CMS-10387 Nursing Home PPS (NP) Item Set

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

MINIMUM DATA SET (MDS) - Version 3.0
RESIDENT ASSESSMENT AND CARE SCREENING
Nursing Home PPS (NP) Item Set

Section A - Identification Information
A0050. Type of Record

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1.
2.
3.

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

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A. National Provider Identifier (NPI):

B. CMS Certification Number (CCN):
C. State Provider Number:

A0200. Type of Provider
Type of provider
Enter Code
1. Nursing home (SNF/NF)
2. Swing Bed

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A0310. Type of Assessment
Enter Code

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Enter Code

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A. Federal OBRA Reason for Assessment
01. Admission assessment (required by day 14)
02. Quarterly review assessment
03. Annual assessment
04. Significant change in status assessment
05. Significant correction to prior comprehensive assessment
06. Significant correction to prior quarterly assessment
99. None of the above
B. PPS Assessment
PPS Scheduled Assessment for a Medicare Part A Stay
01. 5-day scheduled assessment
PPS Unscheduled Assessment for a Medicare Part A Stay
08. IPA - Interim Payment Assessment
Not PPS Assessment
99. None of the above

Enter Code

E.

Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry?
0. No
1. Yes

Enter Code

F.

Entry/discharge reporting
01. Entry tracking record
10. Discharge assessment-return not anticipated
11. Discharge assessment-return anticipated
12. Death in facility tracking record
99. None of the above

A0310 continued on next page

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section A - Identification Information
A0310. Type of Assessment - Continued

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Enter Code

Enter Code

Enter Code

G. Type of discharge - Complete only if A0310F = 10 or 11
1. Planned
2. Unplanned
G1. Is this a SNF Part A Interrupted Stay?
0. No
1. Yes
H. Is this a SNF Part A PPS Discharge Assessment?
0. No
1. Yes

A0410. Unit Certification or Licensure Designation
Enter Code

Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State
Unit is neither Medicare nor Medicaid certified but MDS data is required by the State
Unit is Medicare and/or Medicaid certified

1.
2.
3.

A0500. Legal Name of Resident

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A. First name:

B. Middle initial:

C. Last name:

D. Suffix:

A0600. Social Security and Medicare Numbers

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A. Social Security Number:
B. Medicare number:

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

A0800. Gender

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Enter Code

1.
2.

Male
Female

A0900. Birth Date

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Month

Day

Year

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section A - Identification Information
A1005. Ethnicity
Are you of Hispanic, Latino/a, or Spanish origin?
↓

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Check all that apply
A. No, not of Hispanic, Latino/a, or Spanish origin
B. Yes, Mexican, Mexican American, Chicano/a
C. Yes, Puerto Rican
D. Yes, Cuban
E.

Yes, another Hispanic, Latino/a, or Spanish origin

X.

Resident unable to respond

Y. Resident declines to respond
A1010. Race
What is your race?
↓

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Check all that apply
A. White
B. Black or African American
C. American Indian or Alaska Native
D. Asian Indian
E.

Chinese

F.

Filipino

G. Japanese
H. Korean
I.

Vietnamese

J.

Other Asian

K. Native Hawaiian
L.

Guamanian or Chamorro

M. Samoan
N. Other Pacific Islander
X.

Resident unable to respond

Y.

Resident declines to respond

Z. None of the above
A1110. Language

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A. What is your preferred language?

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Enter Code

B. Do you need or want an interpreter to communicate with a doctor or health care staff?
0. No
1. Yes
9. Unable to determine

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section A - Identification Information
A1200. Marital Status

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1.
2.
3.
4.
5.

Enter Code

Never married
Married
Widowed
Separated
Divorced

A1250. Transportation (from NACHC©)
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?
↓

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Check all that apply
A. Yes, it has kept me from medical appointments or from getting my medications
B. Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need
C. No
X.

Resident unable to respond

Y.

Resident declines to respond

© 2019. National Association of Community Health Centers, Inc., Association of Asian Pacific Community Health Organizations, Oregon Primary Care Association. PRAPARE
and its resources are proprietary information of NACHC and its partners, intended for use by NACHC, its partners, and authorized recipients. Do not publish, copy, or distribute
this information in part or whole without written consent from NACHC.

A1300. Optional Resident Items

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A. Medical record number:
B. Room number:

C. Name by which resident prefers to be addressed:

D. Lifetime occupation(s) - put “/” between two occupations:

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section A - Identification Information
Most Recent Admission/Entry or Reentry into this Facility
A1600. Entry Date

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Month

Day

Year

A1700. Type of Entry

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Enter Code

1.
2.

Admission
Reentry

A1805. Entered From

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Enter Code

01. Home/Community (e.g., private home/apt., board/care, assisted living, group home, transitional living, other
residential care arrangements)
02. Nursing Home (long-term care facility)
03. Skilled Nursing Facility (SNF, swing beds)
04. Short-Term General Hospital (acute hospital, IPPS)
05. Long-Term Care Hospital (LTCH)
06. Inpatient Rehabilitation Facility (IRF, free standing facility or unit)
07. Inpatient Psychiatric Facility (psychiatric hospital or unit)
08. Intermediate Care Facility (ID/DD facility)
09. Hospice (home/non-institutional)
10. Hospice (institutional facility)
11. Critical Access Hospital (CAH)
12. Home under care of organized home health service organization
99. Not listed

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

Month

Day

Year

A2000. Discharge Date
Complete only if A0310F = 10, 11, or 12

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Month

Day

Year

A2105. Discharge Status
Complete only if A0310F = 10, 11, or 12

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Enter Code

01. Home/Community (e.g., private home/apt., board/care, assisted living, group home, transitional living, other residential care
arrangements) → Skip to A2123, Provision of Current Reconciled Medication List to Resident at Discharge
02. Nursing Home (long-term care facility)
03. Skilled Nursing Facility (SNF, swing beds)
04. Short-Term General Hospital (acute hospital, IPPS)
05. Long-Term Care Hospital (LTCH)
06. Inpatient Rehabilitation Facility (IRF, free standing facility or unit)
07. Inpatient Psychiatric Facility (psychiatric hospital or unit)
08. Intermediate Care Facility (ID/DD facility)
09. Hospice (home/non-institutional)
10. Hospice (institutional facility)
11. Critical Access Hospital (CAH)
12. Home under care of organized home health service organization
13. Deceased
99. Not listed → Skip to A2123, Provision of Current Reconciled Medication List to Resident at Discharge

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section A - Identification Information
A2121. Provision of Current Reconciled Medication List to Subsequent Provider at Discharge
Complete only if A0310H = 1 and A2105 = 02-12

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Enter Code

At the time of discharge to another provider, did your facility provide the resident’s current reconciled medication list to the subsequent provider?
0.
1.

