Download:
pdf |
pdf2019 MCBS Facility Instrument
Variable Name
HS-Health Status
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 HA1B
(02) HSFINSCR2 - FINSCRN2
(03) HSFINSCR2 - FINSCRN2
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX HA1
(01) HS2-CCNDOC CASPER_LU-CCN
(-8) BOX HA1
(-9) FBOX HA1
(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
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
BOX HSBEG
routing
CONREFFN
HSCONREF
CODE ONE
HSPRECT
HSPRE
CODE ONE
BOX HA1B
routing
PLACEMENT
Administered in flexible order after FQ and RH sections are completed.
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).
IF THERE ARE NO CONSENT OR REFUSAL ISSUES FOR THIS SECTION, PRESS "1" TO CONTINUE.
IF PLACTYP1= 1/Free Standing Nursing Home, 4/NursingHomeUnitCCRC, 7/HospitalBasedSNF, or
17/Rehabilitation Facility, AND (CAIDCERT=1 OR CARECERT=1 OR CAIDCRT1=1 OR CARECRT1=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? The CMS Certification Number is
a unique six-digit number assigned to any facility certified to participate in Medicare and/or Medicaid.
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.
[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.]
[IF NEEDED: The CMS Certification Number also used to be called the OSCAR Provider Number.]
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.
Please tell me the CMS Certification Number. It would be helpful if I could look at a document with the CMS
Certification Number on it, such as an MDS form or other document. These materials will ensure that I record the
number accurately.
[IF NEEDED: If you don't know the CCN CMS Certification Number I can look up the number using your Facility
name and address.]
[IF REFERENCING THE MDS : The CMS Certification Number can be found in section A0100 B. of the MDS form.]
CCN
CASPER_LU
lookup
(01) (value selected from lookup)
(-8) DON'T KNOW
START TYPING OR DOUBLE CLICK IN THE "CMS CERTIFICATION NUMBER" BOX TO LAUNCH THE LOOKUP.
(-9) REFUSED
(NF) NOT FOUND
IF THE FACILITY RESPONDENT DOES NOT KNOW THE CCN, PROBE TO CONFIRM THAT THE FACILITY IS
CERTIFIED BY MEDICARE AND/OR MEDICAID. AFTER YOU HAVE CONFIRMED THIS, YOU CAN SEARCH
THE LOOKUP USING A DIFFERENT IDENTIFIER, SUCH AS THE FACILITY’S NAME AND/ OR ADDRESS.
(01) BOX HA1C BOX HA1
(-8) BOX HA1C BOX HA1
(-9) BOX HA1C BOX HA1
(NF) BOX HA1
ACCORDING TO THE ADDRESS OF THIS FACILITY, THE FIRST TWO DIGITS OF THE CMS CERTIFICATION
NUMBER SHOULD BE [STATE PREFIX FILL].
[CMS CERTIFICATION NUMBER]
Page 1 of 23
2019 MCBS Facility Instrument
Variable Name
HS-Health Status
MR Screen Name Question Type
Question Text/Description
BOX HA1C
routing
IF CCN= 'NOT FOUND', 'DK', OR 'RF' THEN GO TO HS4-NOTFOUND. ELSE, GO TO HS3-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
BOX HA1
routing
HA1PRE1C
HA1PRE1
CODE ONE
YOU SELECTED 'CCN NOT FOUND', 'DON'T KNOW', OR 'REFUSED'. SELECT 01 TO CONTINUE WITHOUT A
CCN. SELECT 02 TO RETURN TO THE LOOKUP AND SELECT ANOTHER CCN.
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
Code List
Routing
(01) YES
(02) NO, GO BACK TO LOOKUP TO CHANGE
(01) CONTINUE WITHOUT CCN
(02) NO, GO BACK TO LOOKUP TO CHANGE
(01) BOX HA1
(02) CASPER_LU-CCN
(01) BOX HA1
(02) CASPER_LU-CCN
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
(01) CONTINUE
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).
HA1PRE2 - HA1PRE2C
PRESS "1" TO CONTINUE.
RECORD IDENTIFICATION
HA1PRE2C
HA1PRE2
BOX HA2
RECHAVE
HA1
CODE ONE
routing
YES/NO
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
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
(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
[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 (00) NO
[HSREFDATE)/after (LAST MDS DATE)].
(01) YES
(00) HA2B1 - HSCONTN2
(01) BOX HA3
[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
(00) NO, RETURN TO NAVIGATE SCREEN
DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT ANY MDS (01) YES, CONTINUE WITHOUT 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 admission, that is,
(01) CONTINUOUS ANSWER
on or around (HS REF DATE)/What is the assessment date on the full MDS assessment or Quarterly Review that
was completed for (SP) closest to (HS REF DATE) after (HA3A DISPLAY DATE/LAST HS REF DATE)/What is the (-8) DON'T KNOW
(-9) REFUSED
assessment date on that form]?
(00) BOX HCEND
(01) HA9PREB - HA9PRBC
BOX HA4
ENTER DATE IN "MM DD YY" FORMAT.
(IF NO MDS AVAILABLE, BACK UP AND CHANGE THE RESPONSE.)
FORMTYPE1
BOX HA4
routing
BOX HA5
routing
HA4
CODE ONE
BOX HA7
routing
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.
(00) QUARTERLY REVIEW
(01) FULL MDS
(-8) Don't Know
(-9) Refused
(00) BOX HA7
(01) BOX HA7
(-8) BOX HA7
(-9) BOX HA7
Page 2 of 23
2019 MCBS Facility Instrument
Variable Name
CLOSFORM
HS-Health Status
MR Screen Name Question Type
HA5
YES/NO
BOX HA8
routing
BOX HA9AA
routing
BOX HA9BB
routing
BOX HA9CC
routing
FORMREAS
HA6
CODE ONE
FORMREOS
HA6
VERBATIM TEXT
RECMDS
HA7A
YES/NO
ASSESDT2
HA7B
date
BOX HA10
routing
Question Text/Description
Code List
(00) NO
Besides the form you just told me about, does (SP)'s medical record contain any other (full) MDS form (or Quarterly (01) YES
Review form) dated closer to (HS REF DATE)?
(-8) Don't Know
(-9) Refused
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
(01) ADMISSION
3.0, A0310A
(02) ANNUAL
(03) SIGNIFICANT CHANGE IN STATUS
ASSESSMENT DATE: {ASSESSMENT DATE)
(91) OTHER
(-8) Don't Know
What was the primary reason for the assessment on the full MDS assessment dated (BCVAD/CCVAD)?
(-9) Refused
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
(00) NO
Does (SP)'s medical record contain a full MDS assessment dated between (HS DATE RANGE)?
