CMS-10036 IRF- PAI version 4.3

IRF-PAI for the collection of data pertaining to the Inpatient Rehabilitation Facility Prospective Payment System and Quality Reporting Program (CMS-10036)

IRF-PAI-Version-4.3-Effective-10-01-26-v6

OMB: 0938-0842

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0842 can be found here:

2024-08-16 - Revision of a currently approved collection

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTER FOR MEDICARE & MEDICAID SERVICES

OMB No. 0938-0842

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-0842, Expiration date: XX-XX-XXXX. The time required to complete this
information collection is estimated to average 1 hour and 47 minutes per assessment, including the time to
review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ***CMS Disclaimer***Please
do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining
to the information collection burden approved under the associated OMB control number listed on
this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding
where to submit your documents, please contact Ariel Cress at [email protected].

DEPARTMENT OF HEALTH AND HUMAN SERVICES

OMB No. 0938-0842

CENTERS FOR MEDICARE & MEDICAID SERVICES

INPATIENT REHABILITATION FACILITY - PATIENT ASSESSMENT INSTRUMENT
Identification Information
1.

Medical Information

Facility Information

21. Impairment Group*

_
Admission

A. Facility Name

Discharge

Condition requiring admission to rehabilitation; code according to Appendix A.
22.

Etiologic Diagnosis
A.
(Use ICD codes to indicate the etiologic problem
B.
that led to the condition for which the patient is
C.
receiving rehabilitation)
Date of Onset of Impairment
/_ /
MM / DD / YYYY

B. Facility Medicare Provider Number

23.

Patient Medicare Number

Patient Medicaid Number

24.

Patient First Name

5A. Patient Last Name

Use ICD codes to enter comorbid medical conditions

5B. Patient Identification Number
6.

Birth Date

Comorbid Conditions

/
/
MM / DD / YYYY

Social Security Number

Gender (1 - Male; 2 - Female)

10.

Marital Status
(1 - Never Married; 2 - Married; 3 - Widowed;
4 - Separated; 5 - Divorced)

11.

Zip Code of Patient's Pre-Hospital Residence

12.

Admission Date

/
/
MM / DD / YYYY

13.

Assessment Reference Date

/
/
MM / DD / YYYY

14.

Removed

15A. Admit From
(01- Home (private home/apt., board/care, assisted living, group home,
transitional living, other residential care arrangements); 02- Short-term
General Hospital; 03 - Skilled Nursing Facility (SNF); 04 - Intermediate
care; 06 - Home under care of organized home health service
organization; 50 - Hospice (home); 51 - Hospice (medical facility); 61 Swing bed; 62 - Another Inpatient Rehabilitation Facility;
63 - Long-Term Care Hospital (LTCH); 64 - Medicaid Nursing Facility;
65 - Inpatient Psychiatric Facility; 66 - Critical Access Hospital (CAH);
99 - Not Listed)

24A. Are there any arthritis conditions recorded in items #21, #22, or #24 that meet
all of the regulatory requirements for IRF classification (in 42 CFR
412.29(b)(2)(x), (xi), and (xii))?
(0 - No; 1 - Yes)
Height and Weight
(While measuring if the number is X.1-X.4 round down, X.5 or greater
round up)
25A. Height on admission (in inches)
26A. Weight on admission (in pounds)
Measure weight consistently, according to standard facility practice
(e.g., in a.m. after voiding, with shoes off, etc.)

16A. Pre-hospital Living Setting
Use codes from 15A. Admit From
17. Pre-hospital Living With
(Code only if item 16A is 01- Home: Code using 01 - Alone;
02 - Family/Relatives; 03 - Friends; 04 - Attendant; 05 - Other)

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Therapy Information

Discharge Information
40.
41.
42.
43.

Discharge Date

/
/
MM / DD / YYYY

Patient discharged against medical advice?

(0 - No; 1 - Yes)

c. Total minutes of group therapy
d. Total minutes of co-treatment therapy

B. 1st Return Date
MM / DD / YYYY
D. 2nd Return Date

MM / DD / YYYY
E.

