Form CMS-10387 Nursing Home PPS (NP) Item Set

Resident

Identifier

Date

MINIMUM DATA SET (MDS) - Version 3.0

RESIDENT ASSESSMENT AND CARE SCREENING
Nursing Home PPS (NP) Item Set
Section A.

Identification Information.

A0050. Type of Record.
Enter Code

1. Add new record
Continue to A0100, Facility Provider Numbers.
2. Modify existing record
Continue to A0100, Facility Provider Numbers.
3. Inactivate existing record
Skip to X0150, Type of Provider.

A0100. Facility Provider Numbers.
A. National Provider Identifier (NPI):

B. CMS Certification Number (CCN):

C. State Provider Number:

A0200. Type of Provider.
Enter Code

Type of provider.
1. Nursing home (SNF/NF).
2. Swing Bed.

A0300. Optional State Assessment.
Complete only if A0200 = 1.
Enter Code

A. Is this assessment for state payment purposes only?
0. No
1. Yes

A0310. Type of Assessment.
Enter Code

Enter Code

Enter Code

Enter Code

A. Federal OBRA Reason for Assessment.
01. Admission assessment (required by day 14).
02. Quarterly review assessment.
03. Annual assessment.
04. Significant change in status assessment.
05. Significant correction to prior comprehensive assessment.
06. Significant correction to prior quarterly assessment.
99. None of the above.
B. PPS Assessment.
PPS Scheduled Assessment for a Medicare Part A Stay.
01. 5-day scheduled assessment.
PPS Unscheduled Assessment for a Medicare Part A Stay.
08. IPA - Interim Payment Assessment.
Not PPS Assessment.
99. None of the above.
E. Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry?
0. No.
1. Yes.
F. Entry/discharge reporting
01. Entry tracking record.
10. Discharge assessment-return not anticipated.
11. Discharge assessment-return anticipated.
12. Death in facility tracking record.
99. None of the above.

A0310 continued on next page.
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Resident

Identifier

Section A.

Date

Identification Information.

A0310. Type of Assessment - Continued.
Enter Code

Enter Code

Enter Code

G. Type of discharge - Complete only if A0310F = 10 or 11.
1. Planned.
2. Unplanned.
G1. Is this a SNF Part A Interrupted Stay?.
0. No.
1. Yes.
H. Is this a SNF Part A PPS Discharge Assessment?.
0. No.
1. Yes.

A0410. Unit Certification or Licensure Designation.
Enter Code

1. Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State.
2. Unit is neither Medicare nor Medicaid certified but MDS data is required by the State.
3. Unit is Medicare and/or Medicaid certified.

A0500. Legal Name of Resident.
A. First name:

B. Middle initial:

C. Last name:

D. Suffix:

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

_

_

B. Medicare number:

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

A0800. Gender.
Enter Code

1. Male.
2. Female.

A0900. Birth Date.
_
Month

_
Day

Year

A1000. Race/Ethnicity.
Check all that apply.
A. American Indian or Alaska Native.
B. Asian.
C. Black or African American.
D. Hispanic or Latino.
E. Native Hawaiian or Other Pacific Islander.
F. White.

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Resident

Identifier

Section A.

Date

Identification Information.

A1100. Language.
Enter Code

A. Does the resident need or want an interpreter to communicate with a doctor or health care staff?
0. No
Skip to A1200, Marital Status.
1. Yes
Specify in A1100B, Preferred language.
Skip to A1200, Marital Status.
9. Unable to determine.
B. Preferred language:

A1200. Marital Status.
Enter Code

Never married.
Married.
Widowed.
Separated.
Divorced.

1.
2.
3.
4.
5.

A1300. Optional Resident Items.
A. Medical record number:

B. Room number:

C. Name by which resident prefers to be addressed:

D. Lifetime occupation(s) - put "/" between two occupations:

Most Recent Admission/Entry or Reentry into this Facility.
A1600. Entry Date.
_
Month

_
Day

Year

A1700. Type of Entry.
Enter Code

1. Admission.
2. Reentry.

A1800. Entered From.
Enter Code

01.
02.
03.
04.
05.
06.
07.
09.
99.

Community (private home/apt., board/care, assisted living, group home).
Another nursing home or swing bed.
Acute hospital.
Psychiatric hospital.
Inpatient rehabilitation facility.
ID/DD facility.
Hospice.
Long Term Care Hospital (LTCH).
Other.

A1900. Admission Date (Date this episode of care in this facility began).
_
Month

_
Day

Year

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Resident

Identifier

Section A.

Date

Identification Information.

A2000. Discharge Date.
Complete only if A0310F = 10, 11, or 12.
_
Month

_
Day

Year

A2100. Discharge Status.
Complete only if A0310F = 10, 11, or 12.
Enter Code

01.
02.
03.
04.
05.
06.
07.
08.
09.
99.

Community (private home/apt., board/care, assisted living, group home).
Another nursing home or swing bed.
Acute hospital.
Psychiatric hospital.
Inpatient rehabilitation facility.
ID/DD facility.
Hospice.
Deceased.
Long Term Care Hospital (LTCH).
Other.

A2200. Previous Assessment Reference Date for Significant Correction.
Complete only if A0310A = 05 or 06.
_
Month

_
Day

Year

A2300. Assessment Reference Date.
Observation end date:

_
Month

_
Day

Year

A2400. Medicare Stay.
Enter Code

A. Has the resident had a Medicare-covered stay since the most recent entry?
Skip to B0100, Comatose.
0. No
1. Yes
Continue to A2400B, Start date of most recent Medicare stay.
B. Start date of most recent Medicare stay:

_
Month

_
Day

Year

C. End date of most recent Medicare stay - Enter dashes if stay is ongoing:

_
Month

_
Day

Year

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Resident

Identifier

Date

Look back period for all items is 7 days unless another time frame is indicated.
Section B.

Hearing, Speech, and Vision.

B0100. Comatose.
Enter Code

Persistent vegetative state/no discernible consciousness.
Continue to B0200, Hearing.
0. No
1. Yes
Skip to G0110, Activities of Daily Living (ADL) Assistance.

B0200. Hearing.
Enter Code

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

B0300. Hearing Aid.
Enter Code

Hearing aid or other hearing appliance used in completing B0200, Hearing.
0. No.
1. Yes.

B0600. Speech Clarity.
Enter Code

Select best description of speech pattern.
0. Clear speech - distinct intelligible words.
1. Unclear speech - slurred or mumbled words.
2. No speech - absence of spoken words.

B0700. Makes Self Understood.
Enter Code

Ability to express ideas and wants, consider both verbal and non-verbal expression.
0. Understood.
1. Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time.
2. Sometimes understood - ability is limited to making concrete requests.
3. Rarely/never understood.

B0800. Ability To Understand Others.
Enter Code

Understanding verbal content, however able (with hearing aid or device if used).
0. Understands - clear comprehension.
1. Usually understands - misses some part/intent of message but comprehends most conversation.
2. Sometimes understands - responds adequately to simple, direct communication only.
3. Rarely/never understands.

B1000. Vision.
Enter Code

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

B1200. Corrective Lenses.
Enter Code

Corrective lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision.
0. No.
1. Yes.

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Resident

Identifier

Section C.

Date

Cognitive Patterns.

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

0. No (resident is rarely/never understood)
Skip to and complete C0700-C1000, Staff Assessment for Mental Status.
1. Yes
Continue to C0200, Repetition of Three Words.

Brief Interview for Mental Status (BIMS).
C0200. Repetition of Three Words.
Ask resident: “I am going to say three words for you to remember. Please repeat the words after I have said all three.
The words are: sock, blue, and bed. Now tell me the three words.”
Enter Code

Number of words repeated after first attempt.
0. None.
1. One.
2. Two.
3. Three.
After the resident's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece
of furniture"). You may repeat the words up to two more times.

C0300. Temporal Orientation (orientation to year, month, and day).
Ask resident: "Please tell me what year it is right now."
Enter Code

Enter Code

Enter Code

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

C0400. Recall.

