOD
(05) HA29B - HA29BCOD
(06) HA29B - HA29BCOD
(07) HA29B - HA29BCOD
(08) HA29B - HA29BCOD
(09) HA29B - HA29BCOD
(10) HA29B - HA29BCOD
(11) HA29B - HA29BCOD
(12) HA29B - HA29BCOD
(13) HA29B - HA29BCOD
(14) HA29B - HA29BCOD
(15) HA29B - HA29BCOD
(16) HA29B - HA29BCOD
(17) HA29B - HA29BCOD
(18) HA29B - HA29BCOD
(19) HA29B - HA29BCOD
(20) HA29B - HA29BCOD
(21) HA29B - HA29BCOD
(22) HA29B - HA29BCOD
(23) HA29B - HA29BCOD
(24) HA29B - HA29BCOD
(25) HA29B - HA29BCOD
(26) HA29B - HA29BCOD
(27) HA29B - HA29BCOD
(28) HA29B - HA29BCOD
(29) HA29B - HA29BCOD
(30) HA29B - HA29BCOD
(31) HA29B - HA29BCOD
(32) HA29B - HA29BCOD
(33) HA29B - HA29BCOD
(34) HA29B - HA29BCOD
(35) HA29B - HA29BCOD
(36) HA29B - HA29BCOD
(37) HA29B - HA29BCOD
(38) HA29B - HA29BCOD
(39) HA29B - HA29BCOD
(40) HA29B - HA29BCOD
(41) HA29B - HA29BCOD
(42) HA29B - HA29BCOD
(43) HA29B - HA29BCOD
(44) HA29B - HA29BCOD
(45) HA29B - HA29BCOD
(46) HA29B - HA29BCOD
(47) HA29B - HA29BCOD
HA28BOSP
HA28B
VERBATIM TEXT
OTHER (SPECIFY)
(SHOW CARD HA3)
HA28BCD2
HA28B2
CODE ALL
Look at the following list and tell me what active diseases did (SP) have on or around (HS REF DATE).
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
( )
,
,
END-STAGE RENAL DISEASE (ESRD)
(43) RESPIRATORY FAILURE
(44) SCHIZOPHRENIA
(45) SEIZURE DISORDER OR EPILEPSY
(46) THYROID DISORDER (E.G.,
HYPOTHYROIDISM, HYPERTHYROIDISM, AND
HASHIMOTO'S THYROIDITIS)
(47) TOURETTE'S SYNDROME
(48) TRAUMATIC BRAIN INJURY
(49) ULCERATIVE COLITIS, CROHN'S DISEASE, OR
INFLAMMATORY BOWEL DISEASE
(91) OTHER
(96) NONE OF THE ABOVE
( )
(48) HA29B - HA29BCOD
(49) HA29B - HA29BCOD
(91) HA28B - HA28BOSP
(96) HA29B - HA29BCOD
(01) CONTINUOUS ANSWER
HA29B - HA29BCOD
(01) ALZHEIMER'S DISEASE
(02) ANEMIA
(03) ANXIETY DISORDER
(04) APHASIA
(05) ARTHRITIS
(06) ASTHMA, COPD, OR CHRONIC LUNG DISEASE
(07) ATRIAL FIBRILLATION OR OTHER
DYSRHYTHMIAS
(08) BENIGN PROSTATIC HYPERPLASIA
(09) CANCER
(10) CATARACTS, GLAUCOMA, OR MACULAR
DEGENERATION
(11) CEREBRAL PALSY
(12) CEREBROVASCULAR ACCIDENT (CVA),
TRANSIENT ISCHEMIC ATTACK (TIA), OR STROKE
(13) CIRRHOSIS
(14) CORONARY ARTERY DISEASE (E.G., ANGINA,
MI, AND ASHD)
(15) DEEP VENOUS THROMBOSIS (DVT),
PULMONARY EMBOLUS (PE) OR PULMONARY
THROMBO-EMBOLISM (PTE)
(16) DEMENTIA, OTHER THAN ALZHEIMER'S
(17) DEPRESSION
(18) DIABETES MELLITUS (E.G., DIABETIC
RETINOPATHY, NEPHROPATHY, AND
NEUROPATHY)
(19) GASTROESOPHAGEAL REFLUX DISEASE
(GERD) OR ULCER
(20) HEART FAILURE (E.G., CONGESTIVE HEART
FAILURE (CHF) AND PULMONARY EDEMA)
(21) HEMIPLEGIA/HEMIPARESIS
(22) HIP FRACTURE
(23) HUNTINGTON'S DISEASE
(24) HYPERKALEMIA
(25) HYPERLIPIDEMIA (E.G.,
HYPERCHOLESTEROLEMIA)
(26) HYPERTENSION
(27) HYPONATREMIA
(28) MALNUTRITION OR AT RISK FOR
MALNUTRITION
(29) MANIC DEPRESSION (BIPOLAR DISEASE)
(30) MULTIPLE SCLEROSIS
(31) NEUROGENIC BLADDER
(32) OBSTRUCTIVE UROPATHY
(33) ORTHOSTATIC HYPOTENSION
(34) OSTEOPOROSIS
(35) OTHER FRACTURE
(01) HA29B - HA29BCOD
(02) HA29B - HA29BCOD
(03) HA29B - HA29BCOD
(04) HA29B - HA29BCOD
(05) HA29B - HA29BCOD
(06) HA29B - HA29BCOD
(07) HA29B - HA29BCOD
(08) HA29B - HA29BCOD
(09) HA29B - HA29BCOD
(10) HA29B - HA29BCOD
(11) HA29B - HA29BCOD
(12) HA29B - HA29BCOD
(13) HA29B - HA29BCOD
(14) HA29B - HA29BCOD
(15) HA29B - HA29BCOD
(16) HA29B - HA29BCOD
(17) HA29B - HA29BCOD
(18) HA29B - HA29BCOD
(19) HA29B - HA29BCOD
(20) HA29B - HA29BCOD
(21) HA29B - HA29BCOD
(22) HA29B - HA29BCOD
(23) HA29B - HA29BCOD
(24) HA29B - HA29BCOD
(25) HA29B - HA29BCOD
(26) HA29B - HA29BCOD
(27) HA29B - HA29BCOD
(28) HA29B - HA29BCOD
(29) HA29B - HA29BCOD
(30) HA29B - HA29BCOD
(31) HA29B - HA29BCOD
(32) HA29B - HA29BCOD
(33) HA29B - HA29BCOD
(34) HA29B - HA29BCOD
(35) HA29B - HA29BCOD
(36) HA29B - HA29BCOD
(37) HA29B - HA29BCOD
(38) HA29B - HA29BCOD
(36) PARAPLEGIA
(37) PARKINSON'S DISEASE
(38) PERIPHERAL VASCULAR DISEASE (PVD) OR
PERIPHERAL ARTERIAL DISEASE (PAD)
(39) POST TRAUMATIC STRESS DISORDER (PTSD)
(40) PSYCHOTIC DISORDER (OTHER THAN
SCHIZOPHRENIA)
(41) QUADRIPLEGIA
(42) RENAL INSUFFICIENCY, RENAL FAILURE, OR
END-STAGE RENAL DISEASE (ESRD)
(43) RESPIRATORY FAILURE
(44) SCHIZOPHRENIA
(45) SEIZURE DISORDER OR EPILEPSY
(46) THYROID DISORDER (E.G.,
HYPOTHYROIDISM, HYPERTHYROIDISM, AND
HASHIMOTO'S THYROIDITIS)
(47) TOURETTE'S SYNDROME
(48) TRAUMATIC BRAIN INJURY
(49) ULCERATIVE COLITIS, CROHN'S DISEASE, OR
INFLAMMATORY BOWEL DISEASE
(91) OTHER
(96) NONE OF THE ABOVE
(-8) DON'T KNOW
(-9) REFUSED
DIAGNOSES/CONDITIONS
[3.0, Section I
MDS ASSESSMENT DATE: (ASSESSMENT DATE)]
(SHOW CARD HA4)
HA29BCOD
HA29B
BOX HA15B
OTMDSDIA
HA30B
CODE ALL
routing
YES/NO
[What active infections were checked on (SP)'s MDS assessment?]
[Look at the following list and tell me what active infections (SP) had on or around (HS REF DATE)
according to the medical record notes.]
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
WHEN ABSTRACTING FROM THE MDS, ONLY SELECT "96-NONE OF THE ABOVE" IF THAT IS THE BOX
CHECKED ON THE MDS.
IF XPRIMARY <> EMPTY, GO TO HA30B - OTMDSDIA.
ELSE GO TO BOX HA16B.
DIAGNOSES/CONDITIONS
[3.0, I8000
MDS ASSESSMENT DATE: (ASSESSMENT DATE)]
Were there any active diagnoses entered on the MDS form in the section for additional active
diagnoses?
(39) HA29B - HA29BCOD
(40) HA29B - HA29BCOD
(41) HA29B - HA29BCOD
(42) HA29B - HA29BCOD
(43) HA29B - HA29BCOD
(44) HA29B - HA29BCOD
(45) HA29B - HA29BCOD
(46) HA29B - HA29BCOD
(47) HA29B - HA29BCOD
(48) HA29B - HA29BCOD
(49) HA29B - HA29BCOD
(91) DO NOT DISPLAY
(96) HA29B - HA29BCOD
(-8) HA29B - HA29BCOD
(-9) HA29B - HA29BCOD
(01) MULTIDRUG-RESISTANT ORGANISM (MDRO)
(02) PNEUMONIA
(03) SEPTICEMIA
(04) TUBERCULOSIS
(05) URINARY TRACT INFECTION IN LAST 30 DAYS
BOX HA15B
(06) VIRAL HEPATITIS
(07) WOUND INFECTION (OTHER THAN FOOT)
(96) NONE OF THE ABOVE
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX HA16B
(01) HA31B - HA31BCOD
(-8) BOX HA16B
(-9) BOX HA16B
DIAGNOSES/CONDITIONS
[3.0, Section I]
SHOW CARD HA5
HA31BCOD
HA31B
code all
What were the diagnoses?
SELECT ALL THAT APPLY
SEPARATE RESPONSES BY USING THE SPACEBAR.
ENTER ICD-9 10 CODES WHEN DIAGNOSIS TEXT IS MISSING OR ILLEGIBLE.
MDCOTH1
BOX HA16A1
routing
HA31BO1
text
BOX HA16A2
routing
IF HA31B - HA31BCOD INCLUDES 91 90/Other1, THEN GO TO HA31BO1 - MDCOTH1.
ELSE GO TO BOX HA16A2.
ENTER OTHER DIAGNOSIS 1.
OTHER (SPECIFY)
IF HA31B - HA31BCOD INCLUDES 92 91/Other2, THEN GO TO HA31BO2 - MDCOTH2.
