CMS-P-0015A Use of Health Services

2020 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) CASPER_LU-CCN
(-8) BOX HA1
(-9) FBOX HA1

(01) (value selected from lookup)
(-8) DON'T KNOW
(-9) REFUSED
(NF) NOT FOUND

(01) BOX HA1
(-8) BOX HA1
(-9) BOX HA1
(NF) 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
PLACEMENT
Administered in flexible order after FQ and RH sections are completed.
BOX HSBEG

CONREFFN

HSPRECT

HSCONREF

HSPRE

BOX HA1B

routing

CODE ONE

CODE ONE

routing

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 in (MISSING, DK, RF), GO TO HS1-CCNINTRO.
ELSE GO TO BOX HA1.
A CMS Certification Numberhas not yet been reported for this facility even though this facility is certified by
[Medicare/Medicaid/Medicare and Medicaid].

CCNINTRO

HS1

yes/no

Please confirm, does [FACILITY) have a CMS Certification Number, also referred to as a Medicare/Medicaid
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.
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 Medicaire 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.]
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 CMS Certification Number I can look up the number using your Facility name
and address.]

CCN

CASPER_LUH

lookup

[IF REFERENCING THE MDS : The CMS Certification Number can be found in section A0100 B. of the MDS
form.]
START TYPING OR DOUBLE CLICK IN THE "CASPER_LU" BOX TO LAUNCH THE LOOKUP.
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.
ACCORDING TO THE ADDRESS OF THIS FACILITY, THE FIRST TWO DIGITS OF THE CMS
CERTIFICATION NUMBER SHOULD BE [STATE PREFIX FILL].
SEARCH FOR THE FACILITY'S CCN BY TYPING THE CCN IN THE "SEARCH" BOX.WHEN YOU FIND THE
CORRECT CCN, HIGHLIGHT THE ROW AND PRESS THE SELECT BUTTON.

lookup

IF THE FACILITY RESPONDENT DOES NOT KNOW THE CCN, SEARCH THE LOOKUP USING A
DIFFERENT IDENTIFIER, SUCH AS THE FACILITY'S NAME OR ADDRESS.
IF YOU CANNOT FIND THE FACILITY'S CCN, PRESS THE "NOT FOUND" BUTTON.
IF YOU NEED TO EXIT THE LOOKUP, PRESS THE "CLOSE" BUTTON.

Page 1 of 25

2020 MCBS Facility Instrument

Variable Name

HS- Health Status

MR Screen Name Question Type

Question Text/Description

BOX HA1

IF ONLY TIME 2, GO TO BOX HAT2BEG.
ELSE IF FACR.HAINTFLG <> 1/Indicated , GO TO HA1PRE1 - HA1PRE1C.
ELSE GO TO HA1PRE2 - HA1PRE2C.

routing

Code List

Routing

(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

RECORD IDENTIFICATION

HA1PRE1C

HA1PRE1

CODE ONE

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).
PRESS "1" TO CONTINUE.
RECORD IDENTIFICATION

HA1PRE2C

HA1PRE2

CODE ONE

The following questions are about (SP)'s health status on or around (HS REF DATE).
PRESS "1" TO CONTINUE.

BOX HA2

RECHAVE

HA1

routing

YES/NO

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.

(00) NO, RETURN TO NAVIGATE SCREEN
(00) BOX HCEND
(01) YES, CONTINUE WITHOUT MEDICAL RECORDS (01) HA9PREB - HA9PRBC

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

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

BOX HA4

[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

HA2B1

CODE ONE

BOX HA3

routing

DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT ANY
MDS FORMS?
GO TO HA3A - ASSESDT1.
RECORD IDENTIFICATION

ASSESDT1

HA3A

DATE

[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, 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 assessment date on that form]?
ENTER DATE IN "MM DD YY" FORMAT.
(IF NO MDS AVAILABLE, BACK UP AND CHANGE THE RESPONSE.)

BOX HA4

routing

BOX HA5

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

FORMTYPE1

HA4

BOX HA7

CODE ONE

(00) QUARTERLY REVIEW
(01) FULL MDS
Please tell me if the form with the assessment date of (LAST ASSESSMENT DATE) is a full MDS or a quarterly (-8) Don't Know
review.
(-9) Refused

routing

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) BOX HA7
(01) BOX HA7
(-8) BOX HA7
(-9) BOX HA7

Page 2 of 25

2020 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

Question Text/Description

Code List

Routing

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)?