Enter Code

Enter Code

Enter Code

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

C0500. BIMS Summary Score.
Enter Score

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

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Resident

Identifier

Section C.

Date

Cognitive Patterns.

C0600. Should the Staff Assessment for Mental Status (C0700 - C1000) be Conducted?
Enter Code

0. No (resident was able to complete Brief Interview for Mental Status)
Skip to C1310, Signs and Symptoms of Delirium.
1. Yes (resident was unable to complete Brief Interview for Mental Status)
Continue to C0700, Short-term Memory OK.

Staff Assessment for Mental Status.
Do not conduct if Brief Interview for Mental Status (C0200-C0500) was completed.

C0700. Short-term Memory OK.
Enter Code

Seems or appears to recall after 5 minutes.
0. Memory OK.
1. Memory problem.

C0800. Long-term Memory OK.
Enter Code

Seems or appears to recall long past.
0. Memory OK.
1. Memory problem.

C0900. Memory/Recall Ability.
Check all that the resident was normally able to recall.
A. Current season.
B. Location of own room.
C. Staff names and faces.
D. That he or she is in a nursing home/hospital swing bed.
Z. None of the above were recalled.

C1000. Cognitive Skills for Daily Decision Making.
Enter Code

Made decisions regarding tasks of daily life.
0. Independent - decisions consistent/reasonable.
1. Modified independence - some difficulty in new situations only.
2. Moderately impaired - decisions poor; cues/supervision required.
3. Severely impaired - never/rarely made decisions.

Delirium.
C1310. Signs and Symptoms of Delirium (from CAM©).
Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical record.
A. Acute Onset Mental Status Change.
Enter Code

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

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

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

Confusion Assessment Method. ©1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Used with permission.

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Resident

Identifier

Section D.

Date

Mood.

D0100. Should Resident Mood Interview be Conducted? - Attempt to conduct interview with all residents.
Enter Code

0. No (resident is rarely/never understood)
Skip to and complete D0500-D0600, Staff Assessment of Resident Mood
(PHQ-9-OV).
1. Yes
Continue to D0200, Resident Mood Interview (PHQ-9©).

D0200. Resident Mood Interview (PHQ-9©).
Say to resident: "Over the last 2 weeks, have you been bothered by any of the following problems?"
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the resident: "About how often have you been bothered by this?"
Read and show the resident a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
1. Symptom Presence.
0. No (enter 0 in column 2).
1. Yes (enter 0-3 in column 2).
9. No response (leave column 2
blank).

2. Symptom Frequency.
0. Never or 1 day.
1. 2-6 days (several days).
2. 7-11 days (half or more of the days).
3. 12-14 days (nearly every day).

1.
Symptom
Presence.

2.
Symptom
Frequency.

Enter Scores in Boxes

A. Little interest or pleasure in doing things.
B. Feeling down, depressed, or hopeless.
C. Trouble falling or staying asleep, or sleeping too much.
D. Feeling tired or having little energy.
E. Poor appetite or overeating.
F. Feeling bad about yourself - or that you are a failure or have let yourself or your family
down.
G. Trouble concentrating on things, such as reading the newspaper or watching television.
H. Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual.
I.

Thoughts that you would be better off dead, or of hurting yourself in some way.

D0300. Total Severity Score.
Enter Score

Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more items).

Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.

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Resident

Identifier

Section D.

Date

Mood.

D0500. Staff Assessment of Resident Mood (PHQ-9-OV*).

Do not conduct if Resident Mood Interview (D0200-D0300) was completed.
Over the last 2 weeks, did the resident have any of the following problems or behaviors?
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
Then move to column 2, Symptom Frequency, and indicate symptom frequency.
1. Symptom Presence.
0. No (enter 0 in column 2).
1. Yes (enter 0-3 in column 2).

2. Symptom Frequency.
0. Never or 1 day.
1. 2-6 days (several days).
2. 7-11 days (half or more of the days).
3. 12-14 days (nearly every day).

1.
Symptom
Presence.

2.
Symptom
Frequency.

Enter Scores in Boxes

A. Little interest or pleasure in doing things.
B. Feeling or appearing down, depressed, or hopeless.
C. Trouble falling or staying asleep, or sleeping too much.
D. Feeling tired or having little energy.
E. Poor appetite or overeating.
F. Indicating that s/he feels bad about self, is a failure, or has let self or family down.
G. Trouble concentrating on things, such as reading the newspaper or watching television.
H. Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety
or restless that s/he has been moving around a lot more than usual.
I.

States that life isn't worth living, wishes for death, or attempts to harm self.

J.

Being short-tempered, easily annoyed.

D0600. Total Severity Score.
Enter Score

Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 30.

* Copyright © Pfizer Inc. All rights reserved.
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Resident

Identifier

Section E.

Date

Behavior.

E0100. Potential Indicators of Psychosis.
Check all that apply
A. Hallucinations (perceptual experiences in the absence of real external sensory stimuli).
B. Delusions (misconceptions or beliefs that are firmly held, contrary to reality).
Z. None of the above.

Behavioral Symptoms.
E0200. Behavioral Symptom - Presence & Frequency.
Note presence of symptoms and their frequency.
Enter Codes in Boxes.
Coding:
0. Behavior not exhibited.
1. Behavior of this type occurred 1 to 3 days.
2. Behavior of this type occurred 4 to 6 days,
but less than daily.
3. Behavior of this type occurred daily.

A.

Physical behavioral symptoms directed toward others (e.g., hitting,
kicking, pushing, scratching, grabbing, abusing others sexually).

B.

Verbal behavioral symptoms directed toward others (e.g., threatening
others, screaming at others, cursing at others).

C.

Other behavioral symptoms not directed toward others (e.g., physical
symptoms such as hitting or scratching self, pacing, rummaging, public
sexual acts, disrobing in public, throwing or smearing food or bodily wastes,
or verbal/vocal symptoms like screaming, disruptive sounds).

E0800. Rejection of Care - Presence & Frequency.

Enter Code

Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the
resident's goals for health and well-being? Do not include behaviors that have already been addressed (e.g., by discussion or care
planning with the resident or family), and determined to be consistent with resident values, preferences, or goals.
0. Behavior not exhibited.
1. Behavior of this type occurred 1 to 3 days.
2. Behavior of this type occurred 4 to 6 days, but less than daily.
3. Behavior of this type occurred daily.

E0900. Wandering - Presence & Frequency.
Enter Code

Has the resident wandered?
0. Behavior not exhibited
1. Behavior of this type occurred 1 to 3 days.
2. Behavior of this type occurred 4 to 6 days, but less than daily.
3. Behavior of this type occurred daily.

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Resident

Section G.

Identifier

Date

Functional Status.

G0110. Activities of Daily Living (ADL) Assistance.
Refer to the ADL flow chart in the RAI manual to facilitate accurate coding.
Instructions for Rule of 3
￭ When an activity occurs three times at any one given level, code that level.
￭ When an activity occurs three times at multiple levels, code the most dependent, exceptions are total dependence (4), activity must require full assist
every time, and activity did not occur (8), activity must not have occurred at all. Example, three times extensive assistance (3) and three times limited
assistance (2), code extensive assistance (3).
￭ When an activity occurs at various levels, but not three times at any given level, apply the following:
￮ When there is a combination of full staff performance, and extensive assistance, code extensive assistance.
￮ When there is a combination of full staff performance, weight bearing assistance and/or non-weight bearing assistance code limited assistance (2).
If none of the above are met, code supervision.
1. ADL Self-Performance.
Code for resident's performance over all shifts - not including setup. If the ADL activity
occurred 3 or more times at various levels of assistance, code the most dependent - except for
total dependence, which requires full staff performance every time.

2. ADL Support Provided.
Code for most support provided over all
shifts; code regardless of resident's selfperformance classification.

Coding:
Activity Occurred 3 or More Times.
0. Independent - no help or staff oversight at any time.
1. Supervision - oversight, encouragement or cueing.
2. Limited assistance - resident highly involved in activity; staff provide guided maneuvering
of limbs or other non-weight-bearing assistance.
3. Extensive assistance - resident involved in activity, staff provide weight-bearing support.
4. Total dependence - full staff performance every time during entire 7-day period.