ELSE GO TO BOX HA16A3.
(01) AGITATION
(02) ALCOHOL DEPENDENCY
(03) ALLERGIES
(04) ANOREXIA
(05) AORTIC STENOSIS
(06) ATAXIA
(07) ATYPICAL PSYCHOSIS
(08) BLINDNESS
(09) BREAST DISORDERS
(10) CATARACTS
(11) CEREBRAL DEGENERATION
(12) CLINICAL OBESITY
(13) CLOSTRIDIUM DIFFICILE (C.DIFF.)
(14) CONJUNCTIVITIS
(15) CONSTIPATION
(16) DEGENERATIVE JOINT DISEASE
(17) DIAPHRAGMATIC HERNIA (HIATAL HERNIA)
(18) DIVERTICULA OF COLON
(19) DOWN'S SYNDROME
(20) DYSPHAGIA (SWALLOWING DIFFICULTIES)
(21) EDEMA (OTHER THAN PULMONARY)
(22) GASTRITIS/DUODENITIS
(23) GASTROENTERITIS, NONINFECTIOUS
(24) GASTROINTESTINAL HEMORRHAGE
(25) GOUT
(26) HEMORRHAGE OF ESOPHAGUS
(27) HIV INFECTION
(01) BOX HA16A1
(02) BOX HA16A1
(03) BOX HA16A1
(04) BOX HA16A1
(05) BOX HA16A1
(06) BOX HA16A1
(07) BOX HA16A1
(08) BOX HA16A1
(09) BOX HA16A1
(10) DO NOT DISPLAY.
(11) BOX HA16A1
(12) BOX HA16A1
(13) BOX HA16A1
(14) BOX HA16A1
(15) BOX HA16A1
(16) BOX HA16A1
(17) BOX HA16A1
(18) BOX HA16A1
(19) BOX HA16A1
(20) BOX HA16A1
(21) BOX HA16A1
(22) BOX HA16A1
(23) BOX HA16A1
(24) BOX HA16A1
(25) BOX HA16A1
(26) BOX HA16A1
(28) HYPERPLASIA OF PROSTATE
(29) HYPOPOTASSEMIA/HYPOKALEMIA
(30) HYPOTENSION (OTHER THAN ORTHOSTATIC)
(31) INSOMNIA
(32) KYPHOSIS
(33) MISSING LIMB (E.G., AMPUTATION)
(34) NONPSYCHOTIC BRAIN SYNDROME
(35) ORGANIC BRAIN SYNDROME
(36) OSTEOARTHRITIS
(37) PATHOLOGICAL BONE FRACTURE
(38) RENAL URETERAL DISORDER
(39) RESPIRATORY INFECTION
(40) SCOLIOSIS
(41) SEXUALLY TRANSMITTED DISEASES
(42) SPINAL STENOSIS
(43) ULCER OF LEG, CHRONIC
(44) URINARY RETENTION
(45) VERTIGO
(91) (90) OTHER DIAGNOSIS 1
(92) (91) OTHER DIAGNOSIS 2
(93) (92) OTHER DIAGNOSIS 3
(94) (93) OTHER DIAGNOSIS 4
(94) OTHER DIAGNOSIS 5
(95) OTHER DIAGNOSIS 6
(96) OTHER DIAGNOSIS 7
(97) OTHER DIAGNOSIS 8
(98) OTHER DIAGNOSIS 9
(99) OTHER DIAGNOSIS 10
(27) BOX HA16A1
(28) BOX HA16A1
(29) BOX HA16A1
(30) BOX HA16A1
(31) BOX HA16A1
(32) BOX HA16A1
(33) BOX HA16A1
(34) BOX HA16A1
(35) BOX HA16A1
(36) BOX HA16A1
(37) BOX HA16A1
(38) BOX HA16A1
(39) BOX HA16A1
(40) BOX HA16A1
(41) BOX HA16A1
(42) BOX HA16A1
(43) BOX HA16A1
(44) BOX HA16A1
(45) BOX HA16A1
(90) BOX HA16A1
(91) BOX HA16A1
(92) BOX HA16A1
(93) BOX HA16A1
(94) BOX HA16A1
(95) BOX HA16A1
(96) BOX HA16A1
(97) BOX HA16A1
(98) BOX HA16A1
(99) BOX HA16A1
(01) CONTINUOUS ANSWER
BOX HA16A2
MDCOTH2
MDCOTH3
MDCOTH4
MDCOTH5
MDCOTH6
MDCOTH7
MDCOTH8
MDCOTH9
MDCOTH10
HA34PRBC
HA31BO2
TEXT
BOX HA16A3
routing
HA31BO3
TEXT
BOX HA16A4
routing
HA31BO4
TEXT
BOX HA16A5
routing
HA31BO5
TEXT
BOX HA16A6
routing
HA31BO6
TEXT
BOX HA16A7
routing
HA31BO7
TEXT
BOX HA16A8
routing
HA31BO8
TEXT
BOX HA16A9
routing
HA31BO9
TEXT
BOX HA16A10
routing
HA31BO10
TEXT
BOX HA16B
routing
HA34PREB
CODE ONE
ENTER OTHER DIAGNOSIS 2.
OTHER (SPECIFY)
IF HA31B - HA31BCOD INCLUDES 93 92/Other3, THEN GO TO HA31BO3 - MDCOTH3.
ELSE GO TO BOX HA16A4.
ENTER OTHER DIAGNOSIS 3.
OTHER (SPECIFY)
IF HA31B - HA31BCOD INCLUDES 94 93/Other4, THEN GO TO HA31BO4 - MDCOTH4.
ELSE GO TO BOX HA16B.
ENTER OTHER DIAGNOSIS 4.
OTHER (SPECIFY)
IF HA31B - HA31BCOD INCLUDES 94/Other5, THEN GO TO HA31BO5 - MDCOTH5.
ELSE GO TO BOX HA16B.
ENTER OTHER DIAGNOSIS 5.
OTHER (SPECIFY)
IF HA31B - HA31BCOD INCLUDES 95/Other6, THEN GO TO HA31BO6 - MDCOTH6.
ELSE GO TO BOX HA16B.
ENTER OTHER DIAGNOSIS 6.
OTHER (SPECIFY)
IF HA31B - HA31BCOD INCLUDES 96/Other7, THEN GO TO HA31BO7 - MDCOTH7.
ELSE GO TO BOX HA16B.
ENTER OTHER DIAGNOSIS 7.
OTHER (SPECIFY)
IF HA31B - HA31BCOD INCLUDES 97/Other8, THEN GO TO HA31BO8 - MDCOTH8.
ELSE GO TO BOX HA16B.
ENTER OTHER DIAGNOSIS 8.
OTHER (SPECIFY)
IF HA31B - HA31BCOD INCLUDES 98/Other9, THEN GO TO HA31BO9 - MDCOTH9.
ELSE GO TO BOX HA16B.
ENTER OTHER DIAGNOSIS 9.
OTHER (SPECIFY)
IF HA31B - HA31BCOD INCLUDES 99/Other10, THEN GO TO HA31BO10 - MDCOTH10.
ELSE GO TO BOX HA16B.
ENTER OTHER DIAGNOSIS 10.
OTHER (SPECIFY)
IF HA11B - COMATOSE = 1/YesComatose, GO TO BOX HA16AB.
ELSE IF CCN=NON-MISSING THEN GO TO HA10B-HA10BCOD.
ELSE, GO TO HA34PREB - HA34PRBC.
DEHYDRATION
The next few items are about the other conditions (SP) may have had on or around (HS REF DATE).
(Again, please refer to the MDS.)
PRESS "1" TO CONTINUE.
DEHYDRATION
[3.0, J1550]
DEHYD
HA34B
YES/NO
Did (SP) experience dehydration on or around (HS REF DATE)? PRESS F1 KEY FOR COMPLETE
DEFINITIONS.
SWALLOWING/ORAL PROBLEMS
[3.0, K0100]
On or around (HS REF DATE), did (SP) experience the swallowing problem of…
HA37ABCO
HA37AB
CODE ALL
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
WHEN ABSTRACTING FROM THE MDS, ONLY SELECT "96-NONE OF THE ABOVE" IF THAT IS THE BOX
CHECKED ON THE MDS.
(01) CONTINUOUS ANSWER
BOX HA16A3
(01) CONTINUOUS ANSWER
BOX HA16A4
(01) CONTINUOUS ANSWER
BOX HA16B BOX HA16A5
(01) CONTINUOUS ANSWER
BOX HA16A6
(01) CONTINUOUS ANSWER
BOX HA16A7
(01) CONTINUOUS ANSWER
BOX HA16A8
(01) CONTINUOUS ANSWER
BOX HA16A9
(01) CONTINUOUS ANSWER
BOX HA16A10
(01) CONTINUOUS ANSWER
BOX HA16B
(01) CONTINUE
HA34B - DEHYD
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
HA37AB - HA37ABCO
(01) a loss of liquids or solids from mouth when
eating or drinking?
(02) holding food in mouth or cheeks or residual
food in mouth after meals?
(03) coughing or choking during meals or when
swallowing medications?
(04) complaints of difficulty or pain with
swallowing?
(96) NONE OF THE ABOVE
(-8) Don't Know
(-9) Refused
(01) HA37BB - HA37BBCO
(02) HA37BB - HA37BBCO
(03) HA37BB - HA37BBCO
(04) HA37BB - HA37BBCO
(96) HA37BB - HA37BBCO
SWALLOWING/ORAL PROBLEMS
[3.0, L0200]
On or around (HS REF DATE), did (SP) experience the oral problem of…
HA37BBCO
HA37BB
CODE ALL
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
WHEN ABSTRACTING FROM THE MDS, ONLY SELECT "96-NONE OF THE ABOVE" IF THAT IS THE BOX
CHECKED ON THE MDS.
BOX HA16AB
HEIGHT
FCWEIGHT
HA38B
routing
CODE ONE
HA39B
CODE ONE
BOX HA17BB
routing
HA10B
CODE ALL
(01) BOX HA16AB
(02) BOX HA16AB
(03) BOX HA16AB
(04) BOX HA16AB
(05) BOX HA16AB
(06) BOX HA16AB
(07) BOX HA16AB
(96) BOX HA16AB
(01) Continuous
(-8) Don't Know
(-9) Refused
(01) HA39B - FCWEIGHT
(-8) HA39B - FCWEIGHT
(-9) HA39B - FCWEIGHT
(01) Continuous
(-8) Don't Know
(-9) Refused
(01) BOX HA17BB
(-8) BOX HA17BB
(-9) BOX HA17BB
(01)a Living Will?
(02) instructions not to resuscitate?
(03) instructions not to hospitalize?