No - Current reconciled medication list not provided to the subsequent provider → Skip to A2300, Assessment Reference Date
Yes - Current reconciled medication list provided to the subsequent provider

A2122. Route of Current Reconciled Medication List Transmission to Subsequent Provider
Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider.
Complete only if A2121 = 1
↓ Check all that apply
Route of Transmission

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A. Electronic Health Record
B. Health Information Exchange
C. Verbal (e.g., in-person, telephone, video conferencing)
D. Paper-based (e.g., fax, copies, printouts)
E.

Other methods (e.g., texting, email, CDs)

A2123. Provision of Current Reconciled Medication List to Resident at Discharge
Complete only if A0310H = 1 and A2105 = 01, 99

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Enter Code

At the time of discharge, did your facility provide the resident’s current reconciled medication list to the resident, family and/or caregiver?
0. No - Current reconciled medication list not provided to the resident, family and/or caregiver → Skip to A2300, Assessment Reference
Date
1. Yes - Current reconciled medication list provided to the resident, family and/or caregiver

A2124. Route of Current Reconciled Medication List Transmission to Resident
Indicate the route(s) of transmission of the current reconciled medication list to the resident/family/caregiver.
Complete only if A2123 = 1
↓ Check all that apply

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Route of Transmission
A. Electronic Health Record (e.g., electronic access to patient portal)
B. Health Information Exchange
C. Verbal (e.g., in-person, telephone, video conferencing)
D. Paper-based (e.g., fax, copies, printouts)
E.

Other methods (e.g., texting, email, CDs)

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section A - Identification Information
A2300. Assessment Reference Date

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Observation end date:
Month

Day

Year

A2400. Medicare Stay

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Enter Code

A. 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

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B. Start date of most recent Medicare stay:
Month

Day

Year

Month

Day

Year

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

Look back period for all items is 7 days unless another time frame is indicated
Section B - Hearing, Speech, and Vision
B0100. Comatose
Persistent vegetative state/no discernible consciousness
Enter Code
0. No → Continue to B0200, Hearing
1. Yes → Skip to GG0100, Prior Functioning: Everyday Activities

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B0200. Hearing
Ability to hear (with hearing aid or hearing appliances if normally used)
Enter Code
0. Adequate - no difficulty in normal conversation, social interaction, listening to TV
1. Minimal difficulty - difficulty in some environments (e.g., when person speaks softly or setting is noisy)
2. Moderate difficulty - speaker has to increase volume and speak distinctly
3. Highly impaired - absence of useful hearing
B0300. Hearing Aid
Hearing aid or other hearing appliance used in completing B0200, Hearing
Enter Code
0. No
1. Yes

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B0600. Speech Clarity
Select best description of speech pattern
Enter Code
0. Clear speech - distinct intelligible words
1. Unclear speech - slurred or mumbled words
2. No speech - absence of spoken words

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section B - Hearing, Speech, and Vision
B0700. Makes Self Understood
Ability to express ideas and wants, consider both verbal and non-verbal expression
Enter Code
0. Understood
1. Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time
2. Sometimes understood - ability is limited to making concrete requests
3. Rarely/never understood
B0800. Ability To Understand Others
Understanding verbal content, however able (with hearing aid or device if used)
Enter Code
0. Understands - clear comprehension
1. Usually understands - misses some part/intent of message but comprehends most conversation
2. Sometimes understands - responds adequately to simple, direct communication only
3. Rarely/never understands
B1000. Vision
Ability to see in adequate light (with glasses or other visual appliances)
Enter Code
0. Adequate - sees fine detail, such as regular print in newspapers/books
1. Impaired - sees large print, but not regular print in newspapers/books
2. Moderately impaired - limited vision; not able to see newspaper headlines but can identify objects
3. Highly impaired - object identification in question, but eyes appear to follow objects
4. Severely impaired - no vision or sees only light, colors or shapes; eyes do not appear to follow objects
B1200. Corrective Lenses
Corrective lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision
Enter Code
0. No
1. Yes

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B1300. Health Literacy
Complete only if A0310B = 01 or A0310G = 1 and A0310H = 1
How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or
Enter Code
pharmacy?
0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
7. Resident declines to respond
8. Resident unable to respond

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The Single Item Literacy Screener is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section C - Cognitive Patterns
C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
Attempt to conduct interview with all residents

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Enter Code

0.
1.

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
Ask resident: “I am going to say three words for you to remember. Please repeat the words after I have said all three.
The words are: sock, blue, and bed. Now tell me the three words.”
Enter Code
Number of words repeated after first attempt
0. None
1. One
2. Two
3. Three
After the resident’s first attempt, repeat the words using cues (“sock, something to wear; blue, a color; bed, a piece of furniture”). You may repeat
the words up to two more times.
C0300. Temporal Orientation (orientation to year, month, and day)
Ask resident: “Please tell me what year it is right now.”
Enter Code
A. Able to report correct year
0. Missed by > 5 years or no answer
1. Missed by 2-5 years
2. Missed by 1 year
3. Correct

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Ask resident: “What month are we in right now?”
B. Able to report correct month
0. Missed by > 1 month or no answer
1. Missed by 6 days to 1 month
2. Accurate within 5 days
Ask resident: “What day of the week is today?”
Enter Code
C. Able to report correct day of the week
0. Incorrect or no answer
1. Correct
C0400. Recall
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.
Enter Code
A. Able to recall “sock”
0. No - could not recall
1. Yes, after cueing (“something to wear”)
2. Yes, no cue required
Enter Code
B. Able to recall “blue”
0. No - could not recall
1. Yes, after cueing (“a color”)
2. Yes, no cue required
Enter Code
C. Able to recall “bed”
0. No - could not recall
1. Yes, after cueing (“a piece of furniture”)
2. Yes, no cue required
Enter Code

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C0500. BIMS Summary Score

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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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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section C - Cognitive Patterns

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

0.
1.