(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) CONTINUOUS ANSWER
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(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) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused

(01) HA7C - MDSINT1
(-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

HA6

CODE ONE

FORMREOS

HA6

What was the primary reason for the assessment on the full MDS assessment dated (BCVAD/CCVAD)?
VERBATIM TEXT OTHER (SPECIFY)

RECMDS

HA7A

YES/NO

ASSESDT2

HA7B

date

ASSESSMENT DATE: {ASSESSMENT DATE)

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)?
IF NO MDS AVAILABLE, BACK UP AND CHANGE THE RESPONSE.
RECORD IDENTIFICATION
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

CODE ONE

[Please refer to the (FORM TYPE) with the assessment date of (CLOSEST VALID ASSESSMENT DATE) when (01) CONTINUE
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.]]

BOX HA19A

PRESS "1" TO CONTINUE.
BOX HA19A

HA9PRBC

HA9PREB

routing

CODE ONE

IF BASELINE INTERVIEW AND CCN='NF', MISSING, DK, RF, GO TO HA9PREB - HA9PRBC.
ELSE GOTO 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 the information found in (SP)'s medical record) to answer these questions.]

(01) CONTINUE

BOX HA9B

(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

(01) BOX HA10
(02) BOX HA10
(03) BOX HA10
(04) BOX HA10
(05) BOX HA10
(-8) BOX HA10
(-9) BOX HA10

(00) NO (NOT COMATOSE)
(01) YES (COMATOSE)
(-8) Don't Know
(-9) Refused

(00) HA16B - HCHECOND
(01) HA28PREB - HA28PRBC
(-8) HA16B - HCHECOND
(-9) HA16B - HCHECOND

PRESS "1" TO CONTINUE.
BOX HA9B

routing

IF BASELINE INTERVIEW AND CCN= 'NF', MISSING, DK, RF, GO TO HA9B - MENTAL
ELSE IF CCN=NON-MISSING AND PERS.AGE <= 65 AND SP is Incoming Panel Respondent (IPR), GO TO
HA9B-MENTAL.
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

IF CCN=NON-MISSING GO TO BOX HA28
ELSE GO TO HA11B- COMATOSE.
COMATOSE
[3.0, B01000]
Was (SP) in a persistent vegetative state with no discernible consciousness on (HS REF DATE)?

Page 3 of 25

2020 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

Routing

(00) HEARS ADEQUATELY
(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)? Did (02) HEARS WITH MODERATE DIFFICULTY
(03) HEARING HIGHLY IMPAIRED
(she/he) hear adequately, did (she/he) have minimal difficulty, did (she/he) have moderate difficulty, or was
(-8) Don't Know
(her/his) hearing highly impaired?
(-9) Refused
PRESS F1 KEY FOR COMPLETE DEFINITIONS.

(00) HA17B - HCHEAID
(01) HA17B - HCHEAID
(02) HA17B - HCHEAID
(03) HA17B - HCHEAID
(-8) HA17B - HCHEAID
(-9) HA17B - HCHEAID

HEARING/COMMUNICATION
[3.0, B0300]

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) HA18PREB - HA18PRBC
(01) HA18PREB - HA18PRBC
(-8) HA18PREB - HA18PRBC
(-9) HA18PREB - HA18PRBC

(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

Did (she/he) have a hearing aid?
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.
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

HA20B

HA20AB

CODE ONE

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
(04) SEVERELY IMPAIRED
impaired?
(-8) Don't Know
(-9) Refused
PRESS F1 KEY FOR COMPLETE DEFINITIONS.

(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) HA12AAB - MENTCON
(01) HA12AAB - MENTCON
(-8) HA12AAB - MENTCON
(-9) HA12AAB - MENTCON

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(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

Does (SP) use a visual appliance such as glasses, contact lenses, or a magnifying glass?
MENTCON

HA12AAB

YES/NO

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

HA12AB

numeric

ENTER SUMMARY SCORE (0-15) FROM BIMS.
ENTER ''99" IF THE RESIDENT WAS UNABLE TO COMPLETE THE INTERVIEW.

BOX HA12

routing

IF MENTSUM=99, GO TO HA12PREB-HA12PRBC.
ELSE GO TO HA36B-HALLUC.
MEMORY/COGNITIVE SKILLS

HA12PRBC

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.)]
PRESS "1" TO CONTINUE.

Page 4 of 25

2020 MCBS Facility Instrument

Variable Name

CSMEMST

CSMEMLT

HS- Health Status

MR Screen Name Question Type

HA12B

HA13B

CODE ONE

CODE ONE

Question Text/Description
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?
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

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

routing

HA21AB

Yes/No

Did any of (SP)'s behavior…
put the resident at significant risk for physical illness or injury?