3 Interruption Date
rd

MM / DD / YYYY

a. Total minutes of individual therapy
c. Total minutes of group therapy

_
_

d. Total minutes of co-treatment therapy

b. Total minutes of concurrent therapy

O0401C: Speech-Language Pathology
a. Total minutes of individual therapy
b. Total minutes of concurrent therapy

3 Return Date

c. Total minutes of group therapy

d. Total minutes of co-treatment therapy

MM / DD / YYYY

(0 - No; 1 - Yes)
44D. Patient’s discharge destination/living setting, using codes below: (answer
only if 44C = 1; if 44C = 0, skip to item 46)
(01- Home (private home/apt., board/care, assisted living, group home,
transitional living, other residential care arrangements); 02- Short-term
General Hospital; 03 - Skilled Nursing Facility (SNF); 04 - Intermediate
care; 06 - Home under care of organized home health service
organization; 50 - Hospice (home); 51 - Hospice (medical facility); 61 Swing bed; 62 - Another Inpatient Rehabilitation Facility; 63 - LongTerm Care Hospital (LTCH); 64 - Medicaid Nursing Facility; 65 Inpatient Psychiatric Facility; 66 - Critical Access Hospital (CAH); 99 Not Listed)

46.

MM / DD / YYYY

44C. Was the patient discharged alive?

45.

_
_

O0401B: Occupational Therapy

MM / DD / YYYY
2nd Interruption Date

O0401A: Physical Therapy
a. Total minutes of individual therapy
b. Total minutes of concurrent therapy

Program Interruption Dates
(Code only if item 42 is 1 - Yes)

O0401. Week 1: Total Number of Minutes Provided

(0 - No; 1 - Yes)
Program Interruption(s)

A. 1st Interruption Date

OMB No. 0938-0842

O0402. Week 2: Total Number of Minutes Provided
O0402A: Physical Therapy
a. Total minutes of individual therapy
b. Total minutes of concurrent therapy

c. Total minutes of group therapy

d. Total minutes of co-treatment therapy
O0402B: Occupational Therapy
a. Total minutes of individual therapy
c. Total minutes of group therapy

_
_

d. Total minutes of co-treatment therapy

b. Total minutes of concurrent therapy

Discharge to Living With

O0402C: Speech-Language Pathology

(Code only if item 44C is 1 - Yes and 44D is 01 - Home; Code using 1 Alone; 2 - Family / Relatives; 3 - Friends; 4 - Attendant;
5 - Other)

a. Total minutes of individual therapy
b. Total minutes of concurrent therapy

Diagnosis for Interruption or Death

d. Total minutes of co-treatment therapy

c. Total minutes of group therapy

_
_

(Code using ICD code)
47.

Complications during rehabilitation stay
(Use ICD codes to specify up to six conditions that
began with this rehabilitation stay)
A.

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OMB No. 0938-0842
Patient

Identifier

Date

INPATIENT REHABILITATION FACILITY - PATIENT ASSESSMENT INSTRUMENT
QUALITY INDICATORS
ADMISSION
Section A Administrative Information

A1005. Ethnicity
Are you of Hispanic, Latino/a, or Spanish origin?
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, or Spanish origin
X. Patient unable to respond
Y. Patient declines to respond

A1010. Race
What is your race?
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. Patient unable to respond
Y. Patient declines to respond
Z. None of the above

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OMB No. 0938-0842
Patient

Identifier

Date

A1110. Language
A. What is your preferred language?

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

A1400. Payer Information
Check all that apply
A. Medicare (traditional fee-for-service)
B. Medicare (managed care/Part C/Medicare Advantage)
C. Medicaid (traditional fee-for-services)
D. Medicaid (managed care)
E. Workers’ compensation
F. Title programs (e.g., Title III, V, or XX)
G. Other government (e.g., TRICARE, VA, etc.)
H. Private insurance/Medigap
I. Private managed care
J. Self-pay
K. No Payer source
X. Unknown
Y. Other

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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section B Hearing, Vision and Speech

B0200. Hearing
Enter Code

Ability to hear (with hearing aid or hearing appliances if normally used)
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

B1000. Vision
Enter Code

Ability to see in adequate light (with glasses or other visual appliances)
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

B1300. Health Literacy (from Creative Commons©)
How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor
or pharmacy?
Enter Code

0.
1.
2.
3.
4.
7.
8.