No (resident was able to complete Brief Interview for Mental Status) → Skip to C1310, Signs and Symptoms of Delirium
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
Seems or appears to recall after 5 minutes
Enter Code
0. Memory OK
1. Memory problem

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C0800. Long-term Memory OK
Seems or appears to recall long past
Enter Code
0. Memory OK
1. Memory problem
C0900. Memory/Recall Ability
↓

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Check all that the resident was normally able to recall
A. Current season
B. Location of own room
C. Staff names and faces
D. That they are in a nursing home/hospital swing bed
Z.

None of the above were recalled

C1000. Cognitive Skills for Daily Decision Making
Made decisions regarding tasks of daily life
Enter Code
0. Independent - decisions consistent/reasonable
1. Modified independence - some difficulty in new situations only
2. Moderately impaired - decisions poor; cues/supervision required
3. Severely impaired - never/rarely made decisions
Delirium
C1310. Signs and Symptoms of Delirium (from CAM©)

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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?
0. No
1. Yes

Coding:
0. Behavior not present
1. Behavior continuously present, does not fluctuate
2. Behavior present, fluctuates (comes and goes, changes in severity)
Enter Codes
in Boxes
↓

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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

Adapted from: Inouye SK, et al. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method. Copyright 2003, Hospital Elder Life Program, LLC. Not to be reproduced
without permission.

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section D - Mood
D0100. Should Resident Mood Interview be Conducted? - Attempt to conduct interview with all residents

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Enter Code

0.
1.

No (resident is rarely/never understood) → Skip to and complete D0500-D0600, Staff Assessment of Resident Mood (PHQ-9-OV)
Yes → Continue to D0150, Resident Mood Interview (PHQ-2 to 9©)

D0150. Resident Mood Interview (PHQ-2 to 9©)
Say to resident: “Over the last 2 weeks, have you been bothered by any of the following problems?”
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the resident: “About how often have you been bothered by this?”
Read and show the resident a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
1. Symptom Presence
0. No (enter 0 in column 2)
1. Yes (enter 0-3 in column 2)
9. No response (leave column 2 blank)
1.
2.
2. Symptom Frequency
0. Never or 1 day
Symptom
Symptom
1. 2-6 days (several days)
Presence
Frequency
2. 7-11 days (half or more of the days)
↓ Enter Scores in Boxes↓
3. 12-14 days (nearly every day)
A. Little interest or pleasure in doing things
B. Feeling down, depressed, or hopeless

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If both D0150A1 and D0150B1 are coded 9, OR both D0150A2 and D0150B2 are coded 0 or 1, END the PHQ interview; otherwise, continue.
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

D0160. Total Severity Score

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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 required items).

Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section D - Mood
D0500. Staff Assessment of Resident Mood (PHQ-9-OV*)
Do not conduct if Resident Mood Interview (D0150-D0160) was completed
Over the last 2 weeks, did the resident have any of the following problems or behaviors?
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
Then move to column 2, Symptom Frequency, and indicate symptom frequency.
1. Symptom Presence
0. No (enter 0 in column 2)
1. Yes (enter 0-3 in column 2)
2. Symptom Frequency
0. Never or 1 day
1. 2-6 days (several days)
2. 7-11 days (half or more of the days)
3. 12-14 days (nearly every day)
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 they feel bad about self, are a failure, or have 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 they have 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

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Enter Score

1.

2.

Symptom

Symptom

Presence

Frequency

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□

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↓ Enter Scores in Boxes↓

Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 30.

D0700. Social Isolation
Enter Code

How often do you feel lonely or isolated from those around you?
0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
7. Resident declines to respond
8. Resident unable to respond

*Copyright © Pfizer Inc. All rights reserved.

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section E - Behavior
E0100. Potential Indicators of Psychosis
↓ Check all that apply

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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:
0. Behavior not exhibited
1. Behavior of this type occurred 1 to 3 days
2. Behavior of this type occurred 4 to 6 days, but less than daily
3. Behavior of this type occurred daily

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□

Enter Code

A. Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually)

Enter Code

B. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others)

Enter Code

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
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.
Enter Code
0. Behavior not exhibited
1. Behavior of this type occurred 1 to 3 days
2. Behavior of this type occurred 4 to 6 days, but less than daily
3. Behavior of this type occurred daily
E0900. Wandering - Presence & Frequency

□
□

Enter Code

Has the resident wandered?
0. Behavior not exhibited
1. Behavior of this type occurred 1 to 3 days
2. Behavior of this type occurred 4 to 6 days, but less than daily
3. Behavior of this type occurred daily

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section GG - Functional Abilities
GG0100. Prior Functioning: Everyday Activities. Indicate the resident’s usual ability with everyday activities prior to the current illness,
exacerbation, or injury
Complete only if A0310B = 01
Coding:
3. Independent - Resident completed all the activities by themself, with or
without an assistive device, with no assistance from a helper.
2. Needed Some Help - Resident needed partial assistance from another
person to complete any activities.
1. Dependent - A helper completed all the activities for the resident.

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8. Unknown.
9. Not Applicable.

Enter Codes in Boxes
↓
A. Self-Care: Code the resident’s need for assistance with bathing, dressing, using the toilet, or eating prior to the current illness, exacerbation,
or injury.
B. Indoor Mobility (Ambulation): Code the resident’s need for assistance with walking from room to room (with or without a device such as
cane, crutch, or walker) prior to the current illness, exacerbation, or injury.
C. Stairs: Code the resident’s need for assistance with internal or external stairs (with or without a device such as cane, crutch, or walker) prior
to the current illness, exacerbation, or injury.

D. Functional Cognition: Code the resident’s need for assistance with planning regular tasks, such as shopping or remembering to take
medication prior to the current illness, exacerbation, or injury.
GG0110. Prior Device Use. Indicate devices and aids used by the resident prior to the current illness, exacerbation, or injury
Complete only if A0310B = 01
Check all that apply
↓
A. Manual wheelchair

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B. Motorized wheelchair and/or scooter
C. Mechanical lift
D. Walker
E.

Orthotics/Prosthetics

Z. None of the above
GG0115. Functional Limitation in Range of Motion
Code for limitation that interfered with daily functions or placed resident at risk of injury in the last 7 days
Coding:
0. No impairment
1. Impairment on one side
2. Impairment on both sides

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□

Enter Codes in Boxes
↓
A. Upper extremity: (shoulder, elbow, wrist, hand)
B. Lower extremity: (hip, knee, ankle, foot)

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section GG - Functional Abilities - Admission
GG0130. Self-Care (Assessment period is the first 3 days of the stay)
Complete column 1 when A0310A = 01 or when A0310B = 01.
When A0310B = 01, the stay begins on A2400B. When A0310B = 99, the stay begins on A1600.
Code the resident’s usual performance at the start of the stay (admission) for each activity using the 6-point scale. If activity was not attempted at
the start of the stay (admission), 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 themself 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
1.

Admission
Performance

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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.

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section GG - Functional Abilities - Admission
GG0170. Mobility (Assessment period is the first 3 days of the stay)
Complete column 1 when A0310A = 01 or when A0310B = 01.
When A0310B = 01, the stay begins on A2400B. When A0310B = 99, the stay begins on A1600.
Code the resident’s usual performance at the start of the stay (admission) for each activity using the 6-point scale. If activity was not attempted at
the start of the stay (admission), 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 themself 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
1.

Admission
Performance

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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 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 admission 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.

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section GG - Functional Abilities - Admission
GG0170. Mobility (Assessment period is the first 3 days of the stay)
Complete column 1 when A0310A = 01 or when A0310B = 01.
When A0310B = 01, the stay begins on A2400B. When A0310B = 99, the stay begins on A1600.
Code the resident’s usual performance at the start of the stay (admission) for each activity using the 6-point scale. If activity was not attempted at
the start of the stay (admission), 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 themself 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
1.

Admission
Performance

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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 admission 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 admission 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.

□
Q1.

Does the resident use a wheelchair and/or scooter?
0. No → Skip to GG0130, Self Care (Discharge)
1. Yes → Continue to GG0170R, Wheel 50 feet with two turns

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

□□

S.

□

RR1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized
Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.

□

SS1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section GG - Functional Abilities - Discharge
GG0130. Self-Care (Assessment period is the last 3 days of the stay)
Complete column 3 when A0310F = 10 or 11 or when A0310H = 1.
When A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2105 is not = 04, the stay ends on A2400C.
For all other Discharge assessments, the stay ends on A2000.
Code the resident’s usual performance at the end of the stay for each activity using the 6-point scale. If an activity was not attempted at the end
of the 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 themself 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

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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.

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section GG - Functional Abilities - Discharge
GG0170. Mobility (Assessment period is the last 3 days of the stay)
Complete column 3 when A0310F = 10 or 11 or when A0310H = 1.
When A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2105 is not = 04, the stay ends on A2400C.
For all other Discharge assessments, the stay ends on A2000.
Code the resident’s usual performance at the end of the stay for each activity using the 6-point scale. If an activity was not attempted at the end
of the 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 themself 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

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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 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.

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section GG - Functional Abilities - Discharge
GG0170. Mobility (Assessment period is the last 3 days of the stay)
Complete column 3 when A0310F = 10 or 11 or when A0310H = 1.
When A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2105 is not = 04, the stay ends on A2400C.
For all other Discharge assessments, the stay ends on A2000.
Code the resident’s usual performance at the end of the stay for each activity using the 6-point scale. If an activity was not attempted at the end
of the 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 themself 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

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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?
0.
1.

No → Skip to H0100, Appliances
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.

S.

1.
2.

Manual
Motorized

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

□

SS3. Indicate the type of wheelchair or scooter used.
1.
2.

Manual
Motorized

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section H - Bladder and Bowel
H0100. Appliances
↓

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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

H0200. Urinary Toileting Program
Enter Code
A. Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry
or reentry or since urinary incontinence was noted in this facility?
0. No → Skip to H0300, Urinary Continence
1. Yes → Continue to H0200C, Current toileting program or trial
9. Unable to determine → Continue to H0200C, Current toileting program or trial

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C. Current toileting program or trial - Is a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) currently being
used to manage the resident’s urinary continence?
0. No
1. Yes
H0300. Urinary Continence
Enter Code
Urinary continence - Select the one category that best describes the resident
0. Always continent
1. Occasionally incontinent (less than 7 episodes of incontinence)
2. Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding)
3. 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
0. Always continent
1. Occasionally incontinent (one episode of bowel incontinence)
2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)
3. 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
H0500. Bowel Toileting Program
Enter Code
Is a toileting program currently being used to manage the resident’s bowel continence?
0. No
1. Yes
Enter Code

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MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section I - Active Diagnoses
I0020. Indicate the resident’s primary medical condition category
Complete only if A0310B = 01 or 08

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Enter Code

Indicate the resident’s primary medical condition category that best describes the primary reason for admission
01.
02.
03.
04.
05.
06.
07.
08.
09.
10.
11.
12.
13.

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

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

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
Cancer
I0100. Cancer (with or without metastasis)
Heart/Circulation
Heart/Circulation

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□
□
□
□
□

I0200.
I0400.
I0600.
I0700.
I0800.
I0900.

Anemia (e.g., aplastic, iron deficiency, pernicious, and sickle cell)
Coronary Artery Disease (CAD) (e.g., angina, myocardial infarction, and atherosclerotic heart disease (ASHD))
Heart Failure (e.g., congestive heart failure (CHF) and pulmonary edema)
Hypertension
Orthostatic Hypotension
Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)

Gastrointestinal
I1300. Ulcerative Colitis, Crohn’s Disease, or Inflammatory Bowel Disease
Genitourinary
Genitourinary

□
□
□
□

I1500. Renal Insufficiency, Renal Failure, or End-Stage Renal Disease (ESRD)
I1550. Neurogenic Bladder
I1650. Obstructive Uropathy

□
□
□
□
□
□
□

I1700. Multidrug-Resistant Organism (MDRO)
I2000. Pneumonia
I2100. Septicemia
I2200. Tuberculosis
I2300. Urinary Tract Infection (UTI) (LAST 30 DAYS)
I2400. Viral Hepatitis (e.g., Hepatitis A, B, C, D, and E)
I2500. Wound Infection (other than foot)

Infections
Infections

Metabolic
Metabolic

□
□
□
□

I2900. Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)
I3100. Hyponatremia
I3200. Hyperkalemia
I3300. Hyperlipidemia (e.g., hypercholesterolemia)
Musculoskeletal
Musculoskeletal

□
□

I3900. Hip Fracture - any hip fracture that has a relationship to current status, treatments, monitoring (e.g., sub-capital fractures, and fractures of
the trochanter and femoral neck)
I4000. Other Fracture
Neurological
Neurological

