101104-8
Minimum Data Set (MDS) - version 3.0 - Resident Assessment Instrument (RAI) version 1.18.11 during assessment period [CMS Assessment]
Active
Panel Hierarchy
Details for each LOINC in Panel LHC-Forms
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 101104-8 | Minimum Data Set (MDS) - version 3.0 - Resident Assessment Instrument (RAI) version 1.18.11 | |||
| Indent101105-5 | MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set | |||
| Indent Indent101258-2 | Identification Information | |||
| Indent Indent Indent58198-3 | Type of Record | |||
| Indent Indent Indent54581-4 | Facility Provider Numbers | |||
| Indent Indent Indent Indent76468-8 | National Provider Identifier (NPI) | |||
| Indent Indent Indent Indent69417-4 | CMS Certification Number (CCN) | |||
| Indent Indent Indent Indent45398-5 | State Provider Number | |||
| Indent Indent Indent85632-8 | Type of Provider | |||
| Indent Indent Indent90489-6 | Type of Assessment | |||
| Indent Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent Indent54587-1 | Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry? | |||
| Indent Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent Indent71440-2 | Type of discharge | |||
| Indent Indent Indent Indent90525-7 | Is this a SNF Part A Interrupted Stay? | |||
| Indent Indent Indent Indent86525-3 | Is this a SNF Part A PPS Discharge Assessment? | |||
| Indent Indent Indent86526-1 | Unit Certification or Licensure Designation | |||
| Indent Indent Indent54503-8 | Legal Name of Resident | |||
| Indent Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent Indent45393-6 | Middle initial | |||
| Indent Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent Indent45395-1 | Suffix | |||
| Indent Indent Indent45966-9 | Social Security and Medicare Numbers | |||
| Indent Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent Indent45397-7 | Medicare number | |||
| Indent Indent Indent45400-9 | Medicaid Number | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent69854-8 | Ethnicity. Are you of Hispanic, Latino/a, or Spanish origin? | 1..4 | ||
| Indent Indent Indent103708-4 | Race. What is your race? | 1..14 | ||
| Indent Indent Indent93186-5 | Language | |||
| Indent Indent Indent Indent54899-0 | What is your preferred language? | |||
| Indent Indent Indent Indent54588-9 | Do you need or want an interpreter to communicate with a doctor or health care staff? | |||
| Indent Indent Indent45404-1 | Marital Status | |||
| Indent Indent Indent101351-5 | Transportation (from NACHC©) | |||
| Indent Indent Indent54506-1 | Optional Resident Items | |||
| Indent Indent Indent Indent46106-1 | Medical record number | |||
| Indent Indent Indent Indent45403-3 | Room number | |||
| Indent Indent Indent Indent52462-9 | Name by which resident prefers to be addressed | |||
| Indent Indent Indent Indent21843-8 | Lifetime occupation(s) | |||
| Indent Indent Indent54589-7 | Preadmission Screening and Resident Review (PASRR). Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? | |||
| Indent Indent Indent71441-0 | Level II Preadmission Screening and Resident Review (PASRR) Conditions | 1..3 | ||
| Indent Indent Indent86527-9 | Conditions Related to ID/DD Status | 1..4 | ||
| Indent Indent Indent86528-7 | Most Recent Admission/Entry or Reentry into this Facility | |||
| Indent Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent54590-5 | Type of Entry | |||
| Indent Indent Indent Indent85398-6 | Entered From | |||
| Indent Indent Indent52455-3 | Admission Date | {mm/dd/yyyy} | ||
| Indent Indent Indent52525-3 | Discharge Date | {mm/dd/yyyy} | ||
| Indent Indent Indent55128-3 | Discharge Status | |||
| Indent Indent Indent93182-4 | Provision of Current Reconciled Medication List to Subsequent Provider at Discharge | |||
| Indent Indent Indent93184-0 | Route of Current Reconciled Medication List Transmission to Subsequent Provider | 1..5 | ||
| Indent Indent Indent93181-6 | Provision of Current Reconciled Medication List to Resident at Discharge | |||
| Indent Indent Indent93183-2 | Route of Current Reconciled Medication List Transmission to Resident | 1..5 | ||
| Indent Indent Indent54592-1 | Previous Assessment Reference Date for Significant Correction | {mm/dd/yyyy} | ||
| Indent Indent Indent54593-9 | Assessment Reference Date. Observation end date | {mm/dd/yyyy} | ||
| Indent Indent Indent54507-9 | Medicare Stay | |||
| Indent Indent Indent Indent54594-7 | Has the resident had a Medicare-covered stay since the most recent entry? | |||
| Indent Indent Indent Indent54595-4 | Start date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent54596-2 | End date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent101259-0 | Hearing, Speech, and Vision | |||
| Indent Indent Indent54597-0 | Comatose | |||
| Indent Indent Indent95744-9 | Hearing | |||
| Indent Indent Indent54599-6 | Hearing Aid | |||
| Indent Indent Indent54600-2 | Speech Clarity | |||
| Indent Indent Indent95737-3 | Makes Self Understood | |||
| Indent Indent Indent54602-8 | Ability to Understand Others | |||
| Indent Indent Indent95745-6 | Vision | |||
| Indent Indent Indent54604-4 | Corrective Lenses | |||
| Indent Indent Indent103709-2 | Health Literacy | |||
| Indent Indent101260-8 | Cognitive Patterns | |||
| Indent Indent Indent54605-1 | Should Brief Interview for Mental Status (C0200-C0500) be Conducted? | |||
| Indent Indent Indent103694-6 | Brief Interview for Mental Status (BIMS) | |||
| Indent Indent Indent Indent103696-1 | Repetition of Three Words | |||
| Indent Indent Indent Indent103702-7 | Temporal Orientation | |||
| Indent Indent Indent Indent Indent103697-9 | Able to report correct year | |||
| Indent Indent Indent Indent Indent103698-7 | Able to report correct month | |||
| Indent Indent Indent Indent Indent103703-5 | Able to report correct day of the week | |||
| Indent Indent Indent Indent103695-3 | Recall | |||
| Indent Indent Indent Indent Indent103699-5 | Able to recall "sock" | |||
| Indent Indent Indent Indent Indent103700-1 | Able to recall "blue" | |||
| Indent Indent Indent Indent Indent103701-9 | Able to recall "bed" | |||
| Indent Indent Indent Indent103704-3 | BIMS Summary Score | {score} | ||
| Indent Indent Indent54615-0 | Should the Staff Assessment for Mental Status (C0700 - C1000) be Conducted? | |||
| Indent Indent Indent96908-9 | Staff assessment for mental status | |||
| Indent Indent Indent Indent54616-8 | Short-term Memory OK | |||
| Indent Indent Indent Indent54617-6 | Long-term Memory OK | |||
| Indent Indent Indent Indent95743-1 | Memory/Recall Ability | 1..4 | ||
| Indent Indent Indent Indent54624-2 | Cognitive Skills for Daily Decision Making | |||
| Indent Indent Indent96901-4 | Delirium | |||
| Indent Indent Indent Indent95816-5 | Signs and symptoms of delirium (from CAM) | |||
| Indent Indent Indent Indent Indent95813-2 | Acute Onset Mental Change | |||
| Indent Indent Indent Indent Indent95812-4 | Inattention | |||
| Indent Indent Indent Indent Indent95814-0 | Disorganized Thinking | |||
| Indent Indent Indent Indent Indent95815-7 | Altered Level of Consciousness | |||
| Indent Indent101261-6 | Mood | |||
| Indent Indent Indent54634-1 | Should Resident Mood Interview be Conducted? | |||
| Indent Indent Indent54635-8 | Resident Mood Interview (PHQ-2 to 9) | |||
| Indent Indent Indent Indent86843-0 | Symptom Presence | |||
| Indent Indent Indent Indent Indent54636-6 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54638-2 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54640-8 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54642-4 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54644-0 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54646-5 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54648-1 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54650-7 | 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 | |||
| Indent Indent Indent Indent Indent54652-3 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent Indent86844-8 | Symptom Frequency | |||
| Indent Indent Indent Indent Indent54637-4 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54639-0 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54641-6 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54643-2 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54645-7 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54647-3 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54649-9 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54651-5 | 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 | |||
| Indent Indent Indent Indent Indent54653-1 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent103705-0 | Total Severity Score | {score} | ||
| Indent Indent Indent103706-8 | Staff Assessment of Resident Mood (PHQ-9-OV) | |||
| Indent Indent Indent Indent86833-1 | Symptom Presence | |||
| Indent Indent Indent Indent Indent54658-0 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54660-6 | Feeling or appearing down, depressed, or hopeless | |||
| Indent Indent Indent Indent Indent54662-2 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54664-8 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54666-3 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54668-9 | Indicating that they feel bad about self, is a failure, or have let self or family down | |||
| Indent Indent Indent Indent Indent54670-5 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54672-1 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that they have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54673-9 | States that life isn't worth living, wishes for death, or attempts to harm self | |||
| Indent Indent Indent Indent Indent54675-4 | Being short-tempered, easily annoyed | |||
| Indent Indent Indent Indent86891-9 | Symptom Frequency | |||
| Indent Indent Indent Indent Indent54659-8 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54661-4 | Feeling or appearing down, depressed, or hopeless | |||
| Indent Indent Indent Indent Indent54663-0 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54665-5 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54667-1 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54669-7 | Indicating that they feel bad about self, is a failure, or have let self or family down | |||
| Indent Indent Indent Indent Indent54671-3 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54904-8 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that they have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54674-7 | States that life isn't worth living, wishes for death, or attempts to harm self | |||
| Indent Indent Indent Indent Indent54676-2 | Being short-tempered, easily annoyed | |||
| Indent Indent Indent103707-6 | Total Severity Score | {score} | ||
| Indent Indent Indent93159-2 | Social Isolation | |||
| Indent Indent101262-4 | Behavior | |||
| Indent Indent Indent86597-2 | Potential Indicators of Psychosis | 1..2 | ||
| Indent Indent Indent54514-5 | Behavioral Symptom - Presence & Frequency | |||
| Indent Indent Indent Indent54682-0 | Physical behavioral symptoms directed toward others | d/(7.d) | ||
| Indent Indent Indent Indent54683-8 | Verbal behavioral symptoms directed toward others | d/(7.d) | ||
| Indent Indent Indent Indent54684-6 | Other behavioral symptoms not directed toward others | d/(7.d) | ||
| Indent Indent Indent54685-3 | Overall Presence of Behavioral Symptoms.Were any behavioral symptoms in questions E0200 coded 1, 2, or 3? | |||
| Indent Indent Indent54515-2 | Impact on Resident | |||
| Indent Indent Indent Indent54686-1 | Did any of the identified symptom(s): Put the resident at significant risk for physical illness or injury? | |||
| Indent Indent Indent Indent54687-9 | Did any of the identified symptom(s): Significantly interfere with the resident's care? | |||
| Indent Indent Indent Indent54688-7 | Did any of the identified symptom(s): Significantly interfere with the resident's participation in activities or social interactions? | |||
| Indent Indent Indent54516-0 | Impact on Others | |||
| Indent Indent Indent Indent54689-5 | Did any of the identified symptom(s): Put others at significant risk for physical injury? | |||
| Indent Indent Indent Indent54690-3 | Did any of the identified symptom(s): Significantly intrude on the privacy or activity of others? | |||
| Indent Indent Indent Indent54691-1 | Did any of the identified symptom(s): Significantly disrupt care or living environment? | |||
| Indent Indent Indent54692-9 | Rejection of Care - Presence & Frequency | d/(7.d) | ||
| Indent Indent Indent54693-7 | Wandering - Presence & Frequency | d/(7.d) | ||
| Indent Indent Indent54517-8 | Wandering - Impact | |||
| Indent Indent Indent Indent54694-5 | Does the wandering place the resident at significant risk of getting to a potentially dangerous place? | |||
| Indent Indent Indent Indent54695-2 | Does the wandering significantly intrude on the privacy or activities of others? | |||
| Indent Indent Indent54696-0 | Change in Behavior or Other Symptoms.How does resident's current behavior status, care rejection, or wandering compare to prior assessment (OBRA or Scheduled PPS)? | |||
| Indent Indent101263-2 | Preferences for Customary Routine and Activities | |||
| Indent Indent Indent54697-8 | Should Interview for Daily and Activity Preferences be Conducted? | |||
| Indent Indent Indent54519-4 | Interview for Daily Preferences | |||
| Indent Indent Indent Indent54698-6 | While you are in this facility how important is it to you to choose what clothes to wear? | |||
| Indent Indent Indent Indent54699-4 | While you are in this facility how important is it to you to take care of your personal belongings or things? | |||
| Indent Indent Indent Indent54700-0 | While you are in this facility how important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? | |||
| Indent Indent Indent Indent54701-8 | While you are in this facility how important is it to you to have snacks available between meals? | |||
| Indent Indent Indent Indent54702-6 | While you are in this facility how important is it to you to choose your own bedtime? | |||
| Indent Indent Indent Indent54703-4 | While you are in this facility how important is it to you to have your family or a close friend involved in discussions about your care? | |||
| Indent Indent Indent Indent54704-2 | While you are in this facility how important is it to you to be able to use the phone in private? | |||
| Indent Indent Indent Indent54705-9 | While you are in this facility how important is it to you to have a place to lock your things to keep them safe? | |||
| Indent Indent Indent54520-2 | Interview for Activity Preferences | |||
| Indent Indent Indent Indent54706-7 | While you are in this facility how important is it to you to have books, newspapers, and magazines to read? | |||
| Indent Indent Indent Indent54707-5 | While you are in this facility how important is it to you to listen to music you like? | |||
| Indent Indent Indent Indent54708-3 | While you are in this facility how important is it to you to be around animals such as pets? | |||
| Indent Indent Indent Indent54709-1 | While you are in this facility how important is it to you to keep up with the news? | |||
| Indent Indent Indent Indent54710-9 | While you are in this facility how important is it to you to do things with groups of people? | |||
| Indent Indent Indent Indent54711-7 | While you are in this facility how important is it to you to do your favorite activities? | |||
| Indent Indent Indent Indent54712-5 | While you are in this facility how important is it to you to go outside to get fresh air when the weather is good? | |||
| Indent Indent Indent Indent54713-3 | While you are in this facility how important is it to you to participate in religious services or practices? | |||
| Indent Indent Indent54714-1 | Daily and Activity Preferences Primary Respondent. Indicate primary respondent for Daily and Activity Preferences (F0400 and F0500) | |||
| Indent Indent Indent54715-8 | Should the Staff Assessment of Daily and Activity Preferences be Conducted? | |||
| Indent Indent Indent86599-8 | Staff Assessment of Daily and Activity Preferences. Resident Prefers: | 1..21 | ||
| Indent Indent101264-0 | Functional Abilities and Goals | |||
| Indent Indent Indent83239-4 | Prior Functioning: Everyday Activities | |||
| Indent Indent Indent Indent85070-1 | Self-Care | |||
| Indent Indent Indent Indent85071-9 | Indoor Mobility (Ambulation) | |||
| Indent Indent Indent Indent85072-7 | Stairs | |||
| Indent Indent Indent Indent85073-5 | Functional Cognition | |||
| Indent Indent Indent83234-5 | Prior Device Use | 1..5 | ||
| Indent Indent Indent92908-3 | Functional Limitation in Range of Motion | |||
| Indent Indent Indent Indent92850-7 | Upper extremity (shoulder, elbow, wrist, hand) | |||
| Indent Indent Indent Indent92851-5 | Lower extremity (hip, knee, ankle, foot) | |||
| Indent Indent Indent86602-0 | Mobility Devices | 1..4 | ||
| Indent Indent Indent101265-7 | Functional Abilities and Goals - Admission | |||
| Indent Indent Indent Indent101321-8 | Self-Care - Admission Performance | |||
| Indent Indent Indent Indent Indent95019-6 | Eating | |||
| Indent Indent Indent Indent Indent95018-8 | Oral hygiene | |||
| Indent Indent Indent Indent Indent95017-0 | Toileting hygiene | |||
| Indent Indent Indent Indent Indent95015-4 | Shower/bathe self | |||
| Indent Indent Indent Indent Indent95014-7 | Upper body dressing | |||
| Indent Indent Indent Indent Indent95013-9 | Lower body dressing | |||
| Indent Indent Indent Indent Indent95012-1 | Putting on/taking off footwear | |||
| Indent Indent Indent Indent Indent45606-1 | Personal hygiene | |||
| Indent Indent Indent Indent101322-6 | Self-Care - Discharge Goal (Assessment period is the first 3 days of the stay) | |||
| Indent Indent Indent Indent Indent89404-8 | Oral hygiene - functional goal | |||
| Indent Indent Indent Indent Indent89409-7 | Eating | |||
| Indent Indent Indent Indent Indent89389-1 | Toileting hygiene | |||
| Indent Indent Indent Indent Indent89396-6 | Shower/bathe self | |||
| Indent Indent Indent Indent Indent89387-5 | Upper body dressing | |||
| Indent Indent Indent Indent Indent89406-3 | Lower body dressing | |||
| Indent Indent Indent Indent Indent89400-6 | Putting on/taking off footwear | |||
| Indent Indent Indent Indent Indent45606-1 | Personal hygiene | |||
| Indent Indent Indent Indent101323-4 | Mobility - Admission Performance (Assessment period is the first 3 days of the stay) | |||
| Indent Indent Indent Indent Indent95011-3 | Roll left and right | |||
| Indent Indent Indent Indent Indent95010-5 | Sit to lying | |||
| Indent Indent Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent Indent95008-9 | Sit to stand | |||
| Indent Indent Indent Indent Indent95007-1 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent Indent95006-3 | Toilet transfer | |||
| Indent Indent Indent Indent Indent101325-9 | Tub/shower transfer | |||
| Indent Indent Indent Indent Indent95005-5 | Car transfer | |||
| Indent Indent Indent Indent Indent95004-8 | Walk 10 feet | |||
| Indent Indent Indent Indent Indent95003-0 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95002-2 | Walk 150 feet | |||
| Indent Indent Indent Indent Indent95001-4 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent Indent Indent94999-0 | 4 steps | |||
| Indent Indent Indent Indent Indent94998-2 | 12 steps | |||
| Indent Indent Indent Indent Indent94997-4 | Picking up object | |||
| Indent Indent Indent Indent Indent95738-1 | Does the resident use a wheelchair and/or scooter? | |||
| Indent Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent101324-2 | Mobility - Discharge Goal (Assessment period is the first 3 days of stay) | |||
| Indent Indent Indent Indent Indent89398-2 | Roll left and right | |||
| Indent Indent Indent Indent Indent89394-1 | Sit to lying | |||
| Indent Indent Indent Indent Indent85927-2 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent Indent89392-5 | Sit to stand | |||
| Indent Indent Indent Indent Indent89414-7 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent Indent89390-9 | Toilet transfer | |||
| Indent Indent Indent Indent Indent101325-9 | Tub/shower transfer | |||
| Indent Indent Indent Indent Indent89412-1 | Car transfer | |||
| Indent Indent Indent Indent Indent89385-9 | Walk 10 feet | |||
| Indent Indent Indent Indent Indent89381-8 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent Indent89383-4 | Walk 150 feet | |||
| Indent Indent Indent Indent Indent89379-2 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent Indent89420-4 | 1 step (curb) | |||
| Indent Indent Indent Indent Indent89416-2 | 4 steps | |||
| Indent Indent Indent Indent Indent89418-8 | 12 steps | |||
| Indent Indent Indent Indent Indent89402-2 | Picking up object | |||
| Indent Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent101266-5 | Functional Abilities and Goals - Discharge | |||
| Indent Indent Indent Indent101429-9 | Self-Care - Discharge Performance | |||
| Indent Indent Indent Indent Indent89409-7 | Eating | |||
| Indent Indent Indent Indent Indent89404-8 | Oral hygiene | |||
| Indent Indent Indent Indent Indent89389-1 | Toileting hygiene | |||
| Indent Indent Indent Indent Indent89396-6 | Shower/bathe self | |||
| Indent Indent Indent Indent Indent89387-5 | Upper body dressing | |||
| Indent Indent Indent Indent Indent89406-3 | Lower body dressing | |||
| Indent Indent Indent Indent Indent89400-6 | Putting on/taking off footwear | |||
| Indent Indent Indent Indent Indent45606-1 | Personal hygiene | |||
| Indent Indent Indent Indent101431-5 | Mobility - Discharge Performance (Assessment period is the last 3 days of the stay) | |||
| Indent Indent Indent Indent Indent89398-2 | Roll left and right | |||
| Indent Indent Indent Indent Indent89394-1 | Sit to lying | |||
| Indent Indent Indent Indent Indent85927-2 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent Indent89392-5 | Sit to stand | |||
| Indent Indent Indent Indent Indent89414-7 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent Indent89390-9 | Toilet transfer | |||
| Indent Indent Indent Indent Indent101325-9 | Tub/shower transfer | |||
| Indent Indent Indent Indent Indent89412-1 | Car transfer | |||
| Indent Indent Indent Indent Indent89385-9 | Walk 10 feet | |||
| Indent Indent Indent Indent Indent89381-8 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent Indent89383-4 | Walk 150 feet | |||
| Indent Indent Indent Indent Indent89379-2 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent Indent89420-4 | 1 step (curb) | |||
| Indent Indent Indent Indent Indent89416-2 | 4 steps | |||
| Indent Indent Indent Indent Indent89418-8 | 12 steps | |||