Never
Rarely
Sometimes
Often
Always
Patient declines to respond
Patient unable to respond

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

BB0700. Expression of Ideas and Wants (3-day assessment period)
Enter Code

Expression of ideas and wants (consider both verbal and non-verbal expression and excluding language barriers)
4. Expresses complex messages without difficulty and with speech that is clear and easy to understand
3. Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear
2. Frequently exhibits difficulty with expressing needs and ideas
1. Rarely/Never expresses self or speech is very difficult to understand

BB0800. Understanding Verbal and Non-Verbal Content (3-day assessment period)
Enter Code

Understanding verbal and non-verbal content (with hearing aid or device, if used, and excluding language barriers)
4. Understands: Clear comprehension without cues or repetitions
3. Usually understands: Understands most conversations, but misses some part/intent of message. Requires cues at times to
understand
2. Sometimes understands: Understands only basic conversations or simple, direct phrases. Frequently requires cues to understand
1. Rarely/never understands

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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section C Cognitive Patterns

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted? (3-day assessment period)
Attempt to conduct interview with all patients.
Enter Code

0. No (patient is rarely/never understood)
Skip to C0900, Memory/Recall Ability
1. Yes
Continue to C0200, Repetition of Three Words

Brief Interview for Mental Status (BIMS)
C0200. Repetition of Three Words
Ask patient: “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
3. Three
2. Two
1. One
0. None
After the patient's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece of furniture"). You may
repeat the words up to two more times.

C0300. Temporal Orientation (orientation to year, month, and day)

Enter Code

Ask patient: “Please tell me what year it is right now.”
A. Able to report correct year
3. Correct
2. Missed by 1 year
1. Missed by 2 - 5 years
0. Missed by > 5 years or no answer
Ask patient: “What month are we in right now?”
B. Able to report correct month
2. Accurate within 5 days
1. Missed by 6 days to 1 month
0. Missed by > 1 month or no answer
Ask patient: “What day of the week is today?”
C. Able to report correct day of the week
1. Correct
0. Incorrect or no answer

C0400. Recall

Enter Code

Ask patient: “Let's go back to an earlier question. What were those three words that I asked you to repeat?” If unable to remember a word, give
cue (something to wear; a color; a piece of furniture) for that word.
A. Able to recall “sock”
2. Yes, no cue required
1. Yes, after cueing ("something to wear")
0. No - could not recall
B. Able to recall “blue”
2. Yes, no cue required
1. Yes, after cueing ("a color")
0. No - could not recall
C. Able to recall “bed”
2. Yes, no cue required
1. Yes, after cueing ("a piece of furniture")
0. No - could not recall

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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION

Brief Interview for Mental Status (BIMS) – Continued
C0500. BIMS Summary Score
Enter Score

Add scores for questions C0200-C0400 and fill in total score (00-15)
Enter 99 if the patient was unable to complete the interview

C0600. Should the Staff Assessment for Mental Status (C0900) be Conducted?
Enter Code

0. No (patient was able to complete Brief Interview for Mental Status)
Skip to C1310, Signs and Symptoms of Delirium
1. Yes (patient was unable to complete Brief Interview for Mental Status)
Continue to C0900, Memory/Recall Ability

Staff Assessment for Mental Status
Do not conduct if Brief Interview for Mental Status (C0200-C0500) was completed.

C0900. Memory/Recall Ability (3-day assessment period)
Check all that the patient was normally able to recall
A. Current season
B. Location of own room
C. Staff names and faces
E. That they are in a hospital/hospital unit
Z. None of the above were recalled

C1310. Signs and Symptoms of Delirium (from CAM©)
Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical record.