BSELFCAR

HA21AB

Yes/No

Routing

(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
(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) HA21B - BSNOTOT
(01) HA21B - BSNOTOT
(02) HA21B - BSNOTOT
(03) HA21B - BSNOTOT
(-8) HA21B - BSNOTOT
(-9) HA21B - BSNOTOT

(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) 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) HA21AB - BSELFACT
(01) HA21AB - BSELFACT
(-8) HA21AB - BSELFACT
(-9) HA21AB - BSELFACT

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

Code List

BEHAVIORAL SYMPTOMS
[3.0, E0500]
significantly interfere with the resident's care?

Page 5 of 25

2020 MCBS Facility Instrument

Variable Name

BSELFACT

HS- Health Status

MR Screen Name Question Type

HA21AB

YES/NO

Question Text/Description

Code List

Routing

BEHAVIORAL SYMPTOMS
[3.0, E0500]

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(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) HA21BB - BSOTHENV
(01) HA21BB - BSOTHENV
(-8) HA21BB - BSOTHENV
(-9) HA21BB - BSOTHENV

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) HA21CB - BSNOEVAL
(01) HA21CB - BSNOEVAL
(-8) HA21CB - BSNOEVAL
(-9) HA21CB - BSNOEVAL

(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) HA21DB - BSOFTWAN
(01) HA21DB - BSOFTWAN
(02) HA21DB - BSOFTWAN
(03) HA21DB - BSOFTWAN
(-8) HA21DB - BSOFTWAN
(-9) HA21DB - BSOFTWAN

(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) 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

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

HA22PREB - HA22PRBC

significantly interfere with the resident's participation in activities or social interactions?

BSOTHILL

BSOTHACT

HA21BB

HA21BB

YES/NO

YES/NO

BEHAVIORAL SYMPTOMS
[3.0, E0600]
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?

BSOTHENV

HA21BB

YES/NO

BEHAVIORAL SYMPTOMS
[3.0, E0600]
significantly disrupt care or living environment?
BEHAVIORAL SYMPTOMS
[3.0, E0800]

BSNOEVAL

BSOFTWAN

HA21CB

HA21DB

CODE ONE

CODE ONE

How often did (SP) reject evaluation or care that is necessary to achieve (his/her) goals for health and wellbeing 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]

BSWDANGR

HA21EB

YES/NO

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
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,
(01) CONTINUE
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).

(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

Page 6 of 25

2020 MCBS Facility Instrument

Variable Name

PFLOCOMO

HS- Health Status

MR Screen Name Question Type

HA22B

CODE ONE

Question Text/Description

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.

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 - 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

(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
(04) TOTAL DEPENDENCE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused

HA24PREB - HA24PRBC

(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

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.
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.

BOX HA14B

routing

GO TO HA25PREB - HA25PRBC.

Page 7 of 25

2020 MCBS Facility Instrument

Variable Name

HS- Health Status

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(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

HA26B - CTBLADDC

(00) ALWAYS CONTINENT
(01) OCCASIONALLY INCONTINENT
(02) FREQUENTLY INCONTINENT
(03) ALWAYS INCONTINENT
(04) NOT RATED
(-8) Don't Know
(-9) Refused

HA28PREB - HA28PRBC

CONTINENCE
HA25PRBC

HA25PREB

CODE ONE

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

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]

HA26B

CODE ONE

BOX HA28

routing

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.

HA28PREB

CODE ONE

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 (01) CONTINUE
record when answering the following questions.]
PRESS "1" TO CONTINUE.

BOX HA28B

routing

IF XPRIMARY <> EMPTY OR CCN=NON-MISSING , GO TO HA28B - HA28BCD1.
ELSE GO TO HA28B2 - HA28BCD2.

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?

BOX HA28B

Page 8 of 25

2020 MCBS Facility Instrument

Variable Name

HS- Health Status

MR Screen Name Question Type

Question Text/Description

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 9 of 25

2020 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 10 of 25

2020 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
(06) VIRAL HEPATITIS
the 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.

BOX HA15B

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?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) BOX HA16B
(01) HA31B - HA31BCOD
(-8) BOX HA16B
(-9) BOX HA16B

Page 11 of 25

2020 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.

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
(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

(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) 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

Page 12 of 25

2020 MCBS Facility Instrument

Variable Name

MDCOTH1

MDCOTH2

MDCOTH3

MDCOTH4

MDCOTH5

MDCOTH6

MDCOTH7

MDCOTH8

MDCOTH9

MDCOTH10

HS- Health Status

MR Screen Name Question Type
BOX HA16A1

routing

HA31BO1

text

BOX HA16A2

routing

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

Question Text/Description
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)
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.

