IPA item set v1.18.11 removed items

Resident

Identifier

Date

MINIMUM DATA SET (MDS) - Version 3.0

RESIDENT ASSESSMENT AND CARE SCREENING

Interim Payment Assessment (IPA) 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? 0. No
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

A0310. Type of Assessment - Continued

Enter Code

G. Type of discharge - Complete only if A0310F = 10 or 11

1. Planned

2. Unplanned

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.

1. 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

A1000. Race/Ethnicity

_

Day

Year

Check all that apply.

1. American Indian or Alaska Native

2. Asian

3. Black or African American

4. Hispanic or Latino

5. Native Hawaiian or Other Pacific Islander

6. White

A1100. Language Replaced by A 1110 Language

Enter Code

1. 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

2. Preferred language:

A1200. Marital Status

Enter Code

1. Never married

2. Married

3. Widowed

4. Separated

5. Divorced

A1300. Optional Resident Items

1. Medical record number:

2. Room number:

3. Name by which resident prefers to be addressed:

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

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 B0100, Comatose

   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 B		Hearing, Speech, and Vision
B0100. Comatose
Enter Code	Persistent vegetative state/no discernible consciousness No Continue to B0700, Makes Self Understood Yes Skip to GG0130, Self-Care
B0700. Makes Self Understood
Enter Code	Ability to express ideas and wants, consider both verbal and non-verbal expression Understood Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time. Sometimes understood - ability is limited to making concrete requests Rarely/never understood

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted? Attempt to conduct interview with all residents
Enter Code	No (resident is rarely/never understood) Skip to and complete C0700-C1000, Staff Assessment for Mental Status Yes Continue to C0200, Repetition of Three Words

Brief Interview for Mental Status (BIMS)
C0200. Repetition of Three Words
Enter Code			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.” Number of words repeated after first attempt None One Two 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)
Enter Code Enter Code Enter Code			Ask resident: "Please tell me what year it is right now." A. Able to report correct year Missed by > 5 years or no answer Missed by 2-5 years Missed by 1 year Correct
			Ask resident: "What month are we in right now?" B. Able to report correct month Missed by > 1 month or no answer Missed by 6 days to 1 month Accurate within 5 days
			Ask resident: "What day of the week is today?" C. Able to report correct day of the week Incorrect or no answer 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" No - could not recall Yes, after cueing ("something to wear") Yes, no cue required
			B. Able to recall "blue" No - could not recall Yes, after cueing ("a color") Yes, no cue required
			C. Able to recall "bed" No - could not recall Yes, after cueing ("a piece of furniture") 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	No (resident was able to complete Brief Interview for Mental Status) Skip to D0100, Should Resident Mood Interview be Conducted? 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 Memory OK. Memory problem
C1000. Cognitive Skills for Daily Decision Making
Enter Code	Made decisions regarding tasks of daily life Independent - decisions consistent/reasonable. Modified independence - some difficulty in new situations only Moderately impaired - decisions poor; cues/supervision required Severely impaired - never/rarely made decisions

D0100. Should Resident Mood Interview be Conducted? - Attempt to conduct interview with all residents
Enter Code	No (resident is rarely/never understood) Skip to and complete D0500-D0600, Staff Assessment of Resident Mood (PHQ-9-OV) Yes Continue to D0200, Resident Mood Interview (PHQ-9©)

D0200. Resident Mood Interview (PHQ-9©) Replaced by D0150
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.
Symptom Presence 2. Symptom Frequency. No (enter 0 in column 2) 0. Never or 1 day Yes (enter 0-3 in column 2) 1. 2-6 days (several days) 9. No response (leave column 2 2. 7-11 days (half or more of the days) blank) 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 Replaced by D0160
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.

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.
Symptom Presence 2. Symptom Frequency. No (enter 0 in column 2) 0. Never or 1 day Yes (enter 0-3 in column 2) 1. 2-6 days (several days) 7-11 days (half or more of the days) 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.

Section E		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.
Coding: Behavior not exhibited Behavior of this type occurred 1 to 3 days Behavior of this type occurred 4 to 6 days, but less than daily Behavior of this type occurred daily			Enter Codes in Boxes
				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. Behavior not exhibited Behavior of this type occurred 1 to 3 days Behavior of this type occurred 4 to 6 days, but less than daily Behavior of this type occurred daily
E0900. Wandering - Presence & Frequency
Enter Code	Has the resident wandered? Behavior not exhibited Behavior of this type occurred 1 to 3 days Behavior of this type occurred 4 to 6 days, but less than daily. Behavior of this type occurred daily

GG0130. Self-Care (Assessment period is the last 3 days)
Code the resident's usual performance for each activity using the 6-point scale. If an activity was not attempted, 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
5. Interim 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..