Coding:
0. No setup or physical help from staff.
1. Setup help only.
2. One person physical assist.
3. Two+ persons physical assist.
8. ADL activity itself did not occur or family
and/or non-facility staff provided care
100% of the time for that activity over the
entire 7-day period.

Activity Occurred 2 or Fewer Times.
7. Activity occurred only once or twice - activity did occur but only once or twice.
8. Activity did not occur - activity did not occur or family and/or non-facility staff provided
care 100% of the time for that activity over the entire 7-day period.

1.
Self-Performance.

2.
Support.

Enter Codes in Boxes

A. Bed mobility - how resident moves to and from lying position, turns side to side, and
positions body while in bed or alternate sleep furniture.
B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair,
standing position (excludes to/from bath/toilet).
C. Walk in room - how resident walks between locations in his/her room.
D. Walk in corridor - how resident walks in corridor on unit.
E. Locomotion on unit - how resident moves between locations in his/her room and adjacent
corridor on same floor. If in wheelchair, self-sufficiency once in chair.
F. Locomotion off unit - how resident moves to and returns from off-unit locations (e.g., areas
set aside for dining, activities or treatments). If facility has only one floor, how resident
moves to and from distant areas on the floor. If in wheelchair, self-sufficiency once in chair.
G. Dressing - how resident puts on, fastens and takes off all items of clothing, including
donning/removing a prosthesis or TED hose. Dressing includes putting on and changing
pajamas and housedresses.
H. Eating - how resident eats and drinks, regardless of skill. Do not include eating/drinking
during medication pass. Includes intake of nourishment by other means (e.g., tube feeding,
total parenteral nutrition, IV fluids administered for nutrition or hydration).
I. Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off
toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts
clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag or
ostomy bag.
J. Personal hygiene - how resident maintains personal hygiene, including combing hair,
brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths
and showers).

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Resident

Identifier

Section G.

Date

Functional Status.

G0120. Bathing.
How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair). Code for most
dependent in self-performance and support.
Enter Code A. Self-performance.
0. Independent - no help provided.
1. Supervision - oversight help only.
2. Physical help limited to transfer only.
3. Physical help in part of bathing activity.
4. Total dependence.
8. Activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire
7-day period.
Enter Code

B. Support provided.
(Bathing support codes are as defined in item G0110 column 2, ADL Support Provided, above).

G0300. Balance During Transitions and Walking.
After observing the resident, code the following walking and transition items for most dependent.
Enter Codes in Boxes.
Coding:
0. Steady at all times.
1. Not steady, but able to stabilize without staff
assistance.
2. Not steady, only able to stabilize with staff
assistance.
8. Activity did not occur.

A. Moving from seated to standing position.
B. Walking (with assistive device if used).
C. Turning around and facing the opposite direction while walking.
D. Moving on and off toilet.
E. Surface-to-surface transfer (transfer between bed and chair or
wheelchair).

G0400. Functional Limitation in Range of Motion.
Code for limitation that interfered with daily functions or placed resident at risk of injury.
Coding:
0. No impairment.
1. Impairment on one side.
2. Impairment on both sides.

Enter Codes in Boxes.
A. Upper extremity (shoulder, elbow, wrist, hand).
B. Lower extremity (hip, knee, ankle, foot).

G0600. Mobility Devices.
Check all that were normally used.
A. Cane/crutch.
B. Walker.
C. Wheelchair (manual or electric).
D. Limb prosthesis.
Z. None of the above were used.

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Resident

Identifier

Section GG.

Date

Functional Abilities and Goals - Admission (Start of SNF PPS Stay).

GG0100. Prior Functioning: Everyday Activities. Indicate the resident’s usual ability with everyday activities prior to the current
illness, exacerbation, or injury.
Complete only if A0310B = 01.
Enter Codes in Boxes.
Coding:
3. Independent - Resident completed the
activities by him/herself, with or without an
assistive device, with no assistance from a
helper.
2. Needed Some Help - Resident needed partial
assistance from another person to complete
activities.
1. Dependent - A helper completed the activities
for the resident.
8. Unknown.
9. Not Applicable.

A. Self-Care: Code the resident's need for assistance with bathing, dressing, using
the toilet, or eating prior to the current illness, exacerbation, or injury.
B. Indoor Mobility (Ambulation): Code the resident's need for assistance with
walking from room to room (with or without a device such as cane, crutch, or
walker) prior to the current illness, exacerbation, or injury..
C. Stairs: Code the resident's need for assistance with internal or external stairs (with
or without a device such as cane, crutch, or walker) prior to the current illness,
exacerbation, or injury. .
D. Functional Cognition: Code the resident's need for assistance with planning
regular tasks, such as shopping or remembering to take medication prior to the
current illness, exacerbation, or injury.

GG0110. Prior Device Use. Indicate devices and aids used by the resident prior to the current illness, exacerbation, or injury.
Complete only if A0310B = 01.
Check all that apply.
A. Manual wheelchair .
B. Motorized wheelchair and/or scooter .
C. Mechanical lift.
D. Walker.
E. Orthotics/Prosthetics.
Z. None of the above.

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Resident

Section GG.

Identifier

Date

Functional Abilities and Goals - Admission (Start of SNF PPS Stay).

GG0130. Self-Care (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B).
Complete only if A0310B = 01.
Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not
attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the
6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code end of SNF PPS stay (discharge) goal(s).
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
1.
2.
Admission
Discharge
Performance.
Goal.
Enter Codes in Boxes
A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid
once the meal is placed before the resident.
B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and
remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.
C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a
bowel movement. If managing an ostomy, include wiping the opening but not managing equipment..
E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back
and hair). Does not include transferring in/out of tub/shower.
F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.
G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include
footwear.
H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is
appropriate for safe mobility; including fasteners, if applicable.

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Resident

Section GG.

Identifier

Date

Functional Abilities and Goals - Admission (Start of SNF PPS Stay).

GG0170. Mobility (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B).
Complete only if A0310B = 01.
Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not
attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the
6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code end of SNF PPS stay (discharge) goal(s).
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
1.
2.
Admission
Discharge
Performance.
Goal.
Enter Codes in Boxes
A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the
bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with
feet flat on the floor, and with no back support.
D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the
bed..
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to get on and off a toilet or commode.
G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to
open/close door or fasten seat belt.
I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space.
If admission performance is coded 07, 09, 10, or 88
Skip to GG0170M, 1 step (curb)
J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.
K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.

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Resident

Section GG.

Identifier

Date

Functional Abilities and Goals - Admission (Start of SNF PPS Stay).

GG0170. Mobility (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B) - Continued
Complete only if A0310B = 01.
Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not
attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the
6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code end of SNF PPS stay (discharge) goal(s).
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
1.
2.
Admission
Discharge
Performance.
Goal.
Enter Codes in Boxes
L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or
outdoor), such as turf or gravel.
M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
If admission performance is coded 07, 09, 10, or 88
Skip to GG0170P, Picking up object.
N. 4 steps: The ability to go up and down four steps with or without a rail.
If admission performance is coded 07, 09, 10, or 88
Skip to GG0170P, Picking up object.
O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon,
from the floor.
Q1. Does the resident use a wheelchair and/or scooter?
0. No
Skip to GG0130, Self Care (Discharge).
1. Yes.
Continue to GG0170R, Wheel 50 feet with two turns.
R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make
two turns..
RR1. Indicate the type of wheelchair or scooter used.
1. Manual.
2. Motorized.
S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar
space.
SS1. Indicate the type of wheelchair or scooter used.
1. Manual.
2. Motorized.

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Resident

Section GG.

Identifier

Date

Functional Abilities and Goals - Discharge (End of SNF PPS Stay).

GG0130. Self-Care (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C).
Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03.
Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted
at the end of the SNF PPS stay, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
3.
Discharge
Performance.
Enter Codes in Boxes

A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the
meal is placed before the resident.
B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove
dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.
C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel
movement. If managing an ostomy, include wiping the opening but not managing equipment..
E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back
and hair). Does not include transferring in/out of tub/shower.
F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.
G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include
footwear.
H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for
safe mobility; including fasteners, if applicable.