| Indent Indent Indent Indent Indent89402-2 | Picking up object | |||
| Indent Indent Indent Indent Indent95738-1 | Does the resident use a wheelchair and/or scooter? | |||
| Indent Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent101267-3 | Functional Abilities and Goals - OBRA &or Interim | |||
| Indent Indent Indent Indent101430-7 | Self-Care - OBRA/Interim Performance | |||
| Indent Indent Indent Indent Indent95019-6 | Eating | |||
| Indent Indent Indent Indent Indent89409-7 | Eating | |||
| Indent Indent Indent Indent Indent89404-8 | Oral hygiene | |||
| Indent Indent Indent Indent Indent89389-1 | Toileting hygiene | |||
| Indent Indent Indent Indent Indent89396-6 | Shower/bathe self | |||
| Indent Indent Indent Indent Indent89387-5 | Upper body dressing | |||
| Indent Indent Indent Indent Indent89406-3 | Lower body dressing | |||
| Indent Indent Indent Indent Indent89400-6 | Putting on/taking off footwear | |||
| Indent Indent Indent Indent Indent45606-1 | Personal hygiene | |||
| Indent Indent Indent Indent101432-3 | Mobility - OBRA/Interim Performance (Assessment period is the ARD plus 2 previous calendar days) | |||
| Indent Indent Indent Indent Indent89398-2 | Roll left and right | |||
| Indent Indent Indent Indent Indent89394-1 | Sit to lying | |||
| Indent Indent Indent Indent Indent85927-2 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent Indent89392-5 | Sit to stand | |||
| Indent Indent Indent Indent Indent89414-7 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent Indent89390-9 | Toilet transfer | |||
| Indent Indent Indent Indent Indent101325-9 | Tub/shower transfer | |||
| Indent Indent Indent Indent Indent89385-9 | Walk 10 feet | |||
| Indent Indent Indent Indent Indent89381-8 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent Indent89383-4 | Walk 150 feet | |||
| Indent Indent Indent Indent Indent95738-1 | Does the resident use a wheelchair and/or scooter? | |||
| Indent Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent101268-1 | Bladder and Bowel | |||
| Indent Indent Indent86624-4 | Appliances | 1..4 | ||
| Indent Indent Indent54530-1 | Urinary Toileting Program | |||
| Indent Indent Indent Indent54767-9 | Has a trial of a toileting program been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility? | |||
| Indent Indent Indent Indent54768-7 | Response - What was the resident's response to the trial program? | |||
| Indent Indent Indent Indent54769-5 | Current toileting program or trial - Is a toileting program currently being used to manage the resident's urinary continence? | |||
| Indent Indent Indent95735-7 | Urinary Continence | 1..1 | ||
| Indent Indent Indent95736-5 | Bowel Continence | 1..1 | ||
| Indent Indent Indent88695-2 | Bowel Toileting Program | |||
| Indent Indent Indent54773-7 | Bowel Patterns. Constipation present? | |||
| Indent Indent101269-9 | Active Diagnoses | |||
| Indent Indent Indent96095-5 | Indicate the resident's primary medical condition category | 1..1 | ||
| Indent Indent Indent52797-8 | ICD Code | |||
| Indent Indent Indent86671-5 | Active Diagnoses in the last 7 days | 1..* | ||
| Indent Indent Indent52797-8 | Additional active diagnoses | 0..10 | ||
| Indent Indent101270-7 | Health Conditions | |||
| Indent Indent Indent54557-4 | Pain Management | |||
| Indent Indent Indent Indent71447-7 | At any time in the last 5 days, has the resident: Received scheduled pain medication regimen? | |||
| Indent Indent Indent Indent71448-5 | At any time in the last 5 days, has the resident: Received PRN pain medications OR was offered and declined? | |||
| Indent Indent Indent Indent71449-3 | At any time in the last 5 days, has the resident: Received non-medication intervention for pain? | |||
| Indent Indent Indent54828-9 | Should Pain Assessment Interview be Conducted? | |||
| Indent Indent Indent101326-7 | Pain Assessment Interview | |||
| Indent Indent Indent Indent54829-7 | Pain Presence | |||
| Indent Indent Indent Indent54830-5 | Pain Frequency | |||
| Indent Indent Indent Indent93156-8 | Pain Effect on Sleep | |||
| Indent Indent Indent Indent93160-0 | Pain Interference with Therapy Activities | |||
| Indent Indent Indent Indent93158-4 | Pain Interference with Day-to-Day Activities | |||
| Indent Indent Indent Indent54560-8 | Pain Intensity | |||
| Indent Indent Indent Indent Indent54833-9 | Numeric Rating Scale (00-10) | |||
| Indent Indent Indent Indent Indent54834-7 | Verbal Descriptor Scale | |||
| Indent Indent Indent58117-3 | Should the Staff Assessment for Pain be Conducted? | |||
| Indent Indent Indent86672-3 | Staff Assessment for Pain | |||
| Indent Indent Indent Indent86673-1 | Indicators of Pain or Possible Pain in the last 5 days | 1..4 | ||
| Indent Indent Indent Indent58118-1 | Frequency of Indicator of Pain or Possible Pain in the last 5 days | d/(5.d) | ||
| Indent Indent Indent86674-9 | Other Health Conditions | |||
| Indent Indent Indent Indent86675-6 | Shortness of Breath (dyspnea) | 1..3 | ||
| Indent Indent Indent Indent54845-3 | Current Tobacco Use | |||
| Indent Indent Indent Indent54846-1 | Prognosis | |||
| Indent Indent Indent Indent86676-4 | Problem Conditions | 1..4 | ||
| Indent Indent Indent Indent54849-5 | Fall History on Admission/Entry or Reentry | |||
| Indent Indent Indent Indent Indent54850-3 | Did the resident have a fall any time in the last month prior to admission/entry or reentry? | |||
| Indent Indent Indent Indent Indent54851-1 | Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry? | |||
| Indent Indent Indent Indent Indent54852-9 | Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry? | |||
| Indent Indent Indent Indent54853-7 | Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent | |||
| Indent Indent Indent Indent54854-5 | Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent | |||
| Indent Indent Indent Indent Indent54855-2 | No injury | |||
| Indent Indent Indent Indent Indent54856-0 | Injury (except major) | |||
| Indent Indent Indent Indent Indent54857-8 | Major injury | |||
| Indent Indent Indent83274-1 | Prior Surgery | |||
| Indent Indent Indent90542-2 | Recent Surgery Requiring Active SNF Care | |||
| Indent Indent Indent90745-1 | Surgical Procedures | 1..* | ||
| Indent Indent101271-5 | Swallowing &or Nutritional Status | |||
| Indent Indent Indent86677-2 | Swallowing Disorder | 1..4 | ||
| Indent Indent Indent54567-3 | Height and Weight | |||
| Indent Indent Indent Indent103692-0 | Height (in inches) | [in_us];cm;m | ||
| Indent Indent Indent Indent103693-8 | Weight (in pounds) | [lb_av];kg | ||
| Indent Indent Indent54863-6 | Weight Loss | |||
| Indent Indent Indent86678-0 | Weight Gain | |||
| Indent Indent Indent54568-1 | Nutritional Approaches | |||
| Indent Indent Indent Indent101327-5 | Nutritional Approaches. On Admission | 1..4 | ||
| Indent Indent Indent Indent71444-4 | Nutritional Approaches. While NOT a Resident | 1..2 | ||
| Indent Indent Indent Indent71445-1 | Nutritional Approaches. While a Resident | 1..4 | ||
| Indent Indent Indent Indent101328-3 | Nutritional Approaches. At Discharge | 1..4 | ||
| Indent Indent Indent90543-0 | Percent Intake by Artificial Route | |||
| Indent Indent Indent Indent86681-4 | Proportion of total calories the resident received through parenteral or tube feeding. While a Resident | |||
| Indent Indent Indent Indent86687-1 | Proportion of total calories the resident received through parenteral or tube feeding. During Entire 7 Days | |||
| Indent Indent Indent Indent86683-0 | Average fluid intake per day by IV or tube feeding. While a Resident | mL/d;L/d | ||
| Indent Indent Indent Indent86684-8 | Average fluid intake per day by IV or tube feeding. During Entire 7 Days | mL/d;L/d | ||
| Indent Indent101272-3 | Oral/Dental Status | |||
| Indent Indent Indent86706-9 | Dental | 1..7 | ||
| Indent Indent101273-1 | Skin Conditions | |||
| Indent Indent Indent101333-3 | Determination of Pressure Ulcer/Injury Risk | 1..3 | ||
| Indent Indent Indent57280-0 | Risk of Pressure Ulcers/Injuries | |||
| Indent Indent Indent58214-8 | Unhealed Pressure Ulcers/Injuries | |||
| Indent Indent Indent88961-8 | Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage | |||
| Indent Indent Indent Indent54884-2 | Number of Stage 1 pressure injuries | {#} | ||
| Indent Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54886-7 | Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent55125-9 | Number of Stage 3 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54887-5 | Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent55126-7 | Number of Stage 4 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54890-9 | Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54893-3 | Number of unstageable pressure ulcers/injuries due to non-removable dressing/device | {#} | ||
| Indent Indent Indent Indent54894-1 | Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54946-9 | Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar | {#} | ||
| Indent Indent Indent Indent54947-7 | Number of these unstageable pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54950-1 | Number of unstageable pressure injuries presenting as deep tissue injury | {#} | ||
| Indent Indent Indent Indent54951-9 | Number of these unstageable pressure injuries that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent101330-9 | Number of Venous and Arterial Ulcers | {#} | ||
| Indent Indent Indent101331-7 | Other Ulcers, Wounds and Skin Problems | 1..8 | ||
| Indent Indent Indent86748-1 | Skin and Ulcer/Injury Treatments | 1..9 | ||
| Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
| Indent Indent101274-9 | Medications | |||
| Indent Indent Indent54982-4 | Injections | d/(7.d) | ||
| Indent Indent Indent58217-1 | Insulin | |||
| Indent Indent Indent Indent58127-2 | Insulin injections | d/(7.d) | ||
| Indent Indent Indent Indent58128-0 | Orders for insulin | d/(7.d) | ||
| Indent Indent Indent93155-0 | High-Risk Drug Classes: Use and Indication | |||
| Indent Indent Indent Indent93153-5 | Is taking | 1..10 | ||
| Indent Indent Indent Indent93154-3 | Indication noted | 1..10 | ||
| Indent Indent Indent88295-1 | Antipsychotic Medication Review | |||
| Indent Indent Indent Indent88296-9 | Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent? | |||
| Indent Indent Indent Indent88297-7 | Has a gradual dose reduction (GDR) been attempted? | |||
| Indent Indent Indent Indent88298-5 | Date of last attempted GDR | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent88299-3 | Physician documented GDR as clinically contraindicated | |||
| Indent Indent Indent Indent88300-9 | Date physician documented GDR as clinically contraindicated | {mm/dd/yyyy} | ||
| Indent Indent Indent57255-2 | Drug Regimen Review | |||
| Indent Indent Indent57281-8 | Medication Follow-up | |||
| Indent Indent Indent57256-0 | Medication Intervention | |||
| Indent Indent101275-6 | Special Treatments, Procedures, and Programs | |||
| Indent Indent Indent101346-5 | Special Treatments, Procedures, and Programs | |||
| Indent Indent Indent Indent83252-7 | Special Treatments, Procedures, and Programs - On Admission | 1..30 | ||
| Indent Indent Indent Indent86761-4 | Special Treatments, Procedures, and Programs - While a Resident | 1..14 | ||
| Indent Indent Indent Indent93185-7 | Special Treatments, Procedures, and Programs - At Discharge | 1..31 | ||
| Indent Indent Indent69339-0 | Influenza Vaccine | |||
| Indent Indent Indent Indent55019-4 | Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? | |||
| Indent Indent Indent Indent58131-4 | Date influenza vaccine received | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent55020-2 | If influenza vaccine not received, state reason: | |||
| Indent Indent Indent55021-0 | Pneumococcal Vaccine | |||
| Indent Indent Indent Indent55022-8 | Is the resident's Pneumococcal vaccination up to date? | |||
| Indent Indent Indent Indent45956-0 | If Pneumococcal vaccine not received, state reason: | |||
| Indent Indent Indent86762-2 | Therapies | |||
| Indent Indent Indent Indent86763-0 | Speech-Language Pathology and Audiology Services | |||
| Indent Indent Indent Indent Indent58218-9 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent58133-0 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent58134-8 | Group minutes | min | ||
| Indent Indent Indent Indent Indent86765-5 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent45760-6 | Days | d/(7.d) | ||
| Indent Indent Indent Indent Indent55025-1 | Therapy start date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent Indent55026-9 | Therapy end date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent86767-1 | Occupational Therapy | |||
| Indent Indent Indent Indent Indent58219-7 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent58136-3 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent58137-1 | Group minutes | min | ||
| Indent Indent Indent Indent Indent86764-8 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent45762-2 | Days | d/(7.d) | ||
| Indent Indent Indent Indent Indent55027-7 | Therapy start date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent Indent55028-5 | Therapy end date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent86768-9 | Physical Therapy | |||
| Indent Indent Indent Indent Indent58220-5 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent58139-7 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent58140-5 | Group minutes | min | ||
| Indent Indent Indent Indent Indent86766-3 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent45764-8 | Days | d/(7.d) | ||
| Indent Indent Indent Indent Indent55029-3 | Therapy start date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent Indent55030-1 | Therapy end date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent58141-3 | Respiratory Therapy | |||
| Indent Indent Indent Indent Indent45767-1 | Total minutes | min | ||
| Indent Indent Indent Indent Indent45766-3 | Days | d/(7.d) | ||
| Indent Indent Indent Indent58142-1 | Psychological Therapy (by any licensed mental health professional) | |||
| Indent Indent Indent Indent Indent45852-1 | Total minutes | min | ||
| Indent Indent Indent Indent Indent45768-9 | Days | d/(7.d) | ||
| Indent Indent Indent Indent58143-9 | Recreational Therapy (includes recreational and music therapy) | |||
| Indent Indent Indent Indent Indent55035-0 | Total minutes | min | ||
| Indent Indent Indent Indent Indent55036-8 | Days | d/(7.d) | ||
| Indent Indent Indent86769-7 | Distinct Calendar Days of Therapy | d | ||
| Indent Indent Indent90544-8 | Part A Therapies | |||
| Indent Indent Indent Indent90545-5 | Speech-Language Pathology and Audiology Services | |||
| Indent Indent Indent Indent Indent90539-8 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90536-4 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90538-0 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90537-2 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90551-3 | Days | d/{#} | ||
| Indent Indent Indent Indent90546-3 | Occupational Therapy | |||
| Indent Indent Indent Indent Indent90531-5 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90527-3 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90529-9 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90528-1 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90530-7 | Days | d/{#} | ||
| Indent Indent Indent Indent90547-1 | Physical Therapy | |||
| Indent Indent Indent Indent Indent90535-6 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90532-3 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90534-9 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90533-1 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90550-5 | Days | d/{#} | ||
| Indent Indent Indent90548-9 | Distinct Calendar Days of Part A Therapy | {#} | ||
| Indent Indent Indent86773-9 | Restorative Nursing Programs | |||
| Indent Indent Indent Indent86774-7 | Technique. Range of motion (passive) | d/(7.d) | ||
| Indent Indent Indent Indent86775-4 | Technique. Range of motion (active) | d/(7.d) | ||
| Indent Indent Indent Indent86776-2 | Technique. Splint or brace assistance | d/(7.d) | ||
| Indent Indent Indent Indent86777-0 | Training and Skill Practice In: Bed mobility | d/(7.d) | ||
| Indent Indent Indent Indent86778-8 | Training and Skill Practice In: Transfer | d/(7.d) | ||
| Indent Indent Indent Indent86779-6 | Training and Skill Practice In: Walking | d/(7.d) | ||
| Indent Indent Indent Indent86780-4 | Training and Skill Practice In: Dressing and/or grooming | d/(7.d) | ||
| Indent Indent Indent Indent86781-2 | Training and Skill Practice In: Eating and/or swallowing | d/(7.d) | ||
| Indent Indent Indent Indent86782-0 | Training and Skill Practice In: Amputation/prostheses care | d/(7.d) | ||
| Indent Indent Indent Indent86783-8 | Training and Skill Practice In: Communication | d/(7.d) | ||
| Indent Indent101276-4 | Restraints and Alarms | |||
| Indent Indent Indent86785-3 | Physical Restraints | |||
| Indent Indent Indent Indent86786-1 | Used in Bed. Bed rail | d/(7.d) | ||
| Indent Indent Indent Indent86787-9 | Used in Bed. Trunk restraint | d/(7.d) | ||
| Indent Indent Indent Indent86788-7 | Used in Bed. Limb restraint | d/(7.d) | ||
| Indent Indent Indent Indent86789-5 | Used in Bed. Other | d/(7.d) | ||
| Indent Indent Indent Indent86790-3 | Used in Chair or Out of Bed. Trunk restraint | d/(7.d) | ||
| Indent Indent Indent Indent86791-1 | Used in Chair or Out of Bed. Limb restraint | d/(7.d) | ||
| Indent Indent Indent Indent86792-9 | Used in Chair or Out of Bed. Chair prevents rising | d/(7.d) | ||
| Indent Indent Indent Indent86793-7 | Used in Chair or Out of Bed. Other | d/(7.d) | ||
| Indent Indent Indent88309-0 | Alarms | |||
| Indent Indent Indent Indent88310-8 | Bed alarm | |||
| Indent Indent Indent Indent88311-6 | Chair alarm | |||
| Indent Indent Indent Indent88312-4 | Floor mat alarm | |||
| Indent Indent Indent Indent88313-2 | Motion sensor alarm | |||
| Indent Indent Indent Indent88314-0 | Wander/elopement alarm | |||
| Indent Indent Indent Indent88308-2 | Other alarm | |||
| Indent Indent101277-2 | Participation in Assessment and Goal Setting | |||
| Indent Indent Indent101329-1 | Participation in Assessment and Goal Setting | 1..5 | ||
| Indent Indent Indent55056-6 | Resident's Overall Goal | |||
| Indent Indent Indent Indent55057-4 | Resident's overall goal for discharge established during the assessment process. | |||
| Indent Indent Indent Indent55058-2 | Indicate information source for Q0310A | |||
| Indent Indent Indent101436-4 | Discharge Plan | |||
| Indent Indent Indent Indent58146-2 | Is active discharge planning already occurring for the resident to return to the community? | |||
| Indent Indent Indent86795-2 | Resident's Documented Preference to Avoid Being Asked Question Q0500B | |||
| Indent Indent Indent101347-3 | Return to Community | |||
| Indent Indent Indent Indent58149-6 | Do you want to talk to someone about the possiblity of leaving this facility and returning to live and receive services in the community? | |||
| Indent Indent Indent Indent86798-6 | Indicate information source for Q0500B | |||
| Indent Indent Indent86796-0 | Resident's Preference to Avoid Being Asked Question Q0500B Again | |||
| Indent Indent Indent Indent86797-8 | Does resident (or family or significant other or guardian or legally authorized representative only if resident is unable to understand or respond) want to be asked about returning to the community on all assessments? | |||
| Indent Indent Indent Indent86798-6 | Indicate information source for Q0550A | |||
| Indent Indent Indent101435-6 | Referral | |||
| Indent Indent Indent Indent101374-7 | Has a referral been made to the Local Contact Agency (LCA)? | |||
| Indent Indent Indent101332-5 | Reason Referral to Local Contact Agency (LCA) Not Made | |||
| Indent Indent101278-0 | Care Area Assessment (CAA) Summary | |||
| Indent Indent Indent87208-5 | Items From the Most Recent Prior OBRA or Scheduled PPS Assessment | |||
| Indent Indent Indent Indent54583-0 | Prior Assessment Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | Prior Assessment PPS Reason for Assessment | |||
| Indent Indent Indent Indent54593-9 | Prior Assessment Reference Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent103704-3 | Prior Assessment Brief Interview for Mental Status (BIMS) Summary Score | {score} | ||
| Indent Indent Indent Indent103705-0 | Prior Assessment Resident Mood Interview (PHQ-2 to 9©) Total Severity Score | {score} | ||
| Indent Indent Indent Indent103707-6 | Prior Assessment Staff Assessment of Resident Mood (PHQ-9-OV) Total Severity Score | {score} | ||
| Indent Indent Indent87210-1 | CAAs and Care Planning | 0..20 | ||
| Indent Indent Indent Indent87211-9 | CAA Results | |||
| Indent Indent Indent Indent Indent87212-7 | Care Area Triggered | 1..20 | ||
| Indent Indent Indent Indent Indent87213-5 | Care Planning Decision | 1..20 | ||
| Indent Indent101279-8 | Correction Request | |||
| Indent Indent Indent85632-8 | Type of Provider | 1..1 | ||
| Indent Indent Indent87226-7 | Name of Resident | |||
| Indent Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent90492-0 | Type of Assessment | |||
| Indent Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent Indent86525-3 | Is this a SNF Part A PPS Discharge Assessment? | |||
| Indent Indent Indent87216-8 | Date on existing record to be modified/inactivated | |||
| Indent Indent Indent Indent54593-9 | Assessment Reference Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent52525-3 | Discharge Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent Indent87209-3 | Correction Attestation Section | |||
| Indent Indent Indent Indent58200-7 | Correction Number | {#} | ||
| Indent Indent Indent Indent87217-6 | Reasons for Modification | 1..5 | ||
| Indent Indent Indent Indent87225-9 | Reasons for Inactivation | 1..2 | ||
| Indent Indent Indent Indent87218-4 | RN Assessment Coordinator Attestation of Completion | |||
| Indent Indent Indent Indent Indent87219-2 | Attesting individual's first name | |||
| Indent Indent Indent Indent Indent87220-0 | Attesting individual's last name | |||
| Indent Indent Indent Indent Indent87221-8 | Attesting individual's title | |||
| Indent Indent Indent Indent Indent87222-6 | Attestation date | {mm/dd/yyyy} | ||
| Indent Indent101280-6 | Assessment Administration | |||
| Indent Indent Indent90498-7 | Medicare Part A Billing | |||
| Indent Indent Indent Indent55065-7 | Medicare Part A HIPPS code | |||
| Indent Indent Indent Indent55081-4 | Version code | |||
| Indent Indent Indent93053-7 | State Medicaid Billing (if required by the state) | |||
| Indent Indent Indent Indent55068-1 | Case Mix group | |||