(01) YES
(-8) Don't Know
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
(-9) Refused
What is the date of the full MDS assessment closest to (HS REF DATE)?
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
IF NO MDS AVAILABLE, BACK UP AND CHANGE THE RESPONSE.
GO TO HA7C - MDSINT1.
RECORD IDENTIFICATION
Routing
(00) BOX HA8
(01) BOX HA8
(-8) BOX HA8
(-9) BOX HA8
(01) HA7C - MDSINT1
(02) HA7C - MDSINT1
(03) HA7C - MDSINT1
(91) HA6 - FORMREOS
(-8) HA7C - MDSINT1
(-9) HA7C - MDSINT1
HA7C - MDSINT1
(00) HA7C - MDSINT1
(01) HA7B - ASSESDT2
(-8) HA7C - MDSINT1
(-9) HA7C - MDSINT1
(01) BOX HA10
(-8) BOX HA10
(-9) BOX HA10
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
HA7C
BOX HA19A
HA9PRBC
HA9PREB
CODE ONE
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)/please refer to (SP)'s medical
record) to answer the questions.]]
(01) CONTINUE
BOX HA19A
PRESS "1" TO CONTINUE.
IF BASELINE INTERVIEW AND CCN='NF', MISSING, DK, RF, GO TO 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.
ELSE GO TO BOX HA9B
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 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 (01) CONTINUE
the information found in (SP)'s medical record) to answer these questions.]
BOX HA9B
PRESS "1" TO CONTINUE.
BOX HA9B
routing
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 PERS.AGE<= 65 AND SP is Incoming Panel Respondent (IPR), GO TO HA9BMENTAL.
ELSE IF CCN=NON-MISSING, GO TO HA10B-HA10BCOD.
ELSE GO TO BOX HA10
MENTAL HEALTH (ID/DD)
[3.0, A1550]
MENTAL
HA9B
CODE ALL
Did (SP)'s record indicate any history of intellectual disability or developmental disability problems?
SELECT ALL THAT APPLY.
IF SP HAS NO ID/DD PROBLEMS, SELECT NONE OF THE ABOVE
BOX HA10
COMATOSE
HA11B
ROUTING
CODE ONE
(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
(-8) Don't Know
(-9) Refused
IF CCN=NON-MISSING AND PreloadSP.CURELAGE <= 65 AND SP is Incoming Panel Respondent (IPR), GO TO
HA28PREB-HA28PRBC.
IF CCN=NON-MISSING GO TO BOX HA28
ELSE GO TO HA11B- 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 DATE)?
(-9) Refused
(01) BOX HA10
(02) BOX HA10
(03) BOX HA10
(04) BOX HA10
(05) BOX HA10
(-8) BOX HA10
(-9) BOX HA10
(00) HA16B - HCHECOND
(01) HA28PREB - HA28PRBC
(-8) HA16B - HCHECOND
(-9) HA16B - HCHECOND
Page 3 of 23
2019 MCBS Facility Instrument
Variable Name
HS-Health Status
MR Screen Name Question Type
Question Text/Description
Code List
HEARING/COMMUNICATION
[3.0, B0200]
HCHECOND
HCHEAID
HA16B
HA17B
CODE ONE
YES/NO
(00) HEARS ADEQUATELY
(01) HEARS WITH MINIMAL DIFFICULTY
(02) HEARS WITH MODERATE DIFFICULTY
What was the condition of (SP)'s hearing, with a hearing appliance, if used, on or around (HS REF DATE)? Did
(she/he) hear adequately, did (she/he) have minimal difficulty, did (she/he) have moderate difficulty, or was (her/his) (03) HEARING HIGHLY IMPAIRED
(-8) Don't Know
hearing highly impaired?
(-9) Refused
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
(00) NO
HEARING/COMMUNICATION
(01) YES
[3.0, B0300]
(-8) Don't Know
Did (she/he) have a hearing aid?
(-9) Refused
Routing
(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 by others.
(01) CONTINUE
HA18B - HCUNCOND
(00) UNDERSTOOD
(01) USUALLY UNDERSTOOD
(02) SOMETIMES UNDERSTOOD
(03) RARELY/NEVER UNDERSTOOD
(-8) Don't Know
(-9) Refused
(00) HA19B - HCUNDOTH
(01) HA19B - HCUNDOTH
(02) HA19B - HCUNDOTH
(03) HA19B - HCUNDOTH
(-8) HA19B - HCUNDOTH
(-9) HA19B - HCUNDOTH
(00) UNDERSTAND
(01) USUALLY UNDERSTAND
(02) SOMETIMES UNDERSTAND
(03) RARELY/NEVER UNDERSTAND
(-8) Don't Know
(-9) Refused
(00) HA20PREB - HA20PRBC
(01) HA20PREB - HA20PRBC
(02) HA20PREB - HA20PRBC
(03) HA20PREB - HA20PRBC
(-8) HA20PREB - HA20PRBC
(-9) HA20PREB - HA20PRBC
(01) CONTINUE
HA20B - VISION
PRESS "1" TO CONTINUE.
HEARING/COMMUNICATION
[3.0, B0700]
HCUNCOND
HA18B
CODE ONE
Which statement best describes how effective (SP) was at making (herself/himself) understood on or around (HS
REF DATE)? Was (she/he) always understood, usually understood, sometimes understood, or rarely or never
understood?
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
HEARING/COMMUNICATION
[3.0, B0800]
HCUNDOTH
HA19B
CODE ONE
Which statement best describes how well (SP) understood others on or around (HS REF DATE)? Did (SP) always
understand, usually understand, sometimes understand, or rarely or never understand?
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
VISION
HA20PRBC
HA20PREB
CODE ONE
Next is a question concerning (SP)'s vision on or around (HS REF DATE).
PRESS "1" TO CONTINUE.
VISION
[3.0, B1000]
VISION
VISAPPL
MENTCON
HA20B
HA20AB
HA12AAB
CODE ONE
YES/NO
YES/NO
(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, if used?
(03) HIGHLY IMPAIRED
Would you say (her/his) vision was adequate, impaired, moderately impaired, highly impaired, or severely impaired? (04) SEVERELY IMPAIRED
(-8) Don't Know
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
(-9) Refused
(00) HA20AB - VISAPPL
(01) HA20AB - VISAPPL
(02) HA20AB - VISAPPL
(03) HA20AB - VISAPPL
(04) HA20AB - VISAPPL
(-8) HA20AB - VISAPPL
(-9) HA20AB - VISAPPL
VISION
[3.0, B1200]
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA12AAB - MENTCON
(01) HA12AAB - MENTCON
(-8) HA12AAB - MENTCON
(-9) HA12AAB - MENTCON
(00) HA12PREB - HA12PRBC
(01) HA12AB - MENTSUM
(-8) HA12PREB - HA12PRBC
(-9) HA12PREB - HA12PRBC
(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
Does (SP) use a visual appliance such as glasses, contact lenses, or a magnifying glass?