Code List

Routing

(01) CONTINUOUS ANSWER

BOX HA16A2

(01) CONTINUOUS ANSWER

BOX HA16A3

(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

(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

DEHYDRATION
HA34PRBC

HA34PREB

CODE ONE

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.

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.

Page 13 of 25

2020 MCBS Facility Instrument

Variable Name

HS- Health Status

MR Screen Name Question Type

Question Text/Description

SWALLOWING/ORAL PROBLEMS
[3.0, L0200]
HA37BBCO

HEIGHT

HA37BB

CODE ALL

BOX HA16AB

routing

HA38B

CODE ONE

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.

HA39B
BOX HA17BB

CODE ONE
routing

Routing

(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

(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

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?

FCWEIGHT

Code List

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

HA10B

CODE ALL

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

(00) NO
(01) YES
Can you add any other active diagnoses for (SP) on or around (HS REF DATE) that have not yet been
(-8) Don't Know
mentioned? Please refer to the medical record including (SP)'s medications chart for (HS REF DATE MONTH).
(-9) Refused

(00) BOX HA15A
(01) HA33 - HA33CODE
(-8) BOX HA15A
(-9) BOX HA15A

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

Page 14 of 25

2020 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

BOX HA15AA1

routing

HA33O1

TEXT

BOX HA15AA2

routing

HA33O2

TEXT

BOX HA15AA3

routing

HA33O3

TEXT

BOX HA15AA4

routing

HA33O4

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)

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

Page 15 of 25

2020 MCBS Facility Instrument

Variable Name

NMDCOTH5

NMDCOTH6

NMDCOTH7

NMDCOTH8

NMDCOTH9

NMDCOTH10

HA33PREC

HS- Health Status

MR Screen Name Question Type
BOX HA15AA5

routing

HA33O45

TEXT

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 95/Other5, THEN GO TO HA33O5 - NMDCOTH5.
ELSE GO TO BOX HA15A.
ENTER OTHER DIAGNOSIS 5.
OTHER (SPECIFY)
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).

Code List

Routing

(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
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

HA33D - MYOCARD
(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) Continuous

BOX HA17B

(01) PLEASE SEE ITEM DISPLAY INSTRUCTIONS

BOX HA17B

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

HA33D

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?

CATAROP

HA33E

YES/NO

VISION
NOT ON MDS
Has (SP) ever had an operation for cataracts?

BOX HA15F

routing

CAUSEMCR

HA33F

YES/NO

OTHCAUS

HA33G

VERBATIM TEXT

BOX HA15E

routing

HA33H

CODE ALL

BOX HA17B

routing

HA33HCOD

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.]
(Was this/Were any of these) the original cause of (SP)'s becoming eligible for Medicare?
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.

Page 16 of 25

2020 MCBS Facility Instrument

Variable Name

HS- Health Status

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(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

(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) BOX HA17CB
(01) BOX HA17CB
(-8) BOX HA17CB
(-9) BOX HA17CB

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) BOX HA17CB
(01) BOX HA17CB
(-8) BOX HA17CB
(-9) BOX HA17CB

(01) Continue

HA43DA - DRECEXAM

YES/NO

Since (MONTH & DAY OF TODAY'S DATE) a year ago has (SP) had a digital rectal examination of the
prostate?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) HA43DB - BLOODPSA
(01) HA43DB - BLOODPSA
(-8) HA43DB - BLOODPSA
(-9) HA43DB - 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?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) BOX HA17CB
(01) BOX HA17CB
(-8) BOX HA17CB
(-9) BOX HA17CB

BOX HA17CB

routing

IF FALL ROUND, GO TO HA43DC - FLUSHOT.
ELSE GO TO BOX HA17CA.

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) BOX HA17CA
(01) BOX HA17CA
(-8) BOX HA17CA
(-9) BOX HA17CA

(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

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?

PAPSMEAR

HA43B

YES/NO

MAMMOGRAM/PAP SMEAR/HYSERECTOMY
NOT ON MDS
Since (MONTH & DAY OF TODAY'S DATE) a year ago has (SP) had a Pap smear?

BOX HA17C

HYSTEREC

HA43C

routing

YES/NO

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?