(04) restrictions on feeding, medication, or other
treatment restrictions?
(96) NONE CHECKED
(-8) Don't Know
(01)HA32 - OTACTDIA
(02) HA32 - OTACTDIA
(03) HA32 - OTACTDIA
(04) HA32 - OTACTDIA
(96) HA32 - OTACTDIA
(-8) HA32 - OTACTDIA
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX HA15A
(01) HA33 - HA33CODE
(-8) BOX HA15A
(-9) BOX HA15A
IF PERS.PERSRNDC = CURRENT ROUND, OR CURRENT ROUND IS FALL ROUND, GO TO HA38B - HEIGHT.
ELSE, GO TO HA39B - FCWEIGHT.
ORAL/NUTRITIONAL STATUS
[3.0, K0200]
What (is/was) (SP)'s height in inches?
ORAL/NUTRITIONAL STATUS
[3.0, K0200]
What was (SP)'s weight on or around (HS REF DATE)?
GO TO HA10B - HA10BCOD.
ADVANCED DIRECTIVES
NOT ON MDS
(The rest of the health status questionnaire is not from the MDS.)
HA10BCOD
(01) broken or loosely fitting full or partial
denture?
(02) no natural teeth or tooth fragments?
(03) abnormal mouth tissue (ulcers, masses, oral
lesions)?
(04) obvious or likely cavity or broken natural
teeth?
(05) inflamed or bleeding gums or loose natural
teeth?
(06) mouth or facial pain, discomfort or difficulty
with chewing?
(07) UNABLE TO EXAMINE
(96) NONE OF THE ABOVE
(-8) Don't Know
(-9) Refused
Now, please tell me which of the following advanced directives were listed in (SP)'s record or chart for
the period on or around (HS REF DATE).
Did (SP)'s record indicate…
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
DIAGNOSES/CONDITIONS
NOT ON MDS
OTACTDIA
HA32
YES/NO
Can you add any other active diagnoses for (SP) on or around (HS REF DATE) that have not yet been
mentioned? Please refer to the medical record including (SP)'s medications chart for (HS REF DATE
MONTH).
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
DIAGNOSES/CONDITIONS
NOT ON MDS
SHOW CARD HA5
HA33CODE
HA33
CODE ALL
What were the diagnoses?
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
ENTER ICD-9 10 CODES, IF AVAILABLE, WHEN DIAGNOSIS TEXT IS MISSING OR ILLEGIBLE.
NMDCOTH1
BOX HA15AA1
routing
IF HA33 - HA33CODE INCLUDES 91 90/Other1, THEN GO TO HA33O1 - NMDCOTH1.
ELSE GO TO BOX HA15AA2.
HA33O1
TEXT
ENTER OTHER DIAGNOSIS 1.
OTHER (SPECIFY)
BOX HA15AA2
routing
IF HA33 - HA33CODE INCLUDES 92 91/Other2, THEN GO TO HA33O2 - NMDCOTH2.
ELSE GO TO BOX HA15AA3.
(1) AGITATION
(2) ALCOHOL DEPENDENCY
(3) ALLERGIES
(4) ANOREXIA
(5) AORTIC STENOSIS
(6) ATAXIA
(7) ATYPICAL PSYCHOSIS
(8) BLINDNESS
(9) BREAST DISORDERS
(10) CATARACTS
(11) CEREBRAL DEGENERATION
(12) CLINICAL OBESITY
(13) CLOSTRIDIUM DIFFICILE (C.DIFF.)
(14) CONJUNCTIVITIS
(15) CONSTIPATION
(16) DEGENERATIVE JOINT DISEASE
(17) DIAPHRAGMATIC HERNIA (HIATAL HERNIA)
(18) DIVERTICULA OF COLON
(19) DOWN'S SYNDROME
(20) DYSPHAGIA (SWALLOWING DIFFICULTIES)
(21) EDEMA (OTHER THAN PULMONARY)
(22) GASTRITIS/DUODENITIS
(23) GASTROENTERITIS, NONINFECTIOUS
(24) GASTROINTESTINAL HEMORRHAGE
(25) GOUT
(26) HEMORRHAGE OF ESOPHAGUS
(27) HIV INFECTION
(1) BOX HA15AA1
(2) BOX HA15AA1
(3) BOX HA15AA1
(4) BOX HA15AA1
(5) BOX HA15AA1
(6) BOX HA15AA1
(7) BOX HA15AA1
(8) BOX HA15AA1
(9) BOX HA15AA1
(10) DO NOT DISPLAY
(11) BOX HA15AA1
(12 )BOX HA15AA1
(13) BOX HA15AA1
(14) BOX HA15AA1
(15) BOX HA15AA1
(16) BOX HA15AA1
(17) BOX HA15AA1
(18) BOX HA15AA1
(19) BOX HA15AA1
(20) BOX HA15AA1
(21) BOX HA15AA1
(22) BOX HA15AA1
(23) BOX HA15AA1
(24) BOX HA15AA1
(25) BOX HA15AA1
(26) BOX HA15AA1
(28) HYPERPLASIA OF PROSTATE
(29) HYPOPOTASSEMIA/HYPOKALEMIA
(30) HYPOTENSION (OTHER THAN ORTHOSTATIC)
(31) INSOMNIA
(32) KYPHOSIS
(33) MISSING LIMB (E.G., AMPUTATION)
(34) NONPSYCHOTIC BRAIN SYNDROME
(35) ORGANIC BRAIN SYNDROME
(36) OSTEOARTHRITIS
(37) PATHOLOGICAL BONE FRACTURE
(38) RENAL URETERAL DISORDER
(39) RESPIRATORY INFECTION
(40) SCOLIOSIS
(41) SEXUALLY TRANSMITTED DISEASES
(42) SPINAL STENOSIS
(43) ULCER OF LEG, CHRONIC
(44) URINARY RETENTION
(45) VERTIGO
(91) (90) OTHER DIAGNOSIS 1
(92) (91) OTHER DIAGNOSIS 2
(93) (92) OTHER DIAGNOSIS 3
(94) (93) OTHER DIAGNOSIS 4
(94) OTHER DIAGNOSIS 5
(95) OTHER DIAGNOSIS 6
(96) OTHER DIAGNOSIS 7
(97)OTHER DIAGNOSIS 8
(98) OTHER DIAGNOSIS 9
(99) OTHER DIAGNOSIS 10
(27) BOX HA15AA1
(28) BOX HA15AA1
(29) BOX HA15AA1
(30) BOX HA15AA1
(31) BOX HA15AA1
(32) BOX HA15AA1
(33) BOX HA15AA1
(34) BOX HA15AA1
(35) BOX HA15AA1
(36) BOX HA15AA1
(37) BOX HA15AA1
(38) BOX HA15AA1
(39) BOX HA15AA1
(40) BOX HA15AA1
(41) BOX HA15AA1
(42) BOX HA15AA1
(43) BOX HA15AA1
(44) BOX HA15AA1
(45) BOX HA15AA1
(90) BOX HA15AA1
(91) BOX HA15AA1
(92) BOX HA15AA1
(93) BOX HA15AA1
(94) BOX HA15AA1
(95) BOX HA15AA1
(96) BOX HA15AA1
(97) BOX HA15AA1
(98) BOX HA15AA1
(99) BOX HA15AA1
(01) Continuous
BOX HA15AA2
NMDCOTH2
NMDCOTH3
NMDCOTH4
NMDCOTH5
NMDCOTH6
NMDCOTH7
NMDCOTH8
NMDCOTH9
NMDCOTH10
HA33PREC
HA33O2
TEXT
ENTER OTHER DIAGNOSIS 2.
OTHER (SPECIFY)
BOX HA15AA3
routing
IF HA33 - HA33CODE INCLUDES 93 92/Other3, THEN GO TO HA33O3 - NMDCOTH3.
ELSE GO TO BOX HA15AA4.
HA33O3
TEXT
ENTER OTHER DIAGNOSIS 3.
OTHER (SPECIFY)
BOX HA15AA4
routing
IF HA33 - HA33CODE INCLUDES 94 93/Other4, THEN GO TO HA33O4 - NMDCOTH4.
ELSE GO TO BOX HA15A.
HA33O4
TEXT
ENTER OTHER DIAGNOSIS 4.
OTHER (SPECIFY)
BOX HA15AA5
routing
IF HA33 - HA33CODE INCLUDES 94/Other5, THEN GO TO HA33O5 - NMDCOTH5.
ELSE GO TO BOX HA15A.
HA33O45
TEXT
ENTER OTHER DIAGNOSIS 5.
OTHER (SPECIFY)
BOX HA15AA6
routing
IF HA33 - HA33CODE INCLUDES 95/Other6, THEN GO TO HA33O6 - NMDCOTH6.
ELSE GO TO BOX HA15A.
HA33O6
TEXT
ENTER OTHER DIAGNOSIS 6.
OTHER (SPECIFY)
BOX HA15AA7
routing
IF HA33 - HA33CODE INCLUDES 96/Other7, THEN GO TO HA33O7 - NMDCOTH7.
ELSE GO TO BOX HA15A.
HA33O7
TEXT
ENTER OTHER DIAGNOSIS 7.
OTHER (SPECIFY)
BOX HA15AA8
routing
IF HA33 - HA33CODE INCLUDES 97/Other8, THEN GO TO HA33O8 - NMDCOTH8.
ELSE GO TO BOX HA15A.
HA33O8
TEXT
ENTER OTHER DIAGNOSIS 8.
OTHER (SPECIFY)
BOX HA15AA9
routing
IF HA33 - HA33CODE INCLUDES 98/Other9, THEN GO TO HA33O9 - NMDCOTH9.
ELSE GO TO BOX HA15A.
HA33O9
TEXT
ENTER OTHER DIAGNOSIS 9.
OTHER (SPECIFY)
BOX HA15AA10
routing
IF HA33 - HA33CODE INCLUDES 99/Other10, THEN GO TO HA33O10 - NMDCOTH10.
ELSE GO TO BOX HA15A.
HA3310
TEXT
ENTER OTHER DIAGNOSIS 10.
OTHER (SPECIFY)
BOX HA15A
routing
HA33PRE
CODE ONE
IF HA28B - HA28BCD1 OR HA28B2 - HA28BCD2 INCLUDES 9/Cancer, GO TO HA33PRE - HA33PREC.
ELSE, GO TO HA33D - MYOCARD.
[While you are referring to (SP)'s medical record/(Now)] I have some (additional) questions about the
conditions you mentioned earlier. (These questions cannot be found on the MDS).