COGNITIVE PATTERNS
[3.0, C0100]
Should a brief interview for Mental Status (C0200-C0500) be conducted?
BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) SUMMARY SCORE
[3.0, C0500]
MENTSUM
HA12PRBC
CSMEMST
HA12AB
numeric
ENTER SUMMARY SCORE (0-15) FROM BIMS.
BOX HA12
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
HA12PREB
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.)]
HA12B
CODE ONE
PRESS "1" TO CONTINUE.
MEMORY/COGNITIVE SKILLS
[3.0, C0700]
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?
Page 4 of 23
2019 MCBS Facility Instrument
Variable Name
CSMEMLT
HS-Health Status
MR Screen Name Question Type
HA13B
CODE ONE
Question Text/Description
Code List
Routing
MEMORY/COGNITIVE SKILLS
[3.0, C0800]
(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
(02) BEHAVIOR OCCURRED 4 TO 6 DAYS
(03) BEHAVIOR OCCURRED DAILY
(-8) Don't Know
(-9) Refused
(00) HA21B - BSVERBOT
(01) HA21B - BSVERBOT
(02) HA21B - BSVERBOT
(03) HA21B - BSVERBOT
(-8) HA21B - BSVERBOT
(-9) HA21B - BSVERBOT
(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) 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
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
How often did the following behavioral problems occur 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?
Physical behavior symptoms directed toward others.
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
BSELFILL
BSELFCAR
BSELFACT
BSOTHILL
HA21AB
HA21AB
HA21AB
HA21BB
routing
Yes/No
Yes/No
YES/NO
YES/NO
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]
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]
Did any of (SP)'s behavior…
put others at significant risk for physical illness or injury?
Page 5 of 23
2019 MCBS Facility Instrument
Variable Name
HS-Health Status
MR Screen Name Question Type
BSOTHACT
HA21BB
YES/NO
BSOTHENV
HA21BB
YES/NO
BSNOEVAL
HA21CB
CODE ONE
BSOFTWAN
HA21DB
CODE ONE
BSWDANGR
HA21EB
YES/NO
BSWOTACT
HA21EB
YES/NO
Question Text/Description
Code List
BEHAVIORAL SYMPTOMS
[3.0, E0600]
(00) NO
(01) YES
(-8) Don't Know
significantly intrude on the privacy or activities of others?
(-9) Refused
(00) NO
BEHAVIORAL SYMPTOMS
[3.0, E0600]
(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 well-being on (03) BEHAVIOR OCCURRED DAILY
or around (HS REF DATE)? Would you say the behavior was not exhibited, occurred 1 to 3 days, occurred 4 to 6
(-8) Don't Know
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 (HS REF DATE)? Would you say the behavior was not exhibited, occurred
(-8) Don't Know
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
significantly intrude on the privacy or activities of others?
(-9) Refused
ADLS/PHYSICAL FUNCTIONING
Routing
(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
HA21EB - BSWOTACT
HA22PREB - HA22PRBC
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
(01) CONTINUE
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.]
HA22B - PFTRNSFR
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.
(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
Page 6 of 23
2019 MCBS Facility Instrument
Variable Name
PFEATING
HS-Health Status
MR Screen Name Question Type
HA22B
CODE ONE
Question Text/Description
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.
ADLS/PHYSICAL FUNCTIONING
[3.0, G0120]
PFBATHNG
HA23B
CODE ONE
Again referring to the time on or around (HS REF DATE), what was (SP)'s level of self-performance when 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 the activity not occur?
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
Code List
Routing
(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
(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
HA23B - PFBATHNG
(00) INDEPENDENT
(01) SUPERVISION
(02)PHYSICAL HELP LIMITED TO TRANSFER ONLY
(03) PHYSICAL HELP IN PART OF BATHING ACTIVITY
HA24PREB - HA24PRBC
(04) TOTAL DEPENDENCE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
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
HA25PRBC
HA24B
CODE ALL
BOX HA14B
routing
HA25PREB
CODE ONE
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
WHEN ABSTRACTING FROM THE MDS, ONLY SELECT "96-NONE OF THE ABOVE" IF THAT IS THE BOX
CHECKED ON THE MDS.
GO TO HA25PREB - HA25PRBC.
CONTINENCE
The next questions are about (SP)'s bowel and bladder control on or around (HS REF DATE).
PRESS "1" TO CONTINUE.
CTBOWELC
CTBLADDC
HA28PRBC
HA25B
CODE ONE
HA26B
CODE ONE
BOX HA28
routing
HA28PREB
CODE ONE
CONTINENCE
[3.0, H0400]
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]
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?
(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
(-9) Refused
BOX HA14B
(01) CONTINUE
HA25B - CTBOWELC
(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
IF CCN=NON-MISSING AND NOT (FQ.CCN=NON-MISSING AND PERS.AGE <=65 AND SP is Incoming Panel)
GO TO HA10B,
ELSE GO TO HA28PREB-HA28PRBC.
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 in (SP)'s medical record when (01) CONTINUE
answering the following questions.]
PRESS "1" TO CONTINUE.
HA26B - CTBLADDC
HA28PREB - HA28PRBC
BOX HA28B
Page 7 of 23
2019 MCBS Facility Instrument
Variable Name
HS-Health Status
MR Screen Name Question Type
Question Text/Description
BOX HA28B
IF XPRIMARY <> EMPTY OR CCN=NON-MISSING , GO TO HA28B - HA28BCD1.
ELSE GO TO HA28B2 - HA28BCD2.
routing
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.
HA28BOSP
HA28B
VERBATIM TEXT
OTHER (SPECIFY)
Code List
(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
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
(01) CONTINUOUS ANSWER
Routing
(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
(48) HA29B - HA29BCOD
(49) HA29B - HA29BCOD
(91) HA28B - HA28BOSP
(96) HA29B - HA29BCOD
HA29B - HA29BCOD
Page 8 of 23
2019 MCBS Facility Instrument
Variable Name
HS-Health Status
MR Screen Name Question Type
Question Text/Description
(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.