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Resident

Section GG.

Identifier

Date

Functional Abilities and Goals - Discharge (End of SNF PPS Stay).

GG0170. Mobility (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C).
Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03.
Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted
at the end of the SNF PPS stay, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
3.
Discharge
Performance.
Enter Codes in Boxes

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

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Resident

Section GG.

Identifier

Date

Functional Abilities and Goals - Discharge (End of SNF PPS Stay).

GG0170. Mobility (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C) - Continued
Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03.
Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted
at the end of the SNF PPS stay, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
3.
Discharge
Performance.
Enter Codes in Boxes

L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as
turf or gravel.
M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
If discharge performance is coded 07, 09, 10, or 88
Skip to GG0170P, Picking up object.
N. 4 steps: The ability to go up and down four steps with or without a rail.
If discharge performance is coded 07, 09, 10, or 88
Skip to GG0170P, Picking up object.
O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the
floor.
Q3. Does the resident use a wheelchair and/or scooter?
0. No
Skip to H0100, Appliances
1. Yes.
Continue to GG0170R, Wheel 50 feet with two turns
R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns..
RR3. Indicate the type of wheelchair or scooter used.
1. Manual.
2. Motorized.
S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.
SS3. Indicate the type of wheelchair or scooter used.
1. Manual.
2. Motorized.

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Resident

Identifier

Section H.

Date

Bladder and Bowel.

H0100. Appliances.
Check all that apply.
A. Indwelling catheter (including suprapubic catheter and nephrostomy tube).
B. External catheter.
C. Ostomy (including urostomy, ileostomy, and colostomy).
D. Intermittent catheterization.
Z. None of the above.

H0200. Urinary Toileting Program.
Enter Code

Enter Code

A. Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on
admission/entry or reentry or since urinary incontinence was noted in this facility?
0. No
Skip to H0300, Urinary Continence.
1. Yes
Continue to H0200C, Current toileting program or trial.
9. Unable to determine
Continue to H0200C, Current toileting program or trial.
C. Current toileting program or trial - Is a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) currently
being used to manage the resident's urinary continence?
0. No.
1. Yes.

H0300. Urinary Continence.
Enter Code

Urinary continence - Select the one category that best describes the resident.
0. Always continent.
1. Occasionally incontinent (less than 7 episodes of incontinence).
2. Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding).
3. Always incontinent (no episodes of continent voiding).
9. Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days.

H0400. Bowel Continence.
Enter Code

Bowel continence - Select the one category that best describes the resident.
0. Always continent.
1. Occasionally incontinent (one episode of bowel incontinence).
2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement).
3. Always incontinent (no episodes of continent bowel movements).
9. Not rated, resident had an ostomy or did not have a bowel movement for the entire 7 days.

H0500. Bowel Toileting Program.
Enter Code

Is a toileting program currently being used to manage the resident's bowel continence?
0. No.
1. Yes.

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Resident

Identifier

Section I.

Date

Active Diagnoses.

I0020. Indicate the resident’s primary medical condition category.
Complete only if A0310B = 01 or 08.
Enter Code

Indicate the resident's primary medical condition category that best describes the primary reason for admission
01. Stroke.
02. Non-Traumatic Brain Dysfunction.
03. Traumatic Brain Dysfunction.
04. Non-Traumatic Spinal Cord Dysfunction.
05. Traumatic Spinal Cord Dysfunction.
06. Progressive Neurological Conditions.
07. Other Neurological Conditions.
08. Amputation
09. Hip and Knee Replacement.
10. Fractures and Other Multiple Trauma.
11. Other Orthopedic Conditions.
12. Debility, Cardiorespiratory Conditions.
13. Medically Complex Conditions.
I0020B. ICD Code

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Resident

Identifier

Section I.

Date

Active Diagnoses.

Active Diagnoses in the last 7 days - Check all that apply.
Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.
Cancer.
I0100. Cancer (with or without metastasis).
Heart/Circulation.
I0200. Anemia (e.g., aplastic, iron deficiency, pernicious, and sickle cell).
I0400. Coronary Artery Disease (CAD) (e.g., angina, myocardial infarction, and atherosclerotic heart disease (ASHD)).
I0600. Heart Failure (e.g., congestive heart failure (CHF) and pulmonary edema).
I0700. Hypertension.
I0800. Orthostatic Hypotension.
I0900. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD).
Gastrointestinal.
I1300. Ulcerative Colitis, Crohn's Disease, or Inflammatory Bowel Disease.
Genitourinary.
I1500. Renal Insufficiency, Renal Failure, or End-Stage Renal Disease (ESRD).
I1550. Neurogenic Bladder.
I1650. Obstructive Uropathy.
Infections.
I1700. Multidrug-Resistant Organism (MDRO).
I2000. Pneumonia.
I2100. Septicemia.
I2200. Tuberculosis.
I2300. Urinary Tract Infection (UTI) (LAST 30 DAYS).
I2400. Viral Hepatitis (e.g., Hepatitis A, B, C, D, and E).
I2500. Wound Infection (other than foot).
Metabolic.
I2900. Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy).
I3100. Hyponatremia.
I3200. Hyperkalemia.
I3300. Hyperlipidemia (e.g., hypercholesterolemia).
Musculoskeletal.
I3900. Hip Fracture - any hip fracture that has a relationship to current status, treatments, monitoring (e.g., sub-capital fractures, and
fractures of the trochanter and femoral neck).
I4000. Other Fracture.
Neurological.
I4200. Alzheimer's Disease.
I4300. Aphasia.
I4400. Cerebral Palsy.
I4500. Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke.
I4800. Non-Alzheimer's Dementia (e.g. Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia
such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-Jakob diseases).
I4900. Hemiplegia or Hemiparesis.
I5000. Paraplegia.
I5100. Quadriplegia.
I5200. Multiple Sclerosis (MS).
I5250. Huntington's Disease.
I5300. Parkinson's Disease.
I5350. Tourette's Syndrome.
I5400. Seizure Disorder or Epilepsy.
I5500. Traumatic Brain Injury (TBI).

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Resident

Identifier

Section I.

Date

Active Diagnoses.

Active Diagnoses in the last 7 days - Check all that apply.
Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.
Nutritional.
I5600. Malnutrition (protein or calorie) or at risk for malnutrition.
Psychiatric/Mood Disorder.
I5700. Anxiety Disorder.
I5800. Depression (other than bipolar).
I5900. Bipolar Disorder.
I5950. Psychotic Disorder (other than schizophrenia).
I6000. Schizophrenia (e.g., schizoaffective and schizophreniform disorders).
I6100. Post Traumatic Stress Disorder (PTSD).
Pulmonary.
I6200. Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease (e.g., chronic bronchitis and restrictive lung
diseases such as asbestosis).
I6300. Respiratory Failure
Other.
I8000. Additional active diagnoses.
Enter diagnosis on line and ICD code in boxes. Include the decimal for the code in the appropriate box.

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.

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Resident

Identifier

Section J.

Date

Health Conditions.

J0100. Pain Management - Complete for all residents, regardless of current pain level.
At any time in the last 5 days, has the resident:
Enter Code A. Received scheduled pain medication regimen?
0. No.
1. Yes.
Enter Code B. Received PRN pain medications OR was offered and declined?
0. No.
1. Yes.
Enter Code C. Received non-medication intervention for pain?
0. No.
1. Yes.

J0200. Should Pain Assessment Interview be Conducted?
Attempt to conduct interview with all residents. If resident is comatose, skip to J1100, Shortness of Breath (dyspnea).
Enter Code

0. No (resident is rarely/never understood)
1. Yes
Continue to J0300, Pain Presence.

Skip to and complete J0800, Indicators of Pain or Possible Pain.