| Indent Indent Indent Indent55081-4 | Version code | |||
| Indent Indent Indent93052-9 | Alternate State Medicaid Billing (if required by the state) | |||
| Indent Indent Indent Indent58212-2 | Case Mix group | |||
| Indent Indent Indent Indent55081-4 | Version code | |||
| Indent Indent Indent93051-1 | Insurance Billing | |||
| Indent Indent Indent Indent55071-5 | Billing code | |||
| Indent Indent Indent Indent55081-4 | Billing version | |||
| Indent Indent Indent85648-4 | Signature of Persons Completing the Assessment or Entry/Death Reporting | |||
| Indent Indent Indent70127-6 | Signature of RN Assessment Coordinator Verifying Assessment Completion | |||
| Indent Indent Indent Indent70127-6 | Signature: | |||
| Indent Indent Indent Indent30947-6 | Date RN Assessment Coordinator signed assessment as complete: | {mm/dd/yyyy} | ||
| Indent101106-3 | MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set | |||
| Indent Indent101591-6 | Identification Information | |||
| Indent Indent Indent58198-3 | Type of Record | |||
| Indent Indent Indent54581-4 | Facility Provider Numbers | |||
| Indent Indent Indent Indent76468-8 | National Provider Identifier (NPI) | |||
| Indent Indent Indent Indent69417-4 | CMS Certification Number (CCN) | |||
| Indent Indent Indent Indent45398-5 | State Provider Number | |||
| Indent Indent Indent85632-8 | Type of Provider | |||
| Indent Indent Indent86524-6 | Type of Assessment | |||
| Indent Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent Indent54587-1 | Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry? | |||
| Indent Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent Indent71440-2 | Type of discharge | |||
| Indent Indent Indent Indent90525-7 | Is this a SNF Part A Interrupted Stay? | |||
| Indent Indent Indent Indent86525-3 | Is this a SNF Part A PPS Discharge Assessment? | |||
| Indent Indent Indent86526-1 | Unit Certification or Licensure Designation | |||
| Indent Indent Indent54503-8 | Legal Name of Resident | |||
| Indent Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent Indent45393-6 | Middle initial | |||
| Indent Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent Indent45395-1 | Suffix | |||
| Indent Indent Indent45966-9 | Social Security and Medicare Numbers | |||
| Indent Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent Indent45397-7 | Medicare number | |||
| Indent Indent Indent45400-9 | Medicaid Number | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent69854-8 | Ethnicity. Are you of Hispanic, Latino/a, or Spanish origin? | 1..4 | ||
| Indent Indent Indent103708-4 | Race. What is your race? | 1..14 | ||
| Indent Indent Indent93186-5 | Language | |||
| Indent Indent Indent Indent54899-0 | What is your preferred language? | |||
| Indent Indent Indent Indent54588-9 | Do you need or want an interpreter to communicate with a doctor or health care staff? | |||
| Indent Indent Indent45404-1 | Marital Status | |||
| Indent Indent Indent101351-5 | Transportation (from NACHC©) | |||
| Indent Indent Indent54506-1 | Optional Resident Items | |||
| Indent Indent Indent Indent46106-1 | Medical record number | |||
| Indent Indent Indent Indent45403-3 | Room number | |||
| Indent Indent Indent Indent52462-9 | Name by which resident prefers to be addressed | |||
| Indent Indent Indent Indent21843-8 | Lifetime occupation(s) | |||
| Indent Indent Indent86528-7 | Most Recent Admission/Entry or Reentry into this Facility | |||
| Indent Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent54590-5 | Type of Entry | |||
| Indent Indent Indent Indent85398-6 | Entered From | |||
| Indent Indent Indent52455-3 | Admission Date | {mm/dd/yyyy} | ||
| Indent Indent Indent52525-3 | Discharge Date | {mm/dd/yyyy} | ||
| Indent Indent Indent55128-3 | Discharge Status | |||
| Indent Indent Indent93182-4 | Provision of Current Reconciled Medication List to Subsequent Provider at Discharge | |||
| Indent Indent Indent93184-0 | Route of Current Reconciled Medication List Transmission to Subsequent Provider | 1..5 | ||
| Indent Indent Indent93181-6 | Provision of Current Reconciled Medication List to Resident at Discharge | |||
| Indent Indent Indent93183-2 | Route of Current Reconciled Medication List Transmission to Resident | 1..5 | ||
| Indent Indent Indent54592-1 | Previous Assessment Reference Date for Significant Correction | {mm/dd/yyyy} | ||
| Indent Indent Indent54593-9 | Assessment Reference Date. Observation end date | {mm/dd/yyyy} | ||
| Indent Indent Indent54507-9 | Medicare Stay | |||
| Indent Indent Indent Indent54594-7 | Has the resident had a Medicare-covered stay since the most recent entry? | |||
| Indent Indent Indent Indent54595-4 | Start date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent54596-2 | End date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent54508-7 | Hearing, Speech, and Vision | |||
| Indent Indent Indent54597-0 | Comatose | |||
| Indent Indent Indent95744-9 | Hearing | |||
| Indent Indent Indent54599-6 | Hearing Aid | |||
| Indent Indent Indent54600-2 | Speech Clarity | |||
| Indent Indent Indent95737-3 | Makes Self Understood | |||
| Indent Indent Indent54602-8 | Ability to Understand Others | |||
| Indent Indent Indent95745-6 | Vision | |||
| Indent Indent Indent54604-4 | Corrective Lenses | |||
| Indent Indent Indent103709-2 | Health Literacy | |||
| Indent Indent101592-4 | Cognitive Patterns | |||
| Indent Indent Indent54605-1 | Should Brief Interview for Mental Status (C0200-C0500) be Conducted? | |||
| Indent Indent Indent103694-6 | Brief Interview for Mental Status (BIMS) | |||
| Indent Indent Indent Indent103696-1 | Repetition of Three Words | |||
| Indent Indent Indent Indent103702-7 | Temporal Orientation | |||
| Indent Indent Indent Indent Indent103697-9 | Able to report correct year | |||
| Indent Indent Indent Indent Indent103698-7 | Able to report correct month | |||
| Indent Indent Indent Indent Indent103703-5 | Able to report correct day of the week | |||
| Indent Indent Indent Indent103695-3 | Recall | |||
| Indent Indent Indent Indent Indent103699-5 | Able to recall "sock" | |||
| Indent Indent Indent Indent Indent103700-1 | Able to recall "blue" | |||
| Indent Indent Indent Indent Indent103701-9 | Able to recall "bed" | |||
| Indent Indent Indent Indent103704-3 | BIMS Summary Score | {score} | ||
| Indent Indent Indent54615-0 | Should the Staff Assessment for Mental Status (C0700 - C1000) be Conducted? | |||
| Indent Indent Indent83241-0 | Staff Assessment for Mental Status | |||
| Indent Indent Indent Indent54616-8 | Short-term Memory OK | |||
| Indent Indent Indent Indent54617-6 | Long-term Memory OK | |||
| Indent Indent Indent Indent95743-1 | Memory/Recall Ability | 1..4 | ||
| Indent Indent Indent Indent54624-2 | Cognitive Skills for Daily Decision Making | |||
| Indent Indent Indent95816-5 | Signs and Symptoms of Delirium (from CAM©) | |||
| Indent Indent Indent Indent95813-2 | Acute Onset Mental Change | |||
| Indent Indent Indent Indent95812-4 | Inattention | |||
| Indent Indent Indent Indent95814-0 | Disorganized Thinking | |||
| Indent Indent Indent Indent95815-7 | Altered Level of Consciousness | |||
| Indent Indent101594-0 | Mood | |||
| Indent Indent Indent54634-1 | Should Resident Mood Interview be Conducted? | |||
| Indent Indent Indent54635-8 | Resident Mood Interview (PHQ-2 to 9) | |||
| Indent Indent Indent Indent86843-0 | Symptom Presence | |||
| Indent Indent Indent Indent Indent54636-6 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54638-2 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54640-8 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54642-4 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54644-0 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54646-5 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54648-1 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54650-7 | 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 | |||
| Indent Indent Indent Indent Indent54652-3 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent Indent86844-8 | Symptom Frequency | |||
| Indent Indent Indent Indent Indent54637-4 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54639-0 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54641-6 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54643-2 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54645-7 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54647-3 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54649-9 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54651-5 | 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 | |||
| Indent Indent Indent Indent Indent54653-1 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent103705-0 | Total Severity Score | {score} | ||
| Indent Indent Indent103706-8 | Staff Assessment of Resident Mood (PHQ-9-OV) | |||
| Indent Indent Indent Indent86833-1 | Symptom Presence | |||
| Indent Indent Indent Indent Indent54658-0 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54660-6 | Feeling or appearing down, depressed, or hopeless | |||
| Indent Indent Indent Indent Indent54662-2 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54664-8 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54666-3 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54668-9 | Indicating that they feel bad about self, are a failure, or have let self or family down | |||
| Indent Indent Indent Indent Indent54670-5 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54672-1 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that they have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54673-9 | States that life isn't worth living, wishes for death, or attempts to harm self | |||
| Indent Indent Indent Indent Indent54675-4 | Being short-tempered, easily annoyed | |||
| Indent Indent Indent Indent86891-9 | Symptom Frequency | |||
| Indent Indent Indent Indent Indent54659-8 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54661-4 | Feeling or appearing down, depressed, or hopeless | |||
| Indent Indent Indent Indent Indent54663-0 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54665-5 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54667-1 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54669-7 | Indicating that they feel bad about self, are a failure, or have let self or family down | |||
| Indent Indent Indent Indent Indent54671-3 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54904-8 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that they have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54674-7 | States that life isn't worth living, wishes for death, or attempts to harm self | |||
| Indent Indent Indent Indent Indent54676-2 | Being short-tempered, easily annoyed | |||
| Indent Indent Indent103707-6 | Total Severity Score | {score} | ||
| Indent Indent Indent93159-2 | Social Isolation | |||
| Indent Indent86596-4 | Behavior | |||
| Indent Indent Indent86597-2 | Potential Indicators of Psychosis | 1..2 | ||
| Indent Indent54514-5 | Behavioral Symptom - Presence & Frequency | |||
| Indent Indent Indent54682-0 | Physical behavioral symptoms directed toward others | d/(7.d) | ||
| Indent Indent Indent54683-8 | Verbal behavioral symptoms directed toward others | d/(7.d) | ||
| Indent Indent Indent54684-6 | Other behavioral symptoms not directed toward others | d/(7.d) | ||
| Indent Indent54692-9 | Rejection of Care - Presence & Frequency | d/(7.d) | ||
| Indent Indent54693-7 | Wandering - Presence & Frequency | d/(7.d) | ||
| Indent Indent101595-7 | Functional Abilities and Goals | |||
| Indent Indent Indent101596-5 | Prior Functioning: Everyday Activities | |||
| Indent Indent Indent Indent85070-1 | Self-Care | |||
| Indent Indent Indent Indent85071-9 | Indoor Mobility (Ambulation) | |||
| Indent Indent Indent Indent85072-7 | Stairs | |||
| Indent Indent Indent Indent85073-5 | Functional Cognition | |||
| Indent Indent Indent83234-5 | Prior Device Use | 1..5 | ||
| Indent Indent Indent92908-3 | Functional Limitation in Range of Motion | |||
| Indent Indent Indent Indent92850-7 | Upper extremity (shoulder, elbow, wrist, hand) | |||
| Indent Indent Indent Indent92851-5 | Lower extremity (hip, knee, ankle, foot) | |||
| Indent Indent Indent86602-0 | Mobility Devices | 1..4 | ||
| Indent Indent Indent88482-5 | Functional Abilities and Goals - Admission | |||
| Indent Indent Indent Indent83233-7 | Self-Care - Admission Performance | |||
| Indent Indent Indent Indent Indent95019-6 | Eating | |||
| Indent Indent Indent Indent Indent95018-8 | Oral hygiene | |||
| Indent Indent Indent Indent Indent95017-0 | Toileting hygiene | |||
| Indent Indent Indent Indent Indent95015-4 | Shower/bathe self | |||
| Indent Indent Indent Indent Indent95014-7 | Upper body dressing | |||
| Indent Indent Indent Indent Indent95013-9 | Lower body dressing | |||
| Indent Indent Indent Indent Indent95012-1 | Putting on/taking off footwear | |||
| Indent Indent Indent Indent Indent45606-1 | Personal hygiene | |||
| Indent Indent Indent Indent85054-5 | Self-Care - Discharge Goal (Assessment period is the first 3 days of the stay) | |||
| Indent Indent Indent Indent Indent89404-8 | Oral hygiene - functional goal | |||
| Indent Indent Indent Indent Indent89409-7 | Eating | |||
| Indent Indent Indent Indent Indent89389-1 | Toileting hygiene | |||
| Indent Indent Indent Indent Indent89396-6 | Shower/bathe self | |||
| Indent Indent Indent Indent Indent89387-5 | Upper body dressing | |||
| Indent Indent Indent Indent Indent89406-3 | Lower body dressing | |||
| Indent Indent Indent Indent Indent89400-6 | Putting on/taking off footwear | |||
| Indent Indent Indent Indent Indent45606-1 | Personal hygiene | |||
| Indent Indent Indent Indent88330-6 | Mobility - Admission Performance (Assessment period is the first 3 days of the stay) | |||
| Indent Indent Indent Indent Indent95011-3 | Roll left and right | |||
| Indent Indent Indent Indent Indent95010-5 | Sit to lying | |||
| Indent Indent Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent Indent95008-9 | Sit to stand | |||
| Indent Indent Indent Indent Indent95007-1 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent Indent95006-3 | Toilet transfer | |||
| Indent Indent Indent Indent Indent101597-3 | Tub/shower transfer | |||
| Indent Indent Indent Indent Indent95005-5 | Car transfer | |||
| Indent Indent Indent Indent Indent95004-8 | Walk 10 feet | |||
| Indent Indent Indent Indent Indent95003-0 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95002-2 | Walk 150 feet | |||
| Indent Indent Indent Indent Indent95001-4 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent Indent Indent94999-0 | 4 steps | |||
| Indent Indent Indent Indent Indent94998-2 | 12 steps | |||
| Indent Indent Indent Indent Indent94997-4 | Picking up object | |||
| Indent Indent Indent Indent Indent95738-1 | Does the resident use a wheelchair and/or scooter? | |||
| Indent Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent85056-0 | Mobility - Discharge Goal Assessment period is the first 3 days of stay) | |||
| Indent Indent Indent Indent Indent89398-2 | Roll left and right | |||
| Indent Indent Indent Indent Indent89394-1 | Sit to lying | |||
| Indent Indent Indent Indent Indent85927-2 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent Indent89392-5 | Sit to stand | |||
| Indent Indent Indent Indent Indent89414-7 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent Indent89390-9 | Toilet transfer | |||
| Indent Indent Indent Indent Indent101597-3 | Tub/shower transfer | |||
| Indent Indent Indent Indent Indent89412-1 | Car transfer | |||
| Indent Indent Indent Indent Indent89385-9 | Walk 10 feet | |||
| Indent Indent Indent Indent Indent89381-8 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent Indent89383-4 | Walk 150 feet | |||
| Indent Indent Indent Indent Indent89379-2 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent Indent89420-4 | 1 step (curb) | |||
| Indent Indent Indent Indent Indent89416-2 | 4 steps | |||
| Indent Indent Indent Indent Indent89418-8 | 12 steps | |||
| Indent Indent Indent Indent Indent89402-2 | Picking up object | |||
| Indent Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent88483-3 | Functional Abilities and Goals - Discharge | |||
| Indent Indent Indent Indent83254-3 | Self-Care - Discharge Performance | |||
| Indent Indent Indent Indent Indent89409-7 | Eating | |||
| Indent Indent Indent Indent Indent89404-8 | Oral hygiene | |||
| Indent Indent Indent Indent Indent89389-1 | Toileting hygiene | |||
| Indent Indent Indent Indent Indent89396-6 | Shower/bathe self | |||
| Indent Indent Indent Indent Indent89387-5 | Upper body dressing | |||
| Indent Indent Indent Indent Indent89406-3 | Lower body dressing | |||
| Indent Indent Indent Indent Indent89400-6 | Putting on/taking off footwear | |||
| Indent Indent Indent Indent88331-4 | Mobility - Discharge Performance (Assessment period is the last 3 days of the stay) | |||
| Indent Indent Indent Indent Indent89398-2 | Roll left and right | |||
| Indent Indent Indent Indent Indent89394-1 | Sit to lying | |||
| Indent Indent Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent Indent89392-5 | Sit to stand | |||
| Indent Indent Indent Indent Indent89414-7 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent Indent89390-9 | Toilet transfer | |||
| Indent Indent Indent Indent Indent89412-1 | Car transfer | |||
| Indent Indent Indent Indent Indent89385-9 | Walk 10 feet | |||
| Indent Indent Indent Indent Indent89381-8 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent Indent89383-4 | Walk 150 feet | |||
| Indent Indent Indent Indent Indent89379-2 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent Indent Indent89416-2 | 4 steps | |||
| Indent Indent Indent Indent Indent89418-8 | 12 steps | |||
| Indent Indent Indent Indent Indent89402-2 | Picking up object | |||
| Indent Indent Indent Indent Indent95738-1 | Does the resident use a wheelchair and/or scooter? | |||
| Indent Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent101598-1 | Functional Abilities and Goals - OBRA &or Interim | |||
| Indent Indent Indent Indent101599-9 | Self-Care - OBRA/Interim Performance | |||
| Indent Indent Indent Indent Indent89409-7 | Eating | |||
| Indent Indent Indent Indent Indent89404-8 | Oral hygiene | |||
| Indent Indent Indent Indent Indent89389-1 | Toileting hygiene | |||
| Indent Indent Indent Indent Indent89396-6 | Shower/bathe self | |||
| Indent Indent Indent Indent Indent89387-5 | Upper body dressing | |||
| Indent Indent Indent Indent Indent89406-3 | Lower body dressing | |||
| Indent Indent Indent Indent Indent89400-6 | Putting on/taking off footwear | |||
| Indent Indent Indent Indent Indent45606-1 | Personal hygiene | |||
| Indent Indent Indent Indent101600-5 | Mobility - OBRA/Interim Performance (Assessment period is the ARD plus 2 previous calendar days) | |||
| Indent Indent Indent Indent Indent89398-2 | Roll left and right | |||
| Indent Indent Indent Indent Indent89394-1 | Sit to lying | |||
| Indent Indent Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent Indent89392-5 | Sit to stand | |||
| Indent Indent Indent Indent Indent89414-7 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent Indent89390-9 | Toilet transfer | |||
| Indent Indent Indent Indent Indent101597-3 | Tub/shower transfer | |||
| Indent Indent Indent Indent Indent89385-9 | Walk 10 feet | |||
| Indent Indent Indent Indent Indent89381-8 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent Indent89383-4 | Walk 150 feet | |||
| Indent Indent Indent Indent Indent95738-1 | Does the resident use a wheelchair and/or scooter? | |||
| Indent Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent83237-8 | Bladder and Bowel | |||
| Indent Indent Indent86624-4 | Appliances | 1..4 | ||
| Indent Indent Indent54530-1 | Urinary Toileting Program | |||
| Indent Indent Indent Indent54767-9 | Has a trial of a toileting program been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility? | |||
| Indent Indent Indent Indent54769-5 | Current toileting program or trial - Is a toileting program currently being used to manage the resident's urinary continence? | |||
| Indent Indent Indent95735-7 | Urinary Continence | 1..1 | ||
| Indent Indent Indent95736-5 | Bowel Continence | 1..1 | ||
| Indent Indent Indent88695-2 | Bowel Toileting Program | |||
| Indent Indent101601-3 | Active Diagnoses | |||
| Indent Indent Indent96095-5 | Indicate the resident's primary medical condition category | 1..1 | ||
| Indent Indent Indent52797-8 | ICD Code | |||
| Indent Indent Indent86671-5 | Active Diagnoses in the last 7 days | 1..* | ||
| Indent Indent Indent52797-8 | Additional active diagnoses | 0..10 | ||
| Indent Indent101602-1 | Health Conditions | |||
| Indent Indent Indent54557-4 | Pain Management | |||
| Indent Indent Indent Indent71447-7 | At any time in the last 5 days, has the resident: Received scheduled pain medication regimen? | |||
| Indent Indent Indent Indent71448-5 | At any time in the last 5 days, has the resident: Received PRN pain medications OR was offered and declined? | |||
| Indent Indent Indent Indent71449-3 | At any time in the last 5 days, has the resident: Received non-medication intervention for pain? | |||
| Indent Indent Indent54828-9 | Should Pain Assessment Interview be Conducted? | |||
| Indent Indent Indent101603-9 | Pain Assessment Interview | |||
| Indent Indent Indent Indent54829-7 | Pain Presence | |||
| Indent Indent Indent Indent54830-5 | Pain Frequency | |||
| Indent Indent Indent Indent93156-8 | Pain Effect on Sleep | |||
| Indent Indent Indent Indent93160-0 | Pain Interference with Therapy Activities | |||
| Indent Indent Indent Indent93158-4 | Pain Interference with Day-to-Day Activities | |||
| Indent Indent Indent Indent54560-8 | Pain Intensity | |||
| Indent Indent Indent Indent Indent54833-9 | Numeric Rating Scale (00-10) | |||
| Indent Indent Indent Indent Indent54834-7 | Verbal Descriptor Scale | |||
| Indent Indent Indent58117-3 | Should the Staff Assessment for Pain be Conducted? | |||
| Indent Indent Indent86672-3 | Staff Assessment for Pain | |||
| Indent Indent Indent Indent86673-1 | Indicators of Pain or Possible Pain in the last 5 days | 1..4 | ||
| Indent Indent Indent Indent58118-1 | Frequency of Indicator of Pain or Possible Pain in the last 5 days | d/(5.d) | ||
| Indent Indent Indent86674-9 | Other Health Conditions | |||
| Indent Indent Indent Indent86675-6 | Shortness of Breath (dyspnea) | 1..3 | ||
| Indent Indent Indent Indent54846-1 | Prognosis | |||
| Indent Indent Indent Indent86676-4 | Problem Conditions | 1..4 | ||
| Indent Indent Indent Indent54849-5 | Fall History on Admission/Entry or Reentry | |||