Code List
(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
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
Routing
(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
(48) HA29B - HA29BCOD
(49) HA29B - HA29BCOD
(91) DO NOT DISPLAY
(96) HA29B - HA29BCOD
(-8) HA29B - HA29BCOD
(-9) HA29B - HA29BCOD
Page 9 of 23
2019 MCBS Facility Instrument
Variable Name
HS-Health Status
MR Screen Name Question Type
Question Text/Description
Code List
Routing
DIAGNOSES/CONDITIONS
[3.0, Section I
MDS ASSESSMENT DATE: (ASSESSMENT DATE)]
(SHOW CARD HA4)
HA29BCOD
OTMDSDIA
HA29B
CODE ALL
BOX HA15B
routing
HA30B
YES/NO
(01) MULTIDRUG-RESISTANT ORGANISM (MDRO)
(02) PNEUMONIA
(03) SEPTICEMIA
(04) TUBERCULOSIS
[What active infections were checked on (SP)'s MDS assessment?]
(05) URINARY TRACT INFECTION IN LAST 30 DAYS
[Look at the following list and tell me what active infections (SP) had on or around (HS REF DATE) according to the
(06) VIRAL HEPATITIS
medical record notes.]
(07) WOUND INFECTION (OTHER THAN FOOT)
(96) NONE OF THE ABOVE
SELECT ALL THAT APPLY.
(-8) Don't Know
SEPARATE RESPONSES BY USING THE SPACEBAR.
(-9) Refused
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
(00) NO
[3.0, I8000
(01) YES
MDS ASSESSMENT DATE: (ASSESSMENT DATE)]
(-8) Don't Know
(-9) Refused
Were there any active diagnoses entered on the MDS form in the section for additional active diagnoses?
BOX HA15B
(00) BOX HA16B
(01) HA31B - HA31BCOD
(-8) BOX HA16B
(-9) BOX HA16B
Page 10 of 23
2019 MCBS Facility Instrument
Variable Name
HS-Health Status
MR Screen Name Question Type
Question Text/Description
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-10 CODES WHEN DIAGNOSIS TEXT IS MISSING OR ILLEGIBLE.
MDCOTH1
MDCOTH2
BOX HA16A1
routing
HA31BO1
text
BOX HA16A2
routing
HA31BO2
TEXT
IF HA31B - HA31BCOD INCLUDES 91/Other1, THEN GO TO HA31BO1 - MDCOTH1.
ELSE GO TO BOX HA16A2.
ENTER OTHER DIAGNOSIS 1.
OTHER (SPECIFY)
IF HA31B - HA31BCOD INCLUDES 92/Other2, THEN GO TO HA31BO2 - MDCOTH2.
ELSE GO TO BOX HA16A3.
ENTER OTHER DIAGNOSIS 2.
OTHER (SPECIFY)
Code List
Routing
(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
(20) DYSPHAGIA (SWALLOWING DIFFICULTIES)
(21) EDEMA (OTHER THAN PULMONARY)
(22) GASTRITIS/DUODENITIS
(23) GASTROENTERITIS, NONINFECTIOUS
(24) GASTROINTESTINAL HEMORRHAGE
(25) GOUT
(26) HEMORRHAGE OF ESOPHAGUS
(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
(20) BOX HA16A1
(21) BOX HA16A1
(22) BOX HA16A1
(23) BOX HA16A1
(24) BOX HA16A1
(25) BOX HA16A1
(26) BOX HA16A1
(27) HIV INFECTION
(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) OTHER DIAGNOSIS 1
(92) OTHER DIAGNOSIS 2
(93) OTHER DIAGNOSIS 3
(94) OTHER DIAGNOSIS 4
(95) OTHER DIAGNOSIS 5
(96) OTHER DIAGNOSIS 6
(97) OTHER DIAGNOSIS 7
(98) OTHER DIAGNOSIS 8
(99) OTHER DIAGNOSIS 9
(100) 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
(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
(100) BOX HA16A1
(01) CONTINUOUS ANSWER
BOX HA16A2
(01) CONTINUOUS ANSWER
BOX HA16A3
Page 11 of 23
2019 MCBS Facility Instrument
Variable Name
MDCOTH3
MDCOTH4
MDCOTH5
MDCOTH6
MDCOTH7
MDCOTH8
MDCOTH9
MDCOTH10
HA34PRBC
HS-Health Status
MR Screen Name Question Type
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
Question Text/Description
IF HA31B - HA31BCOD INCLUDES 93/Other3, THEN GO TO HA31BO3 - MDCOTH3.
ELSE GO TO BOX HA16A4.
ENTER OTHER DIAGNOSIS 3.
OTHER (SPECIFY)
IF HA31B - HA31BCOD INCLUDES 94/Other4, THEN GO TO HA31BO4 - MDCOTH4.
ELSE GO TO BOX HA16B.
ENTER OTHER DIAGNOSIS 4.
OTHER (SPECIFY)
IF HA31B - HA31BCOD INCLUDES 95/Other5, THEN GO TO HA31BO5 - MDCOTH5.
ELSE GO TO BOX HA16B.
ENTER OTHER DIAGNOSIS 5.
OTHER (SPECIFY)
IF HA31B - HA31BCOD INCLUDES 96/Other6, THEN GO TO HA31BO6 - MDCOTH6.
ELSE GO TO BOX HA16B.
ENTER OTHER DIAGNOSIS 6.
OTHER (SPECIFY)
IF HA31B - HA31BCOD INCLUDES 97/Other7, THEN GO TO HA31BO7 - MDCOTH7.
ELSE GO TO BOX HA16B.
ENTER OTHER DIAGNOSIS 7.
OTHER (SPECIFY)
IF HA31B - HA31BCOD INCLUDES 98/Other8, THEN GO TO HA31BO8 - MDCOTH8.
ELSE GO TO BOX HA16B.
ENTER OTHER DIAGNOSIS 8.
OTHER (SPECIFY)
IF HA31B - HA31BCOD INCLUDES 99/Other9, THEN GO TO HA31BO9 - MDCOTH9.
ELSE GO TO BOX HA16B.
ENTER OTHER DIAGNOSIS 9.
OTHER (SPECIFY)
IF HA31B - HA31BCOD INCLUDES 100/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
Code List
Routing
(01) CONTINUOUS ANSWER
BOX HA16A4
(01) CONTINUOUS ANSWER
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
The next few items are about the other conditions (SP) may have had on or around (HS REF DATE). (Again, please
(01) CONTINUE
refer to the MDS.)
HA34B - DEHYD
PRESS "1" TO CONTINUE.
DEHYD
HA34B
YES/NO
DEHYDRATION
[3.0, J1550]
Did (SP) experience dehydration on or around (HS REF DATE)? PRESS F1 KEY FOR COMPLETE DEFINITIONS.
SWALLOWING/ORAL PROBLEMS
[3.0, K0100]
HA37ABCO
HA37AB
CODE ALL
On or around (HS REF DATE), did (SP) experience the swallowing problem of…
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.