A. Acute Onset Mental Status Change
Enter Code

Is there evidence of an acute change in mental status from the patient'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 Code in Boxes
B. Inattention - Did the patient have difficulty focusing attention, for example being easily distractible
or having difficulty keeping track of what was being said?
C. Disorganized thinking - Was the patient'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 patient 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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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section D Mood

D0150. Patient Mood Interview (PHQ-2 to 9) (from Pfizer Inc.©)
Determine if the patient is rarely/never understood verbally, in writing, or using another method. If rarely/never understood, code D0150A1 and
D0150B1 as 9, No response, leave D0150A2 and D0150B2 blank, end the PHQ-2 interview, and leave D0160, Total Severity Score blank. Otherwise,
say to patient: "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 patient: "About how often have you been bothered by this?"
Read and show the patient a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
1. Symptom Presence
0. No (enter 0 in column 2)
1. Yes (enter 0-3 in column 2)
9. No response (leave column 2 blank)

2. Symptom Frequency
0.
1.
2.
3.

Never or 1 day
2-6 days (several days)
7-11 days (half or more of the days)
12-14 days (nearly every day)

1.
Symptom
Presence

2.
Symptom
Frequency

Enter Scores in Boxes

A. Little interest or pleasure in doing things
B. Feeling down, depressed, or hopeless
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
Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.

D0160. Total Severity Score
Enter Score

Add scores for all frequency responses in column 2, Symptom Frequency. Total score must be between 00 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more required items)

D0700. Social Isolation
How often do you feel lonely or isolated from those around you?
Enter Code

0.
1.
2.
3.
4.
7.
8.

Never
Rarely
Sometimes
Often
Always
Patient declines to respond
Patient unable to respond

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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section GG

Functional Abilities

Section GG Functional Abilities and Goals

GG0100. Prior Functioning: Everyday Activities. Indicate the patient's usual ability with everyday activities prior to the current
illness, exacerbation, or injury.
Coding:
3. Independent - Patient completed all the
activities by themself, with or without an
assistive device, with no assistance from a
helper.
2. Needed Some Help - Patient needed partial
assistance from another person to complete any
activities.
1. Dependent - A helper completed all the
activities for the patient.
8. Unknown
9. Not Applicable

Enter Codes in Boxes
A. Self-Care: Code the patient's need for assistance with bathing, dressing, using
the toilet, and eating prior to the current illness, exacerbation, or injury.
B. Indoor Mobility (Ambulation): Code the patient'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 patient'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 patient'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 patient prior to the current illness, exacerbation, or injury.
Check all that apply.
A. Manual wheelchair
B. Motorized wheelchair and/or scooter
C. Mechanical lift
D. Walker
E. Orthotics/Prosthetics
Z. None of the above

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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section GG

Functional Abilities

GG0130. Self-Care (3-day assessment period)
Code the patient's usual performance at admission for each activity using the 6-point scale. If activity was not attempted at admission, code
the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because patient'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 - Patient completes the activity by themself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or followin g the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient
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. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient 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

Admission
Performance.
Enter Codes in Boxes

A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the
meal is placed before the patient.
B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures
into and from the mouth, and manage denture soaking and rinsing with use of equipment.
C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel
movement. If managing an ostomy, include wiping the opening but not managing equipment.
E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair).
Does not include transferring in/out of tub/shower.
F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.

G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear.
H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe
mobility; including fasteners, if applicable.

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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section GG

Functional Abilities

GG0170. Mobility (3-day assessment period)
Code the patient's usual performance at admission for each activity using the 6-point scale. If activity was not attempted at admission, code
the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because patient'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 - Patient completes the activity by themself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient 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 patient
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. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient 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

Admission
Performance.
Enter Codes in Boxes

A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with 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.

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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section GG

Functional Abilities

GG0170. Mobility (3-day assessment period) - Continued
Code the patient's usual performance at admission for each activity using the 6-point scale. If activity was not attempted at admission, code
the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because patient'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 - Patient completes the activity by themself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient 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 patient
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. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient 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
Admission
Performance
Enter Codes in Boxes

L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf
or gravel.
M. 1 step (curb): The ability to go up and down a curb or up and down one step.
Skip to GG0170P, Picking up object
If admission performance is coded 07, 09, 10, or 88
N. 4 steps: The ability to go up and down four steps with or without a rail.
Skip to GG0170P, Picking up object
If admission performance is coded 07, 09, 10, or 88
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 patient use a wheelchair and/or scooter?
0. No
Skip to H0350, Bladder Continence
1. 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.
RR1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized
S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.
SS1. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

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Patient

Identifier

Date

ADMISSION
Section H

Bladder and Bowel

Section H Bladder and Bowel

H0350. Bladder Continence (3-day assessment period)
Enter Code

Bladder continence - Select the one category that best describes the patient.
0. Always continent (no documented incontinence)
1. Stress incontinence only
2. Incontinent less than daily (e.g., once or twice during the 3-day assessment period)
3. Incontinent daily (at least once a day)
4. Always incontinent
5. No urine output (e.g., renal failure)
9. Not applicable (e.g., indwelling catheter)

H0400. Bowel Continence (3-day assessment period)
Enter Code

Bowel continence - Select the one category that best describes the patient.
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, patient had an ostomy or did not have a bowel movement for the entire 3 days.