Pain Assessment Interview.
J0300. Pain Presence.
Enter Code Ask resident: "Have you had pain or hurting at any time in the last 5 days?"
0. No
Skip to J1100, Shortness of Breath.
1. Yes
Continue to J0400, Pain Frequency.
9. Unable to answer
Skip to J0800, Indicators of Pain or Possible Pain.

J0400. Pain Frequency.
Ask resident: "How much of the time have you experienced pain or hurting over the last 5 days?"
Enter Code

1.
2.
3.
4.
9.

Almost constantly.
Frequently.
Occasionally.
Rarely.
Unable to answer.

J0500. Pain Effect on Function.
A. Ask resident: "Over the past 5 days, has pain made it hard for you to sleep at night?"
Enter Code

Enter Code

0. No.
1. Yes.
9. Unable to answer.
B. Ask resident: "Over the past 5 days, have you limited your day-to-day activities because of pain?"
0. No.
1. Yes.
9. Unable to answer.

J0600. Pain Intensity - Administer ONLY ONE of the following pain intensity questions (A or B).
Enter Rating

Enter Code

A. Numeric Rating Scale (00-10).
Ask resident: "Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten
as the worst pain you can imagine." (Show resident 00 -10 pain scale)
Enter two-digit response. Enter 99 if unable to answer.
B. Verbal Descriptor Scale.
Ask resident: "Please rate the intensity of your worst pain over the last 5 days." (Show resident verbal scale)
1. Mild.
2. Moderate.
3. Severe.
4. Very severe, horrible.
9. Unable to answer.

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Resident

Identifier

Section J.

Date

Health Conditions.

J0700. Should the Staff Assessment for Pain be Conducted?
Enter Code

0. No (J0400 = 1 thru 4)
Skip to J1100, Shortness of Breath (dyspnea).
1. Yes (J0400 = 9)
Continue to J0800, Indicators of Pain or Possible Pain.

Staff Assessment for Pain.
J0800. Indicators of Pain or Possible Pain in the last 5 days.
Check all that apply.
A. Non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning).
B. Vocal complaints of pain (e.g., that hurts, ouch, stop).
C. Facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw).
D. Protective body movements or postures (e.g., bracing, guarding, rubbing or massaging a body part/area, clutching or holding a
body part during movement).
Z. None of these signs observed or documented

If checked, skip to J1100, Shortness of Breath (dyspnea).

J0850. Frequency of Indicator of Pain or Possible Pain in the last 5 days.
Enter Code

Frequency with which resident complains or shows evidence of pain or possible pain.
1. Indicators of pain or possible pain observed 1 to 2 days.
2. Indicators of pain or possible pain observed 3 to 4 days.
3. Indicators of pain or possible pain observed daily.

Other Health Conditions.
J1100. Shortness of Breath (dyspnea).
Check all that apply.
A. Shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring).
B. Shortness of breath or trouble breathing when sitting at rest.
C. Shortness of breath or trouble breathing when lying flat.
Z. None of the above.

J1400. Prognosis.
Enter Code

Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? (Requires physician
documentation).
0. No.
1. Yes.

J1550. Problem Conditions.
Check all that apply.
A. Fever.
B. Vomiting.
C. Dehydrated.
D. Internal bleeding.
Z. None of the above.

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Resident

Identifier

Section J.

Date

Health Conditions.

J1700. Fall History on Admission/Entry or Reentry.
Complete only if A0310A = 01 or A0310E = 1
Enter Code

Enter Code

Enter Code

A. Did the resident have a fall any time in the last month prior to admission/entry or reentry?
0. No.
1. Yes.
9. Unable to determine.
B. Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry?
0. No...
1. Yes.
9. Unable to determine.
C. Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry?
0. No...
1. Yes.
9. Unable to determine.

J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent.
Enter Code

Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more
recent?
0. No
Skip to J2000, Prior Surgery.
Continue to J1900, Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS).
1. Yes

J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent.
Enter Codes in Boxes

Coding:
0. None
1. One
2. Two or more

A. No injury - no evidence of any injury is noted on physical assessment by the nurse or primary
care clinician; no complaints of pain or injury by the resident; no change in the resident's
behavior is noted after the fall.
B. Injury (except major) - skin tears, abrasions, lacerations, superficial bruises, hematomas and
sprains; or any fall-related injury that causes the resident to complain of pain.
C. Major injury - bone fractures, joint dislocations, closed head injuries with altered
consciousness, subdural hematoma.

J2000. Prior Surgery - Complete only if A0310B = 01.
Enter Code

Did the resident have major surgery during the 100 days prior to admission?
0. No.
1. Yes.
8. Unknown.

J2100. Recent Surgery Requiring Active SNF Care - Complete only if A0310B = 01 or 08.
Enter Code

Did the resident have a major surgical procedure during the prior inpatient hospital stay that requires active care during the SNF stay?
0. No.
1. Yes.
8. Unknown.

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Resident

Identifier

Section J.

Date

Health Conditions.

Surgical Procedures - Complete only if J2100 = 1.
Check all that apply.
Major Joint Replacement.
J2300. Knee Replacement - partial or total.
J2310. Hip Replacement - partial or total.
J2320. Ankle Replacement - partial or total.
J2330. Shoulder Replacement - partial or total.
Spinal Surgery.
J2400. Involving the spinal cord or major spinal nerves.
J2410. Involving fusion of spinal bones.
J2420. Involving Iamina, discs, or facets .
J2499. Other major spinal surgery.
Other Orthopedic Surgery.
J2500. Repair fractures of the shoulder (including clavicle and scapula) or arm (but not hand).
J2510. Repair fractures of the pelvis, hip, leg, knee, or ankle (not foot).
J2520. Repair but not replace joints.
J2530. Repair other bones (such as hand, foot, jaw).
J2599. Other major orthopedic surgery.
Neurological Surgery.
J2600. Involving the brain, surrounding tissue or blood vessels (excludes skull and skin but includes cranial nerves).
J2610. Involving the peripheral or autonomic nervous system - open or percutaneous.
J2620. Insertion or removal of spinal or brain neurostimulators, electrodes, catheters, or CSF drainage devices .
J2699. Other major neurological surgery.
Cardiopulmonary Surgery.
J2700. Involving the heart or major blood vessels - open or percutaneous procedures.
J2710. Involving the respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords - open or endoscopic.
J2799. Other major cardiopulmonary surgery .
Genitourinary Surgery.
J2800. Involving male or female organs (such as prostate, testes, ovaries, uterus, vagina, external genitalia).
J2810. Involving the kidneys, ureters, adrenal glands, or bladder - open or laparoscopic (includes creation or removal of
nephrostomies or urostomies).
J2899. Other major genitourinary surgery.
Other Major Surgery.
J2900. Involving tendons, ligaments, or muscles.
J2910. Involving the gastrointestinal tract or abdominal contents from the esophagus to the anus, the biliary tree, gall bladder, liver,
pancreas, or spleen - open or laparoscopic (including creation or removal of ostomies or percutaneous feeding tubes, or hernia repair).
J2920. Involving the endocrine organs (such as thyroid, parathyroid), neck, lymph nodes, or thymus - open.
J2930. Involving the breast.
J2940. Repair of deep ulcers, internal brachytherapy, bone marrow or stem cell harvest or transplant.
J5000. Other major surgery not listed above .

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Resident

Identifier

Section K.

Date

Swallowing/Nutritional Status.

K0100. Swallowing Disorder.
Signs and symptoms of possible swallowing disorder.
Check all that apply.
A. Loss of liquids/solids from mouth when eating or drinking.
B. Holding food in mouth/cheeks or residual food in mouth after meals.
C. Coughing or choking during meals or when swallowing medications.
D. Complaints of difficulty or pain with swallowing.
Z. None of the above.

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

pounds

B. Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight consistently, according to standard
facility practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.).

K0300. Weight Loss.
Enter Code

Loss of 5% or more in the last month or loss of 10% or more in last 6 months.
0. No or unknown.
1. Yes, on physician-prescribed weight-loss regimen.
2. Yes, not on physician-prescribed weight-loss regimen.

