SD item set v1.18.11 removed items

MDS3.0_SD_Dschg_v1.17.2 + removed items redlined.docx

Minimum Data Set 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) for the Collection of Data Related to the Patient Driven Payment Model and the Skilled Nursing Facility QRP (CMS-10387)

SD item set v1.18.11 removed items

OMB: 0938-1140

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Resident

Identifier

Date


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MINIMUM DATA SET (MDS) - Version 3.0

RESIDENT ASSESSMENT AND CARE SCREENING

Shape7 Swing Bed Discharge (SD) 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


  1. National Provider Identifier (NPI):



  1. CMS Certification Number (CCN):



  1. State Provider Number:

A0200. Type of Provider.

Enter Code

Type of provider

  1. Nursing home (SNF/NF)

  2. Swing Bed

A0310. Type of Assessment

Enter Code









Enter Code








Enter Code




Enter Code







Enter Code




Enter Code

A. 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

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?

  1. No

  2. Yes

F. Entry/discharge reporting

01. Entry tracking record

  1. Discharge assessment-return not anticipated

  2. Discharge assessment-return anticipated

  3. Death in facility tracking record

99. None of the above

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

  1. Planned

  2. Unplanned

G1. Is this a SNF Part A Interrupted Stay?

  1. No

  2. Yes (Assessment not required at this time)

A0310 continued on next page

Section A

Identification Information

A0310. Type of Assessment - Continued

Enter Code

H. Is this a SNF Part A PPS Discharge Assessment?

  1. No

  2. Yes

A0410. Unit Certification or Licensure Designation

Enter Code

  1. Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State.

  2. Unit is neither Medicare nor Medicaid certified but MDS data is required by the State

  3. Unit is Medicare and/or Medicaid certified

A0500. Legal Name of Resident.


A. First name: B. Middle initial:



C. Last name: D. Suffix:

A0600. Social Security and Medicare Numbers


A. Social Security Number:

_ _


B. Medicare number:

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



A0800. Gender

Enter Code

  1. Male

  2. Female

A0900. Birth Date


_ _

Month Day Year

A1000. Race/Ethnicity replaced by 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

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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

  1. Never married

  2. Married

  3. Widowed

  4. Separated

  5. Divorced

A1300. Optional Resident Items


  1. Medical record number:



  1. Room number:



  1. Name by which resident prefers to be addressed:



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


Most Recent Admission/Entry or Reentry into this Facility

A1600. Entry Date


_ _

Month Day Year

A1700. Type of Entry

Enter Code

  1. Admission

  2. Reentry

A1800. Entered From Replaced with A1805 Entered From

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

09. Long Term Care Hospital (LTCH)

99. Other



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


_ _

Month Day Year

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A2000. Discharge Date

Identification Information

Complete only if A0310F = 10, 11, or 12

_

Month

_

Day







Year

A2100. Discharge Status Replaced with A2105 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



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Year


Enter Code

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

    1. No Skip to B0100, Comatose

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

  2. Start date of most recent Medicare stay:

_

Month

_

Day






Year

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

_

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_

Day






Year

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Section B

Hearing, Speech, and Vision

B0100. Comatose

Enter Code

Persistent vegetative state/no discernible consciousness

  1. No Continue to C0100, Should Brief Interview for Mental Status (C0200-C0500) be Conducted?

  2. Yes Skip to G0110, Activities of Daily Living (ADL) Assistance.

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C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?

If A0310G = 2 skip to C0700. Otherwise, attempt to conduct interview with all residents

Enter Code

  1. No (resident is rarely/never understood) Skip to and complete C0700-C1000, Staff Assessment for Mental Status

  2. 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

  1. None

  2. One

  3. Two

  4. 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

  1. Missed by > 5 years or no answer

  2. Missed by 2-5 years

  3. Missed by 1 year

  4. Correct

Ask resident: "What month are we in right now?"

B. Able to report correct month

  1. Missed by > 1 month or no answer

  2. Missed by 6 days to 1 month

  3. Accurate within 5 days

Ask resident: "What day of the week is today?"