(01) Continuous
BOX HA15AA3
(01) Continuous
BOX HA15AA4
(01) CONTINUE
BOX HA15A BOX HA15AA5
(01) CONTINUE
BOX HA15AA6
(01) CONTINUE
BOX HA15AA7
(01) CONTINUE
BOX HA15AA8
(01) CONTINUE
BOX HA15AA9
(01) CONTINUE
BOX HA15AA10
(01) CONTINUE
BOX HA15A
(01) CONTINUE
HA33B - HA33BCOD
(01) BLADDER
(02) BREAST
(03) CERVIX
(04) COLON, RECTUM, OR BOWEL
(05) LUNG
(06) OVARY
(07) PROSTATE
(08) SKIN
(09) STOMACH
(10) UTERUS
(91) OTHER
(01) HA33D - MYOCARD
(02) HA33D - MYOCARD
(03) HA33D - MYOCARD
(04) HA33D - MYOCARD
(05) HA33D - MYOCARD
(06) HA33D - MYOCARD
(07) HA33D - MYOCARD
(08) HA33D - MYOCARD
(09) HA33D - MYOCARD
(10) HA33D - MYOCARD
(91) HA33B - CNROTHOS
(01) Continuous answer
HA33D - MYOCARD
PRESS "1" TO CONTINUE.
Please refer to (SP)'s medical record and tell me in what part or parts of the body was the cancer
found?
HA33BCOD
HA33B
CODE ALL
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
CNROTHOS
HA33B
TEXT
OTHER (SPECIFY)
MYOCARD
HA33D
YES/NO
CONDITIONS
NOT ON MDS
Still referring to the medical record, has (SP) ever had a myocardial infarction or heart attack?
CATAROP
HA33E
BOX HA15F
YES/NO
routing
VISION
NOT ON MDS
Has (SP) ever had an operation for cataracts?
IF CORE OR (SP IS CFR, FCF, CFC, OR FFC) OR (SP IS IPR AND PreloadSP.CURELAGE >= 65), GO TO BOX
HA17B.
IF NO CONDITIONS ARE INDICATED, GO TO HA33G - OTHCAUS.
ELSE, GO TO HA33F - CAUSEMCR.
You told me that (SP) has had [READ CONDITIONS LISTED BELOW.]
CAUSEMCR
HA33F
YES/NO
(Was this/Were any of these) the original cause of (SP)'s becoming eligible for Medicare?
OTHCAUS
HA33HCOD
HA33G
VERBATIM TEXT
BOX HA15E
routing
HA33H
CODE ALL
BOX HA17B
routing
What was the original cause of (SP)'s becoming eligible for Medicare?
RECORD VERBATIM
IF RESPONDENT REPORTED MORE THAN ONE CONDITION IN HA28B-HA33E, GO TO HA33H HA33HCOD.
ELSE, GO TO BOX HA17B.
Which of these conditions was a cause of (him/her) becoming eligible for Medicare?
IF SP IS FEMALE, GO TO HA43APRE - HA43APRC.
ELSE GO TO HA43DAPR - HA43DAPC.
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA33E - CATAROP
(01) HA33E - CATAROP
(-8) HA33E - CATAROP
(-9) HA33E - CATAROP
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX HA15F
(01) BOX HA15F
(-8) BOX HA15F
(-9) BOX HA15F
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA33G - OTHCAUS
(01) BOX HA15E
(-8) BOX HA17B
(-9) BOX HA17B
(01) Continous
BOX HA17B
(01) PLEASE SEE ITEM DISPLAY INSTRUCTIONS
BOX HA17B
(01) Continue
HA43A - MAMMOGR
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA43B - PAPSMEAR
(01) HA43B - PAPSMEAR
(-8) HA43B - PAPSMEAR
(-9) HA43B - PAPSMEAR
(00) BOX HA17C
(01) BOX HA17C
(-8) BOX HA17C
(-9) BOX HA17C
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX HA17CB
(01) BOX HA17CB
(-8) BOX HA17CB
(-9) BOX HA17CB
(00) BOX HA17CB
(01) BOX HA17CB
(-8) BOX HA17CB
(-9) BOX HA17CB
(01) Continue
HA43DA - DRECEXAM
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA43DB - BLOODPSA
(01) HA43DB - BLOODPSA
(-8) HA43DB - BLOODPSA
(-9) HA43DB - BLOODPSA
(00) BOX HA17CB
(01) BOX HA17CB
(-8) BOX HA17CB
(-9) BOX HA17CB
MAMMOGRAM/PAP SMEAR/HYSERECTOMY
NOT ON MDS
HA43APRC
HA43APRE
CODE ONE
The next items are about procedures (SP) may have had since (CURRENT MONTH AND DAY) a year ago.
PRESS "1" TO CONTINUE.
MAMMOGR
PAPSMEAR
HA43A
HA43B
BOX HA17C
HYSTEREC
EVERHYST
HA43DAPC
HA43C
HA43D
HA43DAPR
YES/NO
YES/NO
routing
YES/NO
YES/NO
CODE ONE
MAMMOGRAM/PAP SMEAR/HYSERECTOMY
NOT ON MDS
Since (MONTH & DAY OF TODAY'S DATE) a year ago has (SP) had a mammogram or breast x-ray?
MAMMOGRAM/PAP SMEAR/HYSERECTOMY
NOT ON MDS
Since (MONTH & DAY OF TODAY'S DATE) a year ago has (SP) had a Pap smear?
IF SP IS CFC or SP IS IPR OR ((SP IS FFC OR SP IS FCF) AND PreloadSP.HYSTFLAG <> 1/Indicated), GO TO
HA43D - EVERHYST.
ELSE IF PreloadSP.HYSTFLAG = 1/Indicated, GO TO BOX HA17CB.
ELSE, GO TO HA43C - HYSTEREC.
MAMMOGRAM/PAP SMEAR/HYSERECTOMY
NOT ON MDS
Since (MONTH & DAY OF TODAY'S DATE) a year ago has (SP) had a hysterectomy?
MAMMOGRAM/PAP SMEAR/HYSERECTOMY
NOT ON MDS
Has (SP) ever had a hysterectomy?
The next items are about procedures (SP) may have had since (MONTH & DAY OF TODAY'S DATE) a year
ago.
PRESS "1" TO CONTINUE.
DRECEXAM
HA43DA
YES/NO
Since (MONTH & DAY OF TODAY'S DATE) a year ago has (SP) had a digital rectal examination of the
prostate?
BLOODPSA
HA43DB
YES/NO
Since (MONTH & DAY OF TODAY'S DATE) a year ago has (SP) had a blood test for detection of prostate
cancer, such as a PSA?
BOX HA17CB
FLUSHOT
PNUESHOT
EVRSMOKE
routing
HA43DC
YES/NO
BOX HA17CA
routing
HA43DD
YES/NO
HA43E
YES/NO
BOX HA17D
routing
NOWSMOKE
HA43F
YES/NO
HA43GPRC
HA43GPRE
CODE ONE
IF FALL ROUND, GO TO HA43DC - FLUSHOT.
ELSE GO TO BOX HA17CA.
INFLUENZA VACCINE
[3.0, O0250]
(00) NO
Next, a question or two about shots people take to prevent certain illnesses. Did (SP) have a flu shot for (01) YES
(-8) Don't Know
last winter?
(-9) Refused
[EXPLAIN IF NECESSARY: Did (SP) have a flu shot anytime during the period from September (HS
PREVIOUS YEAR) through December (HS PREVIOUS YEAR)?]
IF PreloadSP.PSHOTFLG = 1/Indicated, GO TO HA43E - EVRSMOKE.
ELSE GO TO HA43DD - PNUESHOT.
PNEUMOCOCCAL VACCINE
(00) NO
[3.0, O0300]
(01) YES
(-8) Don't Know
Has (SP) ever had a shot for pneumonia?
(-9) Refused
SMOKING
(00) NO
NOT ON MDS
(01) YES
(-8) Don't Know
The next couple of questions are about smoking. Has (SP) ever smoked cigarettes, cigars, or pipe
(-9) Refused
tobacco?
IF HA11B - COMATOSE = 1/YesComatose, GO TO BOX HA23B.
ELSE IF HA43E - EVRSMOKE = 1/Yes AND SP IS ALIVE, GO TO HA43F - NOWSMOKE.
ELSE GO TO HA43GPRE - HA43GPRC.
SMOKING
(00) NO
NOT ON MDS
(01) YES
(-8) Don't Know
Does (SP) smoke now?
(-9) Refused
IADLS
NOT ON MDS
Now I'm going to ask about how difficult it was, on the average, for (SP) to do certain kinds of activities
(01) CONTINUE
on or around (HS REF DATE). Please tell me for each activity whether (SP) had no difficulty at all, a little
difficulty, some difficulty, a lot of difficulty, or was not able to do it.
PRESS "1" TO CONTINUE.
IADLS
NOT ON MDS
IADSTOOP
HA43G
CODE ONE
SHOW CARD HA6
On or around (HS REF DATE), how much difficulty, if any, did (SP) have…
stooping, crouching, or kneeling?
IADLS
NOT ON MDS
IADLIFT
HA43G
CODE ONE
SHOW CARD HA6
lifting or carrying objects as heavy as 10 pounds, like a sack of potatoes?
IADLS
NOT ON MDS
IADREACH
HA43G
CODE ONE
SHOW CARD HA6
reaching or extending arms above shoulder level?
(00) BOX HA17CA
(01) BOX HA17CA
(-8) BOX HA17CA
(-9) BOX HA17CA
(00) HA43E - EVRSMOKE
(01) HA43E - EVRSMOKE
(-8) HA43E - EVRSMOKE
(-9) HA43E - EVRSMOKE
(00) BOX HA17D
(01) BOX HA17D
(-8) BOX HA17D
(-9) BOX HA17D
(00) HA43GPRE - HA43GPRC
(01) HA43GPRE - HA43GPRC
(-8) HA43GPRE - HA43GPRC
(-9) HA43GPRE - HA43GPRC
HA43G - IADSTOOP
(00) NO DIFFICULTY AT ALL
(01) A LITTLE DIFFICULTY
(02) SOME DIFFICULTY
(03) A LOT OF DIFFICULTY
(04) NOT ABLE TO DO IT
(-8) Don't Know
(-9) Refused
(00) HA43G - IADLIFT
(01) HA43G - IADLIFT
(02) HA43G - IADLIFT
(03) HA43G - IADLIFT
(04) HA43G - IADLIFT
(-8) Don't Know
(-9) Refused
(00) NO DIFFICULTY AT ALL
(01) A LITTLE DIFFICULTY
(02) SOME DIFFICULTY
(03) A LOT OF DIFFICULTY
(04) NOT ABLE TO DO IT
(-8) Don't Know
(-9) Refused
(00) HA43G - IADREACH
(01) HA43G - IADREACH
(02) HA43G - IADREACH
(03) HA43G - IADREACH
(04) HA43G - IADREACH
(-8) HA43G - IADREACH
(-9) HA43G - IADREACH
(00) NO DIFFICULTY AT ALL
(01) A LITTLE DIFFICULTY
(02) SOME DIFFICULTY
(03) A LOT OF DIFFICULTY
(04) NOT ABLE TO DO IT
(-8) Don't Know
(-9) Refused
(00) HA43G - IADGRASP
(01) HA43G - IADGRASP
(02) HA43G - IADGRASP
(03) HA43G - IADGRASP
(04) HA43G - IADGRASP
(-8) HA43G - IADGRASP
(-9) HA43G - IADGRASP
IADLS
NOT ON MDS
IADGRASP
HA43G
CODE ONE
SHOW CARD HA6
either writing or handling and grasping small objects?