SWALLOWING/ORAL PROBLEMS
[3.0, L0200]
HA37BBCO
HA37BB
CODE ALL
BOX HA16AB
routing
On or around (HS REF DATE), did (SP) experience the oral problem of…
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.
(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
(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
(01) BOX HA16AB
(02) BOX HA16AB
(03) BOX HA16AB
(04) BOX HA16AB
(05) BOX HA16AB
(06) BOX HA16AB
(07) BOX HA16AB
(96) BOX HA16AB
IF PERS.PERSRNDC = CURRENT ROUND, OR CURRENT ROUND IS FALL ROUND, GO TO HA38B - HEIGHT.
ELSE, GO TO HA39B - FCWEIGHT.
Page 12 of 23
2019 MCBS Facility Instrument
Variable Name
HEIGHT
FCWEIGHT
HS-Health Status
MR Screen Name Question Type
HA38B
CODE ONE
HA39B
CODE ONE
BOX HA17BB
routing
Question Text/Description
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
Code List
Routing
(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?
Now, please tell me which of the following advanced directives were listed in (SP)'s record or chart for the period on
(04) restrictions on feeding, medication, or other treatment
or around (HS REF DATE).
restrictions?
(96) NONE CHECKED
Did (SP)'s record indicate…
(-8) Don't Know
(The rest of the health status questionnaire is not from the MDS.)
HA10BCOD
HA10B
CODE ALL
(01)HA32 - OTACTDIA
(02) HA32 - OTACTDIA
(03) HA32 - OTACTDIA
(04) HA32 - OTACTDIA
(96) HA32 - OTACTDIA
(-8) HA32 - OTACTDIA
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).
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX HA15A
(01) HA33 - HA33CODE
(-8) BOX HA15A
(-9) BOX HA15A
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
Page 13 of 23
2019 MCBS Facility Instrument
Variable Name
HS-Health Status
MR Screen Name Question Type
Question Text/Description
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-10 CODES, IF AVAILABLE, WHEN DIAGNOSIS TEXT IS MISSING OR ILLEGIBLE.
NMDCOTH1
NMDCOTH2
NMDCOTH3
NMDCOTH4
NMDCOTH5
BOX HA15AA1
routing
HA33O1
TEXT
BOX HA15AA2
routing
HA33O2
TEXT
BOX HA15AA3
routing
HA33O3
TEXT
BOX HA15AA4
routing
HA33O4
TEXT
BOX HA15AA5
routing
HA33O45
TEXT
IF HA33 - HA33CODE INCLUDES 91/Other1, THEN GO TO HA33O1 - NMDCOTH1.
ELSE GO TO BOX HA15AA2.
ENTER OTHER DIAGNOSIS 1.
OTHER (SPECIFY)
IF HA33 - HA33CODE INCLUDES 92/Other2, THEN GO TO HA33O2 - NMDCOTH2.
ELSE GO TO BOX HA15AA3.
ENTER OTHER DIAGNOSIS 2.
OTHER (SPECIFY)
IF HA33 - HA33CODE INCLUDES 93/Other3, THEN GO TO HA33O3 - NMDCOTH3.
ELSE GO TO BOX HA15AA4.
ENTER OTHER DIAGNOSIS 3.
OTHER (SPECIFY)
IF HA33 - HA33CODE INCLUDES 94/Other4, THEN GO TO HA33O4 - NMDCOTH4.
ELSE GO TO BOX HA15A.
ENTER OTHER DIAGNOSIS 4.
OTHER (SPECIFY)
IF HA33 - HA33CODE INCLUDES 95/Other5, THEN GO TO HA33O5 - NMDCOTH5.
ELSE GO TO BOX HA15A.
ENTER OTHER DIAGNOSIS 5.
OTHER (SPECIFY)
Code List
Routing
(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
(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
(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) OTHER DIAGNOSIS 1
(92) OTHER DIAGNOSIS 2
(93) OTHER DIAGNOSIS 3
(94) OTHER DIAGNOSIS 4
(95) OTHER DIAGNOSIS 5
(96) OTHER DIAGNOSIS 6
(97) OTHER DIAGNOSIS 7
(98)OTHER DIAGNOSIS 8
(99) OTHER DIAGNOSIS 9
(100) OTHER DIAGNOSIS 10
(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
(20) BOX HA15AA1
(21) BOX HA15AA1
(22) BOX HA15AA1
(23) BOX HA15AA1
(24) BOX HA15AA1
(25) BOX HA15AA1
(26) BOX HA15AA1
(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
(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
(100) BOX HA15AA1
(01) Continuous
BOX HA15AA2
(01) Continuous
BOX HA15AA3
(01) Continuous
BOX HA15AA4
(01) CONTINUE
BOX HA15AA5
(01) CONTINUE
BOX HA15AA6
Page 14 of 23
2019 MCBS Facility Instrument
Variable Name
NMDCOTH6
NMDCOTH7
NMDCOTH8
NMDCOTH9
NMDCOTH10
HA33PREC
HS-Health Status
MR Screen Name Question Type
BOX HA15AA6
routing
HA33O6
TEXT
BOX HA15AA7
routing
HA33O7
TEXT
BOX HA15AA8
routing
HA33O8
TEXT
BOX HA15AA9
routing
HA33O9
TEXT
BOX HA15AA10
routing
HA3310
TEXT
BOX HA15A
routing
HA33PRE
CODE ONE
Question Text/Description
IF HA33 - HA33CODE INCLUDES 96/Other6, THEN GO TO HA33O6 - NMDCOTH6.
ELSE GO TO BOX HA15A.
ENTER OTHER DIAGNOSIS 6.
OTHER (SPECIFY)
IF HA33 - HA33CODE INCLUDES 97/Other7, THEN GO TO HA33O7 - NMDCOTH7.
ELSE GO TO BOX HA15A.
ENTER OTHER DIAGNOSIS 7.
OTHER (SPECIFY)
IF HA33 - HA33CODE INCLUDES 98/Other8, THEN GO TO HA33O8 - NMDCOTH8.
ELSE GO TO BOX HA15A.
ENTER OTHER DIAGNOSIS 8.
OTHER (SPECIFY)
IF HA33 - HA33CODE INCLUDES 99/Other9, THEN GO TO HA33O9 - NMDCOTH9.
ELSE GO TO BOX HA15A.
ENTER OTHER DIAGNOSIS 9.
OTHER (SPECIFY)
IF HA33 - HA33CODE INCLUDES 100/Other10, THEN GO TO HA33O10 - NMDCOTH10.
ELSE GO TO BOX HA15A.
ENTER OTHER DIAGNOSIS 10.
OTHER (SPECIFY)
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).