Section I Active Diagnoses

Comorbidities and Co-existing Conditions
Check all that apply
I0900. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
I2900. Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)
I7900. None of the above

Section J Health Conditions

J0510. Pain Effect on Sleep
Enter Code

Ask patient: “Over the past 5 days, how much of the time has pain made it hard for you to sleep at night?”
0. Does not apply – I have not had any pain or hurting in the past 5 days
Skip to J1750, History of Falls
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

Ask patient: “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

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J0530. Pain Interference with Day-to-Day Activities
Enter Code

Ask patient: “Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions)
because of pain?”
1. Rarely or not at all
2. Occasionally
3. Frequently
4. Almost constantly
8. Unable to answer

J1750. History of Falls
Enter Code

Has the patient had two or more falls in the past year or any fall with injury in the past year?
0. No
1. Yes
8. Unknown

J2000. Prior Surgery
Enter Code

Did the patient have major surgery during the 100 days prior to admission?
0. No
1. Yes
8. Unknown

Section K Swallowing/Nutritional Status

K0520. Nutritional Approaches
Check all of the following nutritional approaches that apply on admission.
1.
On Admission
Check all that apply
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

Section M

Skin Conditions

Report
based
highest
stage
existingulcers/injuries
ulcers/injuriesat
attheir
their worst;
worst; do not
Report
based
onon
highest
stage
ofof
existing
not "reverse"
"reverse"stage
stage
M0210. Unhealed Pressure Ulcers/Injuries
Enter Code

Does this patient have one or more unhealed pressure ulcers/injuries?
0. No
Skip to N0415, High-Risk Drug Classes: Use and Indication
1. Yes
Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.

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Date

ADMISSION
Section M

Skin Conditions

M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
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. Number of Stage 1 pressure injuries

Enter Number

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

Enter Number

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

Enter Number

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

Enter Number

E. 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

Enter Number

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

Enter Number

G. Unstageable - Deep tissue injury
1. Number of unstageable pressure injuries presenting as deep tissue injury

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OMB No. 0938-0842
Patient

Identifier

Date

ADMISSION
Section N

Medications

Section N Medications

N0415. High-Risk Drug Classes: Use and Indication
1. Is taking
Check if the patient is taking any medications by pharmacological classification, not how it is used,
in the following classes
2. Indication noted
If column 1 is checked, check if there is an indication noted for all medications in the drug class

1.
Is taking

2.
Indication noted

Check all that apply

A. Antipsychotic
E. Anticoagulant
F. Antibiotic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)
Z. None of the above

N2001. Drug Regimen Review
Enter Code

Did a complete drug regimen review identify potential clinically significant medication issues?
0. No - No issues found during review
Skip to O0110, Special Treatments, Procedures, and Programs
1. Yes - Issues found during review
Continue to N2003, Medication Follow-up
9. Not applicable - Patient is not taking any medications
Skip to O0110, Special Treatments, Procedures, and Programs

N2003. Medication Follow-up
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

Section O Special Treatments, Procedures and Programs

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply on admission.
a.
On Admission
Check all that apply
Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
C1. Oxygen Therapy
C2. Continuous
C3. Intermittent
C4. High-concentration

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OMB No. 0938-0842
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Date

ADMISSION
O0110. Special Treatments, Procedures, and Programs - Continued
Check all of the following treatments, procedures, and programs that apply on admission.
a.
On Admission
Check all that apply

Respiratory Therapies (continued)
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. Anticoagulation
H10. Other
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Midline
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the above

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OMB No. 0938-0842
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Identifier

Date

ADMISSION
Section R

Health-Related Social Needs

R0310. Living Situation
Enter Code

What is your living situation today?
0. I have a steady place to live
1. I have a place to live today, but I am worried about losing it in the future
2. I do not have a steady place to live
7. Patient declines to respond
8. Patient unable to respond

Questions on transportation and housing have been derived from the national PRAPARE® social drivers of health assessment tool (2016), which was
developed and is owned by the National Association of Community Health Centers (NACHC). This tool was developed in collaboration with the Association
of Asian Pacific Community Health Organization (AAPCHO) and the Oregon Primary Care Association (OPCA). For additional information, please visit
www.prapare.org.

