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pdf2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
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
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
routing
IF HSDISP = 1/ConsentRequired OR HSDISP = 4/InitialRefusal, GO TO HSCONREF - CONREFFN.
ELSE GO TO HSPRE - HSPRECT.
CONREFFN
HSCONREF
CODE ONE
PLEASE INDICATE THE FINAL (CONSENT/REFUAL) STATUS
FOR THIS SECTION.
HSPRECT
HSPRE
CODE ONE
BOX HA1B
routing
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.]
Page 1 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
Question Type
Question Text/Description
Code List
Routing
(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
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.
BOX HA1
routing
IF ONLY TIME 2, GO TO BOX HAT2BEG.
ELSE IF FACR.HAINTFLG <> 1/Indicated , GO TO HA1PRE1 - HA1PRE1C.
ELSE GO TO HA1PRE2 - HA1PRE2C.
RECORD IDENTIFICATION
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
(01) CONTINUE
forms, and other medical chart notes. Please take a moment to locate the records now and confirm they are the
records closest to (HS REF DATE).
HA1PRE2 - HA1PRE2C
PRESS "1" TO CONTINUE.
RECORD IDENTIFICATION
HA1PRE2C
HA1PRE2
CODE ONE
The following questions are about (SP)'s health status on or around (HS REF DATE).
(01) CONTINUE
BOX HA2
PRESS "1" TO CONTINUE.
BOX HA2
routing
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.
Page 2 of 45
2021 MCBS Facility Instrument
HS- Health Status
Variable Name
MR Screen Name
Question Type
RECHAVE
HA1
YES/NO
HSCONTN1
HA1B
CODE ONE
BOX HA2A
routing
Question Text/Description
RECORD IDENTIFCATION
Do you have (SP)'s medical records for the (admission) period on or around (HS REF DATE)?
Code List
Routing
(0) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA1B - HSCONTN1
(01) BOX HA2A
(-8)HA1B - HSCONTN1
(-9) HA9PREB - HA9PRBC
Is there someone else I should speak with, or do the records exist elsewhere?
(00) NO, RETURN TO NAVIGATE SCREEN
DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT THE MEDICAL (01) YES, CONTINUE WITHOUT MEDICAL RECORDS
RECORDS?
(00) BOX HCEND
(01) HA9PREB - HA9PRBC
GO TO HA2 - RECFORMS.
RECORD IDENTIFICATION
[The last MDS form we collected was dated (LAST MDS DATE).]
RECFORMS
HA2
YES/NO
Do (SP)'s medical records contain (a full./another) MDS assessment (or Quarterly Review) form dated [on or around
[HSREFDATE)/after (LAST MDS DATE)].
(00) NO
(01) YES
(00) HA2B1 - HSCONTN2
(01) BOX HA3
(00) NO, RETURN TO NAVIGATE SCREEN
(01) YES, CONTINUE WITHOUT MDS
(00) BOX HCEND
(01) HA9PREB - HA9PRBC
[A MDS for on or around (HS REF DATE) is preferable.]
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
Is there someone else I should speak with, or do the records exist elsewhere?
HSCONTN2
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
(01) CONTINUOUS ANSWER
completed for (SP) closest to (HS REF DATE) after (HA3A DISPLAY DATE/LAST HS REF DATE)/What is the
(-8) DON'T KNOW
assessment date on that form]?
(-9) REFUSED
BOX HA4
ENTER DATE IN "MM DD YY" FORMAT.
(IF NO MDS AVAILABLE, BACK UP AND CHANGE THE RESPONSE.)
Page 3 of 45
2021 MCBS Facility Instrument
Variable Name
FORMTYPE1
CLOSFORM
HS- Health Status
MR Screen Name
Question Type
Question Text/Description
BOX HA4
routing
IF HA3A - ASSESDT1 = DK, RF AND FIRST TIME AT HA3A - ASSESDT1, GO TO HA9PREB - HA9PRBC.
ELSE, GO TO BOX HA5.
BOX HA5
routing
IF LAST ASSESSMENT DATE ENTRY COLLECTED IN HA3A - ASSESDT1 IS VALID, SET A FLAG AND GO TO HA4 FORMTYPE1.
ELSE GO TO HA5 - CLOSFORM.
HA4
CODE ONE
BOX HA7
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.
HA5
YES/NO
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)?
BOX HA8
routing
IF HA5 - CLOSFORM = 1/Yes, GO TO HA3A - ASSESDT1.
ELSE, GO TO BOX HA9AA.
BOX HA9AA
routing
IF HSTOT = 1 AND FORMTYPE = DK, RF, OR EMPTY, GO TO HA9PREB - HA9PRBC.
ELSE GO TO BOX HA9BB.
BOX HA9BB
routing
GO TO BOX HA9CC.
BOX HA9CC
routing
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.
HA6
CODE ONE
(00) QUARTERLY REVIEW
(01) FULL MDS
(-8) Don't Know
Please tell me if the form with the assessment date of (LAST ASSESSMENT DATE) is a full MDS or a quarterly review.
(-9) Refused
RECORD IDENTIFICATION
RECORD IDENTIIFCATION
3.0, A0310A
FORMREAS
Code List
ASSESSMENT DATE: {ASSESSMENT DATE)
What was the primary reason for the assessment on the full MDS assessment dated (BCVAD/CCVAD)?
Routing
(00) BOX HA7
(01) BOX HA7
(-8) BOX HA7
(-9) BOX HA7
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX HA8
(01) BOX HA8
(-8) BOX HA8
(-9) BOX HA8
(01) ADMISSION
(02) ANNUAL
(03) SIGNIFICANT CHANGE IN STATUS
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) HA7C - MDSINT1
(02) HA7C - MDSINT1
(03) HA7C - MDSINT1
(91) HA6 - FORMREOS
(-8) HA7C - MDSINT1
(-9) HA7C - MDSINT1
Page 4 of 45
2021 MCBS Facility Instrument
HS- Health Status
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
FORMREOS
HA6
VERBATIM TEXT
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
HA7C - MDSINT1
RECMDS
HA7A
YES/NO
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA7C - MDSINT1
(01) HA7B - ASSESDT2
(-8) HA7C - MDSINT1
(-9) HA7C - MDSINT1
ASSESDT2
HA7B
date
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
(01) HA7C - MDSINT1
(-8) HA7C - MDSINT1
(-9) HA7C - MDSINT1
(01) CONTINUE
BOX HA19A
(01) CONTINUE
BOX HA9B
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
answering the following questions. [If the information is not found on the Quarterly Review, (please refer to the full
MDS form with the assessment date of (BACKUP MDS ASSESSMENT DATE)/please refer to (SP)'s medical record)
to answer the questions.]]
PRESS "1" TO CONTINUE.
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.]
PRESS "1" TO CONTINUE.
BOX HA9B
routing
IF BASELINE INTERVIEW AND CCN= 'NF', MISSING, DK, RF, GO TO HA9B - MENTAL
ELSE GO TO BOX HA10
Page 5 of 45
2021 MCBS Facility Instrument
Variable Name
MENTAL
MR Screen Name
HA9B
HS- Health Status
Question Type
CODE ALL
Question Text/Description
Code List
Routing
MENTAL HEALTH (ID/DD)
[3.0, A1550]
(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
(00) HEARS ADEQUATELY
(01) HEARS WITH MINIMAL DIFFICULTY
(02) HEARS WITH MODERATE DIFFICULTY
(03) HEARING HIGHLY IMPAIRED
(-8) Don't Know
(-9) Refused
(00) HA17B - HCHEAID
(01) HA17B - HCHEAID
(02) HA17B - HCHEAID
(03) HA17B - HCHEAID
(-8) HA17B - HCHEAID
(-9) HA17B - HCHEAID
(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
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
COMATOSE
BOX HA10
ROUTING
HA11B
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)?
HEARING/COMMUNICATION
[3.0, B0200]
HCHECOND
HA16B
CODE ONE
What was the condition of (SP)'s hearing, with a hearing appliance, if used, on or around (HS REF DATE)? Did
(she/he) hear adequately, did (she/he) have minimal difficulty, did (she/he) have moderate difficulty, or was (her/his)
hearing highly impaired?
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
HCHEAID
HA17B
YES/NO
HEARING/COMMUNICATION
[3.0, B0300]
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.
Page 6 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
Question Type
Question Text/Description
Code List
HEARING/COMMUNICATION
[3.0, B0700]
HCUNCOND
HA18B
CODE ONE
(00) UNDERSTOOD
(01) USUALLY UNDERSTOOD
(02) SOMETIMES UNDERSTOOD
Which statement best describes how effective (SP) was at making (herself/himself) understood on or around (HS REF
(03) RARELY/NEVER UNDERSTOOD
DATE)? Was (she/he) always understood, usually understood, sometimes understood, or rarely or never understood?
(-8) Don't Know
(-9) Refused
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.
Routing
(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
(00) ADEQUATE
(01) IMPAIRED
(02) MODERATELY IMPAIRED
(03) HIGHLY IMPAIRED
(04) SEVERELY IMPAIRED
(-8) Don't Know
(-9) Refused
(00) HA20AB - VISAPPL
(01) HA20AB - VISAPPL
(02) HA20AB - VISAPPL
(03) HA20AB - VISAPPL
(04) HA20AB - VISAPPL
(-8) HA20AB - VISAPPL
(-9) HA20AB - VISAPPL
(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
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
HA20B
CODE ONE
Which of the following statements best described (SP)'s ability to see in adequate light with visual aids, if used?
