Form CMS-10409 LCDS version 5.00 Admission

Patient

Identifier

Date

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is
0938-1163 (Expiration Date: XX/XX/XXXX). The time required to complete this information collection is estimated to
average 24 minutes per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. *****CMS Disclaimer*****Please do not
send applications, claims, payments, medical records, or any documents containing sensitive information to the
PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection
burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded,
or retained. If you have questions or concerns regarding where to submit your documents, please contact Christy
Hughes at [email protected].

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Patient

Identifier

Date

LONG-TERM CARE HOSPITAL (LTCH) CONTINUITY ASSESSMENT
RECORD & EVALUATION (CARE) DATA SET - Version 5.00
PATIENT ASSESSMENT FORM - ADMISSION

Section A

Administrative Information

A0050. Type of Record.
Enter Code

1. Add new assessment/record
2. Modify existing record
3. Inactivate existing record

A0100. Facility Provider Numbers. Enter Code in boxes provided..
A. National Provider Identifier (NPI):

B. CMS Certification Number (CCN):

C. State Medicaid Provider Number:

A0200. Type of Provider.
Enter Code

3. Long-Term Care Hospital

A0210. Assessment Reference Date.
Observation end date:

_

_
Month

Day

Year

A0220. Admission Date
_

_
Month

Day

Year

A0250. Reason for Assessment .
Enter Code

01.
10.
11.
12.

Admission
Planned discharge
Unplanned discharge .
Expired

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Patient

Identifier

Section A

Date

Administrative Information

Patient Demographic Information .
A0500. Legal Name of Patient.
A. First name:

B. Middle initial:

C. Last name:

D. Suffix:

A0600. Social Security and Medicare Numbers.
A. Social Security Number:

_

_

B. Medicare number (or comparable railroad insurance number):

A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid recipient.

A0800. Gender.
Enter Code

1. Male.
2. Female.

A0900. Birth Date.
_

_
Month

Day

Year

A1005. Ethnicity.
Are you of Hispanic, Latino/a, or Spanish origin?
Check all that apply.
A. No, not of Hispanic, Latino/a, or Spanish origin
B. Yes, Mexican, Mexican American, Chicano/a
C. Yes, Puerto Rican.
D. Yes, Cuban.
E. Yes, another Hispanic, Latino, or Spanish origin.
X. Patient unable to respond.

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Patient

Identifier

Section A

Date

Administrative Information

A1010. Race
What is your race?
Check all that apply.
A. White
B. Black or African American.
C. American Indian or Alaska Native
D. Asian Indian
E.

Chinese

F.

Filipino.

G. Japanese.
H. Korean
I.

Vietnamese.

J.

Other Asian.

K. Native Hawaiian.
L.

Guamanian or Chamorro.

M. Samoan
N. Other Pacific Islander.
X. Patient unable to respond.

A1110. Language.
A. What is your preferred language?

Enter Code

B. Do you need or want an interpreter to communicate with a doctor or health care staff?
0. No
1. Yes
9. Unable to determine

A1200. Marital Status.
Enter Code

1.
2.
3.
4.
5.

Never married.
Married.
Widowed.
Separated.
Divorced.

A1250. Transportation (from NACHC©)
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?
Check all that apply.
A. Yes, it has kept me from medical appointments or from getting my medications
B. Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need
C. No.
X. Patient unable to respond
© 2019. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations, Oregon Primary Care
Association. PRAPARE and its resources are proprietary information of NACHC and its partners, intended for use by NACHC, its partners, and authorized
recipients. Do not publish, copy, or distribute this information in part or whole without written consent from NACHC.

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Patient

Identifier

Section A

Date

Administrative Information

A1400. Payer Information.
Check all that apply
A. Medicare (traditional fee-for-service)
B. Medicare (managed care/Part C/Medicare Advantage)
C. Medicaid (traditional fee-for-service)
D. Medicaid (managed care).
E. Workers' compensation
F. Title programs (e.g., Title III, V, or XX).
G. Other government (e.g., TRICARE, VA, etc.)
H. Private insurance/Medigap.
I. Private managed care
J. Self-pay.
K. No payer source
X. Unknown
Y. Other .