| Indent Indent Indent Indent Indent54850-3 | Did the resident have a fall any time in the last month prior to admission/entry or reentry? | |||
| Indent Indent Indent Indent Indent54851-1 | Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry? | |||
| Indent Indent Indent Indent Indent54852-9 | Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry? | |||
| Indent Indent Indent Indent54853-7 | Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent | |||
| Indent Indent Indent Indent54854-5 | Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent | |||
| Indent Indent Indent Indent Indent54855-2 | No injury | |||
| Indent Indent Indent Indent Indent54856-0 | Injury (except major) | |||
| Indent Indent Indent Indent Indent54857-8 | Major injury | |||
| Indent Indent Indent83274-1 | Prior Surgery | |||
| Indent Indent Indent90542-2 | Recent Surgery Requiring Active SNF Care | |||
| Indent Indent Indent90745-1 | Surgical Procedures | 1..* | ||
| Indent Indent101604-7 | Swallowing &or Nutritional Status | |||
| Indent Indent Indent86677-2 | Swallowing Disorder | 1..4 | ||
| Indent Indent Indent54567-3 | Height and Weight | |||
| Indent Indent Indent Indent103692-0 | Height (in inches) | [in_us];cm;m | ||
| Indent Indent Indent Indent103693-8 | Weight (in pounds) | [lb_av];kg | ||
| Indent Indent Indent54863-6 | Weight Loss | |||
| Indent Indent Indent86678-0 | Weight Gain | |||
| Indent Indent Indent54568-1 | Nutritional Approaches | |||
| Indent Indent Indent Indent101632-8 | Nutritional Approaches. On Admission | 1..4 | ||
| Indent Indent Indent Indent71444-4 | Nutritional Approaches. While NOT a Resident | 1..2 | ||
| Indent Indent Indent Indent71445-1 | Nutritional Approaches. While a Resident | 1..4 | ||
| Indent Indent Indent Indent101605-4 | Nutritional Approaches. At Discharge | 1..4 | ||
| Indent Indent Indent90543-0 | Percent Intake by Artificial Route | |||
| Indent Indent Indent Indent86681-4 | Proportion of total calories the resident received through parenteral or tube feeding. While a Resident | |||
| Indent Indent Indent Indent86687-1 | Proportion of total calories the resident received through parenteral or tube feeding. During Entire 7 Days | |||
| Indent Indent Indent Indent86683-0 | Average fluid intake per day by IV or tube feeding. While a Resident | mL/d;L/d | ||
| Indent Indent Indent Indent86684-8 | Average fluid intake per day by IV or tube feeding. During Entire 7 Days | mL/d;L/d | ||
| Indent Indent101606-2 | Oral/Dental Status | |||
| Indent Indent Indent86706-9 | Dental | 1..2 | ||
| Indent Indent101607-0 | Skin Conditions | |||
| Indent Indent Indent101333-3 | Determination of Pressure Ulcer/Injury Risk | 1..3 | ||
| Indent Indent Indent57280-0 | Risk of Pressure Ulcers/Injuries | |||
| Indent Indent Indent58214-8 | Unhealed Pressure Ulcers/Injuries | |||
| Indent Indent Indent101611-2 | Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage | |||
| Indent Indent Indent Indent54884-2 | Number of Stage 1 pressure injuries | {#} | ||
| Indent Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54886-7 | Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent55125-9 | Number of Stage 3 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54887-5 | Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent55126-7 | Number of Stage 4 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54890-9 | Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54893-3 | Number of unstageable pressure ulcers/injuries due to non-removable dressing/device | {#} | ||
| Indent Indent Indent Indent54894-1 | Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54946-9 | Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar | {#} | ||
| Indent Indent Indent Indent54947-7 | Number of these unstageable pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54950-1 | Number of unstageable pressure injuries presenting as deep tissue injury | {#} | ||
| Indent Indent Indent Indent54951-9 | Number of these unstageable pressure injuries that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent101609-6 | Number of Venous and Arterial Ulcers | {#} | ||
| Indent Indent Indent101610-4 | Other Ulcers, Wounds and Skin Problems | 1..8 | ||
| Indent Indent Indent86748-1 | Skin and Ulcer/Injury Treatments | 1..9 | ||
| Indent Indent86749-9 | Medications | |||
| Indent Indent Indent54982-4 | Injections | d/(7.d) | ||
| Indent Indent Indent58217-1 | Insulin | |||
| Indent Indent Indent Indent58127-2 | Insulin injections | d/(7.d) | ||
| Indent Indent Indent Indent58128-0 | Orders for insulin | d/(7.d) | ||
| Indent Indent Indent101612-0 | High-Risk Drug Classes: Use and Indication | |||
| Indent Indent Indent Indent93153-5 | Is taking | 1..10 | ||
| Indent Indent Indent Indent93154-3 | Indication noted | 0..10 | ||
| Indent Indent Indent88295-1 | Antipsychotic Medication Review | |||
| Indent Indent Indent Indent88296-9 | Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent? | |||
| Indent Indent Indent Indent88297-7 | Has a gradual dose reduction (GDR) been attempted? | |||
| Indent Indent Indent Indent88298-5 | Date of last attempted GDR | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent88299-3 | Physician documented GDR as clinically contraindicated | |||
| Indent Indent Indent Indent88300-9 | Date physician documented GDR as clinically contraindicated | {mm/dd/yyyy} | ||
| Indent Indent Indent57255-2 | Drug Regimen Review | |||
| Indent Indent Indent57281-8 | Medication Follow-up | |||
| Indent Indent Indent57256-0 | Medication Intervention | |||
| Indent Indent101613-8 | Special Treatments, Procedures, and Programs | |||
| Indent Indent Indent101614-6 | Special Treatments, Procedures, and Programs | |||
| Indent Indent Indent Indent83252-7 | Special Treatments, Procedures, and Programs - On Admission | 1..30 | ||
| Indent Indent Indent Indent86761-4 | Special Treatments, Procedures, and Programs - While a Resident | 1..13 | ||
| Indent Indent Indent Indent93185-7 | Special Treatments, Procedures, and Programs - At Discharge | 1..30 | ||
| Indent Indent Indent69339-0 | Influenza Vaccine | |||
| Indent Indent Indent Indent55019-4 | Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? | |||
| Indent Indent Indent Indent58131-4 | Date influenza vaccine received | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent55020-2 | If influenza vaccine not received, state reason: | |||
| Indent Indent Indent55021-0 | Pneumococcal Vaccine | |||
| Indent Indent Indent Indent55022-8 | Is the resident's Pneumococcal vaccination up to date? | |||
| Indent Indent Indent Indent45956-0 | If Pneumococcal vaccine not received, state reason: | |||
| Indent Indent Indent86762-2 | Therapies | |||
| Indent Indent Indent Indent86763-0 | Speech-Language Pathology and Audiology Services | |||
| Indent Indent Indent Indent Indent58218-9 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent58133-0 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent58134-8 | Group minutes | min | ||
| Indent Indent Indent Indent Indent86765-5 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent45760-6 | Days | d/(7.d) | ||
| Indent Indent Indent Indent Indent55025-1 | Therapy start date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent Indent55026-9 | Therapy end date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent86767-1 | Occupational Therapy | |||
| Indent Indent Indent Indent Indent58219-7 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent58136-3 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent58137-1 | Group minutes | min | ||
| Indent Indent Indent Indent Indent86764-8 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent45762-2 | Days | d/(7.d) | ||
| Indent Indent Indent Indent Indent55027-7 | Therapy start date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent Indent55028-5 | Therapy end date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent86768-9 | Physical Therapy | |||
| Indent Indent Indent Indent Indent58220-5 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent58139-7 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent58140-5 | Group minutes | min | ||
| Indent Indent Indent Indent Indent86766-3 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent45764-8 | Days | d/(7.d) | ||
| Indent Indent Indent Indent Indent55029-3 | Therapy start date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent Indent55030-1 | Therapy end date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent58141-3 | Respiratory Therapy | |||
| Indent Indent Indent Indent Indent45766-3 | Days | d/(7.d) | ||
| Indent Indent Indent Indent58142-1 | Psychological Therapy (by any licensed mental health professional) | |||
| Indent Indent Indent Indent Indent45768-9 | Days | d/(7.d) | ||
| Indent Indent Indent86769-7 | Distinct Calendar Days of Therapy | d | ||
| Indent Indent Indent90544-8 | Part A Therapies | |||
| Indent Indent Indent Indent90545-5 | Speech-Language Pathology and Audiology Services | |||
| Indent Indent Indent Indent Indent90539-8 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90536-4 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90538-0 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90537-2 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90551-3 | Days | d/{#} | ||
| Indent Indent Indent Indent90546-3 | Occupational Therapy | |||
| Indent Indent Indent Indent Indent90531-5 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90527-3 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90529-9 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90528-1 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90530-7 | Days | d/{#} | ||
| Indent Indent Indent Indent90547-1 | Physical Therapy | |||
| Indent Indent Indent Indent Indent90535-6 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90532-3 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90534-9 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90533-1 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90550-5 | Days | d/{#} | ||
| Indent Indent Indent90548-9 | Distinct Calendar Days of Part A Therapy | {#} | ||
| Indent Indent Indent86773-9 | Restorative Nursing Programs | |||
| Indent Indent Indent Indent86774-7 | Technique. Range of motion (passive) | d/(7.d) | ||
| Indent Indent Indent Indent86775-4 | Technique. Range of motion (active) | d/(7.d) | ||
| Indent Indent Indent Indent86776-2 | Technique. Splint or brace assistance | d/(7.d) | ||
| Indent Indent Indent Indent86777-0 | Training and Skill Practice In: Bed mobility | d/(7.d) | ||
| Indent Indent Indent Indent86778-8 | Training and Skill Practice In: Transfer | d/(7.d) | ||
| Indent Indent Indent Indent86779-6 | Training and Skill Practice In: Walking | d/(7.d) | ||
| Indent Indent Indent Indent86780-4 | Training and Skill Practice In: Dressing and/or grooming | d/(7.d) | ||
| Indent Indent Indent Indent86781-2 | Training and Skill Practice In: Eating and/or swallowing | d/(7.d) | ||
| Indent Indent Indent Indent86782-0 | Training and Skill Practice In: Amputation/prostheses care | d/(7.d) | ||
| Indent Indent Indent Indent86783-8 | Training and Skill Practice In: Communication | d/(7.d) | ||
| Indent Indent88307-4 | Restraints and Alarms | |||
| Indent Indent Indent86785-3 | Physical Restraints | |||
| Indent Indent Indent Indent86786-1 | Used in Bed. Bed rail | d/(7.d) | ||
| Indent Indent Indent Indent86787-9 | Used in Bed. Trunk restraint | d/(7.d) | ||
| Indent Indent Indent Indent86788-7 | Used in Bed. Limb restraint | d/(7.d) | ||
| Indent Indent Indent Indent86789-5 | Used in Bed. Other | d/(7.d) | ||
| Indent Indent Indent Indent86790-3 | Used in Chair or Out of Bed. Trunk restraint | d/(7.d) | ||
| Indent Indent Indent Indent86791-1 | Used in Chair or Out of Bed. Limb restraint | d/(7.d) | ||
| Indent Indent Indent Indent86792-9 | Used in Chair or Out of Bed. Chair prevents rising | d/(7.d) | ||
| Indent Indent Indent Indent86793-7 | Used in Chair or Out of Bed. Other | d/(7.d) | ||
| Indent Indent Indent88309-0 | Alarms | |||
| Indent Indent Indent Indent88310-8 | Bed alarm | |||
| Indent Indent Indent Indent88311-6 | Chair alarm | |||
| Indent Indent Indent Indent88312-4 | Floor mat alarm | |||
| Indent Indent Indent Indent88313-2 | Motion sensor alarm | |||
| Indent Indent Indent Indent88314-0 | Wander/elopement alarm | |||
| Indent Indent Indent Indent88308-2 | Other alarm | |||
| Indent Indent101615-3 | Participation in Assessment and Goal Setting | |||
| Indent Indent Indent101616-1 | Participation in Assessment and Goal Setting | 1..5 | ||
| Indent Indent Indent55056-6 | Resident's Overall Goal | |||
| Indent Indent Indent Indent55057-4 | Resident's overall goal for discharge established during the assessment process. | |||
| Indent Indent Indent Indent55058-2 | Indicate information source for Q0310A | |||
| Indent Indent Indent101617-9 | Discharge Plan | |||
| Indent Indent Indent Indent58146-2 | Is active discharge planning already occurring for the resident to return to the community? | |||
| Indent Indent Indent86795-2 | Resident's Documented Preference to Avoid Being Asked Question Q0500B | |||
| Indent Indent Indent101618-7 | Return to Community | |||
| Indent Indent Indent Indent58149-6 | Do you want to talk to someone about the possiblity of leaving this facility and returning to live and receive services in the community? | |||
| Indent Indent Indent Indent86798-6 | Indicate information source for Q0500B | |||
| Indent Indent Indent86796-0 | Resident's Preference to Avoid Being Asked Question Q0500B Again | |||
| Indent Indent Indent Indent86797-8 | Does resident (or family or significant other or guardian or legally authorized representative only if resident is unable to understand or respond) want to be asked about returning to the community on all assessments? | |||
| Indent Indent Indent Indent86798-6 | Indicate information source for Q0550A | |||
| Indent Indent Indent101619-5 | Referral | |||
| Indent Indent Indent Indent101620-3 | Has a referral been made to the Local Contact Agency (LCA)? | |||
| Indent Indent Indent101621-1 | Reason Referral to Local Contact Agency (LCA) Not Made | |||
| Indent Indent101622-9 | Correction Request | |||
| Indent Indent Indent85632-8 | Type of Provider | |||
| Indent Indent Indent87226-7 | Name of Resident | |||
| Indent Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent86524-6 | Type of Assessment | |||
| Indent Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent Indent86525-3 | Is this a SNF Part A PPS Discharge Assessment? | |||
| Indent Indent Indent87216-8 | Date on existing record to be modified/inactivated | |||
| Indent Indent Indent Indent54593-9 | Assessment Reference Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent52525-3 | Discharge Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent87209-3 | Correction Attestation Section | |||
| Indent Indent Indent58200-7 | Correction Number | {#} | ||
| Indent Indent Indent87217-6 | Reasons for Modification | 1..5 | ||
| Indent Indent Indent87225-9 | Reasons for Inactivation | 1..2 | ||
| Indent Indent Indent87218-4 | RN Assessment Coordinator Attestation of Completion | |||
| Indent Indent Indent Indent87219-2 | Attesting individual's first name | |||
| Indent Indent Indent Indent87220-0 | Attesting individual's last name | |||
| Indent Indent Indent Indent87221-8 | Attesting individual's title | |||
| Indent Indent Indent Indent87222-6 | Attestation date | {mm/dd/yyyy} | ||
| Indent Indent87223-4 | Assessment Administration | |||
| Indent Indent Indent55064-0 | Medicare Part A Billing | |||
| Indent Indent Indent Indent55065-7 | Medicare Part A HIPPS code | |||
| Indent Indent Indent Indent55081-4 | Version code | |||
| Indent Indent Indent55067-3 | State Medicaid Billing (if required by the state) | |||
| Indent Indent Indent Indent55068-1 | Case Mix group | |||
| Indent Indent Indent Indent55081-4 | Version code | |||
| Indent Indent Indent58422-7 | Alternate State Medicaid Billing (if required by the state) | |||
| Indent Indent Indent Indent58212-2 | Case Mix group | |||
| Indent Indent Indent Indent55081-4 | Version code | |||
| Indent Indent Indent55070-7 | Insurance Billing | |||
| Indent Indent Indent Indent55071-5 | Billing code | |||
| Indent Indent Indent Indent55081-4 | Billing version | |||
| Indent Indent Indent85648-4 | Signature of Persons Completing the Assessment or Entry/Death Reporting | |||
| Indent Indent Indent70127-6 | Signature of RN Assessment Coordinator Verifying Assessment Completion | |||
| Indent Indent Indent Indent70127-6 | Signature: | |||
| Indent Indent Indent Indent30947-6 | Date RN Assessment Coordinator signed assessment as complete: | {mm/dd/yyyy} | ||
| Indent101107-1 | MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set | |||
| Indent Indent101591-6 | Identification Information | |||
| Indent Indent Indent58198-3 | Type of Record | |||
| Indent Indent Indent54581-4 | Facility Provider Numbers | |||
| Indent Indent Indent Indent76468-8 | National Provider Identifier (NPI) | |||
| Indent Indent Indent Indent69417-4 | CMS Certification Number (CCN) | |||
| Indent Indent Indent Indent45398-5 | State Provider Number | |||
| Indent Indent Indent85632-8 | Type of Provider | |||
| Indent Indent Indent86524-6 | Type of Assessment | |||
| Indent Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent Indent54587-1 | Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry? | |||
| Indent Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent Indent71440-2 | Type of discharge | |||
| Indent Indent Indent Indent90525-7 | Is this a SNF Part A Interrupted Stay? | |||
| Indent Indent Indent Indent86525-3 | Is this a SNF Part A PPS Discharge Assessment? | |||
| Indent Indent Indent86526-1 | Unit Certification or Licensure Designation | |||
| Indent Indent Indent54503-8 | Legal Name of Resident | |||
| Indent Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent Indent45393-6 | Middle initial | |||
| Indent Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent Indent45395-1 | Suffix | |||
| Indent Indent Indent45966-9 | Social Security and Medicare Numbers | |||
| Indent Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent Indent45397-7 | Medicare number | |||
| Indent Indent Indent45400-9 | Medicaid Number | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent69854-8 | Ethnicity. Are you of Hispanic, Latino/a, or Spanish origin? | 1..4 | ||
| Indent Indent Indent103708-4 | Race. What is your race? | 1..14 | ||
| Indent Indent Indent93186-5 | Language | |||
| Indent Indent Indent Indent54899-0 | What is your preferred language? | |||
| Indent Indent Indent Indent54588-9 | Do you need or want an interpreter to communicate with a doctor or health care staff? | |||
| Indent Indent Indent45404-1 | Marital Status | |||
| Indent Indent Indent101351-5 | Transportation (from NACHC©) | |||
| Indent Indent Indent54506-1 | Optional Resident Items | |||
| Indent Indent Indent Indent46106-1 | Medical record number | |||
| Indent Indent Indent Indent45403-3 | Room number | |||
| Indent Indent Indent Indent52462-9 | Name by which resident prefers to be addressed | |||
| Indent Indent Indent Indent21843-8 | Lifetime occupation(s) | |||
| Indent Indent Indent86528-7 | Most Recent Admission/Entry or Reentry into this Facility | |||
| Indent Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent54590-5 | Type of Entry | |||
| Indent Indent Indent Indent85398-6 | Entered From | |||
| Indent Indent Indent52455-3 | Admission Date | {mm/dd/yyyy} | ||
| Indent Indent Indent52525-3 | Discharge Date | {mm/dd/yyyy} | ||
| Indent Indent Indent55128-3 | Discharge Status | |||
| Indent Indent Indent93182-4 | Provision of Current Reconciled Medication List to Subsequent Provider at Discharge | |||
| Indent Indent Indent93184-0 | Route of Current Reconciled Medication List Transmission to Subsequent Provider | 1..5 | ||
| Indent Indent Indent93181-6 | Provision of Current Reconciled Medication List to Resident at Discharge | |||
| Indent Indent Indent93183-2 | Route of Current Reconciled Medication List Transmission to Resident | 1..5 | ||
| Indent Indent Indent54593-9 | Assessment Reference Date. Observation end date | {mm/dd/yyyy} | ||
| Indent Indent Indent54507-9 | Medicare Stay | |||
| Indent Indent Indent Indent54594-7 | Has the resident had a Medicare-covered stay since the most recent entry? | |||
| Indent Indent Indent Indent54595-4 | Start date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent54596-2 | End date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent54508-7 | Hearing, Speech, and Vision | |||
| Indent Indent Indent54597-0 | Comatose | |||
| Indent Indent Indent103709-2 | Health Literacy | |||
| Indent Indent101592-4 | Cognitive Patterns | |||
| Indent Indent Indent54605-1 | Should Brief Interview for Mental Status (C0200-C0500) be Conducted? | |||
| Indent Indent Indent103694-6 | Brief Interview for Mental Status (BIMS) | |||
| Indent Indent Indent Indent103696-1 | Repetition of Three Words | |||
| Indent Indent Indent Indent103702-7 | Temporal Orientation | |||
| Indent Indent Indent Indent Indent103697-9 | Able to report correct year | |||
| Indent Indent Indent Indent Indent103698-7 | Able to report correct month | |||
| Indent Indent Indent Indent Indent103703-5 | Able to report correct day of the week | |||
| Indent Indent Indent Indent103695-3 | Recall | |||
| Indent Indent Indent Indent Indent103699-5 | Able to recall "sock" | |||
| Indent Indent Indent Indent Indent103700-1 | Able to recall "blue" | |||
| Indent Indent Indent Indent Indent103701-9 | Able to recall "bed" | |||
| Indent Indent Indent Indent103704-3 | BIMS Summary Score | {score} | ||
| Indent Indent Indent54615-0 | Should the Staff Assessment for Mental Status (C0700 - C1000) be Conducted? | |||
| Indent Indent Indent83241-0 | Staff Assessment for Mental Status | |||
| Indent Indent Indent Indent54616-8 | Short-term Memory OK | |||
| Indent Indent Indent Indent54624-2 | Cognitive Skills for Daily Decision Making | |||
| Indent Indent Indent101593-2 | Delirium | |||
| Indent Indent Indent95816-5 | Signs and Symptoms of Delirium (from CAM©) | |||
| Indent Indent Indent Indent95813-2 | Acute Onset Mental Change | |||
| Indent Indent Indent Indent95812-4 | Inattention | |||
| Indent Indent Indent Indent95814-0 | Disorganized Thinking | |||
| Indent Indent Indent Indent95815-7 | Altered Level of Consciousness | |||
| Indent Indent101594-0 | Mood | |||
| Indent Indent Indent54634-1 | Should Resident Mood Interview be Conducted? | |||
| Indent Indent Indent54635-8 | Resident Mood Interview (PHQ-2 to 9) | |||
| Indent Indent Indent Indent86843-0 | Symptom Presence | |||