Would you say (her/his) vision was adequate, impaired, moderately impaired, highly impaired, or severely impaired?
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
VISAPPL
HA20AB
YES/NO
VISION
[3.0, B1200]
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?
Page 7 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
Question Type
Question Text/Description
BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) SUMMARY SCORE
[3.0, C0500]
MENTSUM
HA12AB
numeric
ENTER SUMMARY SCORE (0-15) FROM BIMS.
Code List
Routing
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX HA12
(-8) HA52-MOOD
(-9) HA52-MOOD
(01) CONTINUE
HA12B - CSMEMST
(00) MEMORY OK
(01) MEMORY PROBLEM
(-8) Don't Know
(-9) Refused
(00) HA13B - CSMEMLT
(01) HA13B - CSMEMLT
(-8) HA13B - CSMEMLT
(-9) HA13B - CSMEMLT
(00) MEMORY OK
(01) MEMORY PROBLEM
(-8) Don't Know
(-9) Refused
(00) HA14B - HA14BCOD
(01) HA14B - HA14BCOD
(-8) HA14B - HA14BCOD
(-9) HA14B - HA14BCOD
(01) the current season?
(02) the location of (her/his) own room?
(03) staff names or faces?
(04) the fact that (she/he) was in a nursing home?
(96) NONE CHECKED
(-8) Don't Know
(01) HA15B - CSDECIS
(02) HA15B - CSDECIS
(03) HA15B - CSDECIS
(04) HA15B - CSDECIS
(96) HA15B - CSDECIS
(-8) HA15B - CSDECIS
ENTER ''99" IF THE RESIDENT WAS UNABLE TO COMPLETE THE INTERVIEW.
BOX HA12
routing
IF MENTSUM=99, GO TO HA12PREB-HA12PRBC.
ELSE GO TO HA52-MOOD.
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.
CSMEMST
HA12B
CODE ONE
CSMEMLT
HA13B
CODE ONE
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.
Page 8 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
Question Type
Question Text/Description
Code List
Routing
(00) INDEPENDENT
(01) MODIFIED INDEPENDENCE
(02) MODERATELY IMPAIRED
(03) SEVERELY IMPAIRED
(-8) Don't Know
(-9) Refused
(00) HA52-MOOD
(01) HA52-MOOD
(02) HA52-MOOD
(03) HA52-MOOD
(-8) HA52-MOOD
(-9) HA52-MOOD
The next section is concerning (SP)’s mood on or around (HS REF DATE).
PRESS "1" TO CONTINUE.
(01) CONTINUE
(01) HA53A- PHQINTRO
MOOD
[3.0, D0100] On or around (HS REF DATE) was a Resident Mood Interview conducted for (SP)?
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
(00) HA54- PHQSYINT
(01) HA53AB-PHQSCORE
(-8) HA54- PHQSYINT
(-9) HA54- PHQSYINT
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.
MOOD
MOOD
PHQINTRO
HA52
HA53A
CODE ONE
yes/no
[IF NEEDED: This is sometimes referred to as the Patient Health Questionnaire-9 or PHQ-9©. If an MDS has been
conducted for the resident, it can be found in section D0100.]
RESIDENT MOOD INTERVIEW (PHQ-9©) SUMMARY SCORE
[3.0, D0300]
PHQSCORE
HA53AB
numeric
ENTER SYMPTOM FREQUENCY SCORE (00-27) FROM PHQ-9©.
(01) CONTINUOUS ANSWER
(-8) DON’T KNOW
(-9) REFUSED
(01) BOX HA26
(-8) HA56 - BEHAV
(-9) HA56 - BEHAV
ENTER “99” IF THE RESIDENT WAS UNABLE TO COMPLETE THE INTERVIEW.
BOX HA26
routing
IF PHQSCORE=99, GO TO HA54 - PHQSYINT.
ELSE GO TO HA56 - BEHAV.
MOOD
[3.0, D0500]
PHQSYINT
HA54
LIST
Over the last 2 weeks, did the resident have any of the following problems or behaviors?
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, D0500].
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
(00) HA54-PHQSYDEP
(01) HA54-PHQSYDEP
(-8) HA54-PHQSYDEP
(-9) HA54-PHQSYDEP
A. Little interest or pleasure in doing things.
Page 9 of 45
2021 MCBS Facility Instrument
HS- Health Status
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
PHQSYDEP
HA54
LIST
B. Feeling or appearing down, depressed, or hopeless.
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
(00) HA54-PHQSYSLP
(01) HA54-PHQSYSLP
(-8) HA54-PHQSYSLP
(-9) HA54-PHQSYSLP
PHQSYSLP
HA54
LIST
C. Trouble falling or staying asleep, or sleeping too much.
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
(00) HA54-PHQSYTIR
(01) HA54-PHQSYTIR
(-8) HA54-PHQSYTIR
(-9) HA54-PHQSYTIR
PHQSYTIR
HA54
LIST
D. Feeling tired or having little energy.
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
(00) HA54-PHQSYAPT
(01) HA54-PHQSYAPT
(-8) HA54-PHQSYAPT
(-9) HA54-PHQSYAPT
PHQSYAPT
HA54
LIST
E. Poor appetite or overeating.
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
(00) HA54-PHQSYSES
(01) HA54-PHQSYSES
(-8) HA54-PHQSYSES
(-9) HA54-PHQSYSES
PHQSYSES
HA54
LIST
F. Indicating that (she/he) feels bad about self, is a failure, or has let self or family down.
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
(00) HA54-PHQSYCON
(01) HA54-PHQSYCON
(-8) HA54-PHQSYCON
(-9) HA54-PHQSYCON
PHQSYCON
HA54
LIST
G. Trouble concentrating on things, such as reading the newspaper or watching television.
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
(00) HA54-PHQSYMOV
(01) HA54-PHQSYMOV
(-8) HA54-PHQSYMOV
(-9) HA54-PHQSYMOV
PHQSYMOV
HA54
LIST
H. Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety or restless that
(she/he) has been moving around a lot more than usual.
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
(00) HA54-PHQSYSUI
(01) HA54-PHQSYSUI
(-8) HA54-PHQSYSUI
(-9) HA54-PHQSYSUI
PHQSYSUI
HA54
LIST
I. States that life isn't worth living, wishes for death, or attempts to harm self.
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
(00) HA54-PHQSYTEM
(01) HA54-PHQSYTEM
(-8) HA54-PHQSYTEM
(-9) HA54-PHQSYTEM
Page 10 of 45
2021 MCBS Facility Instrument
HS- Health Status
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
PHQSYTEM
HA54
LIST
J. Being short-tempered, easily annoyed.
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
(00) BOX HA25A
(01) BOX HA25A
(-8) BOX HA25A
(-9) BOX HA25A
BOX HA25A
routing
IF HA54-PHQSYINT = 1/YES, GO TO HA55A-PHQSFQIN.
ELSE GO TO BOX HA25B.
(00) NEVER OR 1 DAY
(01) 2-6 DAYS (SEVERAL DAYS)
(02) 7-11 DAYS (HALF OR MORE OF THE DAYS)
(03) 12-14 DAYS (NEARLY EVERY DAY)
(-8) DON’T KNOW
(-9) REFUSED
(00) BOX HA25B
(01) BOX HA25B
(02) BOX HA25B
(03) BOX HA25B
(-8) BOX HA25B
(-9) BOX HA25B
(00) NEVER OR 1 DAY
(01) 2-6 DAYS (SEVERAL DAYS)
(02) 7-11 DAYS (HALF OR MORE OF THE DAYS)
(03) 12-14 DAYS (NEARLY EVERY DAY)
(-8) DON’T KNOW
(-9) REFUSED
(00) BOX HA25C
(01) BOX HA25C
(02) BOX HA25C
(03) BOX HA25C
(-8) BOX HA25C
(-9) BOX HA25C
MOOD
[3.0, D0500]
PHQSFQIN
HA55A
CODE ONE
Over the last 2 weeks, would you say the following behavior/ problem was exhibited never or 1 day, for 2 to 6 days
(several days), for 7 to 11 days (half or more of the days), or for 12-14 days (nearly every day)?
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, D0500].
Little interest or pleasure in doing things.
BOX HA25B
routing
IF HA54-PHQSYDEP = 1/YES, GO TO HA55B-PHQSFQDE.
ELSE GO TO BOX HA25C.
MOOD
[3.0, D0500]
PHQSFQDE
HA55B
CODE ONE
Over the last 2 weeks, would you say the following behavior/ problem was exhibited never or 1 day, for 2 to 6 days
(several days), for 7 to 11 days (half or more of the days), or for 12-14 days (nearly every day)?
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, D0500].
Feeling or appearing down, depressed, or hopeless.
BOX HA25C
routing
IF HA54-PHQSYSLP = 1/YES, GO TO HA55C-PHQSFQSL.
ELSE GO TO BOX HA25D.
Page 11 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
Question Type
Question Text/Description
MOOD
[3.0, D0500]
PHQSFQSL
HA55C
CODE ONE
Over the last 2 weeks, would you say the following behavior/ problem was exhibited never or 1 day, for 2 to 6 days
(several days), for 7 to 11 days (half or more of the days), or for 12-14 days (nearly every day)?
