CMS-10036 IRF- PAI version 4.4

DEPARTMENT OF HEALTH AND HUMAN SERVICES

OMB No. 0938-0842

^{CENTER FOR MEDICARE & MEDICAID SERVICES}

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: XXX. 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].

CENTERS FOR MEDICARE & MEDICAID SERVICES

INPATIENT REHABILITATION FACILITY - PATIENT ASSESSMENT INSTRUMENT

Identification Information

Medical Information

Facility Information Facility Name Facility Medicare Provider Number Patient Medicare Number Patient Medicaid Number Patient First Name 5A. Patient Last Name 5B. Patient Identification Number Birth Date / / MM / DD / YYYY Social Security Number Marital Status (1 - Never Married; 2 - Married; 3 - Widowed; 4 - Separated; 5 - Divorced) Zip Code of Patient's Pre-Hospital Residence Admission Date / / MM / DD / YYYY Assessment Reference Date / / MM / DD / YYYY 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) 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)

Impairment Group* _ Admission Discharge Condition requiring admission to rehabilitation; code according to Appendix A. 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 Comorbid Conditions Use ICD codes to enter comorbid medical conditions A. J. S. B. K. T. C. L. U. D. M. V. E. N. W. F. O. X. G. P. Y. Q. R. 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.)

* The impairment codes incorporated or referenced herein are the property of U B Foundation Activities, Inc. ©1993, 2001 U B Foundation Activities, Inc

CENTERS FOR MEDICARE & MEDICAID SERVICES

Discharge Information	Therapy Information
Discharge Date / / MM / DD / YYYY Patient discharged against medical advice? (0 - No; 1 - Yes) Program Interruption(s) (0 - No; 1 - Yes) Program Interruption Dates (Code only if item 42 is 1 - Yes) 1st Interruption Date B. 1st Return Date MM / DD / YYYY MM / DD / YYYY C. 2nd Interruption Date D. 2nd Return Date MM / DD / YYYY MM / DD / YYYY E. 3rd Interruption Date F. 3rd Return Date MM / DD / YYYY MM / DD / YYYY 44C. Was the patient discharged alive? (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 - Long- Term Care Hospital (LTCH); 64 - Medicaid Nursing Facility; 65 - Inpatient Psychiatric Facility; 66 - Critical Access Hospital (CAH); 99 - Not Listed) Discharge to Living With (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) Diagnosis for Interruption or Death (Code using ICD code) Complications during rehabilitation stay (Use ICD codes to specify up to six conditions that began with this rehabilitation stay) A. B. C. D. E. F.	O0401. Week 1: Total Number of Minutes Provided
	O0401A: 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	_
	O0401B: Occupational 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	_
	O0401C: Speech-Language Pathology
	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	_
	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
	b. Total minutes of concurrent therapy	_
	c. Total minutes of group therapy	_
	d. Total minutes of co-treatment therapy	_
	O0402C: Speech-Language Pathology
	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

Section A Administrative Information

A0810. Sex
Enter Code		1. Male 2. Female
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

A1110. Language
Enter Code		What is your preferred language? Do you need or want an interpreter to communicate with a doctor or health care staff? No 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
A1255. Transportation
E nter 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
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.

Section B Hearing, Vision and Speech

B0200. Hearing
Enter Code	Ability to hear (with hearing aid or hearing appliances if normally used) Adequate - no difficulty in normal conversation, social interaction, listening to TV Minimal difficulty - difficulty in some environments (e.g., when person speaks softly or setting is noisy) Moderate difficulty - speaker has to increase volume and speak distinctly Highly impaired - absence of useful hearing
B1000. Vision
Enter Code	Ability to see in adequate light (with glasses or other visual appliances) Adequate - sees fine detail, such as regular print in newspapers/books Impaired - sees large print, but not regular print in newspapers/books Moderately impaired - limited vision; not able to see newspaper headlines but can identify objects Highly impaired - object identification in question, but eyes appear to follow objects 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	Never Rarely Sometimes Often Always 7. Patient declines to respond 8. 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

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	No (patient is rarely/never understood) Skip to C0900, Memory/Recall Ability Yes Continue to C0200, Repetition of Three Words
Brief Interview for Mental Status (BIMS)
C0200. Repetition of Three Words
Enter Code	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.” 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
Enter Code	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
Enter Code	Ask patient: “What day of the week is today?” Able to report correct day of the week 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
Enter Code	B. Able to recall “blue” 2. Yes, no cue required 1. Yes, after cueing ("a color") 0. No - could not recall
Enter Code	C. Able to recall “bed” 2. Yes, no cue required 1. Yes, after cueing ("a piece of furniture") 0. No - could not recall

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	No (patient was able to complete Brief Interview for Mental Status) Skip to C1310, Signs and Symptoms of Delirium 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? No Yes
Coding: Behavior not present Behavior continuously present, does not fluctuate 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)?
			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.