| Indent Indent Indent Indent Indent54636-6 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54638-2 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54640-8 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54642-4 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54644-0 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54646-5 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54648-1 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54650-7 | 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 | |||
| Indent Indent Indent Indent Indent54652-3 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent Indent86844-8 | Symptom Frequency | |||
| Indent Indent Indent Indent Indent54637-4 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54639-0 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54641-6 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54643-2 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54645-7 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54647-3 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54649-9 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54651-5 | 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 | |||
| Indent Indent Indent Indent Indent54653-1 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent103705-0 | Total Severity Score | {score} | ||
| Indent Indent Indent103706-8 | Staff Assessment of Resident Mood (PHQ-9-OV) | |||
| Indent Indent Indent Indent86833-1 | Symptom Presence | |||
| Indent Indent Indent Indent Indent54658-0 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54660-6 | Feeling or appearing down, depressed, or hopeless | |||
| Indent Indent Indent Indent Indent54662-2 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54664-8 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54666-3 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54668-9 | Indicating that they feel bad about self, are a failure, or have let self or family down | |||
| Indent Indent Indent Indent Indent54670-5 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54672-1 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that they have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54673-9 | States that life isn't worth living, wishes for death, or attempts to harm self | |||
| Indent Indent Indent Indent Indent54675-4 | Being short-tempered, easily annoyed | |||
| Indent Indent Indent Indent86891-9 | Symptom Frequency | |||
| Indent Indent Indent Indent Indent54659-8 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54661-4 | Feeling or appearing down, depressed, or hopeless | |||
| Indent Indent Indent Indent Indent54663-0 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54665-5 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54667-1 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54669-7 | Indicating that they feel bad about self, are a failure, or have let self or family down | |||
| Indent Indent Indent Indent Indent54671-3 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54904-8 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that they have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54674-7 | States that life isn't worth living, wishes for death, or attempts to harm self | |||
| Indent Indent Indent Indent Indent54676-2 | Being short-tempered, easily annoyed | |||
| Indent Indent Indent103707-6 | Total Severity Score | {score} | ||
| Indent Indent Indent93159-2 | Social Isolation | |||
| Indent Indent86596-4 | Behavior | |||
| Indent Indent Indent86597-2 | Potential Indicators of Psychosis | 1..2 | ||
| Indent Indent54514-5 | Behavioral Symptom - Presence & Frequency | |||
| Indent Indent Indent54682-0 | Physical behavioral symptoms directed toward others | d/(7.d) | ||
| Indent Indent Indent54683-8 | Verbal behavioral symptoms directed toward others | d/(7.d) | ||
| Indent Indent Indent54684-6 | Other behavioral symptoms not directed toward others | d/(7.d) | ||
| Indent Indent54692-9 | Rejection of Care - Presence & Frequency | d/(7.d) | ||
| Indent Indent54693-7 | Wandering - Presence & Frequency | d/(7.d) | ||
| Indent Indent101595-7 | Functional Abilities and Goals | |||
| Indent Indent Indent92908-3 | Functional Limitation in Range of Motion | |||
| Indent Indent Indent Indent92850-7 | Upper extremity (shoulder, elbow, wrist, hand) | |||
| Indent Indent Indent Indent92851-5 | Lower extremity (hip, knee, ankle, foot) | |||
| Indent Indent Indent86602-0 | Mobility Devices | 1..4 | ||
| Indent Indent Indent88483-3 | Functional Abilities and Goals - Discharge | |||
| Indent Indent Indent Indent83254-3 | Self-Care - Discharge Performance | |||
| Indent Indent Indent Indent Indent89409-7 | Eating | |||
| Indent Indent Indent Indent Indent89404-8 | Oral hygiene | |||
| Indent Indent Indent Indent Indent89389-1 | Toileting hygiene | |||
| Indent Indent Indent Indent Indent89396-6 | Shower/bathe self | |||
| Indent Indent Indent Indent Indent89387-5 | Upper body dressing | |||
| Indent Indent Indent Indent Indent89406-3 | Lower body dressing | |||
| Indent Indent Indent Indent Indent89400-6 | Putting on/taking off footwear | |||
| Indent Indent Indent Indent Indent45606-1 | Personal hygiene | |||
| Indent Indent Indent Indent88331-4 | Mobility - Discharge Performance (Assessment period is the last 3 days of the stay) | |||
| Indent Indent Indent Indent Indent89398-2 | Roll left and right | |||
| Indent Indent Indent Indent Indent89394-1 | Sit to lying | |||
| Indent Indent Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent Indent89392-5 | Sit to stand | |||
| Indent Indent Indent Indent Indent89414-7 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent Indent89390-9 | Toilet transfer | |||
| Indent Indent Indent Indent Indent101597-3 | Tub/shower transfer | |||
| Indent Indent Indent Indent Indent89412-1 | Car transfer | |||
| Indent Indent Indent Indent Indent89385-9 | Walk 10 feet | |||
| Indent Indent Indent Indent Indent89381-8 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent Indent89383-4 | Walk 150 feet | |||
| Indent Indent Indent Indent Indent89379-2 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent Indent Indent89416-2 | 4 steps | |||
| Indent Indent Indent Indent Indent89418-8 | 12 steps | |||
| Indent Indent Indent Indent Indent89402-2 | Picking up object | |||
| Indent Indent Indent Indent Indent95738-1 | Does the resident use a wheelchair and/or scooter? | |||
| Indent Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent83237-8 | Bladder and Bowel | |||
| Indent Indent Indent86624-4 | Appliances | 1..4 | ||
| Indent Indent Indent95735-7 | Urinary Continence | 1..1 | ||
| Indent Indent Indent95736-5 | Bowel Continence | 1..1 | ||
| Indent Indent101601-3 | Active Diagnoses | |||
| Indent Indent Indent86671-5 | Active Diagnoses in the last 7 days | 1..* | ||
| Indent Indent Indent52797-8 | Additional active diagnoses | 0..10 | ||
| Indent Indent101602-1 | Health Conditions | |||
| Indent Indent Indent54557-4 | Pain Management | |||
| Indent Indent Indent Indent71447-7 | At any time in the last 5 days, has the resident: Received scheduled pain medication regimen? | |||
| Indent Indent Indent Indent71448-5 | At any time in the last 5 days, has the resident: Received PRN pain medications OR was offered and declined? | |||
| Indent Indent Indent Indent71449-3 | At any time in the last 5 days, has the resident: Received non-medication intervention for pain? | |||
| Indent Indent Indent54828-9 | Should Pain Assessment Interview be Conducted? | |||
| Indent Indent Indent101603-9 | Pain Assessment Interview | |||
| Indent Indent Indent Indent54829-7 | Pain Presence | |||
| Indent Indent Indent Indent54830-5 | Pain Frequency | |||
| Indent Indent Indent Indent93156-8 | Pain Effect on Sleep | |||
| Indent Indent Indent Indent93160-0 | Pain Interference with Therapy Activities | |||
| Indent Indent Indent Indent93158-4 | Pain Interference with Day-to-Day Activities | |||
| Indent Indent Indent Indent54560-8 | Pain Intensity | |||
| Indent Indent Indent Indent Indent54833-9 | Numeric Rating Scale (00-10) | |||
| Indent Indent Indent Indent Indent54834-7 | Verbal Descriptor Scale | |||
| Indent Indent Indent86674-9 | Other Health Conditions | |||
| Indent Indent Indent Indent86675-6 | Shortness of Breath (dyspnea) | 1..3 | ||
| Indent Indent Indent Indent54846-1 | Prognosis | |||
| Indent Indent Indent Indent86676-4 | Problem Conditions | 1..4 | ||
| Indent Indent Indent Indent54853-7 | Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent | |||
| Indent Indent Indent Indent54854-5 | Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent | |||
| Indent Indent Indent Indent Indent54855-2 | No injury | |||
| Indent Indent Indent Indent Indent54856-0 | Injury (except major) | |||
| Indent Indent Indent Indent Indent54857-8 | Major injury | |||
| Indent Indent101604-7 | Swallowing &or Nutritional Status | |||
| Indent Indent Indent54567-3 | Height and Weight | |||
| Indent Indent Indent Indent103692-0 | Height (in inches) | [in_us];cm;m | ||
| Indent Indent Indent Indent103693-8 | Weight (in pounds) | [lb_av];kg | ||
| Indent Indent Indent54863-6 | Weight Loss | |||
| Indent Indent Indent86678-0 | Weight Gain | |||
| Indent Indent Indent54568-1 | Nutritional Approaches | |||
| Indent Indent Indent Indent71445-1 | Nutritional Approaches. While a Resident | 1..4 | ||
| Indent Indent Indent Indent101605-4 | Nutritional Approaches. At Discharge | 1..4 | ||
| Indent Indent101607-0 | Skin Conditions | |||
| Indent Indent Indent101333-3 | Determination of Pressure Ulcer/Injury Risk | 1..3 | ||
| Indent Indent Indent58214-8 | Unhealed Pressure Ulcers/Injuries | |||
| Indent Indent Indent101611-2 | Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage | |||
| Indent Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54886-7 | Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent55125-9 | Number of Stage 3 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54887-5 | Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent55126-7 | Number of Stage 4 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54890-9 | Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54893-3 | Number of unstageable pressure ulcers/injuries due to non-removable dressing/device | {#} | ||
| Indent Indent Indent Indent54894-1 | Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54946-9 | Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar | {#} | ||
| Indent Indent Indent Indent54947-7 | Number of these unstageable pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54950-1 | Number of unstageable pressure injuries presenting as deep tissue injury | {#} | ||
| Indent Indent Indent Indent54951-9 | Number of these unstageable pressure injuries that were present upon admission/entry or reentry | {#} | ||
| Indent Indent86749-9 | Medications | |||
| Indent Indent Indent101612-0 | High-Risk Drug Classes: Use and Indication | |||
| Indent Indent Indent Indent93153-5 | Is taking | 1..10 | ||
| Indent Indent Indent Indent93154-3 | Indication noted | 1..10 | ||
| Indent Indent Indent57256-0 | Medication Intervention | |||
| Indent Indent101613-8 | Special Treatments, Procedures, and Programs | |||
| Indent Indent Indent101614-6 | Special Treatments, Procedures, and Programs | |||
| Indent Indent Indent Indent86761-4 | Special Treatments, Procedures, and Programs - While a Resident | 1..1 | ||
| Indent Indent Indent Indent93185-7 | Special Treatments, Procedures, and Programs - At Discharge | 1..30 | ||
| Indent Indent Indent69339-0 | Influenza Vaccine | |||
| Indent Indent Indent Indent55019-4 | Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? | |||
| Indent Indent Indent Indent58131-4 | Date influenza vaccine received | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent55020-2 | If influenza vaccine not received, state reason: | |||
| Indent Indent Indent55021-0 | Pneumococcal Vaccine | |||
| Indent Indent Indent Indent55022-8 | Is the resident's Pneumococcal vaccination up to date? | |||
| Indent Indent Indent Indent45956-0 | If Pneumococcal vaccine not received, state reason: | |||
| Indent Indent Indent90544-8 | Part A Therapies | |||
| Indent Indent Indent Indent90545-5 | Speech-Language Pathology and Audiology Services | |||
| Indent Indent Indent Indent Indent90539-8 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90536-4 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90538-0 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90537-2 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90551-3 | Days | d/{#} | ||
| Indent Indent Indent Indent90546-3 | Occupational Therapy | |||
| Indent Indent Indent Indent Indent90531-5 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90527-3 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90529-9 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90528-1 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90530-7 | Days | d/{#} | ||
| Indent Indent Indent Indent90547-1 | Physical Therapy | |||
| Indent Indent Indent Indent Indent90535-6 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90532-3 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90534-9 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90533-1 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90550-5 | Days | d/{#} | ||
| Indent Indent Indent90548-9 | Distinct Calendar Days of Part A Therapy | {#} | ||
| Indent Indent88307-4 | Restraints and Alarms | |||
| Indent Indent Indent86785-3 | Physical Restraints | |||
| Indent Indent Indent Indent86786-1 | Used in Bed. Bed rail | d/(7.d) | ||
| Indent Indent Indent Indent86787-9 | Used in Bed. Trunk restraint | d/(7.d) | ||
| Indent Indent Indent Indent86788-7 | Used in Bed. Limb restraint | d/(7.d) | ||
| Indent Indent Indent Indent86789-5 | Used in Bed. Other | d/(7.d) | ||
| Indent Indent Indent Indent86790-3 | Used in Chair or Out of Bed. Trunk restraint | d/(7.d) | ||
| Indent Indent Indent Indent86791-1 | Used in Chair or Out of Bed. Limb restraint | d/(7.d) | ||
| Indent Indent Indent Indent86792-9 | Used in Chair or Out of Bed. Chair prevents rising | d/(7.d) | ||
| Indent Indent Indent Indent86793-7 | Used in Chair or Out of Bed. Other | d/(7.d) | ||
| Indent Indent101615-3 | Participation in Assessment and Goal Setting | |||
| Indent Indent Indent101617-9 | Discharge Plan | |||
| Indent Indent Indent Indent58146-2 | Is active discharge planning already occurring for the resident to return to the community? | |||
| Indent Indent Indent101619-5 | Referral | |||
| Indent Indent Indent Indent101620-3 | Has a referral been made to the Local Contact Agency (LCA)? | |||
| Indent Indent Indent101621-1 | Reason Referral to Local Contact Agency (LCA) Not Made | |||
| Indent Indent101622-9 | Correction Request | |||
| Indent Indent Indent85632-8 | Type of Provider | |||
| Indent Indent Indent87226-7 | Name of Resident | |||
| Indent Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent86524-6 | Type of Assessment | |||
| Indent Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent Indent86525-3 | Is this a SNF Part A PPS Discharge Assessment? | |||
| Indent Indent Indent87216-8 | Date on existing record to be modified/inactivated | |||
| Indent Indent Indent Indent54593-9 | Assessment Reference Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent52525-3 | Discharge Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent87209-3 | Correction Attestation Section | |||
| Indent Indent Indent58200-7 | Correction Number | {#} | ||
| Indent Indent Indent87217-6 | Reasons for Modification | 1..5 | ||
| Indent Indent Indent87225-9 | Reasons for Inactivation | 1..2 | ||
| Indent Indent Indent87218-4 | RN Assessment Coordinator Attestation of Completion | |||
| Indent Indent Indent Indent87219-2 | Attesting individual's first name | |||
| Indent Indent Indent Indent87220-0 | Attesting individual's last name | |||
| Indent Indent Indent Indent87221-8 | Attesting individual's title | |||
| Indent Indent Indent Indent87222-6 | Attestation date | {mm/dd/yyyy} | ||
| Indent Indent87223-4 | Assessment Administration | |||
| Indent Indent Indent55070-7 | Insurance Billing | |||
| Indent Indent Indent Indent55071-5 | Billing code | |||
| Indent Indent Indent Indent55081-4 | Billing version | |||
| Indent Indent Indent85648-4 | Signature of Persons Completing the Assessment or Entry/Death Reporting | |||
| Indent Indent Indent70127-6 | Signature of RN Assessment Coordinator Verifying Assessment Completion | |||
| Indent Indent Indent Indent70127-6 | Signature: | |||
| Indent Indent Indent Indent30947-6 | Date RN Assessment Coordinator signed assessment as complete: | {mm/dd/yyyy} | ||
| Indent101108-9 | MDS v3.0 - RAI v1.18.11 - Nursing home & Swing bed tracking (NT & ST) item set | |||
| Indent Indent101591-6 | Identification Information | |||
| Indent Indent Indent58198-3 | Type of Record | |||
| Indent Indent Indent54581-4 | Facility Provider Numbers | |||
| Indent Indent Indent Indent76468-8 | National Provider Identifier (NPI) | |||
| Indent Indent Indent Indent69417-4 | CMS Certification Number (CCN) | |||
| Indent Indent Indent Indent45398-5 | State Provider Number | |||
| Indent Indent Indent85632-8 | Type of Provider | |||
| Indent Indent Indent86524-6 | Type of Assessment | |||
| Indent Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent Indent54587-1 | Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry? | |||
| Indent Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent Indent71440-2 | Type of discharge | |||
| Indent Indent Indent Indent86525-3 | Is this a SNF Part A PPS Discharge Assessment? | |||
| Indent Indent Indent86526-1 | Unit Certification or Licensure Designation | |||
| Indent Indent Indent54503-8 | Legal Name of Resident | |||
| Indent Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent Indent45393-6 | Middle initial | |||
| Indent Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent Indent45395-1 | Suffix | |||
| Indent Indent Indent45966-9 | Social Security and Medicare Numbers | |||
| Indent Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent Indent45397-7 | Medicare number | |||
| Indent Indent Indent45400-9 | Medicaid Number | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent69854-8 | Ethnicity. Are you of Hispanic, Latino/a, or Spanish origin? | 1..4 | ||
| Indent Indent Indent103708-4 | Race. What is your race? | 1..14 | ||
| Indent Indent Indent45404-1 | Marital Status | |||
| Indent Indent Indent54506-1 | Optional Resident Items | |||
| Indent Indent Indent Indent46106-1 | Medical record number | |||
| Indent Indent Indent Indent45403-3 | Room number | |||
| Indent Indent Indent Indent52462-9 | Name by which resident prefers to be addressed | |||
| Indent Indent Indent Indent21843-8 | Lifetime occupation(s) | |||
| Indent Indent Indent86528-7 | Most Recent Admission/Entry or Reentry into this Facility | |||
| Indent Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent54590-5 | Type of Entry | |||
| Indent Indent Indent Indent85398-6 | Entered From | |||
| Indent Indent Indent52455-3 | Admission Date | {mm/dd/yyyy} | ||
| Indent Indent Indent52525-3 | Discharge Date | {mm/dd/yyyy} | ||
| Indent Indent Indent55128-3 | Discharge Status | |||
| Indent Indent Indent54507-9 | Medicare Stay | |||
| Indent Indent Indent Indent54594-7 | Has the resident had a Medicare-covered stay since the most recent entry? | |||
| Indent Indent Indent Indent54595-4 | Start date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent54596-2 | End date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent101622-9 | Correction Request | |||
| Indent Indent Indent85632-8 | Type of Provider | |||
| Indent Indent Indent87226-7 | Name of Resident | |||
| Indent Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent86524-6 | Type of Assessment | |||
| Indent Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent Indent86525-3 | Is this a SNF Part A PPS Discharge Assessment? | |||
| Indent Indent Indent87216-8 | Date on existing record to be modified/inactivated | |||
| Indent Indent Indent Indent54593-9 | Assessment Reference Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent52525-3 | Discharge Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent87209-3 | Correction Attestation Section | |||
| Indent Indent Indent58200-7 | Correction Number | {#} | ||
| Indent Indent Indent87217-6 | Reasons for Modification | 1..5 | ||
| Indent Indent Indent87225-9 | Reasons for Inactivation | 1..2 | ||
| Indent Indent Indent87218-4 | RN Assessment Coordinator Attestation of Completion | |||
| Indent Indent Indent Indent87219-2 | Attesting individual's first name | |||
| Indent Indent Indent Indent87220-0 | Attesting individual's last name | |||
| Indent Indent Indent Indent87221-8 | Attesting individual's title | |||
| Indent Indent Indent Indent87222-6 | Attestation date | {mm/dd/yyyy} | ||
| Indent Indent87223-4 | Assessment Administration | |||
| Indent Indent Indent85648-4 | Signature of Persons Completing the Assessment or Entry/Death Reporting | |||
| Indent101109-7 | MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set | |||
| Indent Indent101258-2 | Identification Information | |||
| Indent Indent Indent58198-3 | Type of Record | |||
| Indent Indent Indent54581-4 | Facility Provider Numbers | |||
| Indent Indent Indent Indent76468-8 | National Provider Identifier (NPI) | |||
| Indent Indent Indent Indent69417-4 | CMS Certification Number (CCN) | |||
| Indent Indent Indent Indent45398-5 | State Provider Number | |||
| Indent Indent Indent85632-8 | Type of Provider | |||
| Indent Indent Indent90489-6 | Type of Assessment | |||
| Indent Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent Indent54587-1 | Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry? | |||
| Indent Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent Indent71440-2 | Type of discharge | |||
| Indent Indent Indent Indent86525-3 | Is this a SNF Part A PPS Discharge Assessment? | |||
| Indent Indent Indent86526-1 | Unit Certification or Licensure Designation | |||
| Indent Indent Indent54503-8 | Legal Name of Resident | |||
| Indent Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent Indent45393-6 | Middle initial | |||
| Indent Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent Indent45395-1 | Suffix | |||
| Indent Indent Indent45966-9 | Social Security and Medicare Numbers | |||
| Indent Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent Indent45397-7 | Medicare number | |||
| Indent Indent Indent45400-9 | Medicaid Number | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent69854-8 | Ethnicity. Are you of Hispanic, Latino/a, or Spanish origin? | 1..4 | ||
| Indent Indent Indent103708-4 | Race. What is your race? | 1..14 | ||