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, D0500].
Code List
Routing
(00) NEVER OR 1 DAY
(01) 2-6 DAYS (SEVERAL DAYS)
(02) 7-11 DAYS (HALF OR MORE OF THE DAYS)
(03) 12-14 DAYS (NEARLY EVERY DAY)
(-8) DON’T KNOW
(-9) REFUSED
(00) BOX HA25D
(01) BOX HA25D
(02) BOX HA25D
(03) BOX HA25D
(-8) BOX HA25D
(-9) BOX HA25D
(00) NEVER OR 1 DAY
(01) 2-6 DAYS (SEVERAL DAYS)
(02) 7-11 DAYS (HALF OR MORE OF THE DAYS)
(03) 12-14 DAYS (NEARLY EVERY DAY)
(-8) DON’T KNOW
(-9) REFUSED
(00) BOX HA25E
(01) BOX HA25E
(02) BOX HA25E
(03) BOX HA25E
(-8) BOX HA25E
(-9) BOX HA25E
(00) NEVER OR 1 DAY
(01) 2-6 DAYS (SEVERAL DAYS)
(02) 7-11 DAYS (HALF OR MORE OF THE DAYS)
(03) 12-14 DAYS (NEARLY EVERY DAY)
(-8) DON’T KNOW
(-9) REFUSED
(00) BOX HA25F
(01) BOX HA25F
(02) BOX HA25F
(03) BOX HA25F
(-8) BOX HA25F
(-9) BOX HA25F
Trouble falling or staying asleep, or sleeping too much
BOX HA25D
routing
IF HA54-PHQSYTIR = 1/YES, GO TO HA55D-PHQSFQTI.
ELSE GO TO BOX HA25E.
MOOD
[3.0, D0500]
PHQSFQTI
HA55D
CODE ONE
Over the last 2 weeks, would you say the following behavior/ problem was exhibited never or 1 day, for 2 to 6 days
(several days), for 7 to 11 days (half or more of the days), or for 12-14 days (nearly every day)?
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, D0500].
Feeling tired or having little energy.
BOX HA25E
routing
IF HA54-PHQSYAPT = 1/YES, GO TO HA55E-PHQSFQAP.
ELSE GO TO BOX HA25F.
MOOD
[3.0, D0500]
PHQSFQAP
HA55E
CODE ONE
Over the last 2 weeks, would you say the following behavior/ problem was exhibited never or 1 day, for 2 to 6 days
(several days), for 7 to 11 days (half or more of the days), or for 12-14 days (nearly every day)?
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, D0500].
Poor appetite or overeating.
BOX HA25F
routing
IF HA54-PHQSYSES = 1/YES, GO TO HA55F-PHQSFQSE.
ELSE GO TO BOX BOXHA25G.
Page 12 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
Question Type
Question Text/Description
MOOD
[3.0, D0500]
PHQSFQSE
HA55F
CODE ONE
Over the last 2 weeks, would you say the following behavior/ problem was exhibited never or 1 day, for 2 to 6 days
(several days), for 7 to 11 days (half or more of the days), or for 12-14 days (nearly every day)?
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, D0500].
Code List
Routing
(00) NEVER OR 1 DAY
(01) 2-6 DAYS (SEVERAL DAYS)
(02) 7-11 DAYS (HALF OR MORE OF THE DAYS)
(03) 12-14 DAYS (NEARLY EVERY DAY)
(-8) DON’T KNOW
(-9) REFUSED
(00) BOX HA25G
(01) BOX HA25G
(02) BOX HA25G
(03) BOX HA25G
(-8) BOX HA25G
(-9) BOX HA25G
(00) NEVER OR 1 DAY
(01) 2-6 DAYS (SEVERAL DAYS)
(02) 7-11 DAYS (HALF OR MORE OF THE DAYS)
(03) 12-14 DAYS (NEARLY EVERY DAY)
(-8) DON’T KNOW
(-9) REFUSED
(00) BOX HA25H
(01) BOX HA25H
(02) BOX HA25H
(03) BOX HA25H
(-8) BOX HA25H
(-9) BOX HA25H
(00) NEVER OR 1 DAY
(01) 2-6 DAYS (SEVERAL DAYS)
(02) 7-11 DAYS (HALF OR MORE OF THE DAYS)
(03) 12-14 DAYS (NEARLY EVERY DAY)
(-8) DON’T KNOW
(-9) REFUSED
(00) BOX HA25I
(01) BOX HA25I
(02) BOX HA25I
(03) BOX HA25I
(-8) BOX HA25I
(-9) BOX HA25I
Indicating that (she/he) feels bad about self, is a failure, or has let self or family down.
BOX HA25G
routing
IF HA54-PHQSYCON = 1/YES, GO TO HA55G-PHQSFQCO.
ELSE GO TO BOX HA25H.
MOOD
[3.0, D0500]
PHQSFQCO
HA55G
CODE ONE
Over the last 2 weeks, would you say the following behavior/ problem was exhibited never or 1 day, for 2 to 6 days
(several days), for 7 to 11 days (half or more of the days), or for 12-14 days (nearly every day)?
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, D0500].
Trouble concentrating on things, such as reading the newspaper or watching television.
BOX HA25H
routing
IF HA54-PHQSYMOV = 1/YES, GO TO HA55H-PHQSFQMO.
ELSE GO TO BOX HA25I.
MOOD
[3.0, D0500]
PHQSFQMO
HA55H
CODE ONE
Over the last 2 weeks, would you say the following behavior/ problem was exhibited never or 1 day, for 2 to 6 days
(several days), for 7 to 11 days (half or more of the days), or for 12-14 days (nearly every day)?
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, D0500].
Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety or restless that (she/he)
has been moving around a lot more than usual.
BOX HA25I
routing
IFHA54-PHQSYSUI= 1/YES, GO TO HA55I-PHQSFQSU.
ELSE GO TO BOX HA25J.
Page 13 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
Question Type
Question Text/Description
MOOD
[3.0, D0500]
PHQSFQSU
HA55I
CODE ONE
Over the last 2 weeks, would you say the following behavior/ problem was exhibited never or 1 day, for 2 to 6 days
(several days), for 7 to 11 days (half or more of the days), or for 12-14 days (nearly every day)?
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, D0500].
Code List
Routing
(00) NEVER OR 1 DAY
(01) 2-6 DAYS (SEVERAL DAYS)
(02) 7-11 DAYS (HALF OR MORE OF THE DAYS)
(03) 12-14 DAYS (NEARLY EVERY DAY)
(-8) DON’T KNOW
(-9) REFUSED
(00) BOX HA25J
(01) BOX HA25J
(02) BOX HA25J
(03) BOX HA25J
(-8) BOX HA25J
(-9) BOX HA25J
(00) NEVER OR 1 DAY
(01) 2-6 DAYS (SEVERAL DAYS)
(02) 7-11 DAYS (HALF OR MORE OF THE DAYS)
(03) 12-14 DAYS (NEARLY EVERY DAY)
(-8) DON’T KNOW
(-9) REFUSED
(00) HA56-BEHAV
(01) HA56-BEHAV
(02) HA56-BEHAV
(03) HA56-BEHAV
(-8) HA56-BEHAV
(-9) HA56-BEHAV
(01) CONTINUE
(01) 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
States that life isn't worth living, wishes for death, or attempts to harm self.
BOX HA25J
routing
IF HA54-PHQSYTEM= 1/YES, GO TO HA55J-PHQSFQTE.
ELSE GO TO HA56-BEHAV
MOOD
[3.0, D0500]
PHQSFQTE
HA55J
CODE ONE
Over the last 2 weeks, would you say the following behavior/ problem was exhibited never or 1 day, for 2 to 6 days
(several days), for 7 to 11 days (half or more of the days), or for 12-14 days (nearly every day)?
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, D0500].
Being short-tempered, easily annoyed.
BEHAVIOR
BEHAV
HA56
CODE ONE
The next questions are about (SP)'s experiences and behavior on or around (HS REF DATE).
PRESS "1" TO CONTINUE.
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.
Page 14 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
Question Type
Question Text/Description
Code List
BEHAVIORAL SYMPTOMS
[3.0, E0200]
BSAYSOT
BSVERBOT
HA21B
HA21B
code one
code one
(00) BEHAVIOR NOT EXHIBITED
(01) BEHAVIOR OCCURRED 1 TO 3 DAYS
(02) BEHAVIOR OCCURRED 4 TO 6 DAYS
How often did the following behavioral problems occur on or around (HS REF DATE)? Would you say the behavior was
(03) BEHAVIOR OCCURRED DAILY
not exhibited, occurred 1 to 3 days, occurred 4 to 6 days, but less than daily, or occurred daily?
(-8) Don't Know
(-9) Refused
Physical behavior symptoms directed toward others.
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
BEHAVIORAL SYMPTOMS
[3.0, E0500]
significantly interfere with the resident's care?
BSELFACT
HA21AB
YES/NO
(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
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA21BB - BSOTHILL
(01) HA21BB - BSOTHILL
(-8) HA21BB - BSOTHILL
(-9) HHA21BB - BSOTHILL
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
Routing
BEHAVIORAL SYMPTOMS
[3.0, E0500]
significantly interfere with the resident's participation in activities or social interactions?