R0320. Food
A. Within the past 12 months, you worried that your food would run out before you got money to buy more.
0. Often true
1. Sometimes true
2. Never true
7. Patient declines to respond
8. Patient unable to respond
Enter Code B. Within the past 12 months, you worried that your food would run out before you got money to buy more.
0. Often true
1. Sometimes true
2. Never true
7. Patient declines to respond
8. Patient unable to respond
Hager, E. R., Quigg, A. M., Black, M. M., et al. (2010). Development and Validity of a 2-Item Screen to Identify Families at Risk for Food Insecurity.
Pediatrics, 126(1), 26-32. doi:10.1542/peds.2009-3146.

Enter Code

R0330. Utilities
Enter Code

In the past 12 months, has the electric, gas, oil, or water company threatened to shut off services in your home ?
0. Yes
1. No
2. Already shut off
7. Patient declines to respond
8. Patient unable to respond

Cook, J. T., Frank, D. A., Casey, P. H., et al. (2008). A Brief Indicator of Household Energy Security: Associations with Food Security, Child Health, and Child
Development in US Infants and Toddlers. Pediatrics, 122(4), 867-875. doi:10.1542/peds.2008-0286.
R0340. Transportation
Enter Code

In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting
things needed for daily living?
0. Yes
1. No
7. Patient declines to respond
8. Patient unable to respond

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OMB No. 0938-0842
Patient

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Identifier

DISCHARGE
Section A Administrative Information

A2121. Provision of Current Reconciled Medication List to Subsequent Provider at Discharge
Complete only if 44D = 02, 03, 04, 06, 50, 51, 61, 62, 63, 64, 65, or 66
Enter Code

At the time of discharge to another provider, did your facility provide the patient’s current reconciled medication list to the subsequent
provider?
0. No – Current reconciled medication list not provided to the subsequent provider
Medication List to Patient at Discharge

Skip to A2123, Provision of Current Reconciled

1. 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
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 Patient at Discharge
Complete only if 44D = 01 or 99
Enter Code

At the time of discharge, did your facility provide the patient’s current reconciled medication list to the patient, family and/or caregiver?
0. No – Current reconciled medication list not provided to the patient, family and/or caregiver

Skip to B1300, Health Literacy

1. Yes – Current reconciled medication list provided to the patient, family and/or caregiver

A2124. Route of Current Reconciled Medication List Transmission to Patient
Indicate the route(s) of transmission of the current reconciled medication list to the patient/family/caregiver.
Complete only if A2123 = 1
Route of Transmission

Check all that apply

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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Date

DISCHARGE
Section B Health Literacy

0.
1.
2.
3.
4.
7.
8.

Never
Rarely
Sometimes
Often
Always
Patient declines to respond
Patient unable to respond

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

Section C Cognitive Patterns

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted? (3-day assessment period)
Attempt to conduct interview with all patients.
Enter Code

0. No (patient is rarely/never understood)
Skip to C1310, Signs and Symptoms of Delirium
1. Yes
Continue to C0200, Repetition of Three Words

C0300. Temporal Orientation (orientation to year, month, and day)

Enter Code

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Date

DISCHARGE
Section C Cognitive Patterns

C0400. Recall

Enter Code

C0500. BIMS Summary Score
Enter Score

Add scores for questions C0200-C0400 and fill in total score (00-15)
Enter 99 if the patient was unable to complete the interview

C1310. Signs and Symptoms of Delirium (from CAM©)
Code after completing Brief Interview for Mental Status and reviewing medical record.