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.
Symptom Presence 2. Symptom Frequency No (enter 0 in column 2) 0. Never or 1 day Yes (enter 0-3 in column 2) 1. 2-6 days (several days) 9. No response (leave column 2 blank) 2. 7-11 days (half or more of the days) 3. 12-14 days (nearly every day)		1. Symptom Presence	2. Symptom Frequency
		Enter Scores in Boxes
A. Little interest or pleasure in doing things
B. Feeling down, depressed, or hopeless
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	Never Rarely Sometimes Often Always Patient declines to respond 8. Patient unable to respond

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. Unknown 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

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 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. 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.

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.

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. 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 patient use a wheelchair and/or scooter? No Skip to H0350, Bladder Continence 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. Manual Motorized
	S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.
		SS1. Indicate the type of wheelchair or scooter used. Manual Motorized

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. Always continent (no documented incontinence) Stress incontinence only Incontinent less than daily (e.g., once or twice during the 3-day assessment period) Incontinent daily (at least once a day) Always incontinent No urine output (e.g., renal failure) 9. Not applicable (e.g., indwelling catheter)
H0400. Bowel Continence (3-day assessment period)
E nter Code	Bowel continence - Select the one category that best describes the patient. Always continent Occasionally incontinent (one episode of bowel incontinence) Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement) 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?” Does not apply – I have not had any pain or hurting in the past 5 days Skip to J1750, History of Falls Rarely or not at all Occasionally Frequently Almost constantly 8. Unable to answer
J0520. Pain Interference with Therapy Activities
E nter Code	Ask patient: “Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain?" Does not apply – I have not received rehabilitation therapy in the past 5 days Rarely or not at all Occasionally Frequently Almost constantly 8. Unable to answer

J0530. Pain Interference with Day-to-Day Activities
E nter 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?” Rarely or not at all Occasionally Frequently Almost constantly 8. Unable to answer
J1750. History of Falls
E nter Code	Has the patient had two or more falls in the past year or any fall with injury in the past year? No Yes 8. Unknown
J2000. Prior Surgery
E nter Code	Did the patient have major surgery during the 100 days prior to admission? No 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 on highest stage of existing ulcers/injuries at their worst; do not "reverse" stage
M0210. Unhealed Pressure Ulcers/Injuries
E nter Code	Does this patient have one or more unhealed pressure ulcers/injuries? No Skip to N0415, High-Risk Drug Classes: Use and Indication Yes Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.

Section M

Skin Conditions

M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
Enter Number	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. Number of Stage 1 pressure injuries
Enter Number	Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers
Enter Number	Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Number of Stage 3 pressure ulcers
Enter Number	Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers
Enter Number	Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers/injuries due to non-removable dressing/device
Enter Number	Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar
Enter Number	Unstageable - Deep tissue injury Number of unstageable pressure injuries presenting as deep tissue injury

Section N Medications

N0415. High-Risk Drug Classes: Use and Indication
Is taking Check if the patient is taking any medications by pharmacological classification, not how it is used, in the following classes 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	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
E nter Code	Did a complete drug regimen review identify potential clinically significant medication issues? No - No issues found during review Skip to O0110, Special Treatments, Procedures, and Programs 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
E nter 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? No 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

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

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
E nter Code	At the time of discharge to another provider, did your facility provide the patient’s current reconciled medication list to the subsequent provider? No – Current reconciled medication list not provided to the subsequent provider Skip to A2123, Provision of Current Reconciled Medication List to Patient at Discharge 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
Route of Transmission		Check all that apply
A. Electronic Health Record
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
E nter 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)

Section B Health Literacy

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?
E nter Code	Never Rarely Sometimes Often Always 7. Patient declines to respond 8. 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.
E nter Code	No (patient is rarely/never understood) Skip to C1310, Signs and Symptoms of Delirium Yes Continue to C0200, Repetition of Three Words
Brief Interview for Mental Status (BIMS)
C0200. Repetition of Three Words
E nter Code	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.” 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)
E nter 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
E nter Code	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
E nter Code	Ask patient: “What day of the week is today?” Able to report correct day of the week Correct 0. Incorrect or no answer

Section C Cognitive Patterns

C0400. Recall
E nter 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
E nter Code	B. Able to recall “blue” 2. Yes, no cue required 1. Yes, after cueing ("a color") 0. No - could not recall
E nter Code	C. Able to recall “bed” 2. Yes, no cue required 1. Yes, after cueing ("a piece of furniture") 0. No - could not recall
C0500. BIMS Summary Score
E nter 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
E nter Code	Is there evidence of an acute change in mental status from the patient's baseline? No Yes
Coding: Behavior not present Behavior continuously present, does not fluctuate 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)?
			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.