| Indent Indent Indent45404-1 | Marital Status | |||
| Indent Indent Indent101351-5 | Transportation (from NACHC©) | |||
| Indent Indent Indent54506-1 | Optional Resident Items | |||
| Indent Indent Indent Indent46106-1 | Medical record number | |||
| Indent Indent Indent Indent45403-3 | Room number | |||
| Indent Indent Indent Indent52462-9 | Name by which resident prefers to be addressed | |||
| Indent Indent Indent Indent21843-8 | Lifetime occupation(s) | |||
| Indent Indent Indent86528-7 | Most Recent Admission/Entry or Reentry into this Facility | |||
| Indent Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent54590-5 | Type of Entry | |||
| Indent Indent Indent Indent85398-6 | Entered From | |||
| Indent Indent Indent52455-3 | Admission Date | {mm/dd/yyyy} | ||
| Indent Indent Indent52525-3 | Discharge Date | {mm/dd/yyyy} | ||
| Indent Indent Indent93182-4 | Provision of Current Reconciled Medication List to Subsequent Provider at Discharge | |||
| Indent Indent Indent93184-0 | Route of Current Reconciled Medication List Transmission to Subsequent Provider | 1..5 | ||
| Indent Indent Indent54593-9 | Assessment Reference Date. Observation end date | {mm/dd/yyyy} | ||
| Indent Indent Indent54507-9 | Medicare Stay | |||
| Indent Indent Indent Indent54594-7 | Has the resident had a Medicare-covered stay since the most recent entry? | |||
| Indent Indent Indent Indent54595-4 | Start date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent54596-2 | End date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent101259-0 | Hearing, Speech, and Vision | |||
| Indent Indent Indent103709-2 | Health Literacy | |||
| Indent Indent101260-8 | Cognitive Patterns | |||
| Indent Indent Indent54605-1 | Should Brief Interview for Mental Status (C0200-C0500) be Conducted? | |||
| Indent Indent Indent103694-6 | Brief Interview for Mental Status (BIMS) | |||
| Indent Indent Indent Indent103696-1 | Repetition of Three Words | |||
| Indent Indent Indent Indent103702-7 | Temporal Orientation | |||
| Indent Indent Indent Indent Indent103697-9 | Able to report correct year | |||
| Indent Indent Indent Indent Indent103698-7 | Able to report correct month | |||
| Indent Indent Indent Indent Indent103703-5 | Able to report correct day of the week | |||
| Indent Indent Indent Indent103695-3 | Recall | |||
| Indent Indent Indent Indent Indent103699-5 | Able to recall "sock" | |||
| Indent Indent Indent Indent Indent103700-1 | Able to recall "blue" | |||
| Indent Indent Indent Indent Indent103701-9 | Able to recall "bed" | |||
| Indent Indent Indent Indent103704-3 | BIMS Summary Score | {score} | ||
| Indent Indent Indent96901-4 | Delirium | |||
| Indent Indent Indent Indent95816-5 | Signs and Symptoms of Delirium (from CAM©) | |||
| Indent Indent Indent Indent Indent95813-2 | Acute Onset Mental Change | |||
| Indent Indent Indent Indent Indent95812-4 | Inattention | |||
| Indent Indent Indent Indent Indent95814-0 | Disorganized Thinking | |||
| Indent Indent Indent Indent Indent95815-7 | Altered Level of Consciousness | |||
| Indent Indent101261-6 | Mood | |||
| Indent Indent Indent54634-1 | Should Resident Mood Interview be Conducted? | |||
| Indent Indent Indent54635-8 | Resident Mood Interview (PHQ-2 to 9) | |||
| Indent Indent Indent Indent86843-0 | Symptom Presence | |||
| Indent Indent Indent Indent Indent54636-6 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54638-2 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54640-8 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54642-4 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54644-0 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54646-5 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54648-1 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54650-7 | 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 | |||
| Indent Indent Indent Indent Indent54652-3 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent Indent86844-8 | Symptom Frequency | |||
| Indent Indent Indent Indent Indent54637-4 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54639-0 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54641-6 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54643-2 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54645-7 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54647-3 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54649-9 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54651-5 | 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 | |||
| Indent Indent Indent Indent Indent54653-1 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent103705-0 | Total Severity Score | {score} | ||
| Indent Indent Indent93159-2 | Social Isolation | |||
| Indent Indent101264-0 | Functional Abilities and Goals | |||
| Indent Indent Indent101266-5 | Functional Abilities and Goals - Discharge | |||
| Indent Indent Indent Indent101429-9 | Self-Care - Discharge Performance | |||
| Indent Indent Indent Indent Indent89409-7 | Eating | |||
| Indent Indent Indent Indent Indent89404-8 | Oral hygiene | |||
| Indent Indent Indent Indent Indent89389-1 | Toileting hygiene | |||
| Indent Indent Indent Indent Indent89396-6 | Shower/bathe self | |||
| Indent Indent Indent Indent Indent89387-5 | Upper body dressing | |||
| Indent Indent Indent Indent Indent89406-3 | Lower body dressing | |||
| Indent Indent Indent Indent Indent89400-6 | Putting on/taking off footwear | |||
| Indent Indent Indent Indent101431-5 | Mobility - Discharge Performance (Assessment period is the last 3 days of the Stay) | |||
| Indent Indent Indent Indent Indent89398-2 | Roll left and right | |||
| Indent Indent Indent Indent Indent89394-1 | Sit to lying | |||
| Indent Indent Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent Indent89392-5 | Sit to stand | |||
| Indent Indent Indent Indent Indent89414-7 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent Indent89390-9 | Toilet transfer | |||
| Indent Indent Indent Indent Indent89412-1 | Car transfer | |||
| Indent Indent Indent Indent Indent89385-9 | Walk 10 feet | |||
| Indent Indent Indent Indent Indent89381-8 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent Indent89383-4 | Walk 150 feet | |||
| Indent Indent Indent Indent Indent89379-2 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent Indent Indent89416-2 | 4 steps | |||
| Indent Indent Indent Indent Indent89418-8 | 12 steps | |||
| Indent Indent Indent Indent Indent89402-2 | Picking up object | |||
| Indent Indent Indent Indent Indent95738-1 | Does the resident use a wheelchair and/or scooter? | |||
| Indent Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent101270-7 | Health Conditions | |||
| Indent Indent Indent54828-9 | Should Pain Assessment Interview be Conducted? | |||
| Indent Indent Indent101326-7 | Pain Assessment Interview | |||
| Indent Indent Indent Indent54829-7 | Pain Presence | |||
| Indent Indent Indent Indent93156-8 | Pain Effect on Sleep | |||
| Indent Indent Indent Indent93160-0 | Pain Interference with Therapy Activities | |||
| Indent Indent Indent Indent93158-4 | Pain Interference with Day-to-Day Activities | |||
| Indent Indent Indent54853-7 | Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent | |||
| Indent Indent Indent54854-5 | Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent | |||
| Indent Indent Indent Indent54855-2 | No injury | |||
| Indent Indent Indent Indent54856-0 | Injury (except major) | |||
| Indent Indent Indent Indent54857-8 | Major injury | |||
| Indent Indent101271-5 | Swallowing &or Nutritional Status | |||
| Indent Indent Indent54568-1 | Nutritional Approaches | |||
| Indent Indent Indent Indent101328-3 | Nutritional Approaches. At Discharge | 1..4 | ||
| Indent Indent101273-1 | Skin Conditions | |||
| Indent Indent Indent58214-8 | Unhealed Pressure Ulcers/Injuries | |||
| Indent Indent Indent88961-8 | Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage | |||
| Indent Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54886-7 | Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent55125-9 | Number of Stage 3 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54887-5 | Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent55126-7 | Number of Stage 4 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54890-9 | Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54893-3 | Number of unstageable pressure ulcers/injuries due to non-removable dressing/device | {#} | ||
| Indent Indent Indent Indent54894-1 | Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54946-9 | Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar | {#} | ||
| Indent Indent Indent Indent54947-7 | Number of these unstageable pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54950-1 | Number of unstageable pressure injuries presenting as deep tissue injury | {#} | ||
| Indent Indent Indent Indent54951-9 | Number of these unstageable pressure injuries that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
| Indent Indent101274-9 | Medications | |||
| Indent Indent Indent93155-0 | High-Risk Drug Classes: Use and Indication | |||
| Indent Indent Indent Indent93153-5 | Is taking | 1..10 | ||
| Indent Indent Indent Indent93154-3 | Indication noted | 1..10 | ||
| Indent Indent Indent57256-0 | Medication Intervention | |||
| Indent Indent101275-6 | Special Treatments, Procedures, and Programs | |||
| Indent Indent Indent101346-5 | Special Treatments, Procedures, and Programs | |||
| Indent Indent Indent Indent93185-7 | Special Treatments, Procedures, and Programs - At Discharge | 1..31 | ||
| Indent Indent Indent90544-8 | Part A Therapies | |||
| Indent Indent Indent Indent90545-5 | Speech-Language Pathology and Audiology Services | |||
| Indent Indent Indent Indent Indent90539-8 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90536-4 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90538-0 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90537-2 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90551-3 | Days | d/{#} | ||
| Indent Indent Indent Indent90546-3 | Occupational Therapy | |||
| Indent Indent Indent Indent Indent90531-5 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90527-3 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90529-9 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90528-1 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90530-7 | Days | d/{#} | ||
| Indent Indent Indent Indent90547-1 | Physical Therapy | |||
| Indent Indent Indent Indent Indent90535-6 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90532-3 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90534-9 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90533-1 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90550-5 | Days | d/{#} | ||
| Indent Indent Indent90548-9 | Distinct Calendar Days of Part A Therapy | {#} | ||
| Indent Indent101279-8 | Correction Request | |||
| Indent Indent Indent85632-8 | Type of Provider | 1..1 | ||
| Indent Indent Indent87226-7 | Name of Resident | |||
| Indent Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent90492-0 | Type of Assessment | |||
| Indent Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent Indent86525-3 | Is this a SNF Part A PPS Discharge Assessment? | |||
| Indent Indent Indent87216-8 | Date on existing record to be modified/inactivated | |||
| Indent Indent Indent Indent54593-9 | Assessment Reference Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent52525-3 | Discharge Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent Indent87209-3 | Correction Attestation Section | |||
| Indent Indent Indent Indent58200-7 | Correction Number | {#} | ||
| Indent Indent Indent Indent87217-6 | Reasons for Modification | 1..5 | ||
| Indent Indent Indent Indent87225-9 | Reasons for Inactivation | 1..2 | ||
| Indent Indent Indent Indent87218-4 | RN Assessment Coordinator Attestation of Completion | |||
| Indent Indent Indent Indent Indent87219-2 | Attesting individual's first name | |||
| Indent Indent Indent Indent Indent87220-0 | Attesting individual's last name | |||
| Indent Indent Indent Indent Indent87221-8 | Attesting individual's title | |||
| Indent Indent Indent Indent Indent87222-6 | Attestation date | {mm/dd/yyyy} | ||
| Indent Indent101280-6 | Assessment Administration | |||
| Indent Indent Indent85648-4 | Signature of Persons Completing the Assessment or Entry/Death Reporting | |||
| Indent Indent Indent70127-6 | Signature of RN Assessment Coordinator Verifying Assessment Completion | |||
| Indent Indent Indent Indent70127-6 | Signature: | |||
| Indent Indent Indent Indent30947-6 | Date RN Assessment Coordinator signed assessment as complete: | {mm/dd/yyyy} | ||
| Indent101110-5 | MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set | |||
| Indent Indent101591-6 | Identification Information | |||
| Indent Indent Indent58198-3 | Type of Record | |||
| Indent Indent Indent54581-4 | Facility Provider Numbers | |||
| Indent Indent Indent Indent76468-8 | National Provider Identifier (NPI) | |||
| Indent Indent Indent Indent69417-4 | CMS Certification Number (CCN) | |||
| Indent Indent Indent Indent45398-5 | State Provider Number | |||
| Indent Indent Indent85632-8 | Type of Provider | |||
| Indent Indent Indent86524-6 | Type of Assessment | |||
| Indent Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent Indent54587-1 | Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry? | |||
| Indent Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent Indent71440-2 | Type of discharge | |||
| Indent Indent Indent Indent90525-7 | Is this a SNF Part A Interrupted Stay? | |||
| Indent Indent Indent Indent86525-3 | Is this a SNF Part A PPS Discharge Assessment? | |||
| Indent Indent Indent86526-1 | Unit Certification or Licensure Designation | |||
| Indent Indent Indent54503-8 | Legal Name of Resident | |||
| Indent Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent Indent45393-6 | Middle initial | |||
| Indent Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent Indent45395-1 | Suffix | |||
| Indent Indent Indent45966-9 | Social Security and Medicare Numbers | |||
| Indent Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent Indent45397-7 | Medicare number | |||
| Indent Indent Indent45400-9 | Medicaid Number | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent69854-8 | Ethnicity. Are you of Hispanic, Latino/a, or Spanish origin? | 1..4 | ||
| Indent Indent Indent103708-4 | Race. What is your race? | 1..14 | ||
| Indent Indent Indent93186-5 | Language | |||
| Indent Indent Indent Indent54899-0 | What is your preferred language? | |||
| Indent Indent Indent Indent54588-9 | Do you need or want an interpreter to communicate with a doctor or health care staff? | |||
| Indent Indent Indent45404-1 | Marital Status | |||
| Indent Indent Indent101351-5 | Transportation (from NACHC©) | |||
| Indent Indent Indent54506-1 | Optional Resident Items | |||
| Indent Indent Indent Indent46106-1 | Medical record number | |||
| Indent Indent Indent Indent45403-3 | Room number | |||
| Indent Indent Indent Indent52462-9 | Name by which resident prefers to be addressed | |||
| Indent Indent Indent Indent21843-8 | Lifetime occupation(s) | |||
| Indent Indent Indent86528-7 | Most Recent Admission/Entry or Reentry into this Facility | |||
| Indent Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent54590-5 | Type of Entry | |||
| Indent Indent Indent Indent85398-6 | Entered From | |||
| Indent Indent Indent52455-3 | Admission Date | {mm/dd/yyyy} | ||
| Indent Indent Indent52525-3 | Discharge Date | {mm/dd/yyyy} | ||
| Indent Indent Indent55128-3 | Discharge Status | |||
| Indent Indent Indent93182-4 | Provision of Current Reconciled Medication List to Subsequent Provider at Discharge | |||
| Indent Indent Indent93184-0 | Route of Current Reconciled Medication List Transmission to Subsequent Provider | 1..5 | ||
| Indent Indent Indent93181-6 | Provision of Current Reconciled Medication List to Resident at Discharge | |||
| Indent Indent Indent93183-2 | Route of Current Reconciled Medication List Transmission to Resident | 1..5 | ||
| Indent Indent Indent54593-9 | Assessment Reference Date. Observation end date | {mm/dd/yyyy} | ||
| Indent Indent Indent54507-9 | Medicare Stay | |||
| Indent Indent Indent Indent54594-7 | Has the resident had a Medicare-covered stay since the most recent entry? | |||
| Indent Indent Indent Indent54595-4 | Start date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent54596-2 | End date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent54508-7 | Hearing, Speech, and Vision | |||
| Indent Indent Indent54597-0 | Comatose | |||
| Indent Indent Indent95744-9 | Hearing | |||
| Indent Indent Indent54599-6 | Hearing Aid | |||
| Indent Indent Indent54600-2 | Speech Clarity | |||
| Indent Indent Indent95737-3 | Makes Self Understood | |||
| Indent Indent Indent54602-8 | Ability to Understand Others | |||
| Indent Indent Indent95745-6 | Vision | |||
| Indent Indent Indent54604-4 | Corrective Lenses | |||
| Indent Indent Indent103709-2 | Health Literacy | |||
| Indent Indent101592-4 | Cognitive Patterns | |||
| Indent Indent Indent54605-1 | Should Brief Interview for Mental Status (C0200-C0500) be Conducted? | |||
| Indent Indent Indent103694-6 | Brief Interview for Mental Status (BIMS) | |||
| Indent Indent Indent Indent103696-1 | Repetition of Three Words | |||
| Indent Indent Indent Indent103702-7 | Temporal Orientation | |||
| Indent Indent Indent Indent Indent103697-9 | Able to report correct year | |||
| Indent Indent Indent Indent Indent103698-7 | Able to report correct month | |||
| Indent Indent Indent Indent Indent103703-5 | Able to report correct day of the week | |||
| Indent Indent Indent Indent103695-3 | Recall | |||
| Indent Indent Indent Indent Indent103699-5 | Able to recall "sock" | |||
| Indent Indent Indent Indent Indent103700-1 | Able to recall "blue" | |||
| Indent Indent Indent Indent Indent103701-9 | Able to recall "bed" | |||
| Indent Indent Indent Indent103704-3 | BIMS Summary Score | {score} | ||
| Indent Indent Indent54615-0 | Should the Staff Assessment for Mental Status (C0700 - C1000) be Conducted? | |||
| Indent Indent Indent83241-0 | Staff Assessment for Mental Status | |||
| Indent Indent Indent Indent54616-8 | Short-term Memory OK | |||
| Indent Indent Indent Indent54617-6 | Long-term Memory OK | |||
| Indent Indent Indent Indent95743-1 | Memory/Recall Ability | 1..4 | ||
| Indent Indent Indent Indent54624-2 | Cognitive Skills for Daily Decision Making | |||
| Indent Indent Indent101593-2 | Delirium | |||
| Indent Indent Indent95816-5 | Signs and Symptoms of Delirium (from CAM©) | |||
| Indent Indent Indent Indent95813-2 | Acute Onset Mental Change | |||
| Indent Indent Indent Indent95812-4 | Inattention | |||
| Indent Indent Indent Indent95814-0 | Disorganized Thinking | |||
| Indent Indent Indent Indent95815-7 | Altered Level of Consciousness | |||
| Indent Indent101594-0 | Mood | |||
| Indent Indent Indent54634-1 | Should Resident Mood Interview be Conducted? | |||
| Indent Indent Indent54635-8 | Resident Mood Interview (PHQ-2 to 9) | |||
| Indent Indent Indent Indent86843-0 | Symptom Presence | |||
| Indent Indent Indent Indent Indent54636-6 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54638-2 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54640-8 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54642-4 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54644-0 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54646-5 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54648-1 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54650-7 | 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 | |||
| Indent Indent Indent Indent Indent54652-3 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent Indent86844-8 | Symptom Frequency | |||
| Indent Indent Indent Indent Indent54637-4 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54639-0 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54641-6 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54643-2 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54645-7 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54647-3 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54649-9 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54651-5 | 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 | |||
| Indent Indent Indent Indent Indent54653-1 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent103705-0 | Total Severity Score | {score} | ||
| Indent Indent Indent103706-8 | Staff Assessment of Resident Mood (PHQ-9-OV) | |||
| Indent Indent Indent Indent86833-1 | Symptom Presence | |||
| Indent Indent Indent Indent Indent54658-0 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54660-6 | Feeling or appearing down, depressed, or hopeless | |||
| Indent Indent Indent Indent Indent54662-2 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54664-8 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54666-3 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54668-9 | Indicating that they feel bad about self, are a failure, or have let self or family down | |||
| Indent Indent Indent Indent Indent54670-5 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54672-1 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that they have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54673-9 | States that life isn't worth living, wishes for death, or attempts to harm self | |||
| Indent Indent Indent Indent Indent54675-4 | Being short-tempered, easily annoyed | |||
| Indent Indent Indent Indent86891-9 | Symptom Frequency | |||
| Indent Indent Indent Indent Indent54659-8 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54661-4 | Feeling or appearing down, depressed, or hopeless | |||
| Indent Indent Indent Indent Indent54663-0 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54665-5 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54667-1 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54669-7 | Indicating that they feel bad about self, are a failure, or have let self or family down | |||
| Indent Indent Indent Indent Indent54671-3 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54904-8 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that they have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54674-7 | States that life isn't worth living, wishes for death, or attempts to harm self | |||
| Indent Indent Indent Indent Indent54676-2 | Being short-tempered, easily annoyed | |||
| Indent Indent Indent103707-6 | Total Severity Score | {score} | ||
| Indent Indent Indent93159-2 | Social Isolation | |||
| Indent Indent86596-4 | Behavior | |||
| Indent Indent Indent86597-2 | Potential Indicators of Psychosis | 1..2 | ||