Page 15 of 45
2021 MCBS Facility Instrument
HS- Health Status
Variable Name
MR Screen Name
Question Type
BSOTHILL
HA21BB
YES/NO
BSOTHACT
HA21BB
YES/NO
Question Text/Description
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?
Code List
Routing
(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
BEHAVIORAL SYMPTOMS
[3.0, E0800]
BSNOEVAL
BSOFTWAN
HA21CB
HA21DB
CODE ONE
CODE ONE
(00) BEHAVIOR NOT EXHIBITED
(01) BEHAVIOR OCCURRED 1 TO 3 DAYS
(02) BEHAVIOR OCCURRED 4 TO 6 DAYS
How often did (SP) reject evaluation or care that is necessary to achieve (his/her) goals for health and well-being on or (03) BEHAVIOR OCCURRED DAILY
around (HS REF DATE)? Would you say the behavior was not exhibited, occurred 1 to 3 days, occurred 4 to 6 days,
(-8) Don't Know
but less than daily, or occurred daily?
(-9) Refused
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?
(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
Page 16 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
Question Type
Question Text/Description
Code List
Routing
(01) CONTINUE
HA22B - PFTRNSFR
(00) INDEPENDENT
(01) SUPERVISION
(02) LIMITED ASSISTANCE
(03) EXTENSIVE ASSISTANCE
(04) TOTAL DEPENDENCE
(07) ACTIVITY OCCURRED ONLY ONCE OR TWICE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
HA22B - PFLOCOMO
(00) INDEPENDENT
(01) SUPERVISION
(02) LIMITED ASSISTANCE
(03) EXTENSIVE ASSISTANCE
(04) TOTAL DEPENDENCE
(07) ACTIVITY OCCURRED ONLY ONCE OR TWICE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
HA22B - PFDRSSNG
(00) INDEPENDENT
(01) SUPERVISION
(02) LIMITED ASSISTANCE
(03) EXTENSIVE ASSISTANCE
(04) TOTAL DEPENDENCE
(07) ACTIVITY OCCURRED ONLY ONCE OR TWICE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
HA22B - PFEATING
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, required
supervision, required limited assistance, required extensive assistance, was totally dependent, or if the activity did not
occur. [By self-performance I mean what (SP) actually did for (himself/herself) and how much help was required by
staff members.]
PRESS "1" TO CONTINUE.
ADLS/PHYSICAL FUNCTIONING
[3.0, G0110]
[SHOW CARD HA1]
PFTRNSFR
HA22B
CODE ONE
Please tell me (SP)'s level of self-performance in…
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
transferring (for example, in and out of bed).
PFLOCOMO
HA22B
CODE ONE
ADLS/PHYSICAL FUNCTIONING
[3.0, G0110]
[SHOW CARD HA1]
locomotion on unit.
PFDRSSNG
HA22B
CODE ONE
ADLS/PHYSICAL FUNCTIONING
[3.0, G0110]
[SHOW CARD HA1]
dressing.
Page 17 of 45
2021 MCBS Facility Instrument
Variable Name
PFEATING
MR Screen Name
HA22B
HS- Health Status
Question Type
CODE ONE
Question Text/Description
ADLS/PHYSICAL FUNCTIONING
[3.0, G0110]
[SHOW CARD HA1]
eating.
PFTOILET
HA22B
CODE ONE
ADLS/PHYSICAL FUNCTIONING
[3.0, G0110]
[SHOW CARD HA1]
using the toilet.
ADLS/PHYSICAL FUNCTIONING
[3.0, G0120]
PFBATHNG
HA23B
CODE ONE
Again referring to the time on or around (HS REF DATE), what was (SP)'s level of self-performance when bathing:
was (she/he) independent, did (she/he) require supervision, require physical help limited to transfer only, require
physical help in part of the bathing activity, was (she/he) totally dependent, or did the activity not occur?
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
Code List
Routing
(00) INDEPENDENT
(01) SUPERVISION
(02) LIMITED ASSISTANCE
(03) EXTENSIVE ASSISTANCE
(04) TOTAL DEPENDENCE
(07) ACTIVITY OCCURRED ONLY ONCE OR TWICE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
HA22B - PFTOILET
(00) INDEPENDENT
(01) SUPERVISION
(02) LIMITED ASSISTANCE
(03) EXTENSIVE ASSISTANCE
(04) TOTAL DEPENDENCE
(07) ACTIVITY OCCURRED ONLY ONCE OR TWICE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
HA23B - PFBATHNG
(00) INDEPENDENT
(01) SUPERVISION
(02)PHYSICAL HELP LIMITED TO TRANSFER ONLY
(03) PHYSICAL HELP IN PART OF BATHING ACTIVITY
(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.
Page 18 of 45
2021 MCBS Facility Instrument
Variable Name
HS- Health Status
MR Screen Name
Question Type
Question Text/Description
BOX HA14B
routing
GO TO HA25PREB - HA25PRBC.
HA25PREB
CODE ONE
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
The next questions are about (SP)'s bowel and bladder control on or around (HS REF DATE).
PRESS "1" TO CONTINUE.
CTBOWELC
CTBLADDC
HA25B
CODE ONE
HA26B
CODE ONE
BOX HA28
routing
CONTINENCE
[3.0, H0400]
What was the level of (SP)'s bowel control on or around (HS REF DATE)? Was (she/he) always continent,
occasionally incontinent, frequently incontinent, always incontinent, or was (she/he) not rated?
CONTINENCE
[3.0, H0300]
What was the level of (SP)'s bladder control on or around (HS REF DATE)? Was (she/he) always continent,
occasionally incontinent, frequently incontinent, always incontinent, or was (she/he) not rated?
IF CCN=NON-MISSING GO TO HA10B,
ELSE GO TO HA28PREB-HA28PRBC.
Page 19 of 45
2021 MCBS Facility Instrument
Variable Name
HA28PRBC
MR Screen Name
HS- Health Status
Question Type
Question Text/Description
Code List
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 record when answering the (01) CONTINUE
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.
Routing
BOX HA28B
Page 20 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
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.
Code List
Routing
(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 ENDSTAGE 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) 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
Page 21 of 45
2021 MCBS Facility Instrument
HS- Health Status
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
HA28BOSP
HA28B
VERBATIM TEXT
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
HA29B - HA29BCOD
(01) ALZHEIMER'S DISEASE
(02) ANEMIA
(03) ANXIETY DISORDER
(04) APHASIA
(05) ARTHRITIS
(06) ASTHMA, COPD, OR CHRONIC LUNG DISEASE
(07) ATRIAL FIBRILLATION OR OTHER DYSRHYTHMIAS
(08) BENIGN PROSTATIC HYPERPLASIA
(09) CANCER
(10) CATARACTS, GLAUCOMA, OR MACULAR
DEGENERATION
(11) CEREBRAL PALSY
(12) CEREBROVASCULAR ACCIDENT (CVA), TRANSIENT
ISCHEMIC ATTACK (TIA), OR STROKE
(13) CIRRHOSIS
(14) CORONARY ARTERY DISEASE (E.G., ANGINA, MI,
AND ASHD)
(15) DEEP VENOUS THROMBOSIS (DVT), PULMONARY
EMBOLUS (PE) OR PULMONARY THROMBO-EMBOLISM
(PTE)
(16) DEMENTIA, OTHER THAN ALZHEIMER'S
(17) DEPRESSION
(18) DIABETES MELLITUS (E.G., DIABETIC
RETINOPATHY, NEPHROPATHY, AND NEUROPATHY)
(19) GASTROESOPHAGEAL REFLUX DISEASE (GERD)
OR ULCER
(20) HEART FAILURE (E.G., CONGESTIVE HEART
FAILURE (CHF) AND PULMONARY EDEMA)
(21) HEMIPLEGIA/HEMIPARESIS
(22) HIP FRACTURE
(23) HUNTINGTON'S DISEASE
(24) HYPERKALEMIA
(25) HYPERLIPIDEMIA (E.G.,
HYPERCHOLESTEROLEMIA)
(26) HYPERTENSION
(27) HYPONATREMIA
(28) MALNUTRITION OR AT RISK FOR MALNUTRITION
(29) MANIC DEPRESSION (BIPOLAR DISEASE)
(30) MULTIPLE SCLEROSIS
(31) NEUROGENIC BLADDER
(32) OBSTRUCTIVE UROPATHY
(33) ORTHOSTATIC HYPOTENSION
(34) OSTEOPOROSIS
(35) OTHER FRACTURE
(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 ENDSTAGE 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
(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
(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.
Page 22 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
Question Type
Question Text/Description
DIAGNOSES/CONDITIONS
[3.0, Section I
MDS ASSESSMENT DATE: (ASSESSMENT DATE)]
(SHOW CARD HA4)
HA29BCOD
HA29B
CODE ALL
[What active infections were checked on (SP)'s MDS assessment?]
[Look at the following list and tell me what active infections (SP) had on or around (HS REF DATE) according to the
medical record notes.]
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
WHEN ABSTRACTING FROM THE MDS, ONLY SELECT "96-NONE OF THE ABOVE" IF THAT IS THE BOX
CHECKED ON THE MDS.