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.
Symptom Presence 2. Symptom Frequency No (enter 0 in column 2) 0. Never or 1 day Yes (enter 0-3 in column 2) 1. 2-6 days (several days) 9. No response (leave column 2 blank) 2. 7-11 days (half or more of the days) 3. 12-14 days (nearly every day)		1. Symptom Presence	2. Symptom Frequency
		Enter Scores in Boxes
A. Little interest or pleasure in doing things
B. Feeling down, depressed, or hopeless
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	Never Rarely Sometimes Often Always 7. Patient declines to respond 8. Patient unable to respond

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.

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.

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
E nter 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. 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 patient use a wheelchair and/or scooter? No Skip to J0510, Pain Effect on Sleep Yes Continue to GG0170R, Wheel 50 feet with two turns
	R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns.
		RR3. Indicate the type of wheelchair or scooter used. Manual Motorized
	S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.
		SS3. Indicate the type of wheelchair or scooter used. Manual Motorized

Section J

Health Conditions

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?” Does not apply – I have not had any pain or hurting in the past 5 days Skip to J1800, Any Falls Since Admission Rarely or not at all Occasionally Frequently 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?" Does not apply – I have not received rehabilitation therapy in the past 5 days Rarely or not at all Occasionally Frequently Almost constantly 8. Unable to answer
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?” Rarely or not at all Occasionally Frequently Almost constantly 8. Unable to answer
J1800. Any Falls Since Admission
Enter Code	Has the patient had any falls since admission? No Skip to K0520, Nutritional Approaches Yes Continue to J1900, Number of Falls Since Admission
J1900. Number of Falls Since Admission
Coding: None One Two or more		Enter Codes in Boxes
			A. No injury: No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the 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

K0520. Nutritional Approaches
Last 7 Days Check all of the nutritional approaches that were received in the last 7 days 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	Does this patient have one or more unhealed pressure ulcers/injuries? No Skip to N0415, High-Risk Drug Classes: Use and Indication Yes Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
Enter Number	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. Number of Stage 1 pressure injuries
Enter Number Enter Number	Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister. Number of Stage 2 pressure ulcers If 0 Skip to M0300C, Stage 3 Number of these Stage 2 pressure ulcers that were present upon admission - enter how many were noted at the time of admission
Enter Number Enter Number	Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Number of Stage 3 pressure ulcers If 0 Skip to M0300D, Stage 4 Number of these Stage 3 pressure ulcers that were present upon admission - enter how many were noted at the time of admission
Enter Number Enter Number	Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Number of Stage 4 pressure ulcers If 0 Skip to M0300E, Unstageable - Non-removable dressing/device Number of these Stage 4 pressure ulcers that were present upon admission - enter how many were noted at the time of admission

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
Enter Number Enter Number	Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers/injuries due to non-removable dressing/device If 0 Skip to M0300F, Unstageable - Slough and/or eschar Number of these unstageable pressure ulcers/injuries that were present upon admission - enter how many were noted at the time of admission
Enter Number Enter Number	Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar If 0 Skip to M0300G, Unstageable - Deep tissue injury Number of these unstageable pressure ulcers that were present upon admission - enter how many were noted at the time of admission
Enter Number Enter Number	Unstageable - Deep tissue injury Number of unstageable pressure injuries presenting as deep tissue injury If 0 Skip to N0415, High-Risk Drug Classes: Use and Indication Number of these unstageable pressure injuries that were present upon admission - enter how many were noted at the time of admission

Section N Medications

N0415. High-Risk Drug Classes: Use and Indication
Is taking Check if the patient is taking any medications by pharmacological classification, not how it is used, in the following classes 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	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? No Yes 9. Not applicable - There were no potential clinically significant medication issues identified since admission or patient is not taking any medications.

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)

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
None of the Above
Z1. None of the above

DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB No. 0938-0842 CENTERS FOR MEDICARE & MEDICAID SERVICES

Section Z	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.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.