A. Acute Onset Mental Status Change
Enter Code

Is there evidence of an acute change in mental status from the patient's baseline?
0. No
1. Yes
Enter Code in Boxes

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

B. Inattention - Did the patient have difficulty focusing attention, for example being easily distractible
or having difficulty keeping track of what was being said?
C. Disorganized thinking - Was the patient'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 patient 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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DISCHARGE
Section D Mood

D0150. Patient Mood Interview (PHQ-2 to 9) (from Pfizer Inc.©)
Determine if the patient is rarely/never understood verbally, in writing, or using another method. If rarely/never understoo d, code D0150A1 and
D0150B1 as 9, No response, leave D0150A2 and D0150B2 blank, end the PHQ-2 interview, and leave D0160, Total Severity Score blank. Otherwise,
say to patient: "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 patient: "About how often have you been bothered by this?"
Read and show the patient a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
1. Symptom Presence
0. No (enter 0 in column 2)
1. Yes (enter 0-3 in column 2)
9. No response (leave column 2 blank)

2. Symptom Frequency
0.
1.
2.
3.

Never or 1 day
2-6 days (several days)
7-11 days (half or more of the days)
12-14 days (nearly every day)

1.
Symptom
Presence

2.
Symptom
Frequency

Enter Scores in Boxes

D0160. Total Severity Score
Enter Score

D0700. Social Isolation
How often do you feel lonely or isolated from those around you?
Enter Code

0.
1.
2.
3.
4.
7.
8.

Never
Rarely
Sometimes
Often
Always
Patient declines to respond
Patient unable to respond

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DISCHARGE
Section GG Functional Abilities and Goals

GG0130. Self-Care (3-day assessment period)
Code the patient's usual performance at discharge for each activity using the 6-point scale. If activity was not attempted at discharge, code
the reason. If the patient has an incomplete stay, skip discharge GG0130 items.
Coding:
Safety and Quality of Performance - If helper assistance is required because patient'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 - Patient completes the activity by themself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient 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 patient
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. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns

3.Discharge
Performance
Enter Codes in Boxes

A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once
the meal is placed before the patient.
B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove
dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.
C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel
movement. If managing an ostomy, include wiping the opening but not managing equipment.
E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and
hair). Does not include transferring in/out of tub/shower.
F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.

G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear.
H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate
for safe mobility; including fasteners, if applicable.

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DISCHARGE
GG0170. Mobility (3-day assessment period)
Code the patient's usual performance at discharge for each activity using the 6-point scale. If activity was not attempted at discharge, code
the reason. If the patient has an incomplete stay, skip discharge GG0170 items.
Coding:
Safety and Quality of Performance - If helper assistance is required because patient'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 - Patient completes the activity by themself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient 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 patient
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. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns

3.Discharge
Performance
Enter Codes in Boxes

A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with no back
support.
D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to get on and off a toilet or commode.
G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/
close door or fasten seat belt.
I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space.
If discharge performance is coded 07, 09, 10, or 88
Skip to GG0170M, 1 step (curb)
J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.
K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.

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DISCHARGE
GG0170. Mobility (3-day assessment period) - Continued
Code the patient's usual performance at discharge for each activity using the 6-point scale. If activity was not attempted at discharge, code
the reason. If the patient has an incomplete stay, skip discharge GG0170 items.
Coding:
Safety and Quality of Performance - If helper assistance is required because patient'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 - Patient completes the activity by themself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; patient 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 patient
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. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the patient to complete the activity.
If activity was not attempted, code reason:
07. Patient refused
09. Not applicable - Not attempted and the patient did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns

3.Discharge
Performance
Enter Codes in Boxes

L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as
turf or gravel.
M. 1 step (curb): The ability to go up and down a curb or up and down one step.
Skip to GG0170P, Picking up object
If discharge performance is coded 07, 09, 10, or 88
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 patient use a wheelchair and/or scooter?
0. No
Skip to J0510, Pain Effect on Sleep
1. Yes
Continue to GG0170R, Wheel 50 feet with two turns
R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns.
RR3. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized
S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.
SS3. Indicate the type of wheelchair or scooter used.
1. Manual
2. Motorized