K0310. Weight Gain.
Enter Code

Gain of 5% or more in the last month or gain of 10% or more in last 6 months.
0. No or unknown.
1. Yes, on physician-prescribed weight-gain regimen.
2. Yes, not on physician-prescribed weight-gain regimen.

K0510. Nutritional Approaches.
Check all of the following nutritional approaches that were performed during the last 7 days.
1. While NOT a Resident.
Performed while NOT a resident of this facility and within the last 7 days. Only check column 1 if
resident entered (admission or reentry) IN THE LAST 7 DAYS. If resident last entered 7 or more days
ago, leave column 1 blank.
2. While a Resident.
Performed while a resident of this facility and within the last 7 days.

1.
While NOT a
Resident.

2.
While a
Resident.

Check all that apply

A. Parenteral/IV feeding.
B. Feeding tube - nasogastric or abdominal (PEG).
C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food,
thickened liquids).
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol).
Z. None of the above.

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Resident

Identifier

Section K.

Date

Swallowing/Nutritional Status.

K0710. Percent Intake by Artificial Route - Complete K0710 only if Column 1 and/or Column 2 are checked for K0510A and/or K0510B.
2. While a Resident.
Performed while a resident of this facility and within the last 7 days.
3. During Entire 7 Days.
Performed during the entire last 7 days.

2.
While a
Resident.

3.
During Entire
7 Days.
Enter Codes

A. Proportion of total calories the resident received through parenteral or tube feeding.
1. 25% or less.
2. 26-50%.
3. 51% or more.
B. Average fluid intake per day by IV or tube feeding.
1. 500 cc/day or less.
2. 501 cc/day or more.

Section L.

Oral/Dental Status.

L0200. Dental
Check all that apply.
A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose).
F. Mouth or facial pain, discomfort or difficulty with chewing.

Section M.

Skin Conditions.

Report based on highest stage of existing ulcers/injuries at their worst;
do not "reverse" stage.
M0100. Determination of Pressure Ulcer/Injury Risk.
Check all that apply.
A. Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device.
B. Formal assessment instrument/tool (e.g., Braden, Norton, or other).
C. Clinical assessment.
Z. None of the above.

M0150. Risk of Pressure Ulcers/Injuries.
Enter Code

Is this resident at risk of developing pressure ulcers/injuries?
0. No.
1. Yes.

M0210. Unhealed Pressure Ulcers/Injuries.
Enter Code

Does this resident have one or more unhealed pressure ulcers/injuries?
0. No
Skip to M1030, Number of Venous and Arterial Ulcers.
1. Yes
Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.

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Resident

Identifier

Section M.

Date

Skin Conditions.

M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.
A. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not
have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.
Enter Number

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

1. Number of Stage 2 pressure ulcers.- If 0
Enter Number

Skip to M0300C, Stage 3.

2. Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted
at the time of admission/entry or reentry.
C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be
present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Enter Number

1. Number of Stage 3 pressure ulcers - If 0
Enter Number

Skip to M0300D, Stage 4.

2. Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry .
D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the
wound bed. Often includes undermining and tunneling.

Enter Number

1. Number of Stage 4 pressure ulcers - If 0
Enter Number

Skip to M0300E, Unstageable - Non-removable dressing/device.

2. Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry.
E. Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device.

Enter Number

Enter Number

1. Number of unstageable pressure ulcers/injuries due to non-removable dressing/device - If 0
Unstageable - Slough and/or eschar.

Skip to M0300F,

2. Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry - enter how many
were noted at the time of admission/entry or reentry.
F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar.

Enter Number

Enter Number

1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar - If 0
Unstageable - Deep tissue injury.

Skip to M0300G,

2. Number of these unstageable pressure ulcers that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry.
G. Unstageable - Deep tissue injury:

Enter Number

Enter Number

1. Number of unstageable pressure injuries presenting as deep tissue injury - If 0
Number of Venous and Arterial Ulcers.

Skip to M1030,

2. Number of these unstageable pressure injuries that were present upon admission/entry or reentry - enter how many were
noted at the time of admission/entry or reentry.

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Resident

Identifier

Section M.

Date

Skin Conditions.

M1030. Number of Venous and Arterial Ulcers.
Enter Number

Enter the total number of venous and arterial ulcers present.

M1040. Other Ulcers, Wounds and Skin Problems.
Check all that apply.
Foot Problems.
A. Infection of the foot (e.g., cellulitis, purulent drainage).
B. Diabetic foot ulcer(s).
C. Other open lesion(s) on the foot.
Other Problems.
D. Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion).
E. Surgical wound(s).
F. Burn(s) (second or third degree).
G. Skin tear(s).
H. Moisture Associated Skin Damage (MASD) (e.g., incontinence-associated dermatitis [IAD], perspiration, drainage).
None of the Above.
Z. None of the above were present.

M1200. Skin and Ulcer/Injury Treatments.
Check all that apply.
A. Pressure reducing device for chair.
B. Pressure reducing device for bed.
C. Turning/repositioning program.
D. Nutrition or hydration intervention to manage skin problems.
E. Pressure ulcer/injury care.
F. Surgical wound care.
G. Application of nonsurgical dressings (with or without topical medications) other than to feet.
H. Applications of ointments/medications other than to feet.
I. Application of dressings to feet (with or without topical medications).
Z. None of the above were provided.

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Resident

Identifier

Section N.

Date

Medications.

N0300. Injections.
Enter Days

Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less
than 7 days. If 0
Skip to N0410, Medications Received.

N0350. Insulin.
Enter Days

A. Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry
or reentry if less than 7 days.

Enter Days

B. Orders for insulin - Record the number of days the physician (or authorized assistant or practitioner) changed the resident's
insulin orders during the last 7 days or since admission/entry or reentry if less than 7 days.

N0410. Medications Received.
Indicate the number of DAYS the resident received the following medications by pharmacological classification, not how it is used, during the
last 7 days or since admission/entry or reentry if less than 7 days. Enter "0" if medication was not received by the resident during the last 7 days.
Enter Days

Enter Days

Enter Days

Enter Days

Enter Days

Enter Days

Enter Days

Enter Days

A. Antipsychotic.
B. Antianxiety.
C. Antidepressant.
D. Hypnotic.
E. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin).
F. Antibiotic.
G. Diuretic.
H. Opioid.

N2001. Drug Regimen Review - Complete only if A0310B = 01.
Enter Code

Did a complete drug regimen review identify potential clinically significant medication issues?
0. No - No issues found during review.
1. Yes - Issues found during review.
9. NA - Resident is not taking any medications.

N2003. Medication Follow-up - Complete only if N2001 =1.
Enter Code

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

N2005. Medication Intervention - Complete only if A0310H = 1.
Enter Code

Did the facility contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next
calendar day each time potential clinically significant medication issues were identified since the admission?
0. No.
1. Yes.
9. NA - There were no potential clinically significant medication issues identified since admission or resident is not taking any
medications.

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Resident

Identifier

Section O.

Date

Special Treatments, Procedures, and Programs.

O0100. Special Treatments, Procedures, and Programs.
Check all of the following treatments, procedures, and programs that were performed during the last 14 days.
1. While NOT a Resident.
Performed while NOT a resident of this facility and within the last 14 days. Only check column 1 if
1.
2.
resident entered (admission or reentry) IN THE LAST 14 DAYS. If resident last entered 14 or more days
While NOT a
While a
ago, leave column 1 blank.
Resident.
Resident.
2. While a Resident.
Performed while a resident of this facility and within the last 14 days.
Check all that apply
Cancer Treatments.
A. Chemotherapy.
B. Radiation.
Respiratory Treatments.
C. Oxygen therapy.
D. Suctioning.
E. Tracheostomy care.
F. Invasive Mechanical Ventilator (ventilator or respirator).
Other.
H. IV medications.
I. Transfusions.
J. Dialysis.
K. Hospice care.
M. Isolation or quarantine for active infectious disease (does not include standard body/fluid
precautions).