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
CNROTHOS
HA33B
TEXT
MYOCARD
CATAROP
HA33D
HA33E
YES/NO
YES/NO
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
OTHER (SPECIFY)
CONDITIONS
NOT ON MDS
Still referring to the medical record, has (SP) ever had a myocardial infarction or heart attack?
VISION
NOT ON MDS
Has (SP) ever had an operation for cataracts?
BOX HA15F
routing
Routing
(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) Continuous answer
(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
HA33D - MYOCARD
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA33E - CATAROP
(01) HA33E - CATAROP
(-8) HA33E - CATAROP
(-9) HA33E - CATAROP
(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) HA43B - PAPSMEAR
(01) HA43B - PAPSMEAR
(-8) HA43B - PAPSMEAR
(-9) HA43B - PAPSMEAR
IF CORE OR (SP IS CFR, FCF, CFC, OR FFC) OR (SP IS IPR AND PERS.AGE >= 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
OTHCAUS
HA33G
VERBATIM TEXT
What was the original cause of (SP)'s becoming eligible for Medicare?
RECORD VERBATIM
BOX HA15E
routing
IF RESPONDENT REPORTED MORE THAN ONE CONDITION IN HA28B-HA33E, GO TO HA33H - HA33HCOD.
ELSE, GO TO BOX HA17B.
HA33H
CODE ALL
BOX HA17B
routing
HA33HCOD
Code List
(Was this/Were any of these) the original cause of (SP)'s becoming eligible for Medicare?
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.
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
HA43A
YES/NO
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?
Page 15 of 23
2019 MCBS Facility Instrument
Variable Name
PAPSMEAR
MR Screen Name Question Type
HA43B
BOX HA17C
HYSTEREC
EVERHYST
HS-Health Status
HA43C
HA43D
YES/NO
routing
YES/NO
YES/NO
Question Text/Description
Code List
Routing
MAMMOGRAM/PAP SMEAR/HYSERECTOMY
NOT ON MDS
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(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
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?
HA43DAPC
HA43DAPR
CODE ONE
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
routing
IF FALL ROUND, GO TO HA43DC - FLUSHOT.
ELSE GO TO BOX HA17CA.
INFLUENZA VACCINE
[3.0, O0250]
FLUSHOT
PNUESHOT
HA43DC
YES/NO
BOX HA17CA
routing
HA43DD
YES/NO
(00) NO
(01) YES
Next, a question or two about shots people take to prevent certain illnesses. Did (SP) have a flu shot for last winter?
(-8) Don't Know
(-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
[3.0, O0300]
Has (SP) ever had a shot for pneumonia?
EVRSMOKE
HA43E
YES/NO
SMOKING
NOT ON MDS
The next couple of questions are about smoking. Has (SP) ever smoked cigarettes, cigars, or pipe tobacco?
BOX HA17D
NOWSMOKE
HA43F
routing
YES/NO
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
NOT ON MDS
Does (SP) smoke now?
IADLS
NOT ON MDS
HA43GPRC
HA43GPRE
CODE ONE
IADSTOOP
HA43G
CODE ONE
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA43E - EVRSMOKE
(01) HA43E - EVRSMOKE
(-8) HA43E - EVRSMOKE
(-9) HA43E - EVRSMOKE
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX HA17D
(01) BOX HA17D
(-8) BOX HA17D
(-9) BOX HA17D
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA43GPRE - HA43GPRC
(01) HA43GPRE - HA43GPRC
(-8) HA43GPRE - HA43GPRC
(-9) HA43GPRE - HA43GPRC
Now I'm going to ask about how difficult it was, on the average, for (SP) to do certain kinds of activities on or around
(01) CONTINUE
(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
SHOW CARD HA6
On or around (HS REF DATE), how much difficulty, if any, did (SP) have…
stooping, crouching, or kneeling?
(00) BOX HA17CA
(01) BOX HA17CA
(-8) BOX HA17CA
(-9) BOX HA17CA
(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
HA43G - IADSTOOP
(00) HA43G - IADLIFT
(01) HA43G - IADLIFT
(02) HA43G - IADLIFT
(03) HA43G - IADLIFT
(04) HA43G - IADLIFT
(-8) Don't Know
(-9) Refused
Page 16 of 23
2019 MCBS Facility Instrument
Variable Name
HS-Health Status
MR Screen Name Question Type
Question Text/Description
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?
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?
IADLS
NOT ON MDS
DIFUSEPH
HA43H1
CODE ONE
Now I'm going to ask about some everyday activities and whether (SP) had any difficulty doing them by
(himself/herself) because of a health or physical problem on or around (HS REF DATE).
Did (SP) have any difficulty on or around (HS REF DATE) using the telephone?
IADLS
NOT ON MDS
REASNOPH
DIFSHOP
REASNOSH
DIFMONEY
REASNOMM
HA43I1
HA43H2
HA43I2
HA43H3
HA43I3
BOX HA17F
SPHEALTH
HA43J
CODE ONE
CODE ONE
CODE ONE
CODE ONE
CODE ONE
routing
CODE ONE
You said that using the telephone is something that (SP) doesn't do.
Is this because of a health or physical problem?
IADLS
NOT ON MDS
Did (SP) have any difficulty on or around (HS REF DATE) shopping for personal items (such as toilet items or
medicines)?
IADLS
NOT ON MDS
You said that shopping is something that (SP) doesn't do.
Is this because of a health or physical problem?
IADLS
NOT ON MDS
Did (SP) have any difficulty on or around (HS REF DATE) managing money (like keeping track of money or paying
bills)?
IADLS
NOT ON MDS
You said that managing money is something that (SP) doesn't do.