EVERHYST

HA43D

YES/NO

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

BLOODPSA

HA43DA

INFLUENZA VACCINE
Next, a question or two about shots people take to prevent certain illnesses. Did (SP) have a flu shot for last
winter?
FLUSHOT

HA43DC

YES/NO

[EXPLAIN IF NECESSARY: Did (SP) have a flu shot anytime during the period from September (HS
PREVIOUS YEAR) through December (HS PREVIOUS YEAR)?]
IF THE FACILITY RESPONDENT IS UNSURE AND THIS INFORMATION CANNOT BE FOUND IN THE
MEDICAL CHART, BUT THERE IS AN MDS AVAILABLE, YOU CAN REFERENCE THE MDS ITEM [3.0,
O0250].

BOX HA17CA

routing

IF PreloadSP.PSHOTFLG = 1/Indicated, GO TO HA43E - EVRSMOKE.
ELSE GO TO HA43DD - PNUESHOT.
PNEUMOCOCCAL VACCINE

PNUESHOT

EVRSMOKE

HA43DD

HA43E

YES/NO

YES/NO

Has (SP) ever had a shot for pneumonia?
IF THE FACILITY RESPONDENT IS UNSURE AND THIS INFORMATION CANNOT BE FOUND IN THE
MEDICAL CHART, BUT THERE IS AN MDS AVAILABLE, YOU CAN REFERENCE THE MDS ITEM [3.0,
O0300].
SMOKING
NOT ON MDS
The next couple of questions are about smoking. Has (SP) ever smoked cigarettes, cigars, or pipe tobacco?

BOX HA17D

routing

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.

Page 17 of 25

2020 MCBS Facility Instrument

Variable Name

NOWSMOKE

HS- Health Status

MR Screen Name Question Type

HA43F

YES/NO

Question Text/Description

Code List

Routing

SMOKING
NOT ON MDS

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) HA43GPRE - HA43GPRC
(01) HA43GPRE - HA43GPRC
(-8) HA43GPRE - HA43GPRC
(-9) HA43GPRE - HA43GPRC

(01) CONTINUE

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

(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

(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

Does (SP) smoke now?
IADLS
NOT ON MDS
HA43GPRC

HA43GPRE

CODE ONE

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 (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?
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

HA43I1

CODE ONE

You said that using the telephone is something that (SP) doesn't do.
Is this because of a health or physical problem?

DIFSHOP

HA43H2

CODE ONE

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)?

Page 18 of 25

2020 MCBS Facility Instrument

Variable Name

HS- Health Status

MR Screen Name Question Type

Question Text/Description
IADLS
NOT ON MDS

REASNOSH

HA43I2

CODE ONE

You said that shopping is something that (SP) doesn't do.
Is this because of a health or physical problem?

DIFMONEY

HA43H3

CODE ONE

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

REASNOMM

HA43I3

CODE ONE

You said that managing money is something that (SP) doesn't do.
Is this because of a health or physical problem?

BOX HA17F

routing

HA43J

CODE ONE

[Finally, I have a few questions on (SP)'s general health.]
In general, compared to other people of (his/her) age, would you say that (SP)'s health is excellent, very good,
good, fair or poor?

GENHLTH

LIMACTIV

HA43K

CODE ONE

HA43L

CODE ONE

BOX HA23B

routing

HA51B

CODE ONE

routing

(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
(03) FAIR
(04) POOR
(-8) Don't Know
(-9) Refused

(00) HA43K - GENHLTH
(01) HA43K - GENHLTH
(02) HA43K - GENHLTH
(03) HA43K - GENHLTH
(04) HA43K - GENHLTH
(-8) HA43K - GENHLTH
(-9) HA43K - GENHLTH

(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
Compared to one year ago, how would you rate (SP)'s health in general now? Would you say (SP)'s health is . . (04) much worse now than one year ago?
(-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) none of the time,
(01) some of the time,
(02) most of the time, or
(03) all of the time?
How much of the time during the past month has (SP)'s health limited (his/her) social activities, like visiting with
(-8) Don't Know
friends or close relatives? Would you say . . .
(-9) Refused

(00) BOX HA23B
(01) BOX HA23B
(02) BOX HA23B
(03) BOX HA23B
(-8) BOX HA23B
(-9) BOX HA23B

GENERAL HEALTH
NOT ON MDS

IF BQ9-EDLEVELF = DK, RF, OR EMPTY, GO TO HA51B - HEDULEV.
ELSE GO TO BOX HA24.

As far as you know, what (is/was) the highest level of schooling (SP) completed?
IF DK, USE CATEGORIES AS PROBES.