C. Able to report correct day of the week

  1. Incorrect or no answer

  2. 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"

  1. No - could not recall

  2. Yes, after cueing ("something to wear")

  3. Yes, no cue required

B. Able to recall "blue"

  1. No - could not recall

  2. Yes, after cueing ("a color")

  3. Yes, no cue required

C. Able to recall "bed"

  1. No - could not recall

  2. Yes, after cueing ("a piece of furniture")

  3. Yes, no cue required

C0500. BIMS Summary Score

Enter Score

Add scores for questions C0200-C0400 and fill in total score (00-15)

Enter 99 if the resident was unable to complete the interview




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

Enter Code

  1. No (resident was able to complete Brief Interview for Mental Status) Skip to C1310, Signs and Symptoms of Delirium

  2. 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

  1. Memory OK.

  2. Memory problem

C1000. Cognitive Skills for Daily Decision Making

Enter Code

Made decisions regarding tasks of daily life

  1. Independent - decisions consistent/reasonable.

  2. Modified independence - some difficulty in new situations only

  3. Moderately impaired - decisions poor; cues/supervision required

  4. Severely impaired - never/rarely made decisions


Delirium

C1310. Signs and Symptoms of Delirium (from CAM©)

Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical record

A. Acute Onset Mental Status Change

Enter Code

Is there evidence of an acute change in mental status from the resident's baseline?

  1. No

  2. Yes



Coding:

  1. Behavior not present

  2. Behavior continuously present, does not fluctuate

  3. Behavior present, fluctuates (comes and goes, changes in severity)

Enter Codes in Boxes


B. Inattention - Did the resident have difficulty focusing attention, for example, being easily distractible or

having difficulty keeping track of what was being said?

C. Disorganized Thinking - Was the resident's thinking disorganized or incoherent (rambling or irrelevant

conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?

D. Altered Level of Consciousness - Did the resident have altered level of consciousness, as indicated by

any of the following criteria?

  • vigilant - startled easily to any sound or touch

  • lethargic - repeatedly dozed off when being asked questions, but responded to voice or touch

  • stuporous - very difficult to arouse and keep aroused for the interview

  • comatose - could not be aroused

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

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D0100. Should Resident Mood Interview be Conducted? - If A0310G = 2 skip to E0100. Otherwise, attempt to conduct interview

with all residents


Enter Code

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

  2. 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.

  1. Symptom Presence 2. Symptom Frequency.

    1. No (enter 0 in column 2) 0. Never or 1 day

    2. 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.

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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 2. Symptom Frequency.

    1. No (enter 0 in column 2) 0. Never or 1 day

    2. Yes (enter 0-3 in column 2) 1. 2-6 days (several days)

    3. 7-11 days (half or more of the days)

    4. 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.













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* 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:

  1. Behavior not exhibited

  2. Behavior of this type occurred 1 to 3 days

  3. Behavior of this type occurred 4 to 6 days,

but less than daily

  1. 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.

  1. Behavior not exhibited

  2. Behavior of this type occurred 1 to 3 days

  3. Behavior of this type occurred 4 to 6 days, but less than daily

  4. Behavior of this type occurred daily

E0900. Wandering - Presence & Frequency

Enter Code

Has the resident wandered?

  1. Behavior not exhibited

  2. Behavior of this type occurred 1 to 3 days

  3. Behavior of this type occurred 4 to 6 days, but less than daily.

  4. Behavior of this type occurred daily

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Section G

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 2. ADL Support Provided

Code for resident's performance over all shifts - not including setup. If the ADL activity Code for most support provided over all occurred 3 or more times at various levels of assistance, code the most dependent - except for shifts; code regardless of resident's self- total dependence, which requires full staff performance every time. performance classification

Coding: Coding:

Activity Occurred 3 or More Times 0. No setup or physical help from staff.

    1. Independent - no help or staff oversight at any time 1. Setup help only.

    2. Supervision - oversight, encouragement or cueing 2. One person physical assist

    3. Limited assistance - resident highly involved in activity; staff provide guided maneuvering 3. Two+ persons physical assist.

of limbs or other non-weight-bearing assistance 8. ADL activity itself did not occur or family

    1. Extensive assistance - resident involved in activity, staff provide weight-bearing support and/or non-facility staff provided care

    2. Total dependence - full staff performance every time during entire 7-day period 100% of the time for that activity over the

Activity Occurred 2 or Fewer Times entire 7-day period

7. Activity occurred only once or twice - activity did occur but only once or twice

8. Activity did not occur - activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period

1.

Self-Performance

2.