OTMDSDIA
BOX HA15B
routing
HA30B
YES/NO
Code List
Routing
(01) MULTIDRUG-RESISTANT ORGANISM (MDRO)
(02) PNEUMONIA
(03) SEPTICEMIA
(04) TUBERCULOSIS
(05) URINARY TRACT INFECTION IN LAST 30 DAYS
(06) VIRAL HEPATITIS
(07) WOUND INFECTION (OTHER THAN FOOT)
(96) NONE OF THE ABOVE
(-8) Don't Know
(-9) Refused
BOX HA15B
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX HA16B
(01) HA31B - HA31BCOD
(-8) BOX HA16B
(-9) BOX HA16B
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?
Page 23 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
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
(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
(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 24 of 45
2021 MCBS Facility Instrument
Variable Name
MDCOTH1
MDCOTH2
MDCOTH3
MDCOTH4
MDCOTH5
HS- Health Status
MR Screen Name
Question Type
Question Text/Description
BOX HA16A1
routing
IF HA31B - HA31BCOD INCLUDES 91/Other1, THEN GO TO HA31BO1 - MDCOTH1.
ELSE GO TO BOX HA16A2.
HA31BO1
text
ENTER OTHER DIAGNOSIS 1.
OTHER (SPECIFY)
BOX HA16A2
routing
IF HA31B - HA31BCOD INCLUDES 92/Other2, THEN GO TO HA31BO2 - MDCOTH2.
ELSE GO TO BOX HA16A3.
HA31BO2
TEXT
ENTER OTHER DIAGNOSIS 2.
OTHER (SPECIFY)
BOX HA16A3
routing
IF HA31B - HA31BCOD INCLUDES 93/Other3, THEN GO TO HA31BO3 - MDCOTH3.
ELSE GO TO BOX HA16A4.
HA31BO3
TEXT
ENTER OTHER DIAGNOSIS 3.
OTHER (SPECIFY)
BOX HA16A4
routing
IF HA31B - HA31BCOD INCLUDES 94/Other4, THEN GO TO HA31BO4 - MDCOTH4.
ELSE GO TO BOX HA16B.
HA31BO4
TEXT
ENTER OTHER DIAGNOSIS 4.
OTHER (SPECIFY)
BOX HA16A5
routing
IF HA31B - HA31BCOD INCLUDES 95/Other5, THEN GO TO HA31BO5 - MDCOTH5.
ELSE GO TO BOX HA16B.
HA31BO5
TEXT
ENTER OTHER DIAGNOSIS 5.
OTHER (SPECIFY)
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
Page 25 of 45
2021 MCBS Facility Instrument
Variable Name
MDCOTH6
MDCOTH7
MDCOTH8
MDCOTH9
MDCOTH10
HS- Health Status
MR Screen Name
Question Type
Question Text/Description
BOX HA16A6
routing
IF HA31B - HA31BCOD INCLUDES 96/Other6, THEN GO TO HA31BO6 - MDCOTH6.
ELSE GO TO BOX HA16B.
HA31BO6
TEXT
ENTER OTHER DIAGNOSIS 6.
OTHER (SPECIFY)
BOX HA16A7
routing
IF HA31B - HA31BCOD INCLUDES 97/Other7, THEN GO TO HA31BO7 - MDCOTH7.
ELSE GO TO BOX HA16B.
HA31BO7
TEXT
ENTER OTHER DIAGNOSIS 7.
OTHER (SPECIFY)
BOX HA16A8
routing
IF HA31B - HA31BCOD INCLUDES 98/Other8, THEN GO TO HA31BO8 - MDCOTH8.
ELSE GO TO BOX HA16B.
HA31BO8
TEXT
ENTER OTHER DIAGNOSIS 8.
OTHER (SPECIFY)
BOX HA16A9
routing
IF HA31B - HA31BCOD INCLUDES 99/Other9, THEN GO TO HA31BO9 - MDCOTH9.
ELSE GO TO BOX HA16B.
HA31BO9
TEXT
ENTER OTHER DIAGNOSIS 9.
OTHER (SPECIFY)
BOX HA16A10
routing
IF HA31B - HA31BCOD INCLUDES 100/Other10, THEN GO TO HA31BO10 - MDCOTH10.
ELSE GO TO BOX HA16B.
HA31BO10
TEXT
ENTER OTHER DIAGNOSIS 10.
OTHER (SPECIFY)
Code List
Routing
(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
Page 26 of 45
2021 MCBS Facility Instrument
Variable Name
HS- Health Status
MR Screen Name
Question Type
Question Text/Description
BOX HA16B
routing
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) 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
(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
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.
SWALLOWING/ORAL PROBLEMS
[3.0, L0200]
HA37BBCO
HA37BB
CODE ALL
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.
Page 27 of 45
2021 MCBS Facility Instrument
Variable Name
HEIGHT
HS- Health Status
MR Screen Name
Question Type
Question Text/Description
BOX HA16AB
routing
IF PERS.PERSRNDC = CURRENT ROUND, OR CURRENT ROUND IS FALL ROUND, GO TO HA38B - HEIGHT.
ELSE, GO TO HA39B - FCWEIGHT.
HA38B
CODE ONE
ORAL/NUTRITIONAL STATUS
[3.0, K0200]
What (is/was) (SP)'s height in inches?
FCWEIGHT
HA39B
CODE ONE
ORAL/NUTRITIONAL STATUS
[3.0, K0200]
What was (SP)'s weight on or around (HS REF DATE)?
BOX HA17BB
routing
Code List
Routing
(01) Continuous
(-8) Don't Know
(-9) Refused
(01) HA39B - FCWEIGHT
(-8) HA39B - FCWEIGHT
(-9) HA39B - FCWEIGHT
(01) Continuous
(-8) Don't Know
(-9) Refused
(01) BOX HA17BB
(-8) BOX HA17BB
(-9) BOX HA17BB
GO TO HA10B - HA10BCOD.
ADVANCED DIRECTIVES
NOT ON MDS
(01)a Living Will?
(02) instructions not to resuscitate?
(03) instructions not to hospitalize?
Now, please tell me which of the following advanced directives were listed in (SP)'s record or chart for the period on or
(04) restrictions on feeding, medication, or other treatment
around (HS REF DATE).
restrictions?
(96) NONE CHECKED
Did (SP)'s record indicate…
(-8) Don't Know
(The rest of the health status questionnaire is not from the MDS.)
HA10BCOD
HA10B
CODE ALL
(01)HA32 - OTACTDIA
(02) HA32 - OTACTDIA
(03) HA32 - OTACTDIA
(04) HA32 - OTACTDIA
(96) HA32 - OTACTDIA
(-8) HA32 - OTACTDIA
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
Page 28 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
Question Type
Question Text/Description
DIAGNOSES/CONDITIONS
NOT ON MDS
OTACTDIA
HA32
YES/NO
Can you add any other active diagnoses for (SP) on or around (HS REF DATE) that have not yet been mentioned?
Please refer to the medical record including (SP)'s medications chart for (HS REF DATE MONTH).
Code List
Routing
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX HA15A
(01) HA33 - HA33CODE
(-8) BOX HA15A
(-9) BOX HA15A
(1) AGITATION
(2) ALCOHOL DEPENDENCY
(3) ALLERGIES
(4) ANOREXIA
(5) AORTIC STENOSIS
(6) ATAXIA
(7) ATYPICAL PSYCHOSIS
(8) BLINDNESS
(9) BREAST DISORDERS
(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
(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
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
DIAGNOSES/CONDITIONS
NOT ON MDS
SHOW CARD HA5
HA33CODE
HA33
CODE ALL
What were the diagnoses?
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
ENTER ICD-10 CODES, IF AVAILABLE, WHEN DIAGNOSIS TEXT IS MISSING OR ILLEGIBLE.
BOX HA15AA1
routing
IF HA33 - HA33CODE INCLUDES 91/Other1, THEN GO TO HA33O1 - NMDCOTH1.
ELSE GO TO BOX HA15AA2.
Page 29 of 45
2021 MCBS Facility Instrument
HS- Health Status
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
NMDCOTH1
HA33O1
TEXT
ENTER OTHER DIAGNOSIS 1.
OTHER (SPECIFY)
(01) Continuous
BOX HA15AA2
BOX HA15AA2
routing
IF HA33 - HA33CODE INCLUDES 92/Other2, THEN GO TO HA33O2 - NMDCOTH2.
ELSE GO TO BOX HA15AA3.
Page 30 of 45
2021 MCBS Facility Instrument
HS- Health Status
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
NMDCOTH2
HA33O2
TEXT
ENTER OTHER DIAGNOSIS 2.
OTHER (SPECIFY)
(01) Continuous
BOX HA15AA3
BOX HA15AA3
routing
IF HA33 - HA33CODE INCLUDES 93/Other3, THEN GO TO HA33O3 - NMDCOTH3.
ELSE GO TO BOX HA15AA4.
HA33O3
TEXT
ENTER OTHER DIAGNOSIS 3.
OTHER (SPECIFY)
(01) Continuous
BOX HA15AA4
BOX HA15AA4
routing
IF HA33 - HA33CODE INCLUDES 94/Other4, THEN GO TO HA33O4 - NMDCOTH4.
ELSE GO TO BOX HA15A.
HA33O4
TEXT
ENTER OTHER DIAGNOSIS 4.