Pre-Admission Service Use .
A1805. Admitted From
Enter Code

01.
02.
03.
04.
05.
06.
07.
08.
09.
10.
11.
12.
99.

Home/Community (e.g., private home/apt., board/care, assisted living, group home, transitional living, other residential care
arrangements)
Nursing Home (long-term care facility)
Skilled Nursing Facility (SNF, swing bed)
Short-Term General Hospital (acute hospital, IPPS)
Long-Term Care Hospital (LTCH)
Inpatient Rehabilitation Facility (IRF, free standing facility or unit)
Inpatient Psychiatric Facility (psychiatric hospital or unit)
Intermediate Care Facility (ID/DD facility)
Hospice (home/non-institutional)
Hospice (institutional facility)
Critical Access Hospital (CAH)
Home under care of organized home health service organization
Not Listed

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Patient

Identifier

Section B

Date

Hearing, Speech, and Vision

B0100. Comatose.
Enter Code

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

B0200. Hearing
Enter Code

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

B1000. Vision
Enter Code

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

B1300. Health Literacy (from Creative Commons©)
How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor
or pharmacy?
Enter Code

0.
1.
2.
3.
4.
8.

Never
Rarely
Sometimes
Often
Always
Patient unable to respond

The Single Item Literacy Screener is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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

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

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

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

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Patient

Identifier

Section C

Date

Cognitive Patterns

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

0. No (patient is rarely/never understood)
Skip to C1310, Signs and Symptoms of Delirium (from CAM©)
1. Yes
Continue to C0200, Repetition of Three Words

Brief Interview for Mental Status (BIMS)
C0200. Repetition of Three Words

Enter Code

Ask patient: “I am going to say three words for you to remember. Please repeat the words after I have said all three.
The words are: sock, blue, and bed. Now tell me the three words.”
Number of words repeated after first attempt
0. None
1. One
2. Two
3. Three
After the patient’s first attempt, repeat the words using cues (“sock, something to wear; blue, a color; bed, a piece of furniture”). You may
repeat the words up to two more times.

C0300. Temporal Orientation (orientation to year, month, and day)

Enter Code

Enter Code

Enter Code

Ask patient: “Please tell me what year it is right now."
A. Able to report correct year
0. Missed by > 5 years or no answer
1. Missed by 2-5 years
2. Missed by 1 year
3. Correct
Ask patient: “What month are we in right now?"
B. Able to report correct month
0. Missed by > 1 month or no answer
1. Missed by 6 days to 1 month
2. Accurate within 5 days
Ask patient: “What day of the week is today?"
C. Able to report correct day of the week
0. Incorrect or no answer
1. Correct

C0400. Recall
Enter Code

Enter Code

Enter Code

Ask patient: “Let's go back to an earlier question. What were those three words that I asked you to repeat?”
If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.
A. Able to recall “sock”
0. No - could not recall
1. Yes, after cueing ("something to wear")
2. Yes, no cue required
B. Able to recall “blue”
0. No - could not recall
1. Yes, after cueing ("a color")
2. Yes, no cue required
C. Able to recall “bed”
0. No - could not recall
1. Yes, after cueing ("a piece of furniture")
2. Yes, no cue required

C0500. BIMS Summary Score
Enter Score

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

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Patient

Identifier

Section C

Date

Cognitive Patterns

C1310. Signs and Symptoms of Delirium (from CAM©)
Code after completing Brief Interview for Mental Status and reviewing medical record.

A. Acute Onset Mental Status Change
Enter Code

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

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

Enter Code in Boxes.
B. Inattention - Did the patient have difficulty focusing attention, for example being easily distractible
or having difficulty keeping track of what was being said?
C. Disorganized thinking - Was the patient's thinking disorganized or incoherent (rambling or
irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to
subject)?
D. Altered level of consciousness - Did the patient have altered level of consciousness as
indicated by any of the following criteria?
• vigilant - startled easily to any sound or touch
• lethargic - repeatedly dozed off when being asked questions, but responded to voice or
touch
• stuporous - very difficult to arouse and keep aroused for the interview
• comatose - could not be aroused

Adapted from: Inouye SK, et al. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method. Copyright 2003, Hospital Elder Life Program, LLC. Not to
be reproduced without permission.