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
Code List
Routing
(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) 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) 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) 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) HA43G - IADGRASP
(01) HA43G - IADGRASP
(02) HA43G - IADGRASP
(03) HA43G - IADGRASP
(04) HA43G - IADGRASP
(-8) HA43G - IADGRASP
(-9) HA43G - IADGRASP
(00) HA43G - IADWALK
(01) HA43G - IADWALK
(02) HA43G - IADWALK
(03) HA43G - IADWALK
(04) HA43G - IADWALK
(-8) HA43G - IADWALK
(-9) HA43G - IADWALK
(00) HA43H1 - DIFUSEPH
(01) HA43H1 - DIFUSEPH
(02) HA43H1 - DIFUSEPH
(03) HA43H1 - DIFUSEPH
(04) HA43H1 - DIFUSEPH
(-8) HA43H1 - DIFUSEPH
(-9) HA43H1 - DIFUSEPH
(00) NO
(01) YES
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(00) HA43H2 - DIFSHOP
(01) HA43H2 - DIFSHOP
(03) HA43I1 - REASNOPH
(-8) HA43H2 - DIFSHOP
(-9) HA43H2 - DIFSHOP
(00) NO
(01)YES
(-8) Don't Know
(-9) Refused
(00) HA43H2 - DIFSHOP
(01) HA43H2 - DIFSHOP
(-8) HA43H2 - DIFSHOP
(-9) HA43H2 - DIFSHOP
(00) NO
(01) YES
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(00) HA43H3 - DIFMONEY
(01) HA43H3 - DIFMONEY
(03) HA43I2 - REASNOSH
(-8) HA43H3 - DIFMONEY
(-9) HA43H3 - DIFMONEY
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA43H3 - DIFMONEY
(01) HA43H3 - DIFMONEY
(-8) HA43H3 - DIFMONEY
(-9) HA43H3 - DIFMONEY
(00) NO
(01) YES
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(00) BOX HA17F
(01) BOX HA17F
(03)HA43I3 - REASNOMM
(-8) BOX HA17F
(-9) BOX HA17F
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX HA17F
(01) BOX HA17F
(-8) BOX HA17F
(-9) BOX HA17F
(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 good, good, (-8) Don't Know
(-9) Refused
fair or poor?
(00) HA43K - GENHLTH
(01) HA43K - GENHLTH
(02) HA43K - GENHLTH
(03) HA43K - GENHLTH
(04) HA43K - GENHLTH
(-8) HA43K - GENHLTH
(-9) HA43K - GENHLTH
Page 17 of 23
2019 MCBS Facility Instrument
Variable Name
GENHLTH
HS-Health Status
MR Screen Name Question Type
HA43K
CODE ONE
Question Text/Description
GENERAL HEALTH
NOT ON MDS
Compared to one year ago, how would you rate (SP)'s health in general now? Would you say (SP)'s health is . . .
LIMACTIV
HA43L
CODE ONE
BOX HA23B
routing
GENERAL HEALTH
NOT ON MDS
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 . . .
IF BQ9-EDLEVELF = DK, RF, OR EMPTY, GO TO HA51B - HEDULEV.
ELSE GO TO BOX HA24.
EDUCATION LEVEL
NOT ON MDS
HEDULEV
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
routing
IF HS2REF <> EMPTY OR DK AND (HS2DOI = EMPTY OR HA1PRE2T2 - HA1PRE2C = 1/Continue), GO TO BOX
HAT2BEG.
ELSE GO TO HC2 - DIDABSTR.
Code List
Routing
(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
(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) HA43L - LIMACTIV
(01) HA43L - LIMACTIV
(02) HA43L - LIMACTIV
(03) HA43L - LIMACTIV
(04) HA43L - LIMACTIV
(-8) HA43L - LIMACTIV
(-9) HA43L - LIMACTIV
(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
(01) NO KNOWLEDGEABLE RESPONDENT AVAILABLE
(02) NO TIME/STAFF BURDEN TOO GREAT
(03) REFUSAL--UNWILLING TO COOPERATE
(91) OTHER
(01) BOX HCEND
(02) BOX HCEND
(03) BOX HCEND
(91)HC3 - WHYABSOS
(01) CONTINUOUS ANSWER
BOX HCEND
DID YOU ABSTRACT?
DIDABSTR
HC2
CODE ONE
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
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) assessments, the Quarterly
(01) CONTINUE
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).
HA1PRE2T2 - HA1PRE2C
PRESS "1" TO CONTINUE.
RECORD IDENTIFICATION
HA1PRE2C
HA1PRE2T2
BOX HA2T2
RECHAVE
HA1T2
CODE ONE
routing
YES/NO
[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 status on or
around (T2 REF DATE)].
PRESS "1" TO CONTINUE.
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
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
HA1BT2
CODE ONE
DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT THE
MEDICAL RECORDS?
(01) CONTINUE
BOX HA2T2
(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
Page 18 of 23
2019 MCBS Facility Instrument
Variable Name
RECFORMS
HS-Health Status
MR Screen Name Question Type
BOX HA2AT2
routing
HA2T2
YES/NO
Question Text/Description
Code List
Routing
(00) NO
(01) YES
(00) HA2B1T2 - HSCONTN2
(01) HA2BT2 - RECFORM2
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?
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
ASSESDT1
HA3BT2
DATE
(00) NO, RETURN TO NAVIGATE SCREEN
DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT ANY MDS (01) YES, CONTINUE WITHOUT MDS
FORMS?
RECORD IDENTIFICATION
(00) NO
(01) YES
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?
(00) NO, RETURN TO NAVIGATE SCREEN
(01) YES, CONTINUE WITH THIS RESPONDENT
DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT?
RECORD IDENTIFICATION
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.
(00) BOX HCENDT2
(01) HA9PREBT2 - HA9PRBC
(00) HA2CT2 - HSCONTN3
(01) HA3BT2 - ASSESDT1
(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
(01) ADMISSION
(02) ANNUAL
(03) SIGNIFICANT CHANGE IN STATUS
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) Continuous answer
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(01)Continuous Answer
(-8) Don't Know
(-9) Refused
(01) HA7CT2 - MDSINT1
(02) HA7CT2 - MDSINT1
(03) HA7CT2 - MDSINT1
(91) HA6T2 - FORMREOS
(-8) HA7CT2 - MDSINT1
(-9) HA7CT2 - MDSINT1
HA7CT2 - MDSINT1
(00) HA7CT2 - MDSINT1
(01) HA7BT2 - ASSESDT2
(-8) HA7CT2 - MDSINT1
(-9) HA7CT2 - MDSINT1
(01) BOX HA10T2
(-8) BOX HA10T2
(-9) BOX HA10T2
(IF NO MDS AVAILABLE, BACK UP AND CHANGE THE RESPONSE.)
FORMTYPE1
CLOSFORM
BOX HA4T2
routing
IF HA3BT2 - ASSESDT1 = DK, RF AND FIRST TIME AT HA3BT2 - ASSESDT1, GO TO HA9PREBT2 - HA9PRBC.
ELSE GO TO BOX HA5T2.
BOX HA5T2
routing
IF LAST ASSESSMENT DATE ENTRY COLLECTED IN HA3BT2 - ASSESDT1 IS VALID, GO TO HA4T2 FORMTYPE1.
ELSE GO TO HA5T2 - CLOSFORM.
RECORD IDENTIFICATION
HA4T2
CODE ONE
BOX HA7T2
routing
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
HA5T2
YES/NO
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)?
BOX HA8T2
routing
BOX HA9T2A
routing
BOX HA9T2B
routing
BOX HA9T2C
routing
FORMREAS
HA6T2
CODE ONE
FORMREOS
HA6T2
VERBATIM TEXT
RECMDS
HA7AT2
YES/NO
ASSESDT2
HA7BT2
NUMERIC
BOX HA10T2
routing
Please tell me if the form with the assessment date of (T2 ASSESS DATE) is a full MDS or a quarterly review.