OTHER (SPECIFY)
(01) CONTINUE
BOX HA15AA5
BOX HA15AA5
routing
IF HA33 - HA33CODE INCLUDES 95/Other5, THEN GO TO HA33O5 - NMDCOTH5.
ELSE GO TO BOX HA15A.
HA33O45
TEXT
ENTER OTHER DIAGNOSIS 5.
OTHER (SPECIFY)
(01) CONTINUE
BOX HA15AA6
BOX HA15AA6
routing
IF HA33 - HA33CODE INCLUDES 96/Other6, THEN GO TO HA33O6 - NMDCOTH6.
ELSE GO TO BOX HA15A.
HA33O6
TEXT
ENTER OTHER DIAGNOSIS 6.
OTHER (SPECIFY)
(01) CONTINUE
BOX HA15AA7
BOX HA15AA7
routing
IF HA33 - HA33CODE INCLUDES 97/Other7, THEN GO TO HA33O7 - NMDCOTH7.
ELSE GO TO BOX HA15A.
HA33O7
TEXT
ENTER OTHER DIAGNOSIS 7.
OTHER (SPECIFY)
(01) CONTINUE
BOX HA15AA8
BOX HA15AA8
routing
IF HA33 - HA33CODE INCLUDES 98/Other8, THEN GO TO HA33O8 - NMDCOTH8.
ELSE GO TO BOX HA15A.
HA33O8
TEXT
ENTER OTHER DIAGNOSIS 8.
OTHER (SPECIFY)
(01) CONTINUE
BOX HA15AA9
BOX HA15AA9
routing
IF HA33 - HA33CODE INCLUDES 99/Other9, THEN GO TO HA33O9 - NMDCOTH9.
ELSE GO TO BOX HA15A.
NMDCOTH3
NMDCOTH4
NMDCOTH5
NMDCOTH6
NMDCOTH7
NMDCOTH8
Page 31 of 45
2021 MCBS Facility Instrument
HS- Health Status
Variable Name
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
NMDCOTH9
HA33O9
TEXT
ENTER OTHER DIAGNOSIS 9.
OTHER (SPECIFY)
(01) CONTINUE
BOX HA15AA10
BOX HA15AA10
routing
IF HA33 - HA33CODE INCLUDES 100/Other10, THEN GO TO HA33O10 - NMDCOTH10.
ELSE GO TO BOX HA15A.
HA3310
TEXT
ENTER OTHER DIAGNOSIS 10.
OTHER (SPECIFY)
(01) CONTINUE
BOX HA15A
BOX HA15A
routing
IF HA28B - HA28BCD1 OR HA28B2 - HA28BCD2 INCLUDES 9/Cancer, GO TO HA33PRE - HA33PREC.
ELSE, GO TO HA33D - MYOCARD.
HA33PRE
CODE ONE
(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
OTHER (SPECIFY)
(01) Continuous answer
HA33D - MYOCARD
CONDITIONS
NOT ON MDS
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA33E - CATAROP
(01) HA33E - CATAROP
(-8) HA33E - CATAROP
(-9) HA33E - CATAROP
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX HA15F
(01) BOX HA15F
(-8) BOX HA15F
(-9) BOX HA15F
NMDCOTH10
HA33PREC
[While you are referring to (SP)'s medical record/(Now)] I have some (additional) questions about the conditions you
mentioned earlier. (These questions cannot be found on the MDS).
PRESS "1" TO CONTINUE.
Please refer to (SP)'s medical record and tell me in what part or parts of the body was the cancer found?
HA33BCOD
HA33B
CODE ALL
CNROTHOS
HA33B
TEXT
MYOCARD
HA33D
YES/NO
SELECT ALL THAT APPLY.
SEPARATE RESPONSES BY USING THE SPACEBAR.
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
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.
Page 32 of 45
2021 MCBS Facility Instrument
HS- Health Status
Variable Name
MR Screen Name
Question Type
CAUSEMCR
HA33F
YES/NO
OTHCAUS
HA33G
VERBATIM TEXT
What was the original cause of (SP)'s becoming eligible for Medicare?
RECORD VERBATIM
BOX HA15E
routing
IF RESPONDENT REPORTED MORE THAN ONE CONDITION IN HA28B-HA33E, GO TO HA33H - HA33HCOD.
ELSE, GO TO BOX HA17B.
HA33H
CODE ALL
Which of these conditions was a cause of (him/her) becoming eligible for Medicare?
BOX HA17B
routing
IF SP IS FEMALE, GO TO HA43APRE - HA43APRC.
ELSE GO TO HA43DAPR - HA43DAPC.
HA33HCOD
Question Text/Description
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?
Code List
Routing
(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
(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
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?
HYSTEREC
BOX HA17C
routing
HA43C
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?
Page 33 of 45
2021 MCBS Facility Instrument
HS- Health Status
Variable Name
MR Screen Name
Question Type
Question Text/Description
HA43DAPC
HA43DAPR
CODE ONE
DRECEXAM
HA43DA
YES/NO
Since (MONTH & DAY OF TODAY'S DATE) a year ago has (SP) had a digital rectal examination of the prostate?
BLOODPSA
HA43DB
YES/NO
(00) NO
Since (MONTH & DAY OF TODAY'S DATE) a year ago has (SP) had a blood test for detection of prostate cancer, such (01) YES
as a PSA?
(-8) Don't Know
(-9) Refused
BOX HA17CB
routing
IF FALL ROUND, GO TO HA43DC - FLUSHOT.
ELSE GO TO BOX HA17CA.
The next items are about procedures (SP) may have had since (MONTH & DAY OF TODAY'S DATE) a year ago.
PRESS "1" TO CONTINUE.
Code List
Routing
(01) Continue
HA43DA - DRECEXAM
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA43DB - BLOODPSA
(01) HA43DB - BLOODPSA
(-8) HA43DB - BLOODPSA
(-9) HA43DB - BLOODPSA
(00) BOX HA17CB
(01) BOX HA17CB
(-8) BOX HA17CB
(-9) BOX HA17CB
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)?]
(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
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA43GPRE - HA43GPRC
(01) HA43GPRE - HA43GPRC
(-8) HA43GPRE - HA43GPRC
(-9) HA43GPRE - HA43GPRC
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
HA43DD
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].
EVRSMOKE
HA43E
YES/NO
SMOKING
NOT ON MDS
The next couple of questions are about smoking. Has (SP) ever smoked cigarettes, cigars, or pipe tobacco?
NOWSMOKE
BOX HA17D
routing
HA43F
YES/NO
IF HA11B - COMATOSE = 1/YesComatose, GO TO BOX HA23B.
ELSE IF HA43E - EVRSMOKE = 1/Yes AND SP IS ALIVE, GO TO HA43F - NOWSMOKE.
ELSE GO TO HA43GPRE - HA43GPRC.
SMOKING
NOT ON MDS
Does (SP) smoke now?
Page 34 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
Question Type
Question Text/Description
Code List
Routing
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
(01) CONTINUE
(HS REF DATE). Please tell me for each activity whether (SP) had no difficulty at all, a little difficulty, some difficulty, a
lot of difficulty, or was not able to do it.
HA43G - IADSTOOP
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?
(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
Page 35 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
Question Type
Question Text/Description
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)?
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
REASNOMM
HA43I3
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
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
HA43K
CODE ONE
GENERAL HEALTH
NOT ON MDS
Compared to one year ago, how would you rate (SP)'s health in general now? Would you say (SP)'s health is . . .
LIMACTIV
HA43L
CODE ONE
Routing
(00) NO
(01)YES
(-8) Don't Know
(-9) Refused
(00) HA43H2 - DIFSHOP
(01) HA43H2 - DIFSHOP
(-8) HA43H2 - DIFSHOP
(-9) HA43H2 - DIFSHOP
(00) NO
(01) YES
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(00) HA43H3 - DIFMONEY
(01) HA43H3 - DIFMONEY
(03) HA43I2 - REASNOSH
(-8) HA43H3 - DIFMONEY
(-9) HA43H3 - DIFMONEY
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) HA43H3 - DIFMONEY
(01) HA43H3 - DIFMONEY
(-8) HA43H3 - DIFMONEY
(-9) HA43H3 - DIFMONEY
(00) NO
(01) YES
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(00) BOX HA17F
(01) BOX HA17F
(03)HA43I3 - REASNOMM
(-8) BOX HA17F
(-9) BOX HA17F
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX HA17F
(01) BOX HA17F
(-8) BOX HA17F
(-9) BOX HA17F
(00) EXCELLENT
(01) VERY GOOD
(02) GOOD
(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
(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
IF SP IS ALIVE, GO TO HA43J - SPHEALTH.
ELSE GO TO BOX HA23B.
GENERAL HEALTH
NOT ON MDS
SPHEALTH
Code List
(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 friends
(-8) Don't Know
or close relatives? Would you say . . .
(-9) Refused
GENERAL HEALTH
NOT ON MDS
(00) BOX HA23B
(01) BOX HA23B
(02) BOX HA23B
(03) BOX HA23B
(-8) BOX HA23B
(-9) BOX HA23B
Page 36 of 45
2021 MCBS Facility Instrument
Variable Name
HS- Health Status
MR Screen Name
Question Type
Question Text/Description
BOX HA23B
routing
IF BQ9-EDLEVELF = DK, RF, OR EMPTY, GO TO HA51B - HEDULEV.