| Indent Indent54514-5 | Behavioral Symptom - Presence & Frequency | |||
| Indent Indent Indent54682-0 | Physical behavioral symptoms directed toward others | d/(7.d) | ||
| Indent Indent Indent54683-8 | Verbal behavioral symptoms directed toward others | d/(7.d) | ||
| Indent Indent Indent54684-6 | Other behavioral symptoms not directed toward others | d/(7.d) | ||
| Indent Indent54692-9 | Rejection of Care - Presence & Frequency | d/(7.d) | ||
| Indent Indent54693-7 | Wandering - Presence & Frequency | d/(7.d) | ||
| Indent Indent101595-7 | Functional Abilities and Goals | |||
| Indent Indent Indent101596-5 | Prior Functioning: Everyday Activities | |||
| Indent Indent Indent Indent85070-1 | Self-Care | |||
| Indent Indent Indent Indent85071-9 | Indoor Mobility (Ambulation) | |||
| Indent Indent Indent Indent85072-7 | Stairs | |||
| Indent Indent Indent Indent85073-5 | Functional Cognition | |||
| Indent Indent Indent83234-5 | Prior Device Use | 1..5 | ||
| Indent Indent Indent92908-3 | Functional Limitation in Range of Motion | |||
| Indent Indent Indent Indent92850-7 | Upper extremity (shoulder, elbow, wrist, hand) | |||
| Indent Indent Indent Indent92851-5 | Lower extremity (hip, knee, ankle, foot) | |||
| Indent Indent Indent88482-5 | Functional Abilities and Goals - Admission | |||
| Indent Indent Indent Indent83233-7 | Self-Care - Admission Performance | |||
| Indent Indent Indent Indent Indent95019-6 | Eating | |||
| Indent Indent Indent Indent Indent95018-8 | Oral hygiene | |||
| Indent Indent Indent Indent Indent95017-0 | Toileting hygiene | |||
| Indent Indent Indent Indent Indent95015-4 | Shower/bathe self | |||
| Indent Indent Indent Indent Indent95014-7 | Upper body dressing | |||
| Indent Indent Indent Indent Indent95013-9 | Lower body dressing | |||
| Indent Indent Indent Indent Indent95012-1 | Putting on/taking off footwear | |||
| Indent Indent Indent Indent85054-5 | Self-Care - Discharge Goal (Assessment period is the first 3 days of the stay) | |||
| Indent Indent Indent Indent Indent95019-6 | Eating | |||
| Indent Indent Indent Indent Indent95018-8 | Oral hygiene | |||
| Indent Indent Indent Indent Indent95017-0 | Toileting hygiene | |||
| Indent Indent Indent Indent Indent95015-4 | Shower/bathe self | |||
| Indent Indent Indent Indent Indent95014-7 | Upper body dressing | |||
| Indent Indent Indent Indent Indent95013-9 | Lower body dressing | |||
| Indent Indent Indent Indent Indent95012-1 | Putting on/taking off footwear | |||
| Indent Indent Indent Indent88330-6 | Mobility - Admission Performance (Assessment period is the first 3 days of the stay) | |||
| Indent Indent Indent Indent Indent95011-3 | Roll left and right | |||
| Indent Indent Indent Indent Indent95010-5 | Sit to lying | |||
| Indent Indent Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent Indent95008-9 | Sit to stand | |||
| Indent Indent Indent Indent Indent95007-1 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent Indent95006-3 | Toilet transfer | |||
| Indent Indent Indent Indent Indent95005-5 | Car transfer | |||
| Indent Indent Indent Indent Indent95004-8 | Walk 10 feet | |||
| Indent Indent Indent Indent Indent95003-0 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95002-2 | Walk 150 feet | |||
| Indent Indent Indent Indent Indent95001-4 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent Indent Indent94999-0 | 4 steps | |||
| Indent Indent Indent Indent Indent94998-2 | 12 steps | |||
| Indent Indent Indent Indent Indent94997-4 | Picking up object | |||
| Indent Indent Indent Indent Indent95738-1 | Does the resident use a wheelchair and/or scooter? | |||
| Indent Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent85056-0 | Mobility - Discharge Goal Assessment period is the first 3 days of stay) | |||
| Indent Indent Indent Indent Indent95011-3 | Roll left and right | |||
| Indent Indent Indent Indent Indent95010-5 | Sit to lying | |||
| Indent Indent Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent Indent95008-9 | Sit to stand | |||
| Indent Indent Indent Indent Indent95007-1 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent Indent95006-3 | Toilet transfer | |||
| Indent Indent Indent Indent Indent95005-5 | Car transfer | |||
| Indent Indent Indent Indent Indent95004-8 | Walk 10 feet | |||
| Indent Indent Indent Indent Indent95003-0 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95002-2 | Walk 150 feet | |||
| Indent Indent Indent Indent Indent95001-4 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent Indent Indent94999-0 | 4 steps | |||
| Indent Indent Indent Indent Indent94998-2 | 12 steps | |||
| Indent Indent Indent Indent Indent94997-4 | Picking up object | |||
| Indent Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent88483-3 | Functional Abilities and Goals - Discharge | |||
| Indent Indent Indent Indent83254-3 | Self-Care - Discharge Performance | |||
| Indent Indent Indent Indent Indent95019-6 | Eating | |||
| Indent Indent Indent Indent Indent95018-8 | Oral hygiene | |||
| Indent Indent Indent Indent Indent95017-0 | Toileting hygiene | |||
| Indent Indent Indent Indent Indent95015-4 | Shower/bathe self | |||
| Indent Indent Indent Indent Indent95014-7 | Upper body dressing | |||
| Indent Indent Indent Indent Indent95013-9 | Lower body dressing | |||
| Indent Indent Indent Indent Indent95012-1 | Putting on/taking off footwear | |||
| Indent Indent Indent Indent88331-4 | Mobility - Discharge Performance (Assessment period is the last 3 days of the stay) | |||
| Indent Indent Indent Indent Indent95011-3 | Roll left and right | |||
| Indent Indent Indent Indent Indent95010-5 | Sit to lying | |||
| Indent Indent Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent Indent95008-9 | Sit to stand | |||
| Indent Indent Indent Indent Indent95007-1 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent Indent95006-3 | Toilet transfer | |||
| Indent Indent Indent Indent Indent95005-5 | Car transfer | |||
| Indent Indent Indent Indent Indent95004-8 | Walk 10 feet | |||
| Indent Indent Indent Indent Indent95003-0 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95002-2 | Walk 150 feet | |||
| Indent Indent Indent Indent Indent95001-4 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent Indent Indent94999-0 | 4 steps | |||
| Indent Indent Indent Indent Indent94998-2 | 12 steps | |||
| Indent Indent Indent Indent Indent94997-4 | Picking up object | |||
| Indent Indent Indent Indent Indent95738-1 | Does the resident use a wheelchair and/or scooter? | |||
| Indent Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent83237-8 | Bladder and Bowel | |||
| Indent Indent Indent86624-4 | Appliances | 1..4 | ||
| Indent Indent Indent54530-1 | Urinary Toileting Program | |||
| Indent Indent Indent Indent54767-9 | Has a trial of a toileting program been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility? | |||
| Indent Indent Indent Indent54769-5 | Current toileting program or trial - Is a toileting program currently being used to manage the resident's urinary continence? | |||
| Indent Indent Indent95735-7 | Urinary Continence | |||
| Indent Indent Indent95736-5 | Bowel Continence | |||
| Indent Indent Indent88695-2 | Bowel Toileting Program | |||
| Indent Indent101601-3 | Active Diagnoses | |||
| Indent Indent Indent96095-5 | Indicate the resident's primary medical condition category | |||
| Indent Indent Indent52797-8 | ICD Code | |||
| Indent Indent Indent86671-5 | Active Diagnoses in the last 7 days | 1..* | ||
| Indent Indent Indent52797-8 | Additional active diagnoses | 0..10 | ||
| Indent Indent101602-1 | Health Conditions | |||
| Indent Indent Indent54557-4 | Pain Management | |||
| Indent Indent Indent Indent71447-7 | At any time in the last 5 days, has the resident: Received scheduled pain medication regimen? | |||
| Indent Indent Indent Indent71448-5 | At any time in the last 5 days, has the resident: Received PRN pain medications OR was offered and declined? | |||
| Indent Indent Indent Indent71449-3 | At any time in the last 5 days, has the resident: Received non-medication intervention for pain? | |||
| Indent Indent Indent54828-9 | Should Pain Assessment Interview be Conducted? | |||
| Indent Indent Indent101603-9 | Pain Assessment Interview | |||
| Indent Indent Indent Indent54829-7 | Pain Presence | |||
| Indent Indent Indent Indent54830-5 | Pain Frequency | |||
| Indent Indent Indent Indent93156-8 | Pain Effect on Sleep | |||
| Indent Indent Indent Indent93160-0 | Pain Interference with Therapy Activities | |||
| Indent Indent Indent Indent93158-4 | Pain Interference with Day-to-Day Activities | |||
| Indent Indent Indent Indent54560-8 | Pain Intensity | |||
| Indent Indent Indent Indent Indent54833-9 | Numeric Rating Scale (00-10) | |||
| Indent Indent Indent Indent Indent54834-7 | Verbal Descriptor Scale | |||
| Indent Indent Indent58117-3 | Should the Staff Assessment for Pain be Conducted? | |||
| Indent Indent Indent86672-3 | Staff Assessment for Pain | |||
| Indent Indent Indent Indent86673-1 | Indicators of Pain or Possible Pain in the last 5 days | 1..4 | ||
| Indent Indent Indent Indent58118-1 | Frequency of Indicator of Pain or Possible Pain in the last 5 days | d/(5.d) | ||
| Indent Indent Indent86674-9 | Other Health Conditions | |||
| Indent Indent Indent Indent86675-6 | Shortness of Breath (dyspnea) | 1..3 | ||
| Indent Indent Indent Indent54846-1 | Prognosis | |||
| Indent Indent Indent Indent86676-4 | Problem Conditions | 1..4 | ||
| Indent Indent Indent Indent54849-5 | Fall History on Admission/Entry or Reentry | |||
| Indent Indent Indent Indent Indent54850-3 | Did the resident have a fall any time in the last month prior to admission/entry or reentry? | |||
| Indent Indent Indent Indent Indent54851-1 | Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry? | |||
| Indent Indent Indent Indent Indent54852-9 | Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry? | |||
| Indent Indent Indent Indent54853-7 | Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent | |||
| Indent Indent Indent Indent54854-5 | Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent | |||
| Indent Indent Indent Indent Indent54855-2 | No injury | |||
| Indent Indent Indent Indent Indent54856-0 | Injury (except major) | |||
| Indent Indent Indent Indent Indent54857-8 | Major injury | |||
| Indent Indent Indent83274-1 | Prior Surgery | |||
| Indent Indent Indent90542-2 | Recent Surgery Requiring Active SNF Care | |||
| Indent Indent Indent90745-1 | Surgical Procedures | 1..* | ||
| Indent Indent101604-7 | Swallowing &or Nutritional Status | |||
| Indent Indent Indent86677-2 | Swallowing Disorder | 1..4 | ||
| Indent Indent Indent54567-3 | Height and Weight | |||
| Indent Indent Indent Indent103692-0 | Height (in inches) | [in_us];cm;m | ||
| Indent Indent Indent Indent103693-8 | Weight (in pounds) | [lb_av];kg | ||
| Indent Indent Indent54863-6 | Weight Loss | |||
| Indent Indent Indent86678-0 | Weight Gain | |||
| Indent Indent Indent54568-1 | Nutritional Approaches | |||
| Indent Indent Indent Indent101632-8 | Nutritional Approaches. On Admission | 1..4 | ||
| Indent Indent Indent Indent71444-4 | Nutritional Approaches. While NOT a Resident | 1..2 | ||
| Indent Indent Indent Indent71445-1 | Nutritional Approaches. While a Resident | 1..4 | ||
| Indent Indent Indent90543-0 | Percent Intake by Artificial Route | |||
| Indent Indent Indent Indent86681-4 | Proportion of total calories the resident received through parenteral or tube feeding. While a Resident | |||
| Indent Indent Indent Indent86687-1 | Proportion of total calories the resident received through parenteral or tube feeding. During Entire 7 Days | |||
| Indent Indent Indent Indent86683-0 | Average fluid intake per day by IV or tube feeding. While a Resident | mL/d;L/d | ||
| Indent Indent Indent Indent86684-8 | Average fluid intake per day by IV or tube feeding. During Entire 7 Days | mL/d;L/d | ||
| Indent Indent101606-2 | Oral/Dental Status | |||
| Indent Indent Indent86706-9 | Dental | 1..2 | ||
| Indent Indent101607-0 | Skin Conditions | |||
| Indent Indent Indent101333-3 | Determination of Pressure Ulcer/Injury Risk | 1..3 | ||
| Indent Indent Indent57280-0 | Risk of Pressure Ulcers/Injuries | |||
| Indent Indent Indent58214-8 | Unhealed Pressure Ulcers/Injuries | |||
| Indent Indent Indent101611-2 | Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage | |||
| Indent Indent Indent Indent54884-2 | Number of Stage 1 pressure injuries | {#} | ||
| Indent Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54886-7 | Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent55125-9 | Number of Stage 3 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54887-5 | Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent55126-7 | Number of Stage 4 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54890-9 | Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54893-3 | Number of unstageable pressure ulcers/injuries due to non-removable dressing/device | {#} | ||
| Indent Indent Indent Indent54894-1 | Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54946-9 | Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar | {#} | ||
| Indent Indent Indent Indent54947-7 | Number of these unstageable pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54950-1 | Number of unstageable pressure injuries presenting as deep tissue injury | {#} | ||
| Indent Indent Indent Indent54951-9 | Number of these unstageable pressure injuries that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent101609-6 | Number of Venous and Arterial Ulcers | {#} | ||
| Indent Indent Indent101610-4 | Other Ulcers, Wounds and Skin Problems | 1..8 | ||
| Indent Indent Indent86748-1 | Skin and Ulcer/Injury Treatments | 1..9 | ||
| Indent Indent86749-9 | Medications | |||
| Indent Indent Indent54982-4 | Injections | d/(7.d) | ||
| Indent Indent Indent58217-1 | Insulin | |||
| Indent Indent Indent Indent58127-2 | Insulin injections | d/(7.d) | ||
| Indent Indent Indent Indent58128-0 | Orders for insulin | d/(7.d) | ||
| Indent Indent Indent101612-0 | High-Risk Drug Classes: Use and Indication | |||
| Indent Indent Indent Indent93153-5 | Is taking | 1..10 | ||
| Indent Indent Indent Indent93154-3 | Indication noted | 0..10 | ||
| Indent Indent Indent57255-2 | Drug Regimen Review | |||
| Indent Indent Indent57281-8 | Medication Follow-up | |||
| Indent Indent Indent57256-0 | Medication Intervention | |||
| Indent Indent101613-8 | Special Treatments, Procedures, and Programs | |||
| Indent Indent Indent101614-6 | Special Treatments, Procedures, and Programs | |||
| Indent Indent Indent Indent83252-7 | Special Treatments, Procedures, and Programs - On Admission | 1..30 | ||
| Indent Indent Indent Indent86761-4 | Special Treatments, Procedures, and Programs - While a Resident | 1..13 | ||
| Indent Indent Indent Indent93185-7 | Special Treatments, Procedures, and Programs - At Discharge | 1..30 | ||
| Indent Indent Indent69339-0 | Influenza Vaccine | |||
| Indent Indent Indent Indent55019-4 | Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? | |||
| Indent Indent Indent Indent58131-4 | Date influenza vaccine received | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent55020-2 | If influenza vaccine not received, state reason: | |||
| Indent Indent Indent55021-0 | Pneumococcal Vaccine | |||
| Indent Indent Indent Indent55022-8 | Is the resident's Pneumococcal vaccination up to date? | |||
| Indent Indent Indent Indent45956-0 | If Pneumococcal vaccine not received, state reason: | |||
| Indent Indent Indent86762-2 | Therapies | |||
| Indent Indent Indent Indent86763-0 | Speech-Language Pathology and Audiology Services | |||
| Indent Indent Indent Indent Indent58218-9 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent58133-0 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent58134-8 | Group minutes | min | ||
| Indent Indent Indent Indent Indent86765-5 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent45760-6 | Days | d/(7.d) | ||
| Indent Indent Indent Indent Indent55025-1 | Therapy start date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent Indent55026-9 | Therapy end date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent86767-1 | Occupational Therapy | |||
| Indent Indent Indent Indent Indent58219-7 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent58136-3 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent58137-1 | Group minutes | min | ||
| Indent Indent Indent Indent Indent86764-8 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent45762-2 | Days | d/(7.d) | ||
| Indent Indent Indent Indent Indent55027-7 | Therapy start date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent Indent55028-5 | Therapy end date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent86768-9 | Physical Therapy | |||
| Indent Indent Indent Indent Indent58220-5 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent58139-7 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent58140-5 | Group minutes | min | ||
| Indent Indent Indent Indent Indent86766-3 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent45764-8 | Days | d/(7.d) | ||
| Indent Indent Indent Indent Indent55029-3 | Therapy start date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent Indent55030-1 | Therapy end date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent58141-3 | Respiratory Therapy | |||
| Indent Indent Indent Indent Indent45766-3 | Days | d/(7.d) | ||
| Indent Indent Indent Indent58142-1 | Psychological Therapy (by any licensed mental health professional) | |||
| Indent Indent Indent Indent Indent45768-9 | Days | d/(7.d) | ||
| Indent Indent Indent86769-7 | Distinct Calendar Days of Therapy | d | ||
| Indent Indent Indent90544-8 | Part A Therapies | |||
| Indent Indent Indent Indent90545-5 | Speech-Language Pathology and Audiology Services | |||
| Indent Indent Indent Indent Indent90539-8 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90536-4 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90538-0 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90537-2 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90551-3 | Days | d/{#} | ||
| Indent Indent Indent Indent90546-3 | Occupational Therapy | |||
| Indent Indent Indent Indent Indent90531-5 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90527-3 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90529-9 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90528-1 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90530-7 | Days | d/{#} | ||
| Indent Indent Indent Indent90547-1 | Physical Therapy | |||
| Indent Indent Indent Indent Indent90535-6 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90532-3 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90534-9 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90533-1 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90550-5 | Days | d/{#} | ||
| Indent Indent Indent90548-9 | Distinct Calendar Days of Part A Therapy | {#} | ||
| Indent Indent Indent86773-9 | Restorative Nursing Programs | |||
| Indent Indent Indent Indent86774-7 | Technique. Range of motion (passive) | d/(7.d) | ||
| Indent Indent Indent Indent86775-4 | Technique. Range of motion (active) | d/(7.d) | ||
| Indent Indent Indent Indent86776-2 | Technique. Splint or brace assistance | d/(7.d) | ||
| Indent Indent Indent Indent86777-0 | Training and Skill Practice In: Bed mobility | d/(7.d) | ||
| Indent Indent Indent Indent86778-8 | Training and Skill Practice In: Transfer | d/(7.d) | ||
| Indent Indent Indent Indent86779-6 | Training and Skill Practice In: Walking | d/(7.d) | ||
| Indent Indent Indent Indent86780-4 | Training and Skill Practice In: Dressing and/or grooming | d/(7.d) | ||
| Indent Indent Indent Indent86781-2 | Training and Skill Practice In: Eating and/or swallowing | d/(7.d) | ||
| Indent Indent Indent Indent86782-0 | Training and Skill Practice In: Amputation/prostheses care | d/(7.d) | ||
| Indent Indent Indent Indent86783-8 | Training and Skill Practice In: Communication | d/(7.d) | ||
| Indent Indent88307-4 | Restraints and Alarms | |||
| Indent Indent Indent86785-3 | Physical Restraints | |||
| Indent Indent Indent Indent86786-1 | Used in Bed. Bed rail | d/(7.d) | ||
| Indent Indent Indent Indent86787-9 | Used in Bed. Trunk restraint | d/(7.d) | ||
| Indent Indent Indent Indent86788-7 | Used in Bed. Limb restraint | d/(7.d) | ||
| Indent Indent Indent Indent86789-5 | Used in Bed. Other | d/(7.d) | ||
| Indent Indent Indent Indent86790-3 | Used in Chair or Out of Bed. Trunk restraint | d/(7.d) | ||
| Indent Indent Indent Indent86791-1 | Used in Chair or Out of Bed. Limb restraint | d/(7.d) | ||
| Indent Indent Indent Indent86792-9 | Used in Chair or Out of Bed. Chair prevents rising | d/(7.d) | ||
| Indent Indent Indent Indent86793-7 | Used in Chair or Out of Bed. Other | d/(7.d) | ||
| Indent Indent101615-3 | Participation in Assessment and Goal Setting | |||
| Indent Indent Indent101616-1 | Participation in Assessment and Goal Setting | 1..5 | ||
| Indent Indent Indent55056-6 | Resident's Overall Goal | |||
| Indent Indent Indent Indent55057-4 | Resident's overall goal for discharge established during the assessment process. | |||
| Indent Indent Indent Indent55058-2 | Indicate information source for Q0310A | |||
| Indent Indent Indent101617-9 | Discharge Plan | |||
| Indent Indent Indent58146-2 | Is active discharge planning already occurring for the resident to return to the community? | |||
| Indent Indent Indent86795-2 | Resident's Documented Preference to Avoid Being Asked Question Q0500B | |||
| Indent Indent Indent101618-7 | Return to Community | |||
| Indent Indent Indent Indent58149-6 | Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? | |||
| Indent Indent Indent Indent86798-6 | Indicate information source for Q0500B | |||
| Indent Indent Indent86796-0 | Resident's Preference to Avoid Being Asked Question Q0500B Again | |||
| Indent Indent Indent Indent86797-8 | Does resident (or family or significant other or guardian or legally authorized representative only if resident is unable to understand or respond) want to be asked about returning to the community on all assessments? | |||
| Indent Indent Indent Indent86798-6 | Indicate information source for Q0550A | |||
| Indent Indent Indent101619-5 | Referral | |||
| Indent Indent Indent Indent101620-3 | Has a referral been made to the Local Contact Agency (LCA)? | |||
| Indent Indent Indent101621-1 | Reason Referral to Local Contact Agency (LCA) Not Made | |||
| Indent Indent101622-9 | Correction Request | |||
| Indent Indent Indent85632-8 | Type of Provider | |||
| Indent Indent Indent87226-7 | Name of Resident | |||