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]
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).
PRESS F1 KEY FOR COMPLETE DEFINITIONS
What is the date of the full MDS assessment closest to (T2 REF DATE)?
IF NO MDS AVAILABLE, BACK UP AND CHANGE THE RESPONSE.
IF CCN=NON-MISSING THEN GO TO BOX HA17BBT2.
ELSE GO TO HA7CT2 - MDSINT1.
Page 19 of 23
2019 MCBS Facility Instrument
Variable Name
HS-Health Status
MR Screen Name Question Type
Question Text/Description
Code List
Routing
RECORD IDENTIFICATION
MDSINT1
HA9PRBC
HA7CT2
CODE ONE
BOX HA19AT2
routing
HA9PREBT2
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
(01) Continue
MDS form with the assessment date of (BACKUP MDS ASSESSMENT DATE)/If the information is not found on the
MDS form, please refer to (SP)'s medical record) to answer the questions.]
BOX HA19AT2
PRESS "1" TO CONTINUE.
GO TO HA11BT2 - COMATOSE.
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 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 (01) Continue
the information found in (SP)'s medical record) to answer these questions.]
HA11BT2 - COMATOSE
PRESS "1" TO CONTINUE.
COMATOSE
MENTCON
MENTSUM
HA12PRBC
CSMEMST
CSMEMLT
HA11BT2
HA12AABT2
CODE ONE
YES/NO
HA12ABT2
NUMERIC
BOX HA12A
routing
HA12PREBT2
CODE ONE
HA12BT2
HA13BT2
CODE ONE
CODE ONE
COMATOSE
[3.0, B0100]
Was (SP) in a persistent vegetative state with no discernible consciousness on (T2 REF DATE)?
COGNITIVE PATTERNS
[3.0, C0100]
Should a brief interview for Mental Status (C0200-C0500) be conducted?
BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) SUMMARY SCORE
[3.0, C0500]
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]
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?
MEMORY/COGNITIVE SKILLS
[3.0, C0800]
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
HA15BT2
CODE ONE
BOX HA13BT2
routing
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]
BSAYSOT
HA21BT2
CODE ONE
How often did the following behavioral problems occur on or around (T2 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?
Physical behavior symptoms directed toward others.
(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
(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
(02) BEHAVIOR OCCURRED 4 TO 6 DAYS
(03) BEHAVIOR OCCURRED DAILY
(-8) Don't Know
(-9) Refused
(00) HA21BT2 - BSVERBOT
(01) HA21BT2 - BSVERBOT
(02) HA21BT2 - BSVERBOT
(03) HA21BT2 - BSVERBOT
(-8) HA21BT2 - BSVERBOT
(-9) HA21BT2 - BSVERBOT
Page 20 of 23
2019 MCBS Facility Instrument
Variable Name
BSVERBOT
HS-Health Status
MR Screen Name Question Type
HA21BT2
CODE ONE
Question Text/Description
BEHAVIORAL SYMPTOMS
[3.0, E0200]
Verbal behavior symptoms directed toward others.
BSNOTOT
HA21BT2
CODE ONE
BEHAVIORAL SYMPTOMS
[3.0, E0200]
Other behavioral symptoms not directed toward others.
BOX HA21BT2
BSELFILL
HA21ABT2
routing
YES/NO
BSELFCAR
HA21ABT2
YES/NO
BSELFACT
HA21ABT2
YES/NO
BSOTHILL
BSOTHACT
HA21BBT2
HA21BBT2
YES/NO
YES/NO
BSOTHENV
HA21BBT2
YES/NO
BSNOEVAL
HA21CBT2
CODE ONE
BSOFTWAN
HA21DBT2
CODE ONE
BSWDANGR
BSWOTACT
HA21EBT2
HA21EBT2
YES/NO
YES/NO
Code List
Routing
(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) 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
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?
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
(-9) Refused
(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 well-being on (03) BEHAVIOR OCCURRED DAILY
or around (T2 REF DATE)? Would you say the behavior was not exhibited, occurred 1 to 3 days, occurred 4 to 6
(-8) Don't Know
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, occurred
(-8) Don't Know
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?
(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
(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
Page 21 of 23
2019 MCBS Facility Instrument
Variable Name
HS-Health Status
MR Screen Name Question Type
Question Text/Description
Code List
Routing
The next questions are about (SP)'s ability to perform Activities of Daily Living or ADLs, on or around (T2 REF
DATE).
HA22PRBC
HA22PREBT2
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
(01) CONTINUE
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
ADLS/PHYSCIAL FUNCTIONING
[3.0, G0110]
locomotion on unit.
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.
ADLS/PHYSICAL FUNCTIONING
[3.0, G0120]
PFBATHNG
HA23BT2
CODE ONE
Again referring to the time on or around (T2 REF DATE), what was (SP)'s level of self-performance when 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 the activity not occur?
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
HA24PRBC
HA24PREBT2
CODE ONE
The next questions are about modes of locomotion and appliances or devices (SP) might have used on or around
(T2 REF DATE).
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
(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
(00) INDEPENDENT
(01) SUPERVISION
(02) PHYSICAL HELP LIMITED TO TRANSFER ONLY
(03) PHYSICAL HELP IN PART OF BATHING ACTIVITY
(04) TOTAL DEPENDENCE
(07) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
(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
PRESS "1" TO CONTINUE.
Page 22 of 23
2019 MCBS Facility Instrument
Variable Name
HS-Health Status
MR Screen Name Question Type
Question Text/Description
MODES OF LOCOMOTION
[3.0, G0600]
On or around (T2 REF DATE) did (he/she) use…
HA24BCOD
FCWEIGHT
HA24BT2
CODE ALL
BOX HA14BT2
routing
HA39BT2
NUMERIC
BOX HA17BBT2
routing
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
WHEN ABSTRACTING FROM THE MDS, ONLY SELECT "96-NONE OF THE ABOVE" IF THAT IS THE BOX
CHECKED ON THE MDS.
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.
Code List
Routing
(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) BOX HCENDT2
(02) BOX HCENDT2
(03) BOX HCENDT2
(91) HC3T2 - WHYABSOS
(01) Continuous Answer
BOX HCENDT2
(01) CONTINUE
HSFINSCR - FINSCRN
(01) CONTINUE
BOX HSEND
Page 23 of 23
| File Type | application/pdf |
| Author | Samantha Rosner |
| File Modified | 2019-03-22 |
| File Created | 2019-03-22 |