□
□
□
□
□
□
□
□
□
□
□
□

I4200. Alzheimer’s Disease
I4300. Aphasia
I4400. Cerebral Palsy
I4500. Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke
I4800. Non-Alzheimer’s Dementia (e.g. Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia such
as Pick’s disease; and dementia related to stroke, Parkinson’s or Creutzfeldt-Jakob diseases)
I4900. Hemiplegia or Hemiparesis
I5000. Paraplegia
I5100. Quadriplegia
I5200. Multiple Sclerosis (MS)
I5250. Huntington’s Disease
I5300. Parkinson’s Disease
I5350. Tourette’s Syndrome

Neurological continued on next page

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 23 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

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
Neurological - Continued
I5400. Seizure Disorder or Epilepsy
I5500. Traumatic Brain Injury (TBI)

□
□

Nutritional
Nutritional

□

I5600. Malnutrition (protein or calorie) or at risk for malnutrition
Psychiatric/Mood
Psychiatric/Mood Disorder
Disorder

□
□
□
□
□
□

I5700. Anxiety Disorder
I5800. Depression (other than bipolar)
I5900. Bipolar Disorder
I5950. Psychotic Disorder (other than schizophrenia)
I6000. Schizophrenia (e.g., schizoaffective and schizophreniform disorders)
I6100. Post Traumatic Stress Disorder (PTSD)
Pulmonary
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

Other
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.

_________________________________________________________________________________

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

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Page 24 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

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?
0. No
1. Yes
B. Received PRN pain medications OR was offered and declined?
0. No
1. Yes
C. Received non-medication intervention for pain?
0. No
1. Yes

J0200. Should Pain Assessment Interview be Conducted?
Attempt to conduct interview with all residents. If resident is comatose, skip to J1100, Shortness of Breath (dyspnea)

□

Enter Code

0.
1.

No (resident is rarely/never understood) → Skip to and complete J0800, Indicators of Pain or Possible Pain
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?”
0.
1.
9.

No → Skip to J1100, Shortness of Breath
Yes → Continue to J0410, Pain Frequency
Unable to answer → Skip to J0800, Indicators of Pain or Possible Pain

J0410. Pain Frequency

□

Enter Code

Ask resident: “How much of the time have you experienced pain or hurting over the last 5 days?”
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
9. Unable to answer

J0510. Pain Effect on Sleep

□

Ask resident: “Over the past 5 days, how much of the time has pain made it hard for you to sleep at night?”
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer
J0520. Pain Interference with Therapy Activities
Enter Code

□

Enter Code

Ask resident: “Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain?”
0. Does not apply - I have not received rehabilitation therapy in the past 5 days
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 25 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section J - Health Conditions
Pain Assessment Interview - Continued
J0530. Pain Interference with Day-to-Day Activities

□

Enter Code

Ask resident: “Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions)
because of pain?”
1.
2.
3.
4.
8.

Rarely or not at all
Occasionally
Frequently
Almost constantly
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.
2.
3.
4.
9.

Mild
Moderate
Severe
Very severe, horrible
Unable to answer

J0700. Should the Staff Assessment for Pain be Conducted?

□

Enter Code

0.
1.

No (J0410 = 1 thru 4) → Skip to J1100, Shortness of Breath (dyspnea)
Yes (J0410 = 9) → Continue to J0800, Indicators of Pain or Possible Pain

Staff Assessment for Pain
J0800. Indicators of Pain or Possible Pain in the last 5 days
↓

□
□
□
□
□

Check all that apply
A. Non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning)
B. Vocal complaints of pain (e.g., that hurts, ouch, stop)
C. Facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw)
D. Protective body movements or postures (e.g., bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part
during movement)
Z.

None of these signs observed or documented → If checked, skip to J1100, Shortness of Breath (dyspnea)

J0850. Frequency of Indicator of Pain or Possible Pain in the last 5 days

□

Enter Code

Frequency with which resident complains or shows evidence of pain or possible pain
1.
2.
3.

Indicators of pain or possible pain observed 1 to 2 days
Indicators of pain or possible pain observed 3 to 4 days
Indicators of pain or possible pain observed daily

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 26 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

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)
0.
1.

No
Yes

J1550. Problem Conditions
↓

□
□
□
□
□

Check all that apply
A. Fever
B. Vomiting
C. Dehydrated
D. Internal bleeding

Z. None of the above
J1700. Fall History on Admission/Entry or Reentry
Complete only if A0310A = 01 or A0310E = 1

□
□
□

Enter Code

Enter Code

Enter Code

A. Did the resident have a fall any time in the last month prior to admission/entry or reentry?
0.
1.
9.

No
Yes
Unable to determine

B. Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry?
0. No
1. Yes
9. Unable to determine
C. Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry?
0. No
1. Yes
9. Unable to determine

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?
0.
1.

No → Skip to J2000, Prior Surgery
Yes → Continue to J1900, Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS)

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 27 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section J - Health Conditions
J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent
Coding:
0. None
1. One
2. 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

J2000. Prior Surgery - Complete only if A0310B = 01
Enter Code

Did the resident have major surgery during the 100 days prior to admission?
0.
1.
8.

No
Yes
Unknown

J2100. Recent Surgery Requiring Active SNF Care - Complete only if A0310B = 01 or 08

□

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.
1.
8.

No
Yes
Unknown

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 28 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section J - Health Conditions
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
Surgery
Spinal

□
□
□
□
□
□
□
□

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
Other Orthopedic Surgery
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
Neurological Surgery
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
Surgery
Cardiopulmonary

□
□
□

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
Surgery.
J2800. Involving genital systems (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

□
□
□

Other
Other Major
Major Surgery
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

□
□
□
□
□
□

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 29 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

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
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 the most recent 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
0.
1.
2.

No or unknown
Yes, on physician-prescribed weight-loss regimen
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

0. No or unknown
1. Yes, on physician-prescribed weight-gain regimen
2. Yes, not on physician-prescribed weight-gain regimen
K0520. Nutritional Approaches
Check all of the following nutritional approaches that apply
1. On Admission
Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B
2. While Not a Resident
Performed while NOT a resident of this facility and within the last 7 days
Only check column 2 if resident entered (admission or reentry) IN THE LAST 7 DAYS. If resident last entered 7 or more days ago, leave column 2 blank.
3. While a Resident
Performed while a resident of this facility and within the last 7 days
4. At Discharge
Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C

A. Parenteral/IV feeding
B. Feeding tube (e.g., nasogastric or abdominal (PEG))
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

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

1.