Support

Enter Codes in Boxes

A. Bed mobility - how resident moves to and from lying position, turns side to side, and

positions body while in bed or alternate sleep furniture



B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair,

standing position (excludes to/from bath/toilet)

C. Walk in room - how resident walks between locations in his/her room

D. Walk in corridor - how resident walks in corridor on unit.

E. Locomotion on unit - how resident moves between locations in his/her room and adjacent

corridor on same floor. If in wheelchair, self-sufficiency once in chair

F. Locomotion off unit - how resident moves to and returns from off-unit locations (e.g., areas

set aside for dining, activities or treatments). If facility has only one floor, how resident moves to and from distant areas on the floor. If in wheelchair, self-sufficiency once in chair

G. Dressing - how resident puts on, fastens and takes off all items of clothing, including

donning/removing a prosthesis or TED hose. Dressing includes putting on and changing pajamas and housedresses

H. Eating - how resident eats and drinks, regardless of skill. Do not include eating/drinking

during medication pass. Includes intake of nourishment by other means (e.g., tube feeding, total parenteral nutrition, IV fluids administered for nutrition or hydration)

I. Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off

toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag or ostomy bag

J. Personal hygiene - how resident maintains personal hygiene, including combing hair,

brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers)

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Section G

Functional Status

G0120. Bathing

How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair). Code for most

dependent in self-performance and support.

Enter Code

A. Self-performance

  1. Independent - no help provided

  2. Supervision - oversight help only.

  3. Physical help limited to transfer only

  4. Physical help in part of bathing activity

  5. Total dependence

8. Activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period

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.

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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.

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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?

  1. No Skip to H0100, Appliances

  2. Yes Continue to GG0170R, Wheel 50 feet with two turns

R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns.


RR3. Indicate the type of wheelchair or scooter used.

  1. Manual

  2. Motorized

S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.


Shape111

SS3. Indicate the type of wheelchair or scooter used.

  1. Manual

  2. Motorized

Shape115 Shape112 Shape113 Shape114

Section H

Bladder and Bowel

H0100. Appliances

Check all that apply


A. Indwelling catheter (including suprapubic catheter and nephrostomy tube)

B. External catheter

C. Ostomy (including urostomy, ileostomy, and colostomy)

D. Intermittent catheterization

Z. None of the above

H0300. Urinary Continence

Enter Code

Urinary continence - Select the one category that best describes the resident

  1. Always continent.

  2. Occasionally incontinent (less than 7 episodes of incontinence)

  3. Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding)

  4. Always incontinent (no episodes of continent voiding)

9. Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days

H0400. Bowel Continence

Enter Code

Bowel continence - Select the one category that best describes the resident

  1. Always continent.

  2. Occasionally incontinent (one episode of bowel incontinence)

  3. Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)

  4. Always incontinent (no episodes of continent bowel movements)

9. Not rated, resident had an ostomy or did not have a bowel movement for the entire 7 days

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


Heart/Circulation

I0900. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)

Genitourinary

I1550. Neurogenic Bladder

I1650. Obstructive Uropathy

Infections

I2300. Urinary Tract Infection (UTI) (LAST 30 DAYS)

Metabolic

I2900. Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)

Neurological

I5250. Huntington's Disease

I5350. Tourette's Syndrome

Nutritional

I5600. Malnutrition (protein or calorie) or at risk for malnutrition

Psychiatric/Mood Disorder

I5700. Anxiety Disorder

I5900. Bipolar Disorder

I5950. Psychotic Disorder (other than schizophrenia)

I6000. Schizophrenia (e.g., schizoaffective and schizophreniform disorders)

I6100. Post Traumatic Stress Disorder (PTSD)

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.

Shape117 Shape118 Shape119 Shape120 Shape121 Shape122 Shape123 Shape124 Shape125 Shape126 Shape116





























































































Shape133 Shape127 Shape128 Shape129 Shape130 Shape131 Shape132

Section J

Health Conditions

J0100. Pain Management - Complete for all residents, regardless of current pain level

At any time in the last 5 days, has the resident:

Enter Code



Enter Code



Enter Code

A. Received scheduled pain medication regimen?

  1. No

  2. Yes

B. Received PRN pain medications OR was offered and declined?

  1. No

  2. Yes

C. Received non-medication intervention for pain?

  1. No

  2. Yes


J0200. Should Pain Assessment Interview be Conducted?

If resident is comatose or if A0310G = 2 , skip to J1100, Shortness of Breath (dyspnea). Otherwise, attempt to conduct interview with all residents

Enter Code

  1. No (resident is rarely/never understood) Skip to and complete J1100, Shortness of Breath

  2. Yes Continue to J0300, Pain Presence


Pain Assessment Interview

J0300. Pain Presence

Enter Code

Ask resident: "Have you had pain or hurting at any time in the last 5 days?"