IADLS
NOT ON MDS
IADWALK
HA43G
CODE ONE
SHOW CARD HA6
walking a quarter of a mile - that is, about 2 or 3 blocks?
(00) NO DIFFICULTY AT ALL
(01) A LITTLE DIFFICULTY
(02) SOME DIFFICULTY
(03) A LOT OF DIFFICULTY
(04) NOT ABLE TO DO IT
(-8) Don't Know
(-9) Refused
(00) HA43G - IADWALK
(01) HA43G - IADWALK
(02) HA43G - IADWALK
(03) HA43G - IADWALK
(04) HA43G - IADWALK
(-8) HA43G - IADWALK
(-9) HA43G - IADWALK
(00) NO DIFFICULTY AT ALL
(01) A LITTLE DIFFICULTY
(02) SOME DIFFICULTY
(03) A LOT OF DIFFICULTY
(04) NOT ABLE TO DO IT
(-8) Don't Know
(-9) Refused
(00) HA43H1 - DIFUSEPH
(01) HA43H1 - DIFUSEPH
(02) HA43H1 - DIFUSEPH
(03) HA43H1 - DIFUSEPH
(04) HA43H1 - DIFUSEPH
(-8) HA43H1 - DIFUSEPH
(-9) HA43H1 - DIFUSEPH
IADLS
NOT ON MDS
DIFUSEPH
REASNOPH
DIFSHOP
REASNOSH
DIFMONEY
REASNOMM
HA43H1
HA43I1
HA43H2
HA43I2
HA43H3
CODE ONE
CODE ONE
CODE ONE
CODE ONE
CODE ONE
HA43I3
CODE ONE
BOX HA17F
routing
(00) NO
(01) YES
Now I'm going to ask about some everyday activities and whether (SP) had any difficulty doing them by (03) DOESN'T DO
(himself/herself) because of a health or physical problem on or around (HS REF DATE).
(-8) Don't Know
(-9) Refused
Did (SP) have any difficulty on or around (HS REF DATE) using the telephone?
IADLS
NOT ON MDS
(00) NO
(01)YES
You said that using the telephone is something that (SP) doesn't do.
(-8) Don't Know
(-9) Refused
Is this because of a health or physical problem?
IADLS
(00) NO
NOT ON MDS
(01) YES
(03) DOESN'T DO
Did (SP) have any difficulty on or around (HS REF DATE) shopping for personal items (such as toilet
(-8) Don't Know
items or medicines)?
(-9) Refused
IADLS
NOT ON MDS
(00) NO
(01) YES
You said that shopping is something that (SP) doesn't do.
(-8) Don't Know
(-9) Refused
Is this because of a health or physical problem?
IADLS
(00) NO
NOT ON MDS
(01) YES
(03) DOESN'T DO
Did (SP) have any difficulty on or around (HS REF DATE) managing money (like keeping track of money (-8) Don't Know
or paying bills)?
(-9) Refused
IADLS
NOT ON MDS
(00) NO
(01) YES
You said that managing money is something that (SP) doesn't do.
(-8) Don't Know
(-9) Refused
Is this because of a health or physical problem?
IF SP IS ALIVE, GO TO HA43J - SPHEALTH.
ELSE GO TO BOX HA23B.
GENERAL HEALTH
NOT ON MDS
SPHEALTH
HA43J
CODE ONE
(00) EXCELLENT
(01) VERY GOOD
(02) GOOD
[Finally, I have a few questions on (SP)'s general health.]
(03) FAIR
(04) POOR
In general, compared to other people of (his/her) age, would you say that (SP)'s health is excellent, very (-8) Don't Know
good, good, fair or poor?
(-9) Refused
(00) HA43H2 - DIFSHOP
(01) HA43H2 - DIFSHOP
(03) HA43I1 - REASNOPH
(-8) HA43H2 - DIFSHOP
(-9) HA43H2 - DIFSHOP
(00) HA43H2 - DIFSHOP
(01) HA43H2 - DIFSHOP
(-8) HA43H2 - DIFSHOP
(-9) HA43H2 - DIFSHOP
(00) HA43H3 - DIFMONEY
(01) HA43H3 - DIFMONEY
(03) HA43I2 - REASNOSH
(-8) HA43H3 - DIFMONEY
(-9) HA43H3 - DIFMONEY
(00) HA43H3 - DIFMONEY
(01) HA43H3 - DIFMONEY
(-8) HA43H3 - DIFMONEY
(-9) HA43H3 - DIFMONEY
(00) BOX HA17F
(01) BOX HA17F
(03)HA43I3 - REASNOMM
(-8) BOX HA17F
(-9) BOX HA17F
(00) BOX HA17F
(01) BOX HA17F
(-8) BOX HA17F
(-9) BOX HA17F
(00) HA43K - GENHLTH
(01) HA43K - GENHLTH
(02) HA43K - GENHLTH
(03) HA43K - GENHLTH
(04) HA43K - GENHLTH
(-8) HA43K - GENHLTH
(-9) HA43K - GENHLTH
GENERAL HEALTH
NOT ON MDS
GENHLTH
HA43K
CODE ONE
Compared to one year ago, how would you rate (SP)'s health in general now? Would you say (SP)'s
health is . . .
GENERAL HEALTH
NOT ON MDS
LIMACTIV
HA43L
CODE ONE
How much of the time during the past month has (SP)'s health limited (his/her) social activities, like
visiting with friends or close relatives? Would you say . . .
BOX HA23B
routing
HA51B
CODE ONE
As far as you know, what (is/was) the highest level of schooling (SP) completed?
IF DK, USE CATEGORIES AS PROBES.
BOX HA24
DIDABSTR
HC2
routing
CODE ONE
(00) HA43L - LIMACTIV
(01) HA43L - LIMACTIV
(02) HA43L - LIMACTIV
(03) HA43L - LIMACTIV
(04) HA43L - LIMACTIV
(-8) HA43L - LIMACTIV
(-9) HA43L - LIMACTIV
(00) none of the time,
(01) some of the time,
(02) most of the time, or
(03) all of the time?
(-8) Don't Know
(-9) Refused
(00) BOX HA23B
(01) BOX HA23B
(02) BOX HA23B
(03) BOX HA23B
(-8) BOX HA23B
(-9) BOX HA23B
(01) NO FORMAL SCHOOLING
(02) ELEMENTARY (1ST-8TH GRADES)
(03) SOME HIGH SCHOOL (9TH-12TH GRADES)
(04) COMPLETED HIGH SCHOOL, NO COLLEGE
(05) TECHNICAL OR TRADE SCHOOL
(06) SOME COLLEGE
(07) COLLEGE GRADUATE
(08) GRADUATE DEGREE
(-8) Don't Know
(-9) Refused
(01) BOX HA24
(02) BOX HA24
(03) BOX HA24
(04) BOX HA24
(05) BOX HA24
(06) BOX HA24
(07) BOX HA24
(08) BOX HA24
(-8) BOX HA24
(-9) BOX HA24
(01) ALL
(02) MAJORITY
(03) HALF
(04) SOME
(05) NONE
(01) HC3 - WHYABSTR
(02) HC3 - WHYABSTR
(03) HC3 - WHYABSTR
(04) HC3 - WHYABSTR
(05) BOX HCEND
IF BQ9-EDLEVELF = DK, RF, OR EMPTY, GO TO HA51B - HEDULEV.
ELSE GO TO BOX HA24.
EDUCATION LEVEL
NOT ON MDS
HEDULEV
(00) much better now than one year ago,
(01) somewhat better now than one year ago,
(02) about the same,
(03) somewhat worse now than one year ago, or
(04) much worse now than one year ago?
(-8) Don't Know
(-9) Refused
IF HS2REF <> EMPTY OR DK AND (HS2DOI = EMPTY OR HA1PRE2T2 - HA1PRE2C = 1/Continue), GO TO
BOX HAT2BEG.
ELSE GO TO HC2 - DIDABSTR.
DID YOU ABSTRACT?
TO ABSTRACT MEANS TO OBTAIN INFORMATION FROM THE BENEFICIARY'S RECORDS FOR ENTRY INTO
THE QUESTIONNAIRE. EXAMPLES OF RECORDS YOU MAY HAVE ABSTRACTED FROM INCLUDE THE
MINIMUM DATA SET (MDS), NURSES NOTES, PHYSICIANS ORDERS, AND/OR OTHER DOCUMENTS
PROVIDED BY THE FACILITY.
USE YOUR BEST JUDGMENT TO DETERMINE WHICH ANSWER IS THE MOST ACCURATE CHOICE FOR THE
AMOUNT YOU ABSTRACTED. IF THERE WAS NO ABSTRACTION AT ALL, PLEASE SELECT "NONE".
WHYABSTR
HC3
CODE ONE
WHY DID YOU ABSTRACT?
WHYABSOS
HC3
BOX HCEND
VERBATIM TEXT
routing
BOX HAT2BEG
routing
OTHER(SPECIFY)
GO TO HSFINSCR2 - FINSCRN2.
IF FACR.HAINTFLG <> 1/Indicated, GO TO HA1PRE1T2 - HA1PRE1C.
ELSE GO TO HA1PRE2T2 - HA1PRE2C.
RECORD IDENTIFICATION
HA1PRE1C
HA1PRE1T2
CODE ONE
(01) NO KNOWLEDGEABLE RESPONDENT
AVAILABLE
(02) NO TIME/STAFF BURDEN TOO GREAT
(03) REFUSAL--UNWILLING TO COOPERATE
(91) OTHER
(01) CONTINUOUS ANSWER
The next questions are about (SP)'s health status on or around (T2 REF DATE). We have found that
much of the data we are collecting is usually located in the resident's (full Minimum Data Set (MDS)
(01) CONTINUE
assessments, the Quarterly Review forms, and other medical chart notes/medical record). Please take
a moment to locate the records now and confirm they are the records closest to (T2 REF DATE).
(01) BOX HCEND
(02) BOX HCEND
(03) BOX HCEND
(91)HC3 - WHYABSOS
BOX HCEND
HA1PRE2T2 - HA1PRE2C
PRESS "1" TO CONTINUE.
RECORD IDENTIFICATION
HA1PRE2C
HA1PRE2T2
CODE ONE
[Those are all of the questions we have about (SP)'s health on (HS REF DATE). Now, I would like to ask
some questions about (his/her) health at (T2 REF DATE)./The following questions are about (SP)'s health (01) CONTINUE
status on or around (T2 REF DATE)].
PRESS "1" TO CONTINUE.
BOX HA2T2
BOX HA2T2
routing
IF HA2-RECFORMS = 1/Yes OR (HA2-RECFORMS = EMPTY AND Prelaod.HSFORMS = 1/Indicated), GO TO
HA2BT2 - RECFORM2. ELSE IF HS1REF <> EMPTY, GO TO HA9PREBT2 - HA9PRBC.
ELSE GO TO HA1T2 - RECHAVE.
RECORD IDENTIFCATION
RECHAVE
HA1T2
YES/NO
Do you have (SP)'s medical records for the period on or around (T2 REF DATE)?
Is there someone else I should speak with, or do the records exist elsewhere?
HSCONTN1
RECFORMS
HA1BT2
CODE ONE
BOX HA2AT2
routing
HA2T2
YES/NO
DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT THE
MEDICAL RECORDS?
IF (PLACTYPE = 4/NursingHomeUnitCCRC, 7/HospitalBasedSNF OR 17/RehabilitationFacility) OR
FQ.COMPLEXF = 1/Indicated, GO TO HA2T2 - RECFORMS.
ELSE GO TO HA9PREBT2 - HA9PRBC.
RECORD IDENTIFICATION
Do the medical records contain any full MDS assessment or Quarterly Review Forms?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA1BT2 - HSCONTN1
(01) BOX HA2AT2
(-8) HA1BT2 - HSCONTN1
(-9) HA9PREBT2 - HA9PRBC
(00) NO, RETURN TO NAVIGATE SCREEN
(01) YES, CONTINUE WITHOUT MEDICAL
RECORDS
(00) BOX HCENDT2
(01) HA9PREBT2 - HA9PRBC
(00) NO
(01) YES
(00) HA2B1T2 - HSCONTN2
(01) HA2BT2 - RECFORM2
(00) NO, RETURN TO NAVIGATE SCREEN
(01) YES, CONTINUE WITHOUT MDS
(00) BOX HCENDT2
(01) HA9PREBT2 - HA9PRBC
(00) NO
(01) YES
(00) HA2CT2 - HSCONTN3
(01) HA3BT2 - ASSESDT1
(00) NO, RETURN TO NAVIGATE SCREEN
(01) YES, CONTINUE WITH THIS RESPONDENT
(00) BOX HCENDT2
(01) HA9PREBT2 - HA9PRBC
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
(01) BOX HA4T2
(-8) BOX HA4T2
(-9) BOX HA4T2
(00) QUARTERLY REVIEW
(01) FULL MDS
(-8) Don't Know
(-9) Refused
(00) BOX HA7T2
(01) BOX HA7T2
(-8) BOX HA7T2
(-9) BOX HA7T2
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX HA8T2
(01) BOX HA8T2
(-8) BOX HA8T2
(-9) BOX HA8T2
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
Is there someone else I should speak with, or do the records exist elsewhere?
HSCONTN2
HA2B1T2
CODE ONE
RECFORM2
HA2BT2
YES/NO
HSCONTN3
HA2CT2
CODE ONE
DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT ANY
MDS FORMS?
RECORD IDENTIFICATION
Do (SP)'s medical records contain (a full/another) MDS assessment or Quarterly Review form dated
[after (PreloadSP.PRVHSREF)/after (PreloadSP.LASTVAD)/on or around (T2 REF DATE)/after BCVAD)]?
Is there someone else I should speak with, or do the records exist elsewhere?
DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT?
RECORD IDENTIFICATION
ASSESDT1
HA3BT2
DATE
What is the assessment date on the full MDS assessment or Quarterly Review that was completed
closest to (T2 REF DATE) for (SP) after (RAD+14)/BCVAD/PreloadSP.LASTVAD].
ENTER DATE IN "MM DD YY" FORMAT.
(IF NO MDS AVAILABLE, BACK UP AND CHANGE THE RESPONSE.)
BOX HA4T2
BOX HA5T2
FORMTYPE1
CLOSFORM
routing
routing
HA4T2
CODE ONE
BOX HA7T2
routing
HA5T2
YES/NO
BOX HA8T2
routing
BOX HA9T2A
routing
BOX HA9T2B
routing
BOX HA9T2C
routing
IF HA3BT2 - ASSESDT1 = DK, RF AND FIRST TIME AT HA3BT2 - ASSESDT1, GO TO HA9PREBT2 - HA9PRBC.
ELSE GO TO BOX HA5T2.
IF LAST ASSESSMENT DATE ENTRY COLLECTED IN HA3BT2 - ASSESDT1 IS VALID, GO TO HA4T2 FORMTYPE1.
ELSE GO TO HA5T2 - CLOSFORM.
RECORD IDENTIFICATION
Please tell me if the form with the assessment date of (T2 ASSESS DATE) is a full MDS or a quarterly
review.
IF MOST RECENT ASSESSMENT DATE IS COMPLETE THEN COMPARE WITH T2 REF DATE. IF NUMBER OF
DAYS BETWEEN ASSESSMENT DATE AND T2 REF DATE MORE THAN +/- 7, GO TO HA5T2 - CLOSFORM.
ELSE GO TO BOX HA9T2A
Besides the form you just told me about, does (SP)'s medical record contain any other MDS form or
Quarterly Review form dated closer to (T2 REF DATE)?
IF HA5T2 - CLOSFORM = 1/Yes, GO TO HA3BT2 - ASSESDT1. ELSE GO TO BOX HA9T2A.
IF T2TOT = 1 AND (FORMTYPE = DK, RF, OR EMPTY), GO TO HA9PREBT2 - HA9PRBC.
ELSE GO TO BOX HA9T2B.
GO TO BOX HA9T2C.
IF CVATYPE = 1/FullMDS, GO TO HA6T2 - FORMREAS.
ELSE IF CVATYPE = 0/QuarterlyReview, AND XBACKUP = EMPTY, GO TO HA7AT2 - RECMDS.
ELSE GO TO HA7CT2 - MDSINT1.
RECORD IDENTIIFCATION
[3.0, A0310A]
FORMREAS
HA6T2
CODE ONE
ASSESSMENT DATE: {ASSESSMENT DATE)
What was the primary reason for the assessment on the full MDS assessment dated
(TCVAD)?
OTHER (SPECIFY)
Does (SP)'s medical record contain a full MDS assessment dated between (T2 DATE
RANGE).
FORMREOS
HA6T2
VERBATIM TEXT
RECMDS
HA7AT2
YES/NO
PRESS F1 KEY FOR COMPLETE DEFINITIONS
What is the date of the full MDS assessment closest to (T2 REF DATE)?
ASSESDT2
HA7BT2
BOX HA10T2
MDSINT1
HA7CT2
BOX HA19AT2
HA9PRBC
COMATOSE
MENTCON
HA9PREBT2
HA11BT2
HA12AABT2
NUMERIC
HA12ABT2
BOX HA12A
HA12PRBC
HA12PREBT2
HA12BT2
(01) Continuous answer
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(01)Continuous Answer
(-8) Don't Know
(-9) Refused
HA7CT2 - MDSINT1
(00) HA7CT2 - MDSINT1
(01) HA7BT2 - ASSESDT2
(-8) HA7CT2 - MDSINT1
(-9) HA7CT2 - MDSINT1
(01) BOX HA10T2
(-8) BOX HA10T2
(-9) BOX HA10T2
routing
CODE ONE
Please refer to the (FORM TYPE) with the assessment date of (CLOSEST VALID ASSESSMENT DATE)
when answering the following questions. [If the information is not found on the Quarterly Review,
please refer to the full MDS form with the assessment date of (BACKUP MDS ASSESSMENT DATE)/If the (01) Continue
information is not found on the MDS form, please refer to (SP)'s medical record) to answer the
questions.]
routing
PRESS "1" TO CONTINUE.
GO TO HA11BT2 - COMATOSE.
MENTAL HEALTH (ID/DD)
CODE ONE
Now I have some questions concerning (SP)'s health on or around [(HS REF DATE)/(his/her) admission
to the (facility/home)]. [(Please refer to (SP)'s medical record/Since I will be collecting information
about (SP) on or around (HS REF DATE) and there is no MDS or Quarterly Review available close to that
(01) Continue
date, please refer to (SP)'s medical record for the information/Since you do not have a medical record
at hand for reference, please think about the information found in (SP)'s medical record) to answer
these questions.]
CODE ONE
YES/NO
PRESS "1" TO CONTINUE.
COMATOSE
[3.0, B0100]
Was (SP) in a persistent vegetative state with no discernible consciousness on (T2 REF DATE)?
COGNITIVE PATTERNS
[3.0, C0100]
NUMERIC
routing
CODE ONE
ENTER SUMMARY SCORE (0 -15) FROM BIMS.
ENTER ''99" IF THE RESIDENT WAS UNABLE TO COMPLETE THE INTERVIEW.
IF MENTSUM=99, GO TO HA12PREBT2-HA12PRBC.
ELSE GO TO BOX HA13BT2.
MEMORY/COGNITIVE SKILLS
[(Since (SP) was recorded as being unable to complete the Brief Interview for Mental Status, the next
series of questions deal with (SP)'s memory recall ability./The next series of questions deal with (SP)'s
memory or recall ability.)]
PRESS "1" TO CONTINUE.
MEMORY/COGNITIVE SKILLS
[3.0, C0700]
CSMEMST
(01) HA7CT2 - MDSINT1
(02) HA7CT2 - MDSINT1
(03) HA7CT2 - MDSINT1
(91) HA6T2 - FORMREOS
(-8) HA7CT2 - MDSINT1
(-9) HA7CT2 - MDSINT1
IF NO MDS AVAILABLE, BACK UP AND CHANGE THE RESPONSE.
IF CCN=NON-MISSING THEN GO TO BOX HA17BBT2.
ELSE GO TO HA7CT2 - MDSINT1.
RECORD IDENTIFICATION
Should a brief interview for Mental Status (C0200-C0500) be conducted?
BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) SUMMARY SCORE
[3.0, C0500]
MENTSUM
(01) ADMISSION
(02) ANNUAL
(03) SIGNIFICANT CHANGE IN STATUS
(91) OTHER
(-8) Don't Know
(-9) Refused
CODE ONE
On or around (T2 REF DATE), was (SP)'s short-term memory okay, that is, did (he/she) seem or appear
to recall things after 5 minutes?
BOX HA19AT2
HA11BT2 - COMATOSE
(00) NO (NOT COMATOSE)
(01) YES (COMATOSE)
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA12AABT2 - MENTCON
(01) HA39BT2 - FCWEIGHT
(-8) HA12AABT2 - MENTCON
(-9) HA12AABT2 - MENTCON
(00) HA12PREBT2 - HA12PRBC
(01) HA12ABT2 - MENTSUM
(-8) HA12PREBT2 - HA12PRBC
(-9) HA12PREBT2 - HA12PRBC
(01) CONTINOUS ANSWER
(-8) Don't Know
(-9) Refused
(01) BOX HA12A
(-8) BOX HA13BT2
(-9) BOX HA13BT2
(01) CONTINUE
HA12BT2 - CSMEMST
(00) MEMORY OK
(01) MEMORY PROBLEM
(-8) Don't Know
(-9) Refused
(00) HA13BT2 - CSMEMLT
(01) HA13BT2 - CSMEMLT
(-8) HA13BT2 - CSMEMLT
(-9) HA13BT2 - CSMEMLT
MEMORY/COGNITIVE SKILLS
[3.0, C0800]
CSMEMLT
HA13BT2
CODE ONE
Was (SP)'s long-term memory okay; that is, did (she/he) seem or appear to recall events in the distant
past?
MEMORY/COGNITIVE SKILLS
[3.0, C0900]
HA14BCOD
HA14BT2
CODE ALL
On or around (T2 REF DATE), was (SP) able to recall…
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
MEMORY/COGNITIVE SKILLS
[3.0, C1000]
CSDECIS
BSAYSOT
HA15BT2
CODE ONE
BOX HA13BT2
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HA21BT2
CODE ONE
BSVERBOT
HA21BT2
CODE ONE
BSNOTOT
HA21BT2
CODE ONE
BOX HA21BT2
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BSELFILL
HA21ABT2
YES/NO
BSELFCAR
HA21ABT2
YES/NO
BSELFACT
HA21ABT2
YES/NO
BSOTHILL
HA21BBT2
YES/NO
How skilled was (SP) in making daily decisions? Was (she/he) independent, did (she/he) exhibit
modified independence, was (she/he) moderately impaired, or was (she/he) severely impaired?
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
GO TO HA21BT2 - BSAYSOT
BEHAVIORAL SYMPTOMS
[3.0, E0200]
(00) MEMORY OK
(01) MEMORY PROBLEM
(-8) Don't Know
(-9) Refused
(00) HA14BT2 - HA14BCOD
(01) HA14BT2 - HA14BCOD
(-8) HA14BT2 - HA14BCOD
(-9) HA14BT2 - HA14BCOD
(01) the current season?
(02) the location of (her/his) own room?
(03) staff names or faces?
(04) the fact that (she/he) was in a nursing home?
(96) NONE CHECKED
(-8) Don't Know
(01) HA15BT2 - CSDECIS
(02) HA15BT2 - CSDECIS
(03) HA15BT2 - CSDECIS
(04) HA15BT2 - CSDECIS
(96) HA15BT2 - CSDECIS
(-8) HA15BT2 - CSDECIS
(00) INDEPENDENT
(01) MODIFIED INDEPENDENCE
(02) MODERATELY IMPAIRED
(03) SEVERELY IMPAIRED
(-8) Don't Know
(-9) Refused
(00) BOX HA13BT2
(01) BOX HA13BT2
(02) BOX HA13BT2
(03) BOX HA13BT2
(-8) BOX HA13BT2
(-9) BOX HA13BT2
(00) BEHAVIOR NOT EXHIBITED
(01) BEHAVIOR OCCURRED 1 TO 3 DAYS
How often did the following behavioral problems occur on or around (T2 REF DATE)? Would you say the (02) BEHAVIOR OCCURRED 4 TO 6 DAYS
behavior was not exhibited, occurred 1 to 3 days, occurred 4 to 6 days, but less than daily, or occurred (03) BEHAVIOR OCCURRED DAILY
daily?
(-8) Don't Know
(-9) Refused
Physical behavior symptoms directed toward others.
(00) BEHAVIOR NOT EXHIBITED
(01) BEHAVIOR OCCURRED 1 TO 3 DAYS
BEHAVIORAL SYMPTOMS
(02) BEHAVIOR OCCURRED 4 TO 6 DAYS
[3.0, E0200]
(03) BEHAVIOR OCCURRED DAILY
(-8) Don't Know
Verbal behavior symptoms directed toward others.
(-9) Refused
(00) BEHAVIOR NOT EXHIBITED
BEHAVIORAL SYMPTOMS
(01) BEHAVIOR OCCURRED 1 TO 3 DAYS
[3.0, E0200]
(02) BEHAVIOR OCCURRED 4 TO 6 DAYS
(03) BEHAVIOR OCCURRED DAILY
Other behavioral symptoms not directed toward others.
(-8) Don't Know
(-9) Refused
IF HA21BT2 - BSAYSOT and HA21BT2 - BSVERBOT and HA21BT2 - BSNOTOT = 0/BehaviorNotExhibited,
GO TO HA21CBT2 - BSNOEVAL.
ELSE GO TO HA21ABT2 - BSELFILL.
BEHAVIORAL SYMPTOMS
[3.0, E0500]
(00) NO
(01) YES
Did any of (SP)'s behavior…
(-8) Don't Know
(-9) Refused
put the resident at significant risk for physical illness or injury?
BEHAVIORAL SYMPTOMS
(00) NO
[3.0, E0500]
(01) YES
(-8) Don't Know
significantly interfere with the resident's care?
(-9) Refused
BEHAVIORAL SYMPTOMS
(00) NO
[3.0, E0500]
(01) YES
(-8) Don't Know
significantly interfere with the resident's participation in activities or social interactions?
(-9) Refused
BEHAVIORAL SYMPTOMS
[3.0, E0600]
(00) NO
(01) YES
Did any of (SP)'s behavior…
(-8) Don't Know
(-9) Refused
put others at significant risk for physical illness or injury?
(00) HA21BT2 - BSVERBOT
(01) HA21BT2 - BSVERBOT
(02) HA21BT2 - BSVERBOT
(03) HA21BT2 - BSVERBOT
(-8) HA21BT2 - BSVERBOT
(-9) HA21BT2 - BSVERBOT
(00) HA21BT2 - BSNOTOT
(01) HA21BT2 - BSNOTOT
(02) HA21BT2 - BSNOTOT
(03) HA21BT2 - BSNOTOT
(-8) HA21BT2 - BSNOTOT
(-9) HA21BT2 - BSNOTOT
(00) BOX HA21BT2
(01) BOX HA21BT2
(02) BOX HA21BT2
(03) BOX HA21BT2
(-8) BOX HA21BT2
(-9) BOX HA21BT2
(00) HA21ABT2 - BSELFCAR
(01) HA21ABT2 - BSELFCAR
(-8) HA21ABT2 - BSELFCAR
(-9) HA21ABT2 - BSELFCAR
(00) HA21ABT2 - BSELFACT
(01) HA21ABT2 - BSELFACT
(-8) HA21ABT2 - BSELFACT
(-9) HA21ABT2 - BSELFACT
(00) HA21BBT2 - BSOTHILL
(01) HA21BBT2 - BSOTHILL
(-8) HA21BBT2 - BSOTHILL
(-9) HA21BBT2 - BSOTHILL
(00) HA21BBT2 - BSOTHACT
(01) HA21BBT2 - BSOTHACT
(-8) HA21BBT2 - BSOTHACT
(-9) HA21BBT2 - BSOTHACT
BSOTHACT
HA21BBT2
YES/NO
BSOTHENV
HA21BBT2
YES/NO
BSNOEVAL
HA21CBT2
CODE ONE
BSOFTWAN
HA21DBT2
CODE ONE
BSWDANGR
HA21EBT2
YES/NO
BSWOTACT
HA21EBT2
YES/NO
HA22PRBC
HA22PREBT2
CODE ONE
BEHAVIORAL SYMPTOMS
[3.0, E0600]
significantly intrude on the privacy or activities of others?
BEHAVIORAL SYMPTOMS
[3.0, E0600]
(00) NO
(01) YES
(-8) Don't Know
significantly disrupt care or living environment?
(-9) Refused
BEHAVIORAL SYMPTOMS
(00) BEHAVIOR NOT EXHIBITED
[3.0, E0800]
(01) BEHAVIOR OCCURRED 1 TO 3 DAYS
(02) BEHAVIOR OCCURRED 4 TO 6 DAYS
How often did (SP) reject evaluation or care that is necessary to achieve (his/her) goals for health and (03) BEHAVIOR OCCURRED DAILY
well-being on or around (T2 REF DATE)? Would you say the behavior was not exhibited, occurred 1 to 3 (-8) Don't Know
days, occurred 4 to 6 days, but less than daily, or occurred daily?
(-9) Refused
(00) BEHAVIOR NOT EXHIBITED
BEHAVIORAL SYMPTOMS
(01) BEHAVIOR OCCURRED 1 TO 3 DAYS
[3.0, E0900]
(02) BEHAVIOR OCCURRED 4 TO 6 DAYS
(03) BEHAVIOR OCCURRED DAILY
How often did (SP) wander on or around (T2 REF DATE)? Would you say the behavior was not exhibited,
(-8) Don't Know
occurred 1 to 3 days, occurred 4 to 6 days, but less than daily, or occurred daily?
(-9) Refused
BEHAVIORAL SYMPTOMS
[3.0, E1000]
(00) NO
(01) YES
Did any of (SP)'s wandering…
(-8) Don't Know
(-9) Refused
place the resident at significant risk of getting to a potentially dangerous place?
BEHAVIORAL SYMPTOMS
(00) NO
[3.0, E1000]
(01) YES
(-8) Don't Know
BSWOTACT
(-9) Refused
significantly intrude on the privacy or activities of others?
The next questions are about (SP)'s ability to perform Activities of Daily Living or ADLs, on or around (T2
REF DATE).
I will read you a list of activities and would like you to tell me if (SP)'s self-performance was
independent, required supervision, required limited assistance, required extensive assistance, was
totally dependent, or if the activity did not occur. [By self-performance I mean what (SP) actually did
for (himself/herself) and how much help was required by staff members.]
PRESS "1" TO CONTINUE.
ADLS/PHYSCIAL FUNCTIONING
[3.0, G0110]
(SHOW CARD HA1)
PFTRNSFR
HA22BT2
CODE ONE
Please tell me (SP)'s level of self-performance in…
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
transferring (for example, in and out of bed).