BOX HA24

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

GENERAL HEALTH
NOT ON MDS

EDUCATION LEVEL
NOT ON MDS
HEDULEV

Routing

IF SP IS ALIVE, GO TO HA43J - SPHEALTH.
ELSE GO TO BOX HA23B.
GENERAL HEALTH
NOT ON MDS

SPHEALTH

Code List

(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

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?

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?

Page 19 of 25

2020 MCBS Facility Instrument

HS- Health Status

Variable Name

MR Screen Name Question Type

WHYABSOS

HC3
BOX HCEND
BOX HAT2BEG

Question Text/Description

VERBATIM TEXT OTHER(SPECIFY)
routing
GO TO HSFINSCR2 - FINSCRN2.
IF FACR.HAINTFLG <> 1/Indicated, GO TO HA1PRE1T2 - HA1PRE1C.
routing
ELSE GO TO HA1PRE2T2 - HA1PRE2C.

Code List

Routing

(01) CONTINUOUS ANSWER

BOX HCEND

(01) CONTINUE

HA1PRE2T2 - HA1PRE2C

RECORD IDENTIFICATION

HA1PRE1C

HA1PRE1T2

CODE ONE

The next questions are about (SP)’s medical records for the period 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 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).
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 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).
PRESS "1" TO CONTINUE.
RECORD IDENTIFICATION

HA1PRE2C

HA1PRE2T2

CODE ONE

Now, I would like to ask some questions about (his/her) medical records for the period on or around (T2 REF
DATE).
Those are all of the questions we have about (SP)'s health on (HS REF DATE). Now, I would like to ask some (01) CONTINUE
questions about (his/her) health at (T2 REF DATE)./The following questions are about (SP)'s health status on or
around (T2 REF DATE).

BOX HA2T2

PRESS "1" TO CONTINUE.
BOX HA2T2

RECHAVE

HA1T2

routing

YES/NO

IF HA2-RECFORMS = 1/Yes OR (HA2-RECFORMS = EMPTY AND Prelaod.HSFORMS = 1/Indicated), GO TO
HA2BT2 - RECFORM2. ELSE IF HS1REF <> EMPTY, GO TO BOX HA9PRBCT2.
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

BOX HA2AT2

routing

DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT THE
MEDICAL RECORDS?

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) HA1BT2 - HSCONTN1
(01) BOX HA2AT2
(-8) HA1BT2 - HSCONTN1
(-9) BOX HA9PRBCT2

(00) NO, RETURN TO NAVIGATE SCREEN
(00) BOX HCENDT2
(01) YES, CONTINUE WITHOUT MEDICAL RECORDS (01) BOX HA9PRBCT2

IF (PLACTYPE = 4/NursingHomeUnitCCRC, 7/HospitalBasedSNF OR 17/RehabilitationFacility) OR
FQ.COMPLEXF = 1/Indicated, GO TO HA2T2 - RECFORMS.
ELSE GO TO BOX HA9PRBCT2.
RECORD IDENTIFICATION

RECFORMS

HA2T2

YES/NO

Do the medical records contain any full MDS assessment or Quarterly Review Forms?

(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) BOX HA9PRBCT2

(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) BOX HA9PRBCT2

(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused

(01) BOX HA4T2
(-8) BOX HA4T2
(-9) BOX HA4T2

PRESS F1 KEY FOR COMPLETE DEFINITIONS.
Is there someone else I should speak with, or do the records exist elsewhere?
HSCONTN2

HA2B1T2

CODE ONE

DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT ANY
MDS FORMS?
RECORD IDENTIFICATION

RECFORM2

HA2BT2

YES/NO

HSCONTN3

HA2CT2

CODE ONE

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

routing

BOX HA5T2

routing

IF HA3BT2 - ASSESDT1 = DK, RF AND FIRST TIME AT HA3BT2 - ASSESDT1, GO TO BOX HA9PRBCT2.
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.

Page 20 of 25

2020 MCBS Facility Instrument

Variable Name

FORMTYPE1

MR Screen Name Question Type

HA4T2

CODE ONE

Question Text/Description
RECORD IDENTIFICATION
Please tell me if the form with the assessment date of (T2 ASSESS DATE) is a full MDS or a quarterly review.