ELSE GO TO BOX HA24.
EDUCATION LEVEL
NOT ON MDS
HEDULEV
HA51B
CODE ONE
As far as you know, what (is/was) the highest level of schooling (SP) completed?
IF DK, USE CATEGORIES AS PROBES.
BOX HA24
routing
Code List
Routing
(01) NO FORMAL SCHOOLING
(02) ELEMENTARY (1ST-8TH GRADES)
(03) SOME HIGH SCHOOL (9TH-12TH GRADES)
(04) COMPLETED HIGH SCHOOL, NO COLLEGE
(05) TECHNICAL OR TRADE SCHOOL
(06) SOME COLLEGE
(07) COLLEGE GRADUATE
(08) GRADUATE DEGREE
(-8) Don't Know
(-9) Refused
(01) BOX HA24
(02) BOX HA24
(03) BOX HA24
(04) BOX HA24
(05) BOX HA24
(06) BOX HA24
(07) BOX HA24
(08) BOX HA24
(-8) BOX HA24
(-9) BOX HA24
(01) ALL
(02) MAJORITY
(03) HALF
(04) SOME
(05) NONE
(01) HC3 - WHYABSTR
(02) HC3 - WHYABSTR
(03) HC3 - WHYABSTR
(04) HC3 - WHYABSTR
(05) BOX HCEND
IF 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?
(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
WHYABSOS
HC3
VERBATIM TEXT
OTHER(SPECIFY)
(01) CONTINUOUS ANSWER
BOX HCEND
BOX HCEND
routing
GO TO HSFINSCR2 - FINSCRN2.
BOX HAT2BEG
routing
IF FACR.HAINTFLG <> 1/Indicated, GO TO HA1PRE1T2 - HA1PRE1C.
ELSE GO TO HA1PRE2T2 - HA1PRE2C.
(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.
Page 37 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
Question Type
Question Text/Description
Code List
Routing
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
routing
RECHAVE
HA1T2
YES/NO
HSCONTN1
HA1BT2
CODE ONE
BOX HA2AT2
routing
HA2T2
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)?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
Is there someone else I should speak with, or do the records exist elsewhere?
(00) NO, RETURN TO NAVIGATE SCREEN
DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT THE MEDICAL (01) YES, CONTINUE WITHOUT MEDICAL RECORDS
RECORDS?
(00) HA1BT2 - HSCONTN1
(01) BOX HA2AT2
(-8) HA1BT2 - HSCONTN1
(-9) BOX HA9PRBCT2
(00) BOX HCENDT2
(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
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
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
Is there someone else I should speak with, or do the records exist elsewhere?
HSCONTN2
HA2B1T2
CODE ONE
RECFORM2
HA2BT2
YES/NO
HSCONTN3
HA2CT2
CODE ONE
DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT ANY MDS
FORMS?
RECORD IDENTIFICATION
Do (SP)'s medical records contain (a full/another) MDS assessment or Quarterly Review form dated [after
(PreloadSP.PRVHSREF)/after (PreloadSP.LASTVAD)/on or around (T2 REF DATE)/after BCVAD)]?
Is there someone else I should speak with, or do the records exist elsewhere?
DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT?
RECORD IDENTIFICATION
ASSESDT1
HA3BT2
DATE
What is the assessment date on the full MDS assessment or Quarterly Review that was completed closest to (T2 REF
(01) CONTINUOUS ANSWER
DATE) for (SP) after (RAD+14)/BCVAD/PreloadSP.LASTVAD].
(-8) Don't Know
(-9) Refused
ENTER DATE IN "MM DD YY" FORMAT.
(01) BOX HA4T2
(-8) BOX HA4T2
(-9) BOX HA4T2
(IF NO MDS AVAILABLE, BACK UP AND CHANGE THE RESPONSE.)
BOX HA4T2
routing
IF HA3BT2 - ASSESDT1 = DK, RF AND FIRST TIME AT HA3BT2 - ASSESDT1, GO TO BOX HA9PRBCT2.
ELSE GO TO BOX HA5T2.
Page 38 of 45
2021 MCBS Facility Instrument
Variable Name
FORMTYPE1
CLOSFORM
HS- Health Status
MR Screen Name
Question Type
Question Text/Description
Code List
Routing
BOX HA5T2
routing
IF LAST ASSESSMENT DATE ENTRY COLLECTED IN HA3BT2 - ASSESDT1 IS VALID, GO TO HA4T2 FORMTYPE1.
ELSE GO TO HA5T2 - CLOSFORM.
HA4T2
CODE ONE
(00) QUARTERLY REVIEW
(01) FULL MDS
(-8) Don't Know
(-9) Refused
(00) BOX HA7T2
(01) BOX HA7T2
(-8) BOX HA7T2
(-9) BOX HA7T2
BOX HA7T2
routing
IF MOST RECENT ASSESSMENT DATE IS COMPLETE THEN COMPARE WITH T2 REF DATE. IF NUMBER OF
DAYS BETWEEN ASSESSMENT DATE AND T2 REF DATE MORE THAN +/- 7, GO TO HA5T2 - CLOSFORM.
ELSE GO TO BOX HA9T2A
HA5T2
YES/NO
Besides the form you just told me about, does (SP)'s medical record contain any other MDS form or Quarterly Review
form dated closer to (T2 REF DATE)?
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(00) BOX HA8T2
(01) BOX HA8T2
(-8) BOX HA8T2
(-9) BOX HA8T2
BOX HA8T2
routing
IF HA5T2 - CLOSFORM = 1/Yes, GO TO HA3BT2 - ASSESDT1. ELSE GO TO BOX HA9T2A.
BOX HA9T2A
routing
IF T2TOT = 1 AND (FORMTYPE = DK, RF, OR EMPTY), GO TO BOX HA9PRBCT2.
ELSE GO TO BOX HA9T2B.
BOX HA9T2B
routing
GO TO BOX HA9T2C.
BOX HA9T2C
routing
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.
What was the primary reason for the assessment on the full MDS assessment dated (TCVAD)?
(01) ADMISSION
(02) ANNUAL
(03) SIGNIFICANT CHANGE IN STATUS
(91) OTHER
(-8) Don't Know
(-9) Refused
(01)BOX HA10T2
(02) BOX HA10T2
(03) BOX HA10T2
(91) HA6T2 - FORMREOS
(-8) BOX HA10T2
(-9) BOX HA10T2
OTHER (SPECIFY)
(01) Continuous answer
BOX HA10T2
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
(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
RECORD IDENTIFICATION
Please tell me if the form with the assessment date of (T2 ASSESS DATE) is a full MDS or a quarterly review.
RECORD IDENTIIFCATION
[3.0, A0310A]
FORMREAS
HA6T2
CODE ONE
FORMREOS
HA6T2
VERBATIM TEXT
RECMDS
HA7AT2
YES/NO
ASSESDT2
HA7BT2
NUMERIC
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.
Page 39 of 45
2021 MCBS Facility Instrument
Variable Name
HS- Health Status
MR Screen Name
Question Type
Question Text/Description
BOX HA10T2
routing
IF CCN=NON-MISSING THEN GO TO BOX HA17BBT2.
ELSE GO TO HA7CT2 - MDSINT1.
Code List
Routing
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 full MDS
(01) Continue
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
IF CCN=NON-MISSING THEN GO TO BOX HA17BBT2.
ELSE GO TO HA9PREBT2-HA9PRBC
BOX HA9PRBCT2
HA9PRBC
HA9PREBT2
GO TO HA11BT2 - COMATOSE.
CODE ONE
Now I have some questions concerning (SP)'s health on or around [(HS REF DATE)/(his/her) admission to the
(facility/home)]. [(Please refer to (SP)'s medical record/Since I will be collecting information about (SP) on or around
(HS REF DATE) and there is no MDS or Quarterly Review available close to that 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
(01) CONTINUE
HA12BT2 - CSMEMST
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.
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.
Page 40 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
Question Type
CSMEMST
HA12BT2
CODE ONE
CSMEMLT
HA13BT2
CODE ONE
Question Text/Description
MEMORY/COGNITIVE SKILLS
[3.0, C0700]
(00) HA13BT2 - CSMEMLT
(01) HA13BT2 - CSMEMLT
(-8) HA13BT2 - CSMEMLT
(-9) HA13BT2 - CSMEMLT
MEMORY/COGNITIVE SKILLS
[3.0, C0800]
(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
MEMORY/COGNITIVE SKILLS
[3.0, C0900]
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
BSVERBOT
HA21BT2
HA21BT2
CODE ONE
CODE ONE
(00) BEHAVIOR NOT EXHIBITED
(01) BEHAVIOR OCCURRED 1 TO 3 DAYS
(02) BEHAVIOR OCCURRED 4 TO 6 DAYS
How often did the following behavioral problems occur on or around (T2 REF DATE)? Would you say the behavior was
(03) BEHAVIOR OCCURRED DAILY
not exhibited, occurred 1 to 3 days, occurred 4 to 6 days, but less than daily, or occurred daily?
(-8) Don't Know
(-9) Refused
Physical behavior symptoms directed toward others.
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
Routing
(00) MEMORY OK
(01) MEMORY PROBLEM
(-8) Don't Know
On or around (T2 REF DATE), was (SP)'s short-term memory okay, that is, did (he/she) seem or appear to recall things
(-9) Refused
after 5 minutes?