  1. No Skip to J1100, Shortness of Breath

  2. Yes Continue to J0400, Pain Frequency

9. Unable to answer Skip to J1100, Shortness of Breath (dyspnea)

J0400. Pain Frequency


Enter Code

Ask resident: "How much of the time have you experienced pain or hurting over the last 5 days?"

  1. Almost constantly

  2. Frequently.

  3. Occasionally

  4. Rarely

9. Unable to answer

J0500. Pain Effect on Function


Enter Code





Enter Code

A. Ask resident: "Over the past 5 days, has pain made it hard for you to sleep at night?"

0. No

1. Yes

9. Unable to answer

B. Ask resident: "Over the past 5 days, have you limited your day-to-day activities because of pain?"

0. No

1. Yes

9. Unable to answer

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


Enter Rating





Enter Code

A. Numeric Rating Scale (00-10)

Ask resident: "Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine." (Show resident 00 -10 pain scale)

Enter two-digit response. Enter 99 if unable to answer.

B. Verbal Descriptor Scale

Ask resident: "Please rate the intensity of your worst pain over the last 5 days." (Show resident verbal scale)

  1. Mild

  2. Moderate

  3. Severe

  4. Very severe, horrible

9. Unable to answer

Section J

Health Conditions

Other Health Conditions

J1100. Shortness of Breath (dyspnea)

Check all that apply


A. Shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring)

B. Shortness of breath or trouble breathing when sitting at rest.

C. Shortness of breath or trouble breathing when lying flat

Z. None of the above

J1400. Prognosis


Enter Code

Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? (Requires physician

documentation)

  1. No.

  2. Yes

J1550. Problem Conditions

Check all that apply


A. Fever

B. Vomiting

C. Dehydrated

D. Internal bleeding

Z. None of the above

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?

  1. No Skip to K0200, Height and Weight

  2. 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:

  1. None

  2. One

  3. 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

Shape134 Shape135 Shape136 Shape137 Shape138


Section K

Swallowing/Nutritional Status

K0200. Height and Weight - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up



inches




pounds


A. Height (in inches). Record most recent height measure since admission/entry or reentry

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

K0300. Weight Loss


Enter Code

Loss of 5% or more in the last month or loss of 10% or more in last 6 months

  1. No or unknown

  2. Yes, on physician-prescribed weight-loss regimen

  3. Yes, not on physician-prescribed weight-loss regimen

K0310. Weight Gain


Enter Code

Gain of 5% or more in the last month or gain of 10% or more in last 6 months

  1. No or unknown

  2. Yes, on physician-prescribed weight-gain regimen

  3. Yes, not on physician-prescribed weight-gain regimen

K0510. Nutritional Approaches Replaced by K0520 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

  1. 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)

For the following items, if A0310G = 2, skip to M0100, Determination of Pressure Ulcer/Injury Risk

C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids)



D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol)

Z. None of the above


Shape144 Shape139 Shape140 Shape141 Shape142 Shape143







Section M

Skin Conditions

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

M0100. Determination of Pressure Ulcer/Injury Risk.

Check all that apply


A. Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device.

M0210. Unhealed Pressure Ulcers/Injuries

Enter Code

Does this resident have one or more unhealed pressure ulcers/injuries?

  1. No Skip to N0410, Medications Received

  2. 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







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


  1. Number of Stage 2 pressure ulcers - If 0 Skip to M0300C, Stage 3


  1. 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

  1. 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 - If 0 Skip to M0300D, Stage 4


    1. 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

  1. 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 - If 0 Skip to M0300E, Unstageable - Non-removable dressing/device


    1. 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.

  1. Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device


    1. Number of unstageable pressure ulcers/injuries due to non-removable dressing/device - If 0 Skip to M0300F, Unstageable - Slough and/or eschar

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

  1. 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 - If 0 Skip to M0300G, Unstageable - Deep tissue injury

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

M0300 continued on next page

Shape145 Shape146 Shape147 Shape148


Shape152 Shape149 Shape150 Shape151

Section M

Skin Conditions

M0300 - Continued



Enter Number




Enter Number

G. Unstageable - Deep tissue injury:


  1. Number of unstageable pressure injuries presenting as deep tissue injury - If 0 Skip to N0410, Medications Received


  1. 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

N0410. Medications Received Replaced by N0415 High-Risk Drug Classes: Use and Indication

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

Enter Days



Enter Days



Enter Days



Enter Days



Enter Days



Enter Days



Enter Days

A. Antipsychotic.

B. Antianxiety

C. Antidepressant.

D. Hypnotic.

E. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin)

F. Antibiotic

G. Diuretic.

Enter Days

H. Opioid

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

Special Treatments, Procedures, and Programs

O0100. Special Treatments, Procedures, and Programs Replaced by O)110 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 resident entered (admission or reentry) IN THE LAST 14 DAYS. If resident last entered 14 or more days ago, leave column 1 blank

  1. While a Resident.

Performed while a resident of this facility and within the last 14 days


1.