Section GG		Functional Abilities and Goals - Interim Payment Assessment
GG0170. Mobility (Assessment period is the last 3 days)
Code the resident's usual performance for each activity using the 6-point scale. If an activity was not attempted, 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
5. Interim Performance
Enter Codes in Boxes
	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.
	I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. If interim performance is coded 07, 09, 10, or 88 Skip to H0100, Appliances
	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 H		Bladder and Bowel
H0100. Appliances
Check all that apply
	C. Ostomy (including urostomy, ileostomy, and colostomy)
	D. Intermittent catheterization
	Z. None of the above
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? No Yes
H0500. Bowel Toileting Program
Enter Code	Is a toileting program currently being used to manage the resident's bowel continence? No Yes

Section I		Active Diagnoses
I0020. Indicate the resident’s primary medical condition category
Enter Code	Indicate the resident's primary medical condition category that best describes the primary reason for admission Stroke Non-Traumatic Brain Dysfunction Traumatic Brain Dysfunction Non-Traumatic Spinal Cord Dysfunction Traumatic Spinal Cord Dysfunction Progressive Neurological Conditions Other Neurological Conditions Amputation Hip and Knee Replacement Fractures and Other Multiple Trauma Other Orthopedic Conditions Debility, Cardiorespiratory Conditions Medically Complex Conditions I0020B. ICD Code

Section I		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
	Gastrointestinal
	I1300. Ulcerative Colitis, Crohn's Disease, or Inflammatory Bowel Disease
	Infections
	I1700. Multidrug-Resistant Organism (MDRO) I2000. Pneumonia I2100. Septicemia I2500. Wound Infection (other than foot)
	Metabolic
	I2900. Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)
	Neurological
	I4300. Aphasia I4400. Cerebral Palsy I4500. Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke I4900. Hemiplegia or Hemiparesis I5100. Quadriplegia I5200. Multiple Sclerosis (MS) I5300. Parkinson's Disease I5500. Traumatic Brain Injury (TBI)
	Nutritional
	I5600. Malnutrition (protein or calorie) or at risk for malnutrition
	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
	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.

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
		Z. None of the above
J2100. Recent Surgery Requiring Active SNF Care
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
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.

Section J		Health Conditions
Surgical Procedures - Continued
Check all that apply
	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

Section K		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
K0300. Weight Loss
Enter Code	Loss of 5% or more in the last month or loss of 10% or more in last 6 months No or unknown Yes, on physician-prescribed weight-loss regimen Yes, not on physician-prescribed weight-loss regimen
K0510. Nutritional Approaches Replaced by K0520 Check all of the following nutritional approaches that were performed during the last 7 days
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 While a Resident.			1. While NOT a Resident.	2. While a Resident
Performed while a resident of this facility and within the last 7 days			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)
Z. None of the above

Section K	Swallowing/Nutritional Status
K0710. Percent Intake by Artificial Route - Complete K0710 only if Column 2 is checked for K0510A and/or K0510B
While a Resident. Performed while a resident of this facility and within the last 7 days 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 25% or less 26-50% 51% or more
B. Average fluid intake per day by IV or tube feeding 500 cc/day or less 501 cc/day or more

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 M1030, Number of Venous and Arterial Ulcers 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	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 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 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 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 1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar
Enter Number

Section M		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

Section N		Medications
N0350. Insulin
Enter Days 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
	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 Replaced by O0110 Special Treatments, Procedures, and Programs Check all of the following treatments, procedures, and programs that were performed during the last 14 days
2. While a Resident. Performed while a resident of this facility and within the last 14 days			2. While a Resident
			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
O0400. Therapies
Enter Number of Days	D. Respiratory Therapy
	2. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days

Section O		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

Section X		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 Nursing home (SNF/NF) 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	Male Female
X0400. Birth Date (A0900 on existing record to be modified/inactivated)
	_ _ Month Day Year

Section X		Correction Request
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? No Yes
X0600. Type of Assessment (A0310 on existing record to be modified/inactivated)
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
	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
X0700. Date on existing record to be modified/inactivated
	A. Assessment Reference Date (A2300 on existing record to be modified/inactivated) - Complete only if X0600B = 08 _ _ 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:

Section Z		Assessment Administration
Z0100. Medicare Part A Billing
	Medicare Part A HIPPS code: Version code:

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 Interim Payment Assessment (IPA) Version 1.17.2 Effective 10/01/2020

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