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Patient

Identifier

Section D

Date

Mood

D0150. Patient Mood Interview (PHQ-2 to 9) (from Pfizer Inc.©)
Say to patient: "Over the last 2 weeks, have you been bothered by any of the following problems?"
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the patient: "About how often have you been bothered by this?"
Read and show the patient a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
1. Symptom Presence
0. No (enter 0 in column 2)
1. Yes (enter 0-3 in column 2)
9. No response (leave column 2 blank)

2. Symptom Frequency
0.
1.
2.
3.

Never or 1 day
2-6 days (several days)
7-11 days (half or more of the days)
12-14 days (nearly every day)

1.
Symptom
Presence

2.
Symptom
Frequency

Enter Scores in Boxes

A. Little interest or pleasure in doing things
B. Feeling down, depressed, or hopeless
If either D0150A2 or D0150B2 is coded 2 or 3, CONTINUE asking the questions below. If not, END the PHQ interview.
C. Trouble falling or staying asleep, or sleeping too much
D. Feeling tired or having little energy
E. Poor appetite or overeating
F. Feeling bad about yourself – or that you are a failure or have let yourself or your family down
G. Trouble concentrating on things, such as reading the newspaper or watching television
H. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or
restless that you have been moving around a lot more than usual
I. Thoughts that you would be better off dead, or of hurting yourself in some way
Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.

D0160. Total Severity Score
Enter Score

Add scores for all frequency responses in column 2, Symptom Frequency. Total score must be between 02 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more required items)

D0700. Social Isolation
How often do you feel lonely or isolated from those around you?
Enter Code

0.
1.
2.
3.
4.
8.

Never
Rarely
Sometimes
Often
Always
Patient unable to respond

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Patient

Identifier

Section GG

Date

Functional Abilities and Goals

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

Enter Codes in Boxes.
B. Indoor Mobility (Ambulation): Code the patient's
need for assistance with walking from room to room
(with or without a device such as cane, crutch, or
walker) prior to the current illness, exacerbation, or
injury.

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

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Patient

Identifier

Section GG

Date

Functional Abilities and Goals

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

1.
Admission
Performance

2.
Discharge
Goal.

Enter Codes in Boxes
A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or
liquid once the meal is placed before the patient.
B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and
remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.
C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a
bowel movement. If managing an ostomy, include wiping the opening but not managing equipment.
D. Wash upper body: The ability to wash, rinse, and dry the face, hands, chest, and arms while sitting in a chair or
bed.

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Patient

Identifier

Section GG

Date

Functional Abilities and Goals

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

1.
Admission
Performance

2.
Discharge
Goal.

Enter Codes in Boxes
A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on
the bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed
with no back support.
D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the
bed.
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to get on and off a toilet or commode. If admission performance is coded 07, 09, 10, or
88
Skip to GG0170I, Walk 10 feet
G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability
to open/close door or fasten seat belt.
I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. If admission
performance is coded 07, 09, 10, or 88
Skip to GG0170M, 1 step (curb)
J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.
K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.

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Patient

Identifier

Section GG

Date

Functional Abilities and Goals

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

1.
Admission
Performance

2.
Discharge
Goal.

Enter Codes in Boxes
L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or
outdoor), such as turf or gravel.
M. 1 step (curb): The ability to go up and down a curb or up and down one step. If admission performance is
coded 07, 09, 10, or 88
Skip to GG0170P, Picking up object
N. 4 steps: The ability to go up and down four steps with or without a rail. If admission performance is coded 07, 09,
10, or 88
Skip to GG0170P, Picking up object
O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon,
from the floor.
Q1. Does the patient use a wheelchair and/or scooter?
0. No
Skip to H0350, Bladder Continence
1. Yes
Continue to GG0170R, Wheel 50 feet with two turns
R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and
make two turns.
RR1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized
S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar
space.
SS1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

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Patient

Identifier

Section H

Date

Bladder and Bowel

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

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

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

Bowel continence - Select the one category that best describes the patient..
0. Always continent
1. Occasionally incontinent (one episode of bowel incontinence)
2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)
3. Always incontinent (no episodes of continent bowel movements)
9. Not rated, patient had an ostomy or did not have a bowel movement for the entire 3 days.

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Patient

Identifier

Section I

Date

Active Diagnoses

I0050. Indicate the patient's primary medical condition category.
Enter Code

Indicate the patient's primary medical condition category.
1. Acute Onset Respiratory Condition (e.g., aspiration and specified bacterial pneumonias)
2. Chronic Respiratory Condition (e.g., chronic obstructive pulmonary disease)
3. Acute Onset and Chronic Respiratory Conditions
4. Chronic Cardiac Condition (e.g., heart failure)
5. Other Medical Condition If “Other Medical Condition,” enter the ICD code in the boxes.
I0050A.

Comorbidities and Co-existing Conditions
Check all that apply
Cancers.
I0103. Metastatic Cancer
I0104. Severe Cancer
Heart/Circulation.
I0605. Severe Left Systolic/Ventricular Dysfunction (known ejection fraction < 30%).
I0900. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD).
Genitourinary
I1501. Chronic Kidney Disease, Stage 5
I1502. Acute Renal Failure
Infections
I2101. Septicemia, Sepsis, Systemic Inflammatory Response Syndrome/Shock
I2600. Central Nervous System Infections, Opportunistic Infections, Bone/Joint/Muscle Infections/Necrosis
Metabolic
I2900. Diabetes Mellitus (DM)
Musculoskeletal
I4100. Major Lower Limb Amputation (e.g., above knee, below knee)
Neurological
I4501. Stroke
I4801. Dementia
I4900. Hemiplegia or Hemiparesis
I5000. Paraplegia
I5101. Complete Tetraplegia
I5102. Incomplete Tetraplegia
I5110. Other Spinal Cord Disorder/Injury (e.g., myelitis, cauda equina syndrome)
I5200. Multiple Sclerosis (MS)
I5250. Huntington's Disease
I5300. Parkinson's Disease
I5450. Amyotrophic Lateral Sclerosis
I5455. Other Progressive Neuromuscular Disease
I5460. Locked-In State
I5470. Severe Anoxic Brain Damage, Cerebral Edema, or Compression of Brain
I5480. Other Severe Neurological Injury, Disease, or Dysfunction

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Patient

Identifier

Section I

Date

Active Diagnoses

Nutritional
I5601. Malnutrition (protein or calorie)
Post-Transplant
I7100. Lung Transplant
I7101. Heart Transplant
I7102. Liver Transplant
I7103. Kidney Transplant
I7104. Bone Marrow Transplant
None of the Above
I7900. None of the above

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Patient

Identifier

Section J

Date

Health Conditions

J0510. Pain Effect on Sleep
Enter Code

Ask patient: “Over the past 5 days, how much of the time has pain made it hard for you to sleep at night?”
0.
1.
2.
3.
4.
8.

Does not apply – I have not had any pain or hurting in the past 5 days
Rarely or not at all
Occasionally
Frequently
Almost constantly
Unable to answer

Skip to K0200, Height and Weight

J0520. Pain Interference with Therapy Activities
Enter Code

Ask patient: “Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain?"
0. Does not apply – I have not received rehabilitation therapy in the past 5 days
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

J0530. Pain Interference with Day-to-Day Activities
Enter Code

Ask patient: “Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions)
because of pain?”
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

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Patient

Identifier

Section K

Date

Swallowing/Nutritional Status

K0200. Height and Weight - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up.
A. Height (in inches). Record most recent height measure since admission..
inches

pounds

B. Weight (in pounds). Base weight on most recent measure in last 3 days; measure weight consistently, according to standard
facility practice (e.g., in a.m. after voiding, before meal, with shoes off)..

K0520. Nutritional Approaches
Check all of the following nutritional approaches that apply on admission..
1.
On Admission
Check all that apply
A. Parenteral/IV feeding
B. Feeding tube (e.g., nasogastric or abdominal (PEG))
C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids)
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
Z. None of the above

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Patient

Identifier

Section M

Date

Skin Conditions

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

Does this patient have one or more unhealed pressure ulcers/injuries?
0. No
Skip to N0415, High-Risk Drug Classes: Use and Indication.
1. Yes
Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.

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

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

Enter
Number

B. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also
present as an intact or open/ruptured blister.
1. Number of Stage 2 pressure ulcers

Enter
Number

C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be
present but does not obscure the depth of tissue loss. May include undermining and tunneling.
1. Number of Stage 3 pressure ulcers

Enter
Number

D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the
wound bed. Often includes undermining and tunneling.
1. Number of Stage 4 pressure ulcers

Enter
Number

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

Enter
Number

F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar.
1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar

Enter
Number

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

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Patient

Identifier

Section N

Date

Medications

N0415. High-Risk Drug Classes: Use and Indication
1. Is taking
Check if the patient is taking any medications by pharmacological classification, not how it is used,
in the following classes
2. Indication noted
If column 1 is checked, check if there is an indication noted for all medications in the drug class

1.
Is taking

2.
Indication noted

Check all that apply

Check all that apply

A. Antipsychotic
E. Anticoagulant
F. Antibiotic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)
Z. None of the above

N2001. Drug Regimen Review
Enter Code

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

N2003. Medication Follow-up
Enter Code

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

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Patient

Identifier

Section O

Date

Special Treatments, Procedures, and Programs

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply on admission.
a.
On Admission
Check all that apply
Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As Needed
E1. Tracheostomy care
G1. Non-Invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulation
H10. Other
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Midline
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the above

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Patient

Identifier

Section O

Date

Special Treatments, Procedures, and Programs

O0150. Spontaneous Breathing Trial (SBT) (including Tracheostomy Collar Trial (TCT) or Continuous Positive Airway Pressure (CPAP)
Breathing Trial) by Day 2 of the LTCH Stay (Note: Day 2 = Date of Admission to the LTCH (Day 1) + 1 calendar day)
Enter Code

A. Invasive Mechanical Ventilation Support upon Admission to the LTCH
0. No, not on invasive mechanical ventilation support upon admission
Skip to Z0400, Signature of Persons Completing the
Assessment
1. Yes, on invasive mechanical ventilation support upon admission
Continue to O0150A2, Ventilator Weaning Status
Enter Code

A2. Ventilator Weaning Status
0. No, determined to be non-weaning upon admission
Skip to Z0400, Signature of Persons Completing the Assessment
1. Yes, determined to be weaning upon admission
Continue to O0150B, Assessed for readiness for SBT by day 2 of LTCH
stay

Enter Code

B. Assessed for readiness for SBT by day 2 of the LTCH stay
0. No
Skip to Z0400, Signature of Persons Completing the Assessment
1. Yes
Continue to O0150C, Deemed medically ready for SBT by day 2 of the LTCH stay

Enter Code

C. Deemed medically ready for SBT by day 2 of the LTCH stay
0. No
Continue to O0150D, Is there documentation of reason(s) in the patient's medical record that the patient was deemed medically
unready for SBT by day 2 of the LTCH stay?
1. Yes
Continue to O0150E, If the patient was deemed medically ready for SBT, was SBT performed by day 2 of the LTCH stay?

Enter Code

D. Is there documentation of reason(s) in the patient's medical record that the patient was deemed medically unready for
SBT by day 2 of the LTCH stay?
0. No
Skip to Z0400, Signature of Persons Completing the Assessment
1. Yes
Skip to Z0400, Signature of Persons Completing the Assessment

Enter Code

E. If the patient was deemed medically ready for SBT, was SBT performed by day 2 of the LTCH stay?
0. No
1. Yes

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Patient

Section Z

Identifier

Date

Assessment Administration

Z0400. Signature of Persons Completing the Assessment
I certify that the accompanying information accurately reflects patient assessment information for this patient and that I collected or
coordinated collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with
applicable Medicare and Medicaid requirements. I understand that this information is used as a basis for payment from federal funds. I further
understand that payment of such federal funds and continued participation in the government-funded health care programs is conditioned on
the accuracy and truthfulness of this information, and that submitting false information may subject my organization to a 2% reduction in the
Fiscal Year payment determination. I also certify that I am authorized to submit this information by this facility on its behalf.
Date Section
Signature
Title.
Sections.
Completed.

A.
B.
C.

D.
E.
F.
G.
H.
I.
J.
K.
L.
Z0500. Signature of Person Verifying Assessment Completion.
A. Signature:

B. LTCH CARE Data Set Completion Date:

_

_
Month

Final LTCH CARE Data Set Version 5.00, Admission - Effective October 1, 2022

Day

Year

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