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OMB No. 0938-0842
Patient

Identifier

Date

DISCHARGE
Section J

Health Conditions

Section J Health Conditions

J0510. Pain Effect on Sleep
Enter Code

Ask patient: “Over the past 5 days, how much of the time has pain made it hard for you to sleep at night?”
0. Does not apply – I have not had any pain or hurting in the past 5 days
Skip to J1800, Any Falls Since Admission
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

J0530. Pain Interference with Day-to-Day Activities
Enter Code

J1800. Any Falls Since Admission
Enter Code

Has the patient had any falls since admission?
0. No
Skip to K0520, Nutritional Approaches
1. Yes
Continue to J1900, Number of Falls Since Admission

J1900. Number of Falls Since Admission
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 patient; no change in the patient'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 patient to complain of pain
C. Major injury: Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural
hematoma

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OMB No. 0938-0842
Patient

Date

Identifier

DISCHARGE
K0520. Nutritional Approaches
4. Last 7 Days
Check all of the nutritional approaches that were received in the last 7 days
5. At Discharge
Check all of the nutritional approaches that were being received at discharge

4.
Last 7 Days

5.
At Discharge

Check all that apply

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

Section M

Skin Conditions

Report based on highest stage of existing ulcers/injuries at their worst; do not "reverse" stage
M0210. Unhealed Pressure Ulcers/Injuries
Enter Code

M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
Enter Number

Enter Number

2. Number of these Stage 2 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission
C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be
present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Enter Number

1. Number of Stage 3 pressure ulcers
If 0
Skip to M0300D, Stage 4
Enter Number

Enter Number

2. Number of these Stage 3 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission
D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the
wound bed. Often includes undermining and tunneling.
1. Number of Stage 4 pressure ulcers
If 0
Skip to M0300E, Unstageable - Non-removable dressing/device
2. Number of these Stage 4 pressure ulcers that were present upon admission - enter how many were noted at the time of
admission

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OMB No. 0938-0842
Patient

Identifier

Date

DISCHARGE
Section M

Skin Conditions

of existing ulcers/injuries at their worst; do not "reverse" stage
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage - Continued
E. Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device
Enter Number

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

Enter Number

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

Enter Number

2. Number of these unstageable pressure ulcers that were present upon admission - enter how many were noted at the time of
admission
G. Unstageable - Deep tissue injury
1. Number of unstageable pressure injuries presenting as deep tissue injury
If 0
Skip to N0415, High-Risk Drug Classes: Use and Indication

Enter Number

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

Section N Medications

1.
Is taking
Check all that apply

2.
Indication noted
Check all that apply

A. Antipsychotic
E. Anticoagulant
F. Antibiotic
H. Opioid
I. Antiplatelet
J. Hypoglycemic (including insulin)
Z. None of the above

N2005. Medication Intervention
Enter Code

Did the facility contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next
calendar day each time potential clinically significant medication issues were identified since the admission?
0. No
1. Yes
9. Not applicable - There were no potential clinically significant medication issues identified since admission or patient is not
taking any medications.

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OMB No. 0938-0842
Patient

Identifier

Date

DISCHARGE
Section O

Special Treatments, Procedures, and Programs

O0110. Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that apply at discharge.
c.
At Discharge
Check all that apply
Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Therapies
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. Anticoagulation
H10. Other
I1. Transfusions
J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
O1. IV Access
O2. Peripheral
O3. Midline
O4. Central (e.g., PICC, tunneled, port)

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OMB No. 0938-0842
Patient

Identifier

Date

DISCHARGE
Section O

Special Treatments, Procedures, and Programs

O0350. Patient’s COVID-19 vaccination is up to date.
Enter Code

0. No, patient is not up to date
1. Yes, patient is up to date

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Section Z

OMB No. 0938-0842

Assessment Administration
Item Z0400A. Signature of Persons Completing the Assessment

I certify that the accompanying information accurately reflects patient assessment information for this patient 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 patients 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.
Signature

Title

Date Information is Provided

Time

A.
B.

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Page 30

File Type	application/pdf
File Title	Inpatient Rehabilitation Facility - Patient Assessment Instrument Quality Indicators
Subject	Patient assessment; inpatient rehabilitation; admission; discharge
Author	Centers for Medicare & Medicaid Services (CMS)
File Modified	2024-04-03
File Created	2024-04-01