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

BOX HA7T2

CLOSFORM

HS- Health Status

Code List

Routing

(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)BOX HA10T2
(02) BOX HA10T2
(03) BOX HA10T2
(91) HA6T2 - FORMREOS
(-8) BOX HA10T2
(-9) BOX HA10T2
BOX HA10T2
(00) BOX HA10T2
(01) HA7BT2 - ASSESDT2
(-8) BOX HA10T2
(-9) BOX HA10T2

(01)Continuous Answer
(-8) Don't Know
(-9) Refused

(01) BOX HA10T2
(-8) BOX HA10T2
(-9) BOX HA10T2

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 BOX HA9PRBCT2.
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 BOX HA10T2.
RECORD IDENTIIFCATION
[3.0, A0310A]

FORMREAS

HA6T2

CODE ONE

FORMREOS

HA6T2

What was the primary reason for the assessment on the full MDS assessment dated (TCVAD)?
VERBATIM TEXT OTHER (SPECIFY)

RECMDS

HA7AT2

YES/NO

ASSESDT2

HA7BT2

NUMERIC

BOX HA10T2

routing

ASSESSMENT DATE: {ASSESSMENT DATE)

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.
RECORD IDENTIFICATION

MDSINT1

HA7CT2

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
(01) Continue
full 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.
BOX HA19AT2

routing

BOX HA9PRBCT2

HA9PRBC

HA9PREBT2

CODE ONE

GO TO HA11BT2 - COMATOSE.
IF CCN=NON-MISSING THEN GO TO BOX HA17BBT2.
ELSE GO TO HA9PREBT2-HA9PRBC
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 the information found in (SP)'s medical record) to answer these questions.]

(01) Continue

HA11BT2 - COMATOSE

(00) NO (NOT COMATOSE)
(01) YES (COMATOSE)
(-8) Don't Know
(-9) Refused

(00) HA12AABT2 - MENTCON
(01) HA39BT2 - FCWEIGHT
(-8) HA12AABT2 - MENTCON
(-9) HA12AABT2 - MENTCON

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) HA12PREBT2 - HA12PRBC
(01) HA12ABT2 - MENTSUM
(-8) HA12PREBT2 - HA12PRBC
(-9) HA12PREBT2 - HA12PRBC

(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused

(01) BOX HA12A
(-8) BOX HA13BT2
(-9) BOX HA13BT2

PRESS "1" TO CONTINUE.
COMATOSE

HA11BT2

CODE ONE

COMATOSE
[3.0, B0100]
Was (SP) in a persistent vegetative state with no discernible consciousness on (T2 REF DATE)?

MENTCON

HA12AABT2

YES/NO

COGNITIVE PATTERNS
[3.0, C0100]
Should a brief interview for Mental Status (C0200-C0500) be conducted?

MENTSUM

HA12ABT2

NUMERIC

BOX HA12A

routing

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.

Page 21 of 25

2020 MCBS Facility Instrument

Variable Name

HS- Health Status

MR Screen Name Question Type

Question Text/Description

Code List

Routing

(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

(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) 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) BOX HA21BT2
(01) BOX HA21BT2
(02) BOX HA21BT2
(03) BOX HA21BT2
(-8) BOX HA21BT2
(-9) BOX HA21BT2

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) HA21ABT2 - BSELFCAR
(01) HA21ABT2 - BSELFCAR
(-8) HA21ABT2 - BSELFCAR
(-9) HA21ABT2 - BSELFCAR

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) HA21ABT2 - BSELFACT
(01) HA21ABT2 - BSELFACT
(-8) HA21ABT2 - BSELFACT
(-9) HA21ABT2 - BSELFACT

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) HA21BBT2 - BSOTHILL
(01) HA21BBT2 - BSOTHILL
(-8) HA21BBT2 - BSOTHILL
(-9) HA21BBT2 - BSOTHILL

MEMORY/COGNITIVE SKILLS
HA12PRBC

HA12PREBT2

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 recall ability./The next series of questions deal with (SP)'s memory or recall
ability.)]
PRESS "1" TO CONTINUE.

CSMEMST

CSMEMLT

HA12BT2

HA13BT2

CODE ONE

CODE ONE

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

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.

BOX HA13BT2

routing

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.

BSVERBOT

HA21BT2

CODE ONE

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

routing

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]

BSELFILL

HA21ABT2

YES/NO

Did any of (SP)'s behavior…
put the resident at significant risk for physical illness or injury?

BSELFCAR

HA21ABT2

YES/NO

BEHAVIORAL SYMPTOMS
[3.0, E0500]
significantly interfere with the resident's care?

BSELFACT

HA21ABT2

YES/NO

BEHAVIORAL SYMPTOMS
[3.0, E0500]
significantly interfere with the resident's participation in activities or social interactions?

Page 22 of 25

2020 MCBS Facility Instrument

Variable Name

HS- Health Status

MR Screen Name Question Type

Question Text/Description
BEHAVIORAL SYMPTOMS
[3.0, E0600]

BSOTHILL

HA21BBT2

YES/NO

Did any of (SP)'s behavior…
put others at significant risk for physical illness or injury?

