Nursing Home and Swing Bed Tracking (NT/ST) Item Set.

Resident

Identifier

Date

MINIMUM DATA SET (MDS) - Version 3.0.

RESIDENT ASSESSMENT AND CARE SCREENING.
Nursing Home and Swing Bed Tracking (NT/ST) 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

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

G. Type of discharge - Complete only if A0310F = 10 or 11.
1. Planned.
2. Unplanned.
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.

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.

A2400. Medicare Stay.
Enter Code

A. Has the resident had a Medicare-covered stay since the most recent entry?
0. No
Skip to Section X, Correction Request.
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

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

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.

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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