2.

3.

4.

On
Admission

While Not a
Resident

While a
Resident

At
Discharge

□
□
□
□
□

↓ Check all that apply↓

□
□
□

□
□
□
□
□

□
□
□
□
□
Page 30 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section K - Swallowing/Nutritional Status

K0710. Percent Intake by Artificial Route - Complete K0710 only if Column 2 and/or Column 3 are checked for K0520A and/or K0520B
2. While a Resident
Performed while a resident of this facility and within the last 7 days
2.
3.
3. During Entire 7 Days
Performed during the entire last 7 days
While a
During Entire
Resident
A. Proportion of total calories the resident received through parenteral or tube feeding
1. 25% or less
2. 26-50%
3. 51% or more
B. Average fluid intake per day by IV or tube feeding
1. 500 cc/day or less
2. 501 cc/day or more

7 Days

↓ Enter Codes↓

□
□

□
□

Section L - Oral/Dental Status
L0200. Dental
↓

□
□

Check all that apply
A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose)
F.

Mouth or facial pain, discomfort or difficulty with chewing

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
B. Formal assessment instrument/tool (e.g., Braden, Norton, or other)
C. Clinical assessment

Z. None of the above
M0150. Risk of Pressure Ulcers/Injuries

□

Enter Code

Is this resident at risk of developing pressure ulcers/injuries?
0.
1.

No
Yes

M0210. Unhealed Pressure Ulcers/Injuries

□

Enter Code

Does this resident have one or more unhealed pressure ulcers/injuries?
0.
1.

No → Skip to M1030, Number of Venous and Arterial Ulcers
Yes → Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 31 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section M - Skin Conditions
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage

□
□
□
□
□
□
□
□
□
□
□
□
□

Enter Number

Enter Number

A. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a
visible blanching; in dark skin tones only it may appear with persistent blue or purple hues
1.

B. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present
as an intact or open/ruptured blister

Enter Number

Enter Number

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

2.

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.

Number of Stage 3 pressure ulcers - If 0 → Skip to M0300D, Stage 4

2.

Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the
time of admission/entry or reentry

D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound
bed. Often includes undermining and tunneling

Enter Number

Enter Number

1.

C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but
does not obscure the depth of tissue loss. May include undermining and tunneling

Enter Number

Enter Number

E.

1.

Number of Stage 4 pressure ulcers - If 0 → Skip to M0300E, Unstageable - Non-removable dressing/device

2.

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

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

Enter Number

Enter Number

Enter Number

Enter Number

Enter Number

Number of Stage 1 pressure injuries

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 - 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
G. Unstageable - Deep tissue injury:
1.

Number of unstageable pressure injuries presenting as deep tissue injury - If 0 → Skip to M1030, Number of Venous and Arterial
Ulcers

2.

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

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 32 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

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
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)

G. Skin tear(s)
H. Moisture Associated Skin Damage (MASD) (e.g., incontinence-associated dermatitis [IAD], perspiration, drainage)
None of the Above

□

Z.

↓

Check all that apply

None of the above were present

M1200. Skin and Ulcer/Injury Treatments

□
□
□
□
□
□
□
□
□
□

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

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 33 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section N - Medications
N0300. Injections

□
□
□

Enter Days

Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7
days. If 0 → Skip to N0415, High-Risk Drug Classes: Use and Indication

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

N0415. High-Risk Drug Classes: Use and Indication
1.
2.

Is taking
Check if the resident is taking any 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
Indication noted
If Column 1 is checked, check if there is an indication noted for all medications in the drug class
1.
2.
Is taking

Indication noted

↓ Check all that apply↓
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
Z.

Antipsychotic
Antianxiety
Antidepressant
Hypnotic
Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin)
Antibiotic
Diuretic
Opioid
Antiplatelet
Hypoglycemic (including insulin)
Anticonvulsants
None of the above

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

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□
□
□
□
□
□
□
□
□
□
□

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Page 34 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section N - Medications
N2001. Drug Regimen Review - Complete only if A0310B = 01
Did a complete drug regimen review identify potential clinically significant medication issues?
Enter Code

□

0.
1.
9.

No - No issues found during review
Yes - Issues found during review
NA - Resident is not taking any medications

N2003. Medication Follow-up - Complete only if N2001 = 1

□

Enter Code

Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/
recommended actions in response to the identified potential clinically significant medication issues?

0. No
1. Yes
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.
1.
9.

No
Yes
NA - There were no potential clinically significant medication issues identified since admission or resident is not taking any medications

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 35 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section O - Special Treatments, Procedures, and Programs
O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that were performed
a.
b.
c.

On Admission
Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B
While a Resident
Performed while a resident of this facility and within the last 14 days
At Discharge
Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C

a.
On Admission

A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Treatments
C1. Oxygen therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As needed
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulant
H10. Other
I1. Transfusions
O0110 continued on next page

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Check all that apply
↓

↓

Cancer Treatments

b.
While a Resident

c.
At Discharge

↓

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□

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Page 36 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section O - Special Treatments, Procedures, and Programs
O0110. Special Treatments, Procedures, and Programs - Continued
Check all of the following treatments, procedures, and programs that were performed
a.
b.
c.

On Admission
Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B
While a Resident
Performed while a resident of this facility and within the last 14 days
At Discharge
Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C

a.
On Admission

J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
K1. Hospice Care
M1. Isolation or quarantine for active infectious disease
(does not include standard body/fluid precautions)
O1. IV Access
O2. Peripheral
O3. Midline
O4. Central (e.g., PICC, tunneled, port)
None of the Above

↓

□
□
□
□
□
□
□
□

b.
While a Resident

Check all that apply
↓

□
□
□
□
□

Z1. None of the above
O0250. Influenza Vaccine - Refer to current version of RAI manual for current influenza vaccination season and reporting period

□

Enter Code

c.
At Discharge

↓

□
□
□
□
□
□
□
□

A. Did the resident receive the influenza vaccine in this facility for this year’s influenza vaccination season?
0. No → Skip to O0250C, If influenza vaccine not received, state reason
1. 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

□

Enter Code

O0300.

□
□

Enter Code

Enter Code

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
Pneumococcal Vaccine
A. Is the resident’s Pneumococcal vaccination up to date?
0 No → Continue to O0300B, If Pneumococcal vaccine not received, state reason
1. Yes → Skip to O0350, Resident's COVID-19 vaccination is up to date
B. If Pneumococcal vaccine not received, state reason:
1. Not eligible - medical contraindication
2. Offered and declined
3. Not offered

O0350. Resident’s COVID-19 vaccination is up to date

□

Enter Code

0.
1.