PFLOCOMO
HA22BT2
CODE ONE
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
ADLS/PHYSCIAL FUNCTIONING
[3.0, G0110]
locomotion on unit.
(00) HA21BBT2 - BSOTHENV
(01) HA21BBT2 - BSOTHENV
(-8) HA21BBT2 - BSOTHENV
(-9) HA21BBT2 - BSOTHENV
(00) HA21CBT2 - BSNOEVAL
(01) HA21CBT2 - BSNOEVAL
(-8) HA21CBT2 - BSNOEVAL
(-9) HA21CBT2 - BSNOEVAL
(00) HA21DBT2 - BSOFTWAN
(01) HA21DBT2 - BSOFTWAN
(02) HA21DBT2 - BSOFTWAN
(03) HA21DBT2 - BSOFTWAN
(-8) HA21DBT2 - BSOFTWAN
(-9) HA21DBT2 - BSOFTWAN
(00) HA22PREBT2 - HA22PRBC
(01) HA21EBT2 - BSWDANGR
(02) HA21EBT2 - BSWDANGR
(03) HA21EBT2 - BSWDANGR
(-8) HA21EBT2 - BSWDANGR
(-9) HA21EBT2 - BSWDANGR
(00) HA21EBT2 - BSWOTACT
(01) HA21EBT2 - BSWOTACT
(-8) HA21EBT2 - BSWOTACT
(-9) HA21EBT2 - BSWOTACT
(00) HA22PREBT2 - HA22PRBC
(01) HA22PREBT2 - HA22PRBC
(-8) HA22PREBT2 - HA22PRBC
(-9) HA22PREBT2 - HA22PRBC
(01) CONTINUE
HA22BT2 - PFTRNSFR
(00) INDEPENDENT
(01) SUPERVISION
(02) LIMITED ASSISTANCE
(03) EXTENSIVE ASSISTANCE
(04) TOTAL DEPENDENCE
(07) ACTIVITY OCCURRED ONLY ONCE OR TWICE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
(00) HA22BT2 - PFLOCOMO
(01) HA22BT2 - PFLOCOMO
(02) HA22BT2 - PFLOCOMO
(03) HA22BT2 - PFLOCOMO
(04) HA22BT2 - PFLOCOMO
(07) HA22BT2 - PFLOCOMO
(08) HA22BT2 - PFLOCOMO
(-8) HA22BT2 - PFLOCOMO
(-9) HA22BT2 - PFLOCOMO
(00) INDEPENDENT
(01) SUPERVISION
(02) LIMITED ASSISTANCE
(03) EXTENSIVE ASSISTANCE
(04) TOTAL DEPENDENCE
(07) ACTIVITY OCCURRED ONLY ONCE OR TWICE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
(00) IHA22BT2 - PFDRSSNG
(01) HA22BT2 - PFDRSSNG
(02) HA22BT2 - PFDRSSNG
(03) HA22BT2 - PFDRSSNG
(04) HA22BT2 - PFDRSSNG
(07) HA22BT2 - PFDRSSNG
(08) HA22BT2 - PFDRSSNG
(-8) HA22BT2 - PFDRSSNG
(-9) HA22BT2 - PFDRSSNG
PFDRSSNG
HA22BT2
CODE ONE
ADLS/PHYSCIAL FUNCTIONING
[3.0, G0110]
dressing.
PFEATING
HA22BT2
CODE ONE
ADLS/PHYSCIAL FUNCTIONING
[3.0, G0110]
eating.
PFTOILET
HA22BT2
CODE ONE
ADLS/PHYSCIAL FUNCTIONING
[3.0, G0110]
using the toilet.
(00) INDEPENDENT
(01) SUPERVISION
(02) LIMITED ASSISTANCE
(03) EXTENSIVE ASSISTANCE
(04) TOTAL DEPENDENCE
(07) ACTIVITY OCCURRED ONLY ONCE OR TWICE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
(00) HA22BT2 - PFEATING
(01) HA22BT2 - PFEATING
(02) HA22BT2 - PFEATING
(03) HA22BT2 - PFEATING
(04) HA22BT2 - PFEATING
(07) HA22BT2 - PFEATING
(08) AHA22BT2 - PFEATING
(-8) HA22BT2 - PFEATING
(-9) HA22BT2 - PFEATING
(00) INDEPENDENT
(01) SUPERVISION
(02) LIMITED ASSISTANCE
(03) EXTENSIVE ASSISTANCE
(04) TOTAL DEPENDENCE
(07) ACTIVITY OCCURRED ONLY ONCE OR TWICE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
(00) HA22BT2 - PFTOILET
(01) HA22BT2 - PFTOILET
(02) HA22BT2 - PFTOILET
(03) HA22BT2 - PFTOILET
(04) HA22BT2 - PFTOILET
(07) HA22BT2 - PFTOILET
(08) HA22BT2 - PFTOILET
(-8) HA22BT2 - PFTOILET
(-9) HA22BT2 - PFTOILET
(00) INDEPENDENT
(01) SUPERVISION
(02) LIMITED ASSISTANCE
(03) EXTENSIVE ASSISTANCE
(04) TOTAL DEPENDENCE
(07) ACTIVITY OCCURRED ONLY ONCE OR TWICE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
(00) HA23BT2 - PFBATHNG
(01) HA23BT2 - PFBATHNG
(02) HA23BT2 - PFBATHNG
(03) HA23BT2 - PFBATHNG
(04) HA23BT2 - PFBATHNG
(07) HA23BT2 - PFBATHNG
(08) HA23BT2 - PFBATHNG
(-8) HA23BT2 - PFBATHNG
(-9) HA23BT2 - PFBATHNG
ADLS/PHYSICAL FUNCTIONING
[3.0, G0120]
PFBATHNG
HA24PRBC
HA23BT2
HA24PREBT2
CODE ONE
CODE ONE
(00) INDEPENDENT
(01) SUPERVISION
(02) PHYSICAL HELP LIMITED TO TRANSFER ONLY
Again referring to the time on or around (T2 REF DATE), what was (SP)'s level of self-performance when (03) PHYSICAL HELP IN PART OF BATHING
ACTIVITY
bathing: was (she/he) independent, did (she/he) require supervision, require physical help limited to
transfer only, require physical help in part of the bathing activity, was (she/he) totally dependent, or did (04) TOTAL DEPENDENCE
(07) ACTIVITY DID NOT OCCUR
the activity not occur?
(-8) Don't Know
(-9) Refused
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
The next questions are about modes of locomotion and appliances or devices (SP) might have used on
or around (T2 REF DATE).
PRESS "1" TO CONTINUE.
MODES OF LOCOMOTION
[3.0, G0600]
On or around (T2 REF DATE) did (he/she) use…
HA24BCOD
HA24BT2
CODE ALL
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
BOX HA14BT2
FCWEIGHT
routing
HA39BT2
NUMERIC
BOX HA17BBT2
routing
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
GO TO HA39BT2 - FCWEIGHT
ORAL/NUTRITIONAL STATUS
[3.0, K0200]
What was (SP)'s weight on or around (T2 REF DATE)?
GO TO HC2T2 - DIDABSTR.
(00) HA24PREBT2 - HA24PRBC
(01) HA24PREBT2 - HA24PRBC
(02) HA24PREBT2 - HA24PRBC
(03) HA24PREBT2 - HA24PRBC
(04) HA24PREBT2 - HA24PRBC
(07) HA24PREBT2 - HA24PRBC
(-8) HA24PREBT2 - HA24PRBC
(-9) HA24PREBT2 - HA24PRBC
(01) CONTINUE
HA24BT2 - HA24BCOD
(01) a cane or crutch?
(02) a walker?
(03) a manual or electric wheelchair?
(04) a limb prosthesis?
(96) NONE CHECKED
(-8) Don't Know
(-9) Refused
(01) BOX HA14BT2
(02) BOX HA14BT2
(03) BOX HA14BT2
(04) BOX HA14BT2
(96) BOX HA14BT2
(-8) BOX HA14BT2
(-9) BOX HA14BT2
(01) CONTINUOUS
(-8) Don't Know
(-9) Refused
(01) BOX HA17BBT2
(-8) BOX HA17BBT2
(-9) BOX HA17BBT2
DID YOU ABSTRACT?
DIDABSTR
HC2T2
CODE ONE
(01) ALL
TO ABSTRACT MEANS TO OBTAIN INFORMATION FROM THE BENEFICIARY'S RECORDS FOR ENTRY INTO
(02) MAJORITY
THE QUESTIONNAIRE. EXAMPLES OF RECORDS YOU MAY HAVE ABSTRACTED FROM INCLUDE THE
(03) HALF
MINIMUM DATA SET (MDS), NURSES NOTES, PHYSICIANS ORDERS, AND/OR OTHER DOCUMENTS
(04) SOME
PROVIDED BY THE FACILITY.
(05) NONE
(01) HC3T2 - WHYABSTR
(02) HC3T2 - WHYABSTR
(03) HC3T2 - WHYABSTR
(04) HC3T2 - WHYABSTR
(05) BOX HCENDT2
USE YOUR BEST JUDGMENT TO DETERMINE WHICH ANSWER IS THE MOST ACCURATE CHOICE FOR THE
AMOUNT YOU ABSTRACTED. IF THERE WAS NO ABSTRACTION AT ALL, PLEASE SELECT "NONE".
WHYABSTR
HC3T2
CODE ONE
WHY DID YOU ABSTRACT?
WHYABSOS
HC3T2
BOX HCENDT2
VERBATIM TEXT
routing
FINSCRN2
HSFINSCR2
CODE ONE
OTHER (SPECIFY)
GO TO HSFINSCR2 - FINSCRN2.
(RETURN TO NAVIGATOR TO CONTINUE INTERVIEW. THE HEALTH STATUS SECTION WAS NOT
COMPLETED./YOU HAVE COMPLETED THE HEALTH STATUS SECTION FOR THIS SP.)
FINSCRN
HSFINSCR
BOX HSEND
CODE ONE
routing
PRESS "1" TO TO CONTINUE.
PRESS "1" TO RETURN TO NAVIGATION SCREEN.
GO TO NAVIGATOR
(01) NO KNOWLEDGEABLE RESPONDENT
AVAILABLE
(02) NO TIME/STAFF BURDEN TOO GREAT
(03) REFUSAL--UNWILLING TO COOPERATE
(91) OTHER
(01) Continuous Answer
(01) BOX HCENDT2
(02) BOX HCENDT2
(03) BOX HCENDT2
(91) HC3T2 - WHYABSOS
BOX HCENDT2
(01) CONTINUE
HSFINSCR - FINSCRN
(01) CONTINUE
BOX HSEND
| File Type | application/pdf |
| Author | Andrea Mayfield |
| File Modified | 2018-05-04 |
| File Created | 2018-05-04 |