O0250. Influenza Vaccine - Refer to current version of RAI manual for current influenza vaccination season and reporting period.
Enter Code

A. Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season?
0. No
Skip to O0250C, If influenza vaccine not received, state reason.
1. Yes
Continue to O0250B, Date influenza vaccine received.
B. Date influenza vaccine received

_
Month
Enter Code

Complete date and skip to O0300A, Is the resident's Pneumococcal vaccination up to date?

_
Day

Year

C. If influenza vaccine not received, state reason:
1. Resident not in this facility during this year's influenza vaccination season.
2. Received outside of this facility.
3. Not eligible - medical contraindication.
4. Offered and declined.
5. Not offered.
6. Inability to obtain influenza vaccine due to a declared shortage.
9. None of the above.

O0300. Pneumococcal Vaccine.
Enter Code

Enter Code

A. Is the resident's Pneumococcal vaccination up to date?
0. No
Continue to O0300B, If Pneumococcal vaccine not received, state reason.
1. Yes
Skip to O0400, Therapies.
B. If Pneumococcal vaccine not received, state reason:
1. Not eligible - medical contraindication.
2. Offered and declined.
3. Not offered.

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Resident

Section O.

Identifier

Date

Special Treatments, Procedures, and Programs.

O0400. Therapies.
A. Speech-Language Pathology and Audiology Services.
Enter Number of Minutes

1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually
in the last 7 days.

Enter Number of Minutes

2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident
concurrently with one other resident in the last 7 days.

Enter Number of Minutes

3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group
of residents in the last 7 days.
If the sum of individual, concurrent, and group minutes is zero,

Enter Number of Minutes

Enter Number of Days

skip to O0400A5, Therapy start date

3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in
co-treatment sessions in the last 7 days.
4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
5. Therapy start date - record the date the most recent
therapy regimen (since the most recent entry) started.

_
Month

6. Therapy end date - record the date the most recent
therapy regimen (since the most recent entry) ended
- enter dashes if therapy is ongoing.

_
Day

_
Year

Month

_
Day

Year

B. Occupational Therapy.
Enter Number of Minutes

1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually
in the last 7 days.

Enter Number of Minutes

2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident
concurrently with one other resident in the last 7 days.

Enter Number of Minutes

3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group
of residents in the last 7 days.
If the sum of individual, concurrent, and group minutes is zero,

Enter Number of Minutes

Enter Number of Days

skip to O0400B5, Therapy start date

3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in
co-treatment sessions in the last 7 days.
4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
5. Therapy start date - record the date the most recent
therapy regimen (since the most recent entry) started.

_
Month

6. Therapy end date - record the date the most recent
therapy regimen (since the most recent entry) ended
- enter dashes if therapy is ongoing.

_
Day

_
Year

Month

_
Day

Year

O0400 continued on next page

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Resident

Section O.

Identifier

Date

Special Treatments, Procedures, and Programs.

O0400. Therapies - Continued.
C. Physical Therapy.
Enter Number of Minutes

1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually
in the last 7 days.

Enter Number of Minutes

2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident
concurrently with one other resident in the last 7 days.

Enter Number of Minutes

3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group
of residents in the last 7 days.
If the sum of individual, concurrent, and group minutes is zero,

Enter Number of Minutes

Enter Number of Days

skip to O0400C5, Therapy start date

3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in
co-treatment sessions in the last 7 days.
4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
5. Therapy start date - record the date the most recent
therapy regimen (since the most recent entry) started.

_
Month

6. Therapy end date - record the date the most recent
therapy regimen (since the most recent entry) ended
- enter dashes if therapy is ongoing.

_
Day

_
Year

Month

_
Day

Year

D. Respiratory Therapy.
Enter Number of Days

2. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
E. Psychological Therapy (by any licensed mental health professional).
Enter Number of Days

2. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.

O0420. Distinct Calendar Days of Therapy.
Enter Number of Days

Record the number of calendar days that the resident received Speech-Language Pathology and Audiology Services,
Occupational Therapy, or Physical Therapy for at least 15 minutes in the past 7 days.

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Resident

Identifier

Section O.

Date

Special Treatments, Procedures, and Programs.

O0425. Part A Therapies.
Complete only if A0310H = 1.
A. Speech-Language Pathology and Audiology Services.
Enter Number of Minutes

1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually
since the start date of the resident's most recent Medicare Part A stay (A2400B).

Enter Number of Minutes

2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident
concurrently with one other resident since the start date of the resident's most recent Medicare Part A stay
(A2400B).

Enter Number of Minutes

3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group
of residents since the start date of the resident's most recent Medicare Part A stay (A2400B).
If the sum of individual, concurrent, and group minutes is zero,

skip to O0425B, Occupational Therapy

Enter Number of Minutes

4. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in
co-treatment sessions since the start date of the resident's most recent Medicare Part A stay (A2400B).

Enter Number of Days

5. Days - record the number of days this therapy was administered for at least 15 minutes a day since the start date of
the resident's most recent Medicare Part A stay (A2400B).
B. Occupational Therapy.

Enter Number of Minutes

1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually
since the start date of the resident's most recent Medicare Part A stay (A2400B).

Enter Number of Minutes

2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident
concurrently with one other resident since the start date of the resident's most recent Medicare Part A stay
(A2400B).

Enter Number of Minutes

3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group
of residents since the start date of the resident's most recent Medicare Part A stay (A2400B).
If the sum of individual, concurrent, and group minutes is zero,

skip to O0425C, Physical Therapy

Enter Number of Minutes

4. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in
co-treatment sessions since the start date of the resident's most recent Medicare Part A stay (A2400B).

Enter Number of Days

5. Days - record the number of days this therapy was administered for at least 15 minutes a day since the start date of
the resident's most recent Medicare Part A stay (A2400B).
C. Physical Therapy.

Enter Number of Minutes

1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually
since the start date of the resident's most recent Medicare Part A stay (A2400B).

Enter Number of Minutes

2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident
concurrently with one other resident since the start date of the resident's most recent Medicare Part A stay
(A2400B).

Enter Number of Minutes

3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group
of residents since the start date of the resident's most recent Medicare Part A stay (A2400B).
If the sum of individual, concurrent, and group minutes is zero,

skip to O0430, Distinct Calendar Days of Part A Therapy.

Enter Number of Minutes

4. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in
co-treatment sessions since the start date of the resident's most recent Medicare Part A stay (A2400B).

Enter Number of Days

5. Days - record the number of days this therapy was administered for at least 15 minutes a day since the start date of
the resident's most recent Medicare Part A stay (A2400B).

O0430. Distinct Calendar Days of Part A Therapy
Complete only if A0310H = 1.
Enter Number of Days

Record the number of calendar days that the resident received Speech-Language Pathology and Audiology Services,
Occupational Therapy, or Physical Therapy for at least 15 minutes since the start date of the resident's most recent Medicare
Part A stay (A2400B)

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Resident

Identifier

Section O.

Date

Special Treatments, Procedures, and Programs.

O0500. Restorative Nursing Programs.
Record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days
(enter 0 if none or less than 15 minutes daily).
Number
of Days.

Technique.
A. Range of motion (passive).
B. Range of motion (active).
C. Splint or brace assistance.

Number
of Days.

Training and Skill Practice In:
D. Bed mobility.
E. Transfer.
F. Walking.
G. Dressing and/or grooming.
H. Eating and/or swallowing.
I. Amputation/prostheses care.
J. Communication.

O0600. Physician Examinations.
Enter Days

Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) examine the resident?

O0700. Physician Orders.
Enter Days

Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) change the resident's orders?

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Resident

Identifier

Section P.

Date

Restraints and Alarms.

P0100. Physical Restraints.
Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that
the individual cannot remove easily which restricts freedom of movement or normal access to one's body.

Enter Codes in Boxes.
Used in Bed.
A. Bed rail.
B. Trunk restraint.
C. Limb restraint.
Coding:
0. Not used.
1. Used less than daily.
2. Used daily.

D. Other.
Used in Chair or Out of Bed.
E. Trunk restraint.
F. Limb restraint.
G. Chair prevents rising.
H. Other.

Section Q.

Participation in Assessment and Goal Setting.