No, resident is not up to date
Yes, resident is up to date

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 37 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section O - Special Treatments, Procedures, and Programs
O0400. Therapies

□□□□
□□□□
□□□□
□□□□
□
Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Days

A. Speech-Language Pathology and Audiology Services
1.

Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the
last 7 days

2.

Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently
with one other resident in the last 7 days

3.

Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of
residents in the last 7 days
If the sum of individual, concurrent, and group minutes is zero, → skip to O0400A5, Therapy start date
3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment
sessions in the last 7 days
4.

Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days

□□-□□-□□□□
5.

Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started

Month

6.

□□□□
□□□□
□□□□
□□□□
□
Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Day

Year

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

□□-□□-□□□□

Month
Day
B. Occupational Therapy

Year

1.

Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the
last 7 days

2.

Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently
with one other resident in the last 7 days

3.

Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of
residents in the last 7 days
If the sum of individual, concurrent, and group minutes is zero, → skip to O0400B5, Therapy start date

Enter Number of Minutes

Enter Number of Days

3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment
sessions in the last 7 days
4.

Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days

□□-□□-□□□□
5.

Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started

Month

6.

Day

Year

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

□□-□□-□□□□
Month

Day

Year

O0400 continued on next page

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 38 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section O - Special Treatments, Procedures, and Programs
O0400. Therapies - Continued
C. Physical Therapy

□□□□
□□□□
□□□□
□□□□
□
Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

1.

Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the
last 7 days

2.

Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently
with one other resident in the last 7 days

3.

Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of
residents in the last 7 days
If the sum of individual, concurrent, and group minutes is zero, → skip to O0400C5, Therapy start date

Enter Number of Minutes

3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment
sessions in the last 7 days

Enter Number of Days

4.

Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days

□□-□□-□□□□
5.

Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started

Month

6.

Day

Year

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

□□-□□-□□□□
Month

□
□

Year

D. Respiratory Therapy

Enter Number of Days

Enter Number of Days

Day

2.
E.

Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days

Psychological Therapy (by any licensed mental health professional)
2.

Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days

O0420. Distinct Calendar Days of Therapy

□

Enter Number of Days

Record the number of calendar days that the resident received Speech-Language Pathology and Audiology Services,
Occupational Therapy, or Physical Therapy for at least 15 minutes in the past 7 days.

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 39 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section O - Special Treatments, Procedures, and Programs
O0425. Part A Therapies
Complete only if A0310H = 1

□□□□
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□□□□
□□□□
□□□
□□□□
□□□□
□□□□
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

A. Speech-Language Pathology and Audiology Services
1.

Individual minutes - record the total number of minutes this therapy was administered to the resident individually since
the start date of the resident’s most recent Medicare Part A stay (A2400B)

2.

Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently
with one other resident since the start date of the resident’s most recent Medicare Part A stay (A2400B)

3.

Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of
residents since the start date of the resident’s most recent Medicare Part A stay (A2400B)

If the sum of individual, concurrent, and group minutes is zero, → skip to O0425B, Occupational Therapy
4.

Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment
sessions since the start date of the resident’s most recent Medicare Part A stay (A2400B)

5.

Days - record the number of days this therapy was administered for at least 15 minutes a day since the start date of the
resident’s most recent Medicare Part A stay (A2400B)

B. Occupational Therapy
1.

Individual minutes - record the total number of minutes this therapy was administered to the resident individually since
the start date of the resident’s most recent Medicare Part A stay (A2400B)

2.

Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently
with one other resident since the start date of the resident’s most recent Medicare Part A stay (A2400B)

3.

Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of
residents since the start date of the resident’s most recent Medicare Part A stay (A2400B)

If the sum of individual, concurrent, and group minutes is zero, → skip to O0425C, Physical Therapy
4.

Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment
sessions since the start date of the resident’s most recent Medicare Part A stay (A2400B)

5.

Days - record the number of days this therapy was administered for at least 15 minutes a day since the start date of the
resident’s most recent Medicare Part A stay (A2400B)

C. Physical Therapy
1.

Individual minutes - record the total number of minutes this therapy was administered to the resident individually since
the start date of the resident’s most recent Medicare Part A stay (A2400B)

2.

Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently
with one other resident since the start date of the resident’s most recent Medicare Part A stay (A2400B)

3.

Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of
residents since the start date of the resident’s most recent Medicare Part A stay (A2400B)

If the sum of individual, concurrent, and group minutes is zero, → skip to O0430, Distinct Calendar Days of Part A Therapy
4.

Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment
sessions since the start date of the resident’s most recent Medicare Part A stay (A2400B)

5.

Days - record the number of days this therapy was administered for at least 15 minutes a day since the start date of the
resident’s most recent Medicare Part A stay (A2400B)

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 40 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section O - Special Treatments, Procedures, and Programs
O0430. Distinct Calendar Days of Part A Therapy
Complete only if A0310H = 1

□□□

Enter Number of Days

Record the number of calendar days that the resident received Speech-Language Pathology and Audiology Services, Occupational
Therapy, or Physical Therapy for at least 15 minutes since the start date of the resident’s most recent Medicare Part A stay
(A2400B)
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

□
□
□
□
□
□
□
□
□
□

Number
of Days

Technique
A. Range of motion (passive)
B. Range of motion (active)
C. Splint or brace assistance
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

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 41 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

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:
0. Not used
1. Used less than daily
2. 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
Q0110. Participation in Assessment and Goal Setting
Identify all active participants in the assessment process
↓

□
□
□
□
□
□

Check all that apply
A.

Resident

B.

Family

C. Significant other
D. Legal guardian
E.

Other legally authorized representative

Z.