Was (SP)'s long-term memory okay; that is, did (she/he) seem or appear to recall events in the distant past?
HA14BCOD
Code List
(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
IF HA21BT2 - BSAYSOT and HA21BT2 - BSVERBOT and HA21BT2 - BSNOTOT = 0/BehaviorNotExhibited, GO TO
HA21CBT2 - BSNOEVAL.
ELSE GO TO HA21ABT2 - BSELFILL.
Page 41 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
Question Type
Question Text/Description
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?
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?
BSNOEVAL
BSOFTWAN
HA21CBT2
HA21DBT2
CODE ONE
CODE ONE
Code List
Routing
(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
(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
BEHAVIORAL SYMPTOMS
[3.0, E0800]
(00) BEHAVIOR NOT EXHIBITED
(01) BEHAVIOR OCCURRED 1 TO 3 DAYS
(02) BEHAVIOR OCCURRED 4 TO 6 DAYS
How often did (SP) reject evaluation or care that is necessary to achieve (his/her) goals for health and well-being on or (03) BEHAVIOR OCCURRED DAILY
around (T2 REF DATE)? Would you say the behavior was not exhibited, occurred 1 to 3 days, occurred 4 to 6 days, but (-8) Don't Know
less than daily, or occurred daily?
(-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
How often did (SP) wander on or around (T2 REF DATE)? Would you say the behavior was not exhibited, occurred 1 to
(-8) Don't Know
3 days, occurred 4 to 6 days, but less than daily, or occurred daily?
(-9) Refused
(00) HA22PREBT2 - HA22PRBC
(01) HA21EBT2 - BSWDANGR
(02) HA21EBT2 - BSWDANGR
(03) HA21EBT2 - BSWDANGR
(-8) HA21EBT2 - BSWDANGR
(-9) HA21EBT2 - BSWDANGR
BEHAVIORAL SYMPTOMS
[3.0, E0900]
Page 42 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
Question Type
Question Text/Description
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) 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
(01) CONTINUE
HA22BT2 - PFTRNSFR
(00) INDEPENDENT
(01) SUPERVISION
(02) LIMITED ASSISTANCE
(03) EXTENSIVE ASSISTANCE
(04) TOTAL DEPENDENCE
(07) ACTIVITY OCCURRED ONLY ONCE OR TWICE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
(00) HA22BT2 - PFLOCOMO
(01) HA22BT2 - PFLOCOMO
(02) HA22BT2 - PFLOCOMO
(03) HA22BT2 - PFLOCOMO
(04) HA22BT2 - PFLOCOMO
(07) HA22BT2 - PFLOCOMO
(08) HA22BT2 - PFLOCOMO
(-8) HA22BT2 - PFLOCOMO
(-9) HA22BT2 - PFLOCOMO
(00) INDEPENDENT
(01) SUPERVISION
(02) LIMITED ASSISTANCE
(03) EXTENSIVE ASSISTANCE
(04) TOTAL DEPENDENCE
(07) ACTIVITY OCCURRED ONLY ONCE OR TWICE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
(00) IHA22BT2 - PFDRSSNG
(01) HA22BT2 - PFDRSSNG
(02) HA22BT2 - PFDRSSNG
(03) HA22BT2 - PFDRSSNG
(04) HA22BT2 - PFDRSSNG
(07) HA22BT2 - PFDRSSNG
(08) HA22BT2 - PFDRSSNG
(-8) HA22BT2 - PFDRSSNG
(-9) HA22BT2 - PFDRSSNG
(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
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 activity did not
occur. [By self-performance I mean what (SP) actually did for (himself/herself) and how much help was required by
staff members.]
PRESS "1" TO CONTINUE.
ADLS/PHYSCIAL FUNCTIONING
[3.0, G0110]
(SHOW CARD HA1)
PFTRNSFR
HA22BT2
CODE ONE
Please tell me (SP)'s level of self-performance in…
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
transferring (for example, in and out of bed).
PFLOCOMO
HA22BT2
CODE ONE
ADLS/PHYSCIAL FUNCTIONING
[3.0, G0110]
locomotion on unit.
PFDRSSNG
HA22BT2
CODE ONE
ADLS/PHYSCIAL FUNCTIONING
[3.0, G0110]
dressing.
Page 43 of 45
2021 MCBS Facility Instrument
Variable Name
PFEATING
MR Screen Name
HA22BT2
HS- Health Status
Question Type
CODE ONE
Question Text/Description
ADLS/PHYSCIAL FUNCTIONING
[3.0, G0110]
eating.
PFTOILET
HA22BT2
CODE ONE
ADLS/PHYSCIAL FUNCTIONING
[3.0, G0110]
using the toilet.
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 - PFTOILET
(01) HA22BT2 - PFTOILET
(02) HA22BT2 - PFTOILET
(03) HA22BT2 - PFTOILET
(04) HA22BT2 - PFTOILET
(07) HA22BT2 - PFTOILET
(08) HA22BT2 - PFTOILET
(-8) HA22BT2 - PFTOILET
(-9) HA22BT2 - PFTOILET
(00) INDEPENDENT
(01) SUPERVISION
(02) LIMITED ASSISTANCE
(03) EXTENSIVE ASSISTANCE
(04) TOTAL DEPENDENCE
(07) ACTIVITY OCCURRED ONLY ONCE OR TWICE
(08) ACTIVITY DID NOT OCCUR
(-8) Don't Know
(-9) Refused
(00) HA23BT2 - PFBATHNG
(01) HA23BT2 - PFBATHNG
(02) HA23BT2 - PFBATHNG
(03) HA23BT2 - PFBATHNG
(04) HA23BT2 - PFBATHNG
(07) HA23BT2 - PFBATHNG
(08) HA23BT2 - PFBATHNG
(-8) HA23BT2 - PFBATHNG
(-9) HA23BT2 - PFBATHNG
ADLS/PHYSICAL FUNCTIONING
[3.0, G0120]
PFBATHNG
HA23BT2
CODE ONE
HA24PRBC
HA24PREBT2
CODE ONE
(00) INDEPENDENT
(01) SUPERVISION
(02) PHYSICAL HELP LIMITED TO TRANSFER ONLY
Again referring to the time on or around (T2 REF DATE), what was (SP)'s level of self-performance when bathing: was (03) PHYSICAL HELP IN PART OF BATHING ACTIVITY
(04) TOTAL DEPENDENCE
(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?
(07) ACTIVITY DID NOT OCCUR
(-8) Don't Know
PRESS F1 KEY FOR COMPLETE DEFINITIONS.
(-9) Refused
The next questions are about modes of locomotion and appliances or devices (SP) might have used on or around (T2
REF DATE).
(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
GO TO HA39BT2 - FCWEIGHT
ORAL/NUTRITIONAL STATUS
[3.0, K0200]
What was (SP)'s weight on or around (T2 REF DATE)?
BOX HA17BBT2
routing
GO TO HC2T2 - DIDABSTR.
Page 44 of 45
2021 MCBS Facility Instrument
Variable Name
MR Screen Name
HS- Health Status
Question Type
Question Text/Description
Code List
Routing
(01) ALL
(02) MAJORITY
(03) HALF
(04) SOME
(05) NONE
(01) HC3T2 - WHYABSTR
(02) HC3T2 - WHYABSTR
(03) HC3T2 - WHYABSTR
(04) HC3T2 - WHYABSTR
(05) BOX HCENDT2
DID YOU ABSTRACT?
DIDABSTR
HC2T2
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
HC3T2
CODE ONE
WHY DID YOU ABSTRACT?
(01) NO KNOWLEDGEABLE RESPONDENT AVAILABLE
(02) NO TIME/STAFF BURDEN TOO GREAT
(03) REFUSAL--UNWILLING TO COOPERATE
(91) OTHER
(01) BOX HCENDT2
(02) BOX HCENDT2
(03) BOX HCENDT2
(91) HC3T2 - WHYABSOS
WHYABSOS
HC3T2
VERBATIM TEXT
OTHER (SPECIFY)
(01) Continuous Answer
BOX HCENDT2
BOX HCENDT2
routing
GO TO HSFINSCR2 - FINSCRN2.
HSFINSCR2
CODE ONE
(01) CONTINUE
HSFINSCR - FINSCRN
(01) CONTINUE
BOX HSEND
FINSCRN2
(RETURN TO NAVIGATOR TO CONTINUE INTERVIEW. THE HEALTH STATUS SECTION WAS NOT
COMPLETED./YOU HAVE COMPLETED THE HEALTH STATUS SECTION FOR THIS SP.)
PRESS "1" TO TO CONTINUE.
FINSCRN
HSFINSCR
CODE ONE
BOX HSEND
routing
YOU HAVE COMPLETED THE HEALTH STATUS SECTION FOR THIS SP.
PRESS "1" TO RETURN TO NAVIGATION SCREEN.
GO TO NAVIGATOR
Page 45 of 45
| File Type | application/pdf |
| File Title | Medicare Current Beneficiary Survey Section Specifications for HS |
| Subject | Medicare beneficiaries, MCBS facility instrument, 2021, Health Status, HS |
| Author | NORC |
| File Modified | 2021-09-27 |
| File Created | 2021-09-21 |