Q0100. Participation in Assessment.
Enter Code

Enter Code

Enter Code

A. Resident participated in assessment.
0. No.
1. Yes.
B. Family or significant other participated in assessment.
0. No.
1. Yes.
9. Resident has no family or significant other.
C. Guardian or legally authorized representative participated in assessment.
0. No.
1. Yes.
9. Resident has no guardian or legally authorized representative.

Q0300. Resident's Overall Expectation.
Complete only if A0310E = 1.
Enter Code

Enter Code

A. Select one for resident's overall goal established during assessment process.
1. Expects to be discharged to the community.
2. Expects to remain in this facility.
3. Expects to be discharged to another facility/institution.
9. Unknown or uncertain.
B. Indicate information source for Q0300A.
1. Resident.
2. If not resident, then family or significant other.
3. If not resident, family, or significant other, then guardian or legally authorized representative.
9. Unknown or uncertain.

Q0400. Discharge Plan.
Enter Code

A. Is active discharge planning already occurring for the resident to return to the community?
0. No.
1. Yes
Skip to Q0600, Referral.

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Resident

Identifier

Section Q.

Date

Participation in Assessment and Goal Setting.

Q0490. Resident's Preference to Avoid Being Asked Question Q0500B.
Complete only if A0310A = 02, 06, or 99.
Enter Code

Does the resident's clinical record document a request that this question be asked only on comprehensive assessments?
0. No.
1. Yes
Skip to Q0600, Referral.

Q0500. Return to Community.
Enter Code

B. Ask the resident (or family or significant other or guardian or legally authorized representative if resident is unable to understand or
respond): "Do you want to talk to someone about the possibility of leaving this facility and returning to live and

receive services in the community?"
0. No.
1. Yes.
9. Unknown or uncertain.

Q0550. Resident's Preference to Avoid Being Asked Question Q0500B Again.
Enter Code

Enter Code

A. Does the resident (or family or significant other or guardian or legally authorized representative if resident is unable to understand or
respond) want to be asked about returning to the community on all assessments? (Rather than only on comprehensive
assessments.)
0. No - then document in resident's clinical record and ask again only on the next comprehensive assessment...
1. Yes.
8. Information not available.
B. Indicate information source for Q0550A.
1. Resident...
2. If not resident, then family or significant other.
3. If not resident, family or significant other, then guardian or legally authorized representative.
9. None of the above.

Q0600. Referral.
Enter Code

Has a referral been made to the Local Contact Agency? (Document reasons in resident's clinical record)
0. No - referral not needed.
1. No - referral is or may be needed (For more information see Appendix C, Care Area Assessment Resources #20).
2. Yes - referral made.

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Resident

Identifier

Section X.

Date

Correction Request.

Complete Section X only if A0050 = 2 or 3.
Identification of Record to be Modified/Inactivated - The following items identify the existing assessment record that is in error. In this
section, reproduce the information EXACTLY as it appeared on the existing erroneous record, even if the information is incorrect.
This information is necessary to locate the existing record in the National MDS Database.
X0150. Type of Provider (A0200 on existing record to be modified/inactivated).
Enter Code

Type of provider.
1. Nursing home (SNF/NF).
2. Swing Bed.

X0200. Name of Resident (A0500 on existing record to be modified/inactivated).
A. First name:

C. Last name:

X0300. Gender (A0800 on existing record to be modified/inactivated).
Enter Code

1. Male
2. Female

X0400. Birth Date (A0900 on existing record to be modified/inactivated).
_

_

Month

Day

Year

X0500. Social Security Number (A0600A on existing record to be modified/inactivated).
_

_

X0570. Optional State Assessment (A0300A on existing record to be modified/inactivated).
Enter Code

A. Is this assessment for state payment purposes only?.
0. No.
1. Yes.

X0600. Type of Assessment (A0310 on existing record to be modified/inactivated).
Enter Code

Enter Code

Enter Code

Enter Code

A. Federal OBRA Reason for Assessment
01. Admission assessment (required by day 14).
02. Quarterly review assessment.
03. Annual assessment.
04. Significant change in status assessment.
05. Significant correction to prior comprehensive assessment.
06. Significant correction to prior quarterly assessment.
99. None of the above.
B. PPS Assessment.
PPS Scheduled Assessment for a Medicare Part A Stay.
01. 5-day scheduled assessment..
PPS Unscheduled Assessment for a Medicare Part A Stay.
08. IPA - Interim Payment Assessment.
Not PPS Assessment.
99. None of the above.
F. Entry/discharge reporting
01. Entry tracking record.
10. Discharge assessment-return not anticipated.
11. Discharge assessment-return anticipated.
12. Death in facility tracking record.
99. None of the above.
H. Is this a SNF Part A PPS Discharge Assessment?.
0. No.
1. Yes.

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Resident

Identifier

Section X.

Date

Correction Request.

X0700. Date on existing record to be modified/inactivated - Complete one only.
A. Assessment Reference Date (A2300 on existing record to be modified/inactivated) - Complete only if X0600F = 99.

_
Month

_
Day

Year

B. Discharge Date (A2000 on existing record to be modified/inactivated) - Complete only if X0600F = 10, 11, or 12.

_
Month

_
Day

Year

C. Entry Date (A1600 on existing record to be modified/inactivated) - Complete only if X0600F = 01.

_
Month

_
Day

Year

Correction Attestation Section.- Complete this section to explain and attest to the modification/inactivation request.
X0800. Correction Number.
Enter Number

Enter the number of correction requests to modify/inactivate the existing record, including the present one.

X0900. Reasons for Modification.- Complete only if Type of Record is to modify a record in error (A0050 = 2).
Check all that apply.
A. Transcription error.
B. Data entry error.
C. Software product error.
D. Item coding error.
Z. Other error requiring modification.
If "Other" checked, please specify:

X1050. Reasons for Inactivation.- Complete only if Type of Record is to inactivate a record in error (A0050 = 3).
Check all that apply.
A. Event did not occur.
Z. Other error requiring inactivation.
If "Other" checked, please specify:

X1100. RN Assessment Coordinator Attestation of Completion.
A. Attesting individual's first name:

B. Attesting individual's last name:

C. Attesting individual's title:
D. Signature.
E. Attestation date.

_
Month

_
Day

Year

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Resident

Identifier

Section Z.

Date

Assessment Administration.

Z0100. Medicare Part A Billing.
A. Medicare Part A HIPPS code:

B. Version code:

Z0200. State Medicaid Billing (if required by the state).
A. Case Mix group:

B. Version code:

Z0250. Alternate State Medicaid Billing (if required by the state).
A. Case Mix group:

B. Version code:

Z0300. Insurance Billing.
A. Billing code:

B. Billing version:

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Resident

Section Z.

Identifier

Date

Assessment Administration.

Z0400. Signature of Persons Completing the Assessment or Entry/Death Reporting.
I certify that the accompanying information accurately reflects resident assessment information for this resident and that I collected or coordinated
collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable
Medicare and Medicaid requirements. I understand that this information is used as a basis for ensuring that residents receive appropriate and quality
care, and as a basis for payment from federal funds. I further understand that payment of such federal funds and continued participation in the
government-funded health care programs is conditioned on the accuracy and truthfulness of this information, and that I may be personally subject to
or may subject my organization to substantial criminal, civil, and/or administrative penalties for submitting false information. I also certify that I am
authorized to submit this information by this facility on its behalf.
Date Section
Signature
Title
Sections
Completed

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Z0500. Signature of RN Assessment Coordinator Verifying Assessment Completion.
A. Signature:

B. Date RN Assessment Coordinator signed
assessment as complete:

_
Month

_
Day

Year

Legal Notice Regarding MDS 3.0 - Copyright 2011 United States of America and interRAI. This work may be freely used and
distributed solely within the United States. Portions of the MDS 3.0 are under separate copyright protections; Pfizer Inc. holds the
copyright for the PHQ-9; Confusion Assessment Method. © 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted
from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Both Pfizer Inc. and the Hospital Elder Life Program, LLC have granted
permission to use these instruments in association with the MDS 3.0.
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