BSOTHACT

HA21BBT2

YES/NO

BEHAVIORAL SYMPTOMS
[3.0, E0600]
significantly intrude on the privacy or activities of others?

BSOTHENV

HA21BBT2

YES/NO

BEHAVIORAL SYMPTOMS
[3.0, E0600]
significantly disrupt care or living environment?
BEHAVIORAL SYMPTOMS
[3.0, E0800]

BSNOEVAL

BSOFTWAN

HA21CBT2

HA21DBT2

CODE ONE

CODE ONE

How often did (SP) reject evaluation or care that is necessary to achieve (his/her) goals for health and wellbeing 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?
BEHAVIORAL SYMPTOMS
[3.0, E0900]
How often did (SP) wander 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?
BEHAVIORAL SYMPTOMS
[3.0, E1000]

BSWDANGR

HA21EBT2

YES/NO

Did any of (SP)'s wandering…
place the resident at significant risk of getting to a potentially dangerous place?

BSWOTACT

HA21EBT2

YES/NO

BEHAVIORAL SYMPTOMS
[3.0, E1000]
BSWOTACT
significantly intrude on the privacy or activities of others?

Code List

Routing

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) HA21BBT2 - BSOTHACT
(01) HA21BBT2 - BSOTHACT
(-8) HA21BBT2 - BSOTHACT
(-9) HA21BBT2 - BSOTHACT

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) HA21BBT2 - BSOTHENV
(01) HA21BBT2 - BSOTHENV
(-8) HA21BBT2 - BSOTHENV
(-9) HA21BBT2 - BSOTHENV

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) HA21CBT2 - BSNOEVAL
(01) HA21CBT2 - BSNOEVAL
(-8) HA21CBT2 - BSNOEVAL
(-9) HA21CBT2 - BSNOEVAL

(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) HA21DBT2 - BSOFTWAN
(01) HA21DBT2 - BSOFTWAN
(02) HA21DBT2 - BSOFTWAN
(03) HA21DBT2 - BSOFTWAN
(-8) HA21DBT2 - BSOFTWAN
(-9) HA21DBT2 - BSOFTWAN

(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) HA22PREBT2 - HA22PRBC
(01) HA21EBT2 - BSWDANGR
(02) HA21EBT2 - BSWDANGR
(03) HA21EBT2 - BSWDANGR
(-8) HA21EBT2 - BSWDANGR
(-9) HA21EBT2 - BSWDANGR

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) HA21EBT2 - BSWOTACT
(01) HA21EBT2 - BSWOTACT
(-8) HA21EBT2 - BSWOTACT
(-9) HA21EBT2 - BSWOTACT

(00) NO
(01) YES
(-8) Don't Know
(-9) Refused

(00) HA22PREBT2 - HA22PRBC
(01) HA22PREBT2 - HA22PRBC
(-8) HA22PREBT2 - HA22PRBC
(-9) HA22PREBT2 - HA22PRBC

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 supervision, required limited assistance, required extensive assistance, was totally dependent, or if the (01) CONTINUE
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.]

HA22BT2 - PFTRNSFR

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.

(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

Page 23 of 25

2020 MCBS Facility Instrument

Variable Name

PFDRSSNG

HS- Health Status

MR Screen Name Question Type

HA22BT2

CODE ONE

Question Text/Description

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).

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

(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

(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

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.
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.

FCWEIGHT

BOX HA14BT2

routing

HA39BT2

NUMERIC

BOX HA17BBT2

routing

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.

Page 24 of 25

2020 MCBS Facility Instrument

Variable Name

HS- Health Status

MR Screen Name Question Type

Question Text/Description

Code List

Routing

DID YOU ABSTRACT?

DIDABSTR

HC2T2

CODE ONE

(01) ALL
TO ABSTRACT MEANS TO OBTAIN INFORMATION FROM THE BENEFICIARY'S RECORDS FOR ENTRY
(02) MAJORITY
INTO THE QUESTIONNAIRE. EXAMPLES OF RECORDS YOU MAY HAVE ABSTRACTED FROM INCLUDE
(03) HALF
THE 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

WHYABSOS

HC3T2
BOX HCENDT2

FINSCRN2

HSFINSCR2

VERBATIM TEXT OTHER (SPECIFY)
routing
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.)
CODE ONE

FINSCRN

HSFINSCR
BOX HSEND

CODE ONE
routing

WHY DID YOU ABSTRACT?

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

Page 25 of 25