None of the above

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 42 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section Q - Participation in Assessment and Goal Setting
Q0310. Resident’s Overall Goal
Complete only if A0310E = 1

□
□

Enter Code

Enter Code

A. Resident’s overall goal for discharge established during the assessment process
1. Discharge to the community
2. Remain in this facility
3. Discharge to another facility/institution
9. Unknown or uncertain
B. Indicate information source for Q0310A
1. Resident
2. Family
3. Significant other
4. Legal guardian
5. Other legally authorized representative
9. None of the above

Q0400. Discharge Plan

□

Enter Code

A. Is active discharge planning already occurring for the resident to return to the community?
0. No
1. Yes → Skip to Q0610, Referral

Q0490. Resident’s Documented Preference to Avoid Being Asked Question Q0500B
Complete only if A0310A = 02, 06, or 99

□
□

Does resident’s clinical record document a request that this question (Q0500B) be asked only on a comprehensive assessment?
0. No
1. Yes → Skip to Q0610, Referral
Q0500. Return to Community
Enter Code

Enter Code

□

Enter Code

B. Ask the resident (or family or significant other or guardian or legally authorized representative only if resident is unable to understand or
respond): “Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in
the community?”
0. No
1. Yes
9. Unknown or uncertain
C. Indicate information source for Q0500B
1. Resident
2. Family
3. Significant other
4. Legal guardian
5. Other legally authorized representative
9. None of the above

Q0550. Resident’s Preference to Avoid Being Asked Question Q0500B

□

Enter Code

□

Enter Code

A. Does resident (or family or significant other or guardian or legally authorized representative only if resident is unable to understand or
respond) want to be asked about returning to the community on all assessments? (Rather than on comprehensive assessments alone)
0.
1.
8.

No - then document in resident’s clinical record and ask again only on the next comprehensive assessment
Yes
Information not available

C. Indicate information source for Q0550A
1. Resident
2. Family
3. Significant other
4. Legal guardian
5. Other legally authorized representative
9. None of the above

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 43 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section Q - Participation in Assessment and Goal Setting
Q0610. Referral

□

A. Has a referral been made to the Local Contact Agency (LCA)?
0. No
1. Yes
Q0620. Reason Referral to Local Contact Agency (LCA) Not Made
Complete only if Q0610 = 0
Enter Code

□

Enter Code

Indicate reason why referral to LCA was not made
1. LCA unknown
2. Referral previously made
3. Referral not wanted
4. Discharge date 3 or fewer months away
5. Discharge date more than 3 months away

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 44 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

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)

□

1.
2.

Enter Code

Male
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)

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

□□
Enter Code

□□
Enter Code

□□
Enter Code

□

Enter Code

A. Federal OBRA Reason for Assessment
01. Admission assessment (required by day 14)
02. Quarterly review assessment
03. Annual assessment
04. Significant change in status assessment
05. Significant correction to prior comprehensive assessment
06. Significant correction to prior quarterly assessment
99. None of the above
B. PPS Assessment
PPS Scheduled Assessment for a Medicare Part A Stay
01. 5-day scheduled assessment
PPS Unscheduled Assessment for a Medicare Part A Stay
08. IPA - Interim Payment Assessment
Not PPS Assessment
99. None of the above
F.

Entry/discharge reporting
01. Entry tracking record
10. Discharge assessment-return not anticipated
11. Discharge assessment-return anticipated
12. Death in facility tracking record
99. None of the above

H. Is this a SNF Part A PPS Discharge Assessment?
0. No
1. Yes

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 45 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section X - Correction Request
X0700. Date on existing record to be modified/inactivated - Complete one only

□□-□□-□□□□
□□-□□-□□□□
□□-□□-□□□□

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

B.

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

C.

Month
Day
Year
Entry Date (A1600 on existing record to be modified/inactivated) - Complete only if X0600F = 01
Month

Day

Year

Correction Attestation Section - Complete this section to explain and attest to the modification/inactivation request
X0800. Correction Number

□□
Enter Number

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

X0900. Reasons for Modification - Complete only if Type of Record is to modify a record in error (A0050 = 2)
↓

□
□
□
□
□

Check all that apply
A. Transcription error
B. Data entry error
C. Software product error
D. Item coding error
Z.

Other error requiring modification
If “Other” checked, please specify:

X1050. Reasons for Inactivation - Complete only if Type of Record is to inactivate a record in error (A0050 = 3)
↓

□
□

Check all that apply
A. Event did not occur
Z.

Other error requiring inactivation
If “Other” checked, please specify:

X1100. RN Assessment Coordinator Attestation of Completion

□□□□□□□□□□□□
□□□□□□□□□□□□□□□□□□

A. Attesting individual’s first name:

B. Attesting individual’s last name:

C. Attesting individual’s title:
D. Signature
E.

□□-□□-□□□□

Attestation date
Month

Day

Year

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 46 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section Z - Assessment Administration
Z0100. Medicare Part A Billing

□□□□□□□
□□□□□□□□□□

A. Medicare Part A HIPPS code:

B. Version code:

Z0200. State Medicaid Billing (if required by the state)

□□□□□□□□□□
□□□□□□□□□□

A. Case Mix group:

B. Version code:

Z0250. Alternate State Medicaid Billing (if required by the state)

□□□□□□□□□□
□□□□□□□□□□

A. Case Mix group:
B. Version code:

Z0300. Insurance Billing

□□□□□□□□□□
□□□□□□□□□□

A. Billing code:

B. Billing version:

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

Page 47 of 48

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section Z - Assessment Administration
Z0400. Signature of Persons Completing the Assessment or Entry/Death Reporting
I certify that the accompanying information accurately reflects resident assessment information for this resident and that I collected or coordinated collection
of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable Medicare and Medicaid
requirements. I understand that this information is used as a basis for ensuring that residents receive appropriate and quality care, and as a basis for payment
from federal funds. I further understand that payment of such federal funds and continued participation in the government-funded health care programs is
conditioned on the accuracy and truthfulness of this information, and that I may be personally subject to or may subject my organization to substantial criminal,
civil, and/or administrative penalties for submitting false information. I also certify that I am authorized to submit this information by this facility on its behalf.
Signature

Title

Sections

Date Section
Completed

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Z0500. Signature of RN Assessment Coordinator Verifying Assessment Completion
A. Signature:
B. Date RN Assessment Coordinator signed
assessment as complete:

□□-□□-□□□□
Month

Day

Year

Legal Notice Regarding MDS 3.0 - Copyright 2011 United States of America and interRAI. This work may be freely used and distributed solely within the United States.
Portions of the MDS 3.0 are under separate copyright protections; Pfizer Inc. holds the copyright for the PHQ-9; Confusion Assessment Method. © 1988, 2003, Hospital
Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Both Pfizer Inc. and the Hospital Elder Life Program, LLC have
granted permission to use these instruments in association with the MDS 3.0.

MDS 3.0 Nursing Home PPS (NP) Version 1.19.1 Effective 10/01/2024

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