NPE item set v1.18.11 removed items

Resident

Identifier

Date

MINIMUM DATA SET (MDS) - Version 3.0

RESIDENT ASSESSMENT AND CARE SCREENING

Nursing Home Part A PPS Discharge (NPE) Item Set

Section A		Identification Information
A0050. Type of Record
Enter Code	Add new record Continue to A0100, Facility Provider Numbers Modify existing record Continue to A0100, Facility Provider Numbers Inactivate existing record Skip to X0150, Type of Provider
A0100. Facility Provider Numbers
	National Provider Identifier (NPI): CMS Certification Number (CCN): State Provider Number:
A0200. Type of Provider.
Enter Code	Type of provider Nursing home (SNF/NF) Swing Bed
A0300. Optional State Assessment Complete only if A0200 = 1
Enter Code	A. Is this assessment for state payment purposes only? No Yes
A0310. Type of Assessment
Enter Code Enter Code Enter Code Enter Code	A. Federal OBRA Reason for Assessment Admission assessment (required by day 14) Quarterly review assessment Annual assessment Significant change in status assessment Significant correction to prior comprehensive assessment 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? No Yes
	F. Entry/discharge reporting 01. Entry tracking record Discharge assessment-return not anticipated Discharge assessment-return anticipated Death in facility tracking record 99. None of the above
A0310 continued on next page

Section A		Identification Information
A0310. Type of Assessment - Continued
Enter Code Enter Code	G. Type of discharge - Complete only if A0310F = 10 or 11 Planned Unplanned
	H. Is this a SNF Part A PPS Discharge Assessment? No Yes
A0410. Unit Certification or Licensure Designation
Enter Code	Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State. Unit is neither Medicare nor Medicaid certified but MDS data is required by the State 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	Male Female
A0900. Birth Date
	_ _ Month Day Year
A1000. Race/Ethnicity- Replaced with A1005 Ethnicity and A1010 Race
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

Section A		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 9. Unable to determine Skip to A1200, Marital Status B. Preferred language:
A1200. Marital Status
Enter Code	Never married Married Widowed Separated Divorced
A1300. Optional Resident Items
	Medical record number: Room number: Name by which resident prefers to be addressed: 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	Admission Reentry
A1800. Entered From Replaced by A1805 Entered From
Enter Code	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 09. Long Term Care Hospital (LTCH) 99. Other

Section A Identification Information

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

_

Month

_

Day

Year

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

1. Community (private home/apt., board/care, assisted living, group home)

2. Another nursing home or swing bed

3. Acute hospital

4. Psychiatric hospital

5. Inpatient rehabilitation facility

6. ID/DD facility

7. Hospice

8. Deceased

9. Long Term Care Hospital (LTCH)

99. Other

A2300. Assessment Reference Date

Observation end date:

_

Month

A2400. Medicare Stay

_

Day

Year

Enter Code

1. Has the resident had a Medicare-covered stay since the most recent entry?

   0. No Skip to GG0130, Self-Care.

   1. Yes Continue to A2400B, Start date of most recent Medicare stay

2. Start date of most recent Medicare stay:

_

Month

_

Day

Year

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

_

Month

_

Day

Year

Section GG		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.

Section GG		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. If discharge 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.

Section GG			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? No Skip to J1800, Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent 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. Manual 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. Manual Motorized

Section J		Health Conditions
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? No Skip to M0210, Unhealed Pressure Ulcers/Injuries Yes Continue to J1900, Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS)
J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent.
Coding: None One Two or more		Enter Codes in Boxes
			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

Section M		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? No Skip to N2005, Medication Intervention Yes Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
Enter Number Enter Number Enter Number Enter Number Enter Number Enter Number	B. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister Number of Stage 2 pressure ulcers - If 0 Skip to M0300C, Stage 3 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 Number of Stage 3 pressure ulcers - If 0 Skip to M0300D, Stage 4 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 Number of Stage 4 pressure ulcers - If 0 Skip to M0300E, Unstageable - Non-removable dressing/device 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

Section M		Skin Conditions
Enter Number Enter Number Enter Number Enter Number Enter Number Enter Number	E. Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers/injuries due to non-removable dressing/device - If 0 Skip to M0300F, Unstageable - Slough and/or eschar 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 Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar - If 0 Skip to M0300G, Unstageable - Deep tissue injury 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: Number of unstageable pressure injuries presenting as deep tissue injury - If 0 Skip to N2005, Medication Intervention 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

Section N		Medications
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

Section O

O0425. Part A Therapies

Complete only if A0310H = 1

Special Treatments, Procedures, and Programs

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Days

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Days

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Days

1. Speech-Language Pathology and Audiology Services

   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)

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)

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.

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)

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)

1. Occupational Therapy

   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)

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)

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

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)

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)

1. Physical Therapy

   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)

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)

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.

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)

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)

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)

1. 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)

_ _

0. =

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

Enter Code

Enter Code

Enter Code

Enter Code

1. Federal OBRA Reason for Assessment

   1. Admission assessment (required by day 14)

   2. Quarterly review assessment

   3. Annual assessment

   4. Significant change in status assessment

   5. Significant correction to prior comprehensive assessment

   6. Significant correction to prior quarterly assessment

99. None of the above

2. PPS Assessment.

PPS Scheduled Assessment for a Medicare Part A Stay

1. 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

X0700. Date on existing record to be modified/inactivated - Complete one only.

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

_

Month

_

Day

Year

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

_

Month

_

Day

Year

3. 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

1. Transcription error

2. Data entry error

3. Software product error

4. 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

1. Attesting individual's first name:

2. Attesting individual's last name:

3. Attesting individual's title:

4. Signature

5. Attestation date

_

Month

_

Day

Year

Section Z		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.
	Signature		Title	Sections	Date Section 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.

MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.17.2 Effective 10/01/2020

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