| Indent Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent86524-6 | Type of Assessment | |||
| Indent Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent Indent86525-3 | Is this a SNF Part A PPS Discharge Assessment? | |||
| Indent Indent Indent87216-8 | Date on existing record to be modified/inactivated | |||
| Indent Indent Indent Indent54593-9 | Assessment Reference Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent52525-3 | Discharge Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent87209-3 | Correction Attestation Section | |||
| Indent Indent Indent58200-7 | Correction Number | {#} | ||
| Indent Indent Indent87217-6 | Reasons for Modification | 1..5 | ||
| Indent Indent Indent87225-9 | Reasons for Inactivation | 1..2 | ||
| Indent Indent Indent87218-4 | RN Assessment Coordinator Attestation of Completion | |||
| Indent Indent Indent Indent87219-2 | Attesting individual's first name | |||
| Indent Indent Indent Indent87220-0 | Attesting individual's last name | |||
| Indent Indent Indent Indent87221-8 | Attesting individual's title | |||
| Indent Indent Indent Indent87222-6 | Attestation date | {mm/dd/yyyy} | ||
| Indent Indent87223-4 | Assessment Administration | |||
| Indent Indent Indent55064-0 | Medicare Part A Billing | |||
| Indent Indent Indent Indent55065-7 | Medicare Part A HIPPS code | |||
| Indent Indent Indent Indent55081-4 | Version code | |||
| Indent Indent Indent55067-3 | State Medicaid Billing (if required by the state) | |||
| Indent Indent Indent Indent55068-1 | Case Mix group | |||
| Indent Indent Indent Indent55081-4 | Version code | |||
| Indent Indent Indent58422-7 | Alternate State Medicaid Billing (if required by the state) | |||
| Indent Indent Indent Indent58212-2 | Case Mix group | |||
| Indent Indent Indent Indent55081-4 | Version code | |||
| Indent Indent Indent55070-7 | Insurance Billing | |||
| Indent Indent Indent Indent55071-5 | Billing code | |||
| Indent Indent Indent Indent55081-4 | Billing version | |||
| Indent Indent Indent85648-4 | Signature of Persons Completing the Assessment or Entry/Death Reporting | |||
| Indent Indent Indent70127-6 | Signature of RN Assessment Coordinator Verifying Assessment Completion | |||
| Indent Indent Indent Indent70127-6 | Signature: | |||
| Indent Indent Indent Indent30947-6 | Date RN Assessment Coordinator signed assessment as complete: | {mm/dd/yyyy} | ||
| Indent101111-3 | MDS v3.0 - RAI v1.18.11 - Interim Payment Assessment (IPA) item set | |||
| Indent Indent90503-4 | Identification Information | |||
| Indent Indent Indent58198-3 | Type of Record | |||
| Indent Indent Indent54581-4 | Facility Provider Numbers | |||
| Indent Indent Indent Indent76468-8 | National Provider Identifier (NPI) | |||
| Indent Indent Indent Indent69417-4 | CMS Certification Number (CCN) | |||
| Indent Indent Indent Indent45398-5 | State Provider Number | |||
| Indent Indent Indent85632-8 | Type of Provider | |||
| Indent Indent Indent90571-1 | Type of Assessment | |||
| Indent Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent Indent54587-1 | Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry? | |||
| Indent Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent Indent71440-2 | Type of discharge | |||
| Indent Indent Indent86526-1 | Unit Certification or Licensure Designation | |||
| Indent Indent Indent54503-8 | Legal Name of Resident | |||
| Indent Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent Indent45393-6 | Middle initial | |||
| Indent Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent Indent45395-1 | Suffix | |||
| Indent Indent Indent45966-9 | Social Security and Medicare Numbers | |||
| Indent Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent Indent45397-7 | Medicare number | |||
| Indent Indent Indent45400-9 | Medicaid Number | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent69854-8 | Ethnicity. Are you of Hispanic, Latino/a, or Spanish origin? | 1..4 | ||
| Indent Indent Indent103708-4 | Race. What is your race? | 1..14 | ||
| Indent Indent Indent93186-5 | Language | |||
| Indent Indent Indent Indent54899-0 | What is your preferred language? | |||
| Indent Indent Indent Indent54588-9 | Do you need or want an interpreter to communicate with a doctor or health care staff? | |||
| Indent Indent Indent45404-1 | Marital Status | |||
| Indent Indent Indent54506-1 | Optional Resident Items | |||
| Indent Indent Indent Indent46106-1 | Medical record number | |||
| Indent Indent Indent Indent45403-3 | Room number | |||
| Indent Indent Indent Indent52462-9 | Name by which resident prefers to be addressed | |||
| Indent Indent Indent Indent21843-8 | Lifetime occupation(s) | |||
| Indent Indent Indent54593-9 | Assessment Reference Date. Observation end date | {mm/dd/yyyy} | ||
| Indent Indent Indent54507-9 | Medicare Stay | |||
| Indent Indent Indent Indent54594-7 | Has the resident had a Medicare-covered stay since the most recent entry? | |||
| Indent Indent Indent Indent54595-4 | Start date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent54596-2 | End date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent90505-9 | Hearing, Speech, and Vision | |||
| Indent Indent Indent54597-0 | Comatose | |||
| Indent Indent Indent95737-3 | Makes Self Understood | |||
| Indent Indent93050-3 | Cognitive Patterns | |||
| Indent Indent Indent54605-1 | Should Brief Interview for Mental Status (C0200-C0500) be Conducted? | |||
| Indent Indent Indent103694-6 | Brief Interview for Mental Status (BIMS) | |||
| Indent Indent Indent Indent103696-1 | Repetition of Three Words | |||
| Indent Indent Indent Indent103702-7 | Temporal Orientation | |||
| Indent Indent Indent Indent Indent103697-9 | Able to report correct year | |||
| Indent Indent Indent Indent Indent103698-7 | Able to report correct month | |||
| Indent Indent Indent Indent Indent103703-5 | Able to report correct day of the week | |||
| Indent Indent Indent Indent103695-3 | Recall | |||
| Indent Indent Indent Indent Indent103699-5 | Able to recall "sock" | |||
| Indent Indent Indent Indent Indent103700-1 | Able to recall "blue" | |||
| Indent Indent Indent Indent Indent103701-9 | Able to recall "bed" | |||
| Indent Indent Indent Indent103704-3 | BIMS Summary Score | {score} | ||
| Indent Indent Indent54615-0 | Should the Staff Assessment for Mental Status (C0700-C1000) be Conducted? | |||
| Indent Indent Indent86814-1 | Staff Assessment for Mental Status | |||
| Indent Indent Indent Indent54616-8 | Short-term Memory OK | |||
| Indent Indent Indent Indent54624-2 | Cognitive Skills for Daily Decision Making | |||
| Indent Indent90482-1 | Mood | |||
| Indent Indent Indent54634-1 | Should Resident Mood Interview be Conducted? | |||
| Indent Indent Indent54635-8 | Resident Mood Interview (PHQ-2 to 9) | |||
| Indent Indent Indent Indent86843-0 | Symptom Presence | |||
| Indent Indent Indent Indent Indent54636-6 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54638-2 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54640-8 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54642-4 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54644-0 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54646-5 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54648-1 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54650-7 | 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 | |||
| Indent Indent Indent Indent Indent54652-3 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent Indent86844-8 | Symptom Frequency | |||
| Indent Indent Indent Indent Indent54637-4 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54639-0 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54641-6 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54643-2 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54645-7 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54647-3 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54649-9 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54651-5 | 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 | |||
| Indent Indent Indent Indent Indent54653-1 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent103705-0 | Total Severity Score | {score} | ||
| Indent Indent Indent103706-8 | Staff Assessment of Resident Mood (PHQ-9-OV) | |||
| Indent Indent Indent Indent86833-1 | Symptom Presence | |||
| Indent Indent Indent Indent Indent54658-0 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54660-6 | Feeling or appearing down, depressed, or hopeless | |||
| Indent Indent Indent Indent Indent54662-2 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54664-8 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54666-3 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54668-9 | Indicating that they feel bad about self, are a failure, or have let self or family down. | |||
| Indent Indent Indent Indent Indent54670-5 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54672-1 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that they have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54673-9 | States that life isn't worth living, wishes for death, or attempts to harm self | |||
| Indent Indent Indent Indent Indent54675-4 | Being short-tempered, easily annoyed | |||
| Indent Indent Indent Indent86891-9 | Symptom Frequency | |||
| Indent Indent Indent Indent Indent54659-8 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54661-4 | Feeling or appearing down, depressed, or hopeless | |||
| Indent Indent Indent Indent Indent54663-0 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54665-5 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54667-1 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54669-7 | Indicating that they feel bad about self, are a failure, or have let self or family down. | |||
| Indent Indent Indent Indent Indent54671-3 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54904-8 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that they have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54674-7 | States that life isn't worth living, wishes for death, or attempts to harm self | |||
| Indent Indent Indent Indent Indent54676-2 | Being short-tempered, easily annoyed | |||
| Indent Indent Indent103707-6 | Total Severity Score | {score} | ||
| Indent Indent86815-8 | Behavior | |||
| Indent Indent Indent86597-2 | Potential Indicators of Psychosis | 1..2 | ||
| Indent Indent Indent54514-5 | Behavioral Symptom - Presence & Frequency | |||
| Indent Indent Indent Indent54682-0 | Physical behavioral symptoms directed toward others | d/(7.d) | ||
| Indent Indent Indent Indent54683-8 | Verbal behavioral symptoms directed toward others | d/(7.d) | ||
| Indent Indent Indent Indent54684-6 | Other behavioral symptoms not directed toward others | d/(7.d) | ||
| Indent Indent Indent54692-9 | Rejection of Care - Presence & Frequency. Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? | d/(7.d) | ||
| Indent Indent Indent54693-7 | Wandering - Presence & Frequency. Has the resident wandered? | d/(7.d) | ||
| Indent Indent101267-3 | Functional Abilities and Goals - OBRA &or Interim | |||
| Indent Indent Indent101430-7 | Self-Care - OBRA/Interim Performance | |||
| Indent Indent Indent Indent95019-6 | Eating | |||
| Indent Indent Indent Indent89409-7 | Eating | |||
| Indent Indent Indent Indent89404-8 | Oral hygiene | |||
| Indent Indent Indent Indent89389-1 | Toileting hygiene | |||
| Indent Indent Indent101432-3 | Mobility - OBRA/Interim Performance | |||
| Indent Indent Indent Indent89394-1 | Sit to lying | |||
| Indent Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent89392-5 | Sit to stand | |||
| Indent Indent Indent Indent89414-7 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent89390-9 | Toilet transfer | |||
| Indent Indent Indent Indent89385-9 | Walk 10 feet | |||
| Indent Indent Indent Indent89381-8 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent89383-4 | Walk 150 feet | |||
| Indent Indent90507-5 | Bladder and Bowel | |||
| Indent Indent Indent86624-4 | Appliances | 1..2 | ||
| Indent Indent Indent54769-5 | Urinary Toileting Program. Current toileting program or trial - Is a toileting program currently being used to manage the resident's urinary continence? | |||
| Indent Indent Indent88695-2 | Bowel Toileting Program | |||
| Indent Indent90485-4 | Active Diagnoses | |||
| Indent Indent Indent86671-5 | Active Diagnoses in the last 7 days | 1..* | ||
| Indent Indent Indent52797-8 | Additional active diagnoses | 0..10 | ||
| Indent Indent96095-5 | Indicate the resident's primary medical condition category | |||
| Indent Indent52797-8 | ICD Code | |||
| Indent Indent90488-8 | Health Conditions | |||
| Indent Indent Indent86889-3 | Other Health Conditions | |||
| Indent Indent Indent Indent86675-6 | Shortness of Breath (dyspnea) | 1..1 | ||
| Indent Indent Indent Indent86676-4 | Problem Conditions | 1..2 | ||
| Indent Indent Indent90542-2 | Recent Surgery Requiring Active SNF Care | |||
| Indent Indent Indent90745-1 | Surgical Procedures | |||
| Indent Indent90509-1 | Swallowing/Nutritional Status | |||
| Indent Indent Indent86677-2 | Swallowing Disorder | 1..4 | ||
| Indent Indent Indent54863-6 | Weight Loss | |||
| Indent Indent Indent54568-1 | Nutritional Approaches | |||
| Indent Indent Indent Indent71444-4 | Nutritional Approaches. While NOT a Resident | 1..2 | ||
| Indent Indent Indent Indent71445-1 | Nutritional Approaches. While a Resident | 1..3 | ||
| Indent Indent Indent90543-0 | Percent Intake by Artificial Route | |||
| Indent Indent Indent Indent86681-4 | Proportion of total calories the resident received through parenteral or tube feeding. While a Resident | |||
| Indent Indent Indent Indent86687-1 | Proportion of total calories the resident received through parenteral or tube feeding. During Entire 7 Days | |||
| Indent Indent Indent Indent86683-0 | Average fluid intake per day by IV or tube feeding. While a Resident | mL/d;L/d | ||
| Indent Indent Indent Indent86684-8 | Average fluid intake per day by IV or tube feeding. During Entire 7 Days | mL/d;L/d | ||
| Indent Indent89051-7 | Skin Conditions | |||
| Indent Indent Indent58214-8 | Unhealed Pressure Ulcers/Injuries | |||
| Indent Indent Indent86892-7 | Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage | |||
| Indent Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
| Indent Indent Indent Indent55125-9 | Number of Stage 3 pressure ulcers | {#} | ||
| Indent Indent Indent Indent55126-7 | Number of Stage 4 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54946-9 | Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar | {#} | ||
| Indent Indent Indent54970-9 | Number of Venous and Arterial Ulcers | {#} | ||
| Indent Indent Indent88696-0 | Other Ulcers, Wounds and Skin Problems | 1..6 | ||
| Indent Indent Indent86748-1 | Skin and Ulcer/Injury Treatments | 1..9 | ||
| Indent Indent90513-3 | Medications | |||
| Indent Indent Indent58217-1 | Insulin | |||
| Indent Indent Indent Indent58127-2 | Insulin injections | d/(7.d) | ||
| Indent Indent Indent Indent58128-0 | Orders for insulin | d/(7.d) | ||
| Indent Indent101614-6 | Special Treatments, Procedures, and Programs | |||
| Indent Indent Indent86761-4 | Special Treatments, Procedures, and Programs - While a Resident | 1..13 | ||
| Indent Indent Indent55024-4 | Therapies | |||
| Indent Indent Indent Indent58141-3 | Respiratory Therapy | |||
| Indent Indent Indent Indent Indent45766-3 | Respiratory Therapy - Days | d/(7.d) | ||
| Indent Indent Indent Indent86773-9 | Restorative Nursing Programs | |||
| Indent Indent Indent Indent Indent86774-7 | Technique. Range of motion (passive) | d/(7.d) | ||
| Indent Indent Indent Indent Indent86775-4 | Technique. Range of motion (active) | d/(7.d) | ||
| Indent Indent Indent Indent Indent86776-2 | Technique. Splint or brace assistance | d/(7.d) | ||
| Indent Indent Indent Indent Indent86777-0 | Training and Skill Practice In: Bed mobility | d/(7.d) | ||
| Indent Indent Indent Indent Indent86778-8 | Training and Skill Practice In: Transfer | d/(7.d) | ||
| Indent Indent Indent Indent Indent86779-6 | Training and Skill Practice In: Walking | d/(7.d) | ||
| Indent Indent Indent Indent Indent86780-4 | Training and Skill Practice In: Dressing and/or grooming | d/(7.d) | ||
| Indent Indent Indent Indent Indent86781-2 | Training and Skill Practice In: Eating and/or swallowing | d/(7.d) | ||
| Indent Indent Indent Indent Indent86782-0 | Training and Skill Practice In: Amputation/prostheses care | d/(7.d) | ||
| Indent Indent Indent Indent Indent86783-8 | Training and Skill Practice In: Communication | d/(7.d) | ||
| Indent Indent91579-3 | Correction Request | |||
| Indent Indent Indent85632-8 | Type of Provider | |||
| Indent Indent Indent87226-7 | Name of Resident | |||
| Indent Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent91580-1 | Type of Assessment | |||
| Indent Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent87216-8 | Date on existing record to be modified/inactivated. | |||
| Indent Indent Indent Indent54593-9 | Assessment Reference Date | {mm/dd/yyyy} | ||
| Indent Indent Indent87209-3 | Correction Attestation Section | |||
| Indent Indent Indent Indent58200-7 | Correction Number | {#} | ||
| Indent Indent Indent Indent87217-6 | Reasons for Modification | 1..5 | ||
| Indent Indent Indent Indent87225-9 | Reasons for Inactivation | 1..2 | ||
| Indent Indent Indent Indent87218-4 | RN Assessment Coordinator Attestation of Completion | |||
| Indent Indent Indent Indent Indent87219-2 | Attesting individual's first name | |||
| Indent Indent Indent Indent Indent87220-0 | Attesting individual's last name | |||
| Indent Indent Indent Indent Indent87221-8 | Attesting individual's title | |||
| Indent Indent Indent Indent Indent87222-6 | Attestation date | {mm/dd/yyyy} | ||
| Indent Indent90495-3 | Assessment Administration | |||
| Indent Indent Indent90498-7 | Medicare Part A Billing | |||
| Indent Indent Indent Indent55065-7 | Medicare Part A HIPPS code | |||
| Indent Indent Indent Indent55081-4 | Version code | |||
| Indent Indent Indent Indent85648-4 | Signature of Persons Completing the Assessment or Entry/Death Reporting | |||
| Indent Indent Indent Indent70127-6 | Signature of RN Assessment Coordinator Verifying Assessment Completion | |||
| Indent Indent Indent Indent Indent70127-6 | Signature: | |||
| Indent Indent Indent Indent Indent30947-6 | Date RN Assessment Coordinator signed assessment as complete: | {mm/dd/yyyy} | ||
| Indent101112-1 | MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set | |||
| Indent Indent101591-6 | Identification Information | |||
| Indent Indent Indent58198-3 | Type of Record | |||
| Indent Indent Indent54581-4 | Facility Provider Numbers | |||
| Indent Indent Indent Indent76468-8 | National Provider Identifier (NPI) | |||
| Indent Indent Indent Indent69417-4 | CMS Certification Number (CCN) | |||
| Indent Indent Indent Indent45398-5 | State Provider Number | |||
| Indent Indent Indent85632-8 | Type of Provider | |||
| Indent Indent Indent86524-6 | Type of Assessment | |||
| Indent Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent Indent54587-1 | Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry? | |||
| Indent Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent Indent71440-2 | Type of discharge | |||
| Indent Indent Indent Indent90525-7 | Is this a SNF Part A Interrupted Stay? | |||
| Indent Indent Indent Indent86525-3 | Is this a SNF Part A PPS Discharge Assessment? | |||
| Indent Indent Indent86526-1 | Unit Certification or Licensure Designation | |||
| Indent Indent Indent54503-8 | Legal Name of Resident | |||
| Indent Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent Indent45393-6 | Middle initial | |||
| Indent Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent Indent45395-1 | Suffix | |||
| Indent Indent Indent45966-9 | Social Security and Medicare Numbers | |||
| Indent Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent Indent45397-7 | Medicare number | |||
| Indent Indent Indent45400-9 | Medicaid Number | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent69854-8 | Ethnicity. Are you of Hispanic, Latino/a, or Spanish origin? | 1..4 | ||
| Indent Indent Indent103708-4 | Race. What is your race? | 1..14 | ||
| Indent Indent Indent93186-5 | Language | |||
| Indent Indent Indent Indent54899-0 | What is your preferred language? | |||
| Indent Indent Indent Indent54588-9 | Do you need or want an interpreter to communicate with a doctor or health care staff? | |||
| Indent Indent Indent45404-1 | Marital Status | |||
| Indent Indent Indent101351-5 | Transportation (from NACHC©) | |||
| Indent Indent Indent54506-1 | Optional Resident Items | |||
| Indent Indent Indent Indent46106-1 | Medical record number | |||
| Indent Indent Indent Indent45403-3 | Room number | |||
| Indent Indent Indent Indent52462-9 | Name by which resident prefers to be addressed | |||
| Indent Indent Indent Indent21843-8 | Lifetime occupation(s) | |||
| Indent Indent Indent86528-7 | Most Recent Admission/Entry or Reentry into this Facility | |||
| Indent Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent54590-5 | Type of Entry | |||
| Indent Indent Indent Indent85398-6 | Entered From | |||
| Indent Indent Indent52455-3 | Admission Date | {mm/dd/yyyy} | ||
| Indent Indent Indent52525-3 | Discharge Date | {mm/dd/yyyy} | ||
| Indent Indent Indent55128-3 | Discharge Status | |||
| Indent Indent Indent93182-4 | Provision of Current Reconciled Medication List to Subsequent Provider at Discharge | |||
| Indent Indent Indent93184-0 | Route of Current Reconciled Medication List Transmission to Subsequent Provider | 1..5 | ||
| Indent Indent Indent93181-6 | Provision of Current Reconciled Medication List to Resident at Discharge | |||
| Indent Indent Indent93183-2 | Route of Current Reconciled Medication List Transmission to Resident | 1..5 | ||
| Indent Indent Indent54593-9 | Assessment Reference Date. Observation end date | {mm/dd/yyyy} | ||
| Indent Indent Indent54507-9 | Medicare Stay | |||
| Indent Indent Indent Indent54594-7 | Has the resident had a Medicare-covered stay since the most recent entry? | |||
| Indent Indent Indent Indent54595-4 | Start date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent54596-2 | End date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent54508-7 | Hearing, Speech, and Vision | |||
| Indent Indent Indent54597-0 | Comatose | |||
| Indent Indent Indent95744-9 | Hearing | |||
| Indent Indent Indent54599-6 | Hearing Aid | |||
| Indent Indent Indent54600-2 | Speech Clarity | |||
| Indent Indent Indent95737-3 | Makes Self Understood | |||
| Indent Indent Indent54602-8 | Ability to Understand Others | |||
| Indