Optional State Assessment (OSA) Item Set

Resident

Identifier

Date

MINIMUM DATA SET (MDS) - Version 3.0.

RESIDENT ASSESSMENT AND CARE SCREENING.
Optional State Assessment (OSA) 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.
Enter Code

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

Enter Code

B. Assessment type.
1. Start of therapy assessment.
2. End of therapy assessment.
3. Both Start and End of therapy assessment.
4. Change of therapy assessment
5. Other payment assessment.

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:

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Resident

Identifier

Section A.

Date

Identification Information.

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.

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.
9. Unable to determine.
Skip to A1200, Marital Status.
B. Preferred language:

A1200. Marital Status.
Enter Code

1.
2.
3.
4.
5.

Never married.
Married.
Widowed.
Separated.
Divorced.

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:

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Resident

Identifier

Section A.

Date

Identification Information.

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

_
Day

Year

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

_
Day

Year

A2300. Assessment Reference Date.
Observation end date:

_
Month

_
Day

Year

A2400. 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 B0700, Makes Self Understood.
0. No
1. Yes
Skip to G0110, Activities of Daily Living (ADL) Assistance.

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.

Section C.

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.

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Resident

Identifier

Section C.

Date

Cognitive Patterns.

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.

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 D0100, Should Resident Mood Interview be
conducted?
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.

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.

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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

Identifier

Section G.

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).
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.

Section H.

Bladder and Bowel.

H0200. Urinary Toileting Program.
Enter Code

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.

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.

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.
Infections.
I2000. Pneumonia.
I2100. Septicemia.
Metabolic.
I2900. Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy).
Neurological.
I4300. Aphasia.
I4400. Cerebral Palsy.
I4900. Hemiplegia or Hemiparesis.
I5100. Quadriplegia.
I5200. Multiple Sclerosis (MS).
I5300. Parkinson's Disease.
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
None of Above.
I7900. None of the above active diagnoses within the last 7 days.

Section J.

Health Conditions.

Other Health Conditions.
J1100. Shortness of Breath (dyspnea).
Check all that apply.
C. Shortness of breath or trouble breathing when lying flat.
Z. None of the above.

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 K.

Date

Swallowing/Nutritional Status.

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.

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).
Z. None of the above.

K0710. Percent Intake by Artificial Route - Complete K0710 only if Column 1 and/or Column 2 are checked for K0510A and/or K0510B.
3. During Entire 7 Days.
Performed during the entire last 7 days.

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.

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Resident

Identifier

Section M.

Date

Skin Conditions.
Report based on highest stage of existing ulcers/injuries at their worst;
do not "reverse" stage.

M0210. Unhealed Pressure Ulcers/Injuries.
Enter Code

Does this 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.

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

1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar

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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).
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 O0100, Special Treatments, Procedures, and Programs .

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.

Section O.

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.
M. Isolation or quarantine for active infectious disease (does not include standard body/fluid
precautions).
None of the Above.
Z. None of the above.

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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 Days

skip to O0400A5, Therapy start date

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 Days

skip to O0400B5, Therapy start date

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

_
Day

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

_
Year

Month

_
Day

Year

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 Days

skip to O0400C5, Therapy start date

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.

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Resident

Identifier

Section O.

Date

Special Treatments, Procedures, and Programs.

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.

O0450. Resumption of Therapy.
Enter Code

A. Has a previous rehabilitation therapy regimen (speech, occupational, and/or physical therapy) ended, as reported on this End of
Therapy OMRA, and has this regimen now resumed at exactly the same level for each discipline?
0. No
1. Yes

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 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).

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/B on existing record to be modified/inactivated).
Enter Code

Enter Code

A. Is this assessment for state payment purposes only?.
0. No.
1. Yes.
B. Assessment type.
1. Start of therapy assessment.
2. End of therapy assessment.
3. Both Start and End of therapy assessment.
4. Change of therapy assessment
5. Other payment assessment.

X0700. Date on existing record to be modified/inactivated.
A. Assessment Reference Date (A2300 on existing record to be modified/inactivated)

_
Month

_
Day

Year

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Resident

Identifier

Section X.

Date

Correction Request.

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.

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

B. Version code:

Enter Code

C. Is this a Short Stay assessment?
0. No.
1. Yes.

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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