While NOT a Resident.


2.

While a Resident

Check all that apply

K. Hospice care.



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

Enter Code









Enter Code

A. Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season?

  1. No Skip to O0250C, If influenza vaccine not received, state reason

  2. Yes Continue to O0250B, Date influenza vaccine received

B. Date influenza vaccine received Complete date and skip to O0300A, Is the resident's Pneumococcal vaccination up to date?

_ _

Month Day Year

C. If influenza vaccine not received, state reason:

  1. Resident not in this facility during this year's influenza vaccination season

  2. Received outside of this facility.

  3. Not eligible - medical contraindication

  4. Offered and declined.

  5. Not offered

  6. Inability to obtain influenza vaccine due to a declared shortage

9. None of the above.

O0300. Pneumococcal Vaccine.

Enter Code

A. Is the resident's Pneumococcal vaccination up to date?

  1. No Continue to O0300B, If Pneumococcal vaccine not received, state reason

  2. Yes Skip to O0425, Part A Therapies

Enter Code

B. If Pneumococcal vaccine not received, state reason:

  1. Not eligible - medical contraindication

  2. Offered and declined

  3. Not offered

Shape156 Shape157 Shape153 Shape154 Shape155








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. Shape158






      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)

    1. Shape159






      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)

    2. Shape160






      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

    1. Shape161






      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)

    1. 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. Shape162






      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)

    1. Shape163






      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)

    2. Shape164






      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

    1. Shape165






      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)

    1. 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. Shape166






      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)

    1. Shape167






      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)

    2. Shape168






      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

    1. Shape169






      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)

    1. 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

Shape170 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)

Shape177 Shape178 Shape179 Shape171 Shape172 Shape173 Shape174 Shape175 Shape176


































Section P

Restraints and Alarms

P0100. Physical Restraints

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








Coding:

  1. Not used

  2. Used less than daily

  3. Used daily

Enter Codes in Boxes


Used in Bed


A. Bed rail.

B. Trunk restraint

C. Limb restraint

D. Other

Used in Chair or Out of Bed

E. Trunk restraint

F. Limb restraint.

G. Chair prevents rising.

H. Other



Section Q

Participation in Assessment and Goal Setting

Q0400. Discharge Plan

Enter Code

A. Is active discharge planning already occurring for the resident to return to the community?

  1. No

  2. Yes

Q0600. Referral Replaced by Q0610 Referral


Enter Code

Has a referral been made to the Local Contact Agency? (Document reasons in resident's clinical record)

  1. No - referral not needed

  2. No - referral is or may be needed (For more information see Appendix C, Care Area Assessment Resources #20)

  3. Yes - referral made



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

  1. Nursing home (SNF/NF)

  2. Swing Bed

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


A. First name:



C. Last name:

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

Enter Code

  1. Male

  2. Female

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

_

Month

_

Day







Year

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

Shape190 Shape191










_ _


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

  1. 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

  1. Discharge assessment-return not anticipated

  2. Discharge assessment-return anticipated

  3. Death in facility tracking record

99. None of the above

H. Is this a SNF Part A PPS Discharge Assessment?

  1. No

  2. 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

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

_

Month

_

Day






Year

    1. 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

Shape192

Enter Number


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

Shape195 Shape196 Shape193 Shape194
























































































Section Z

Assessment Administration

Z0300. Insurance Billing


  1. Billing code:



  1. Billing version:

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

Shape200 Shape197 Shape198 Shape199

















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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MDS 3.0 Swing Bed Discharge (SD) Version 1.17.2 Effective 10/01/2020

Page 1 of 27


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleMDS 3.0 Swing Bed Discharge (SD) Item Set
SubjectMDS 3.0 assessment items for swing bed Discharge assessments
AuthorCenters for Medicare & Medicaid Services
File Modified0000-00-00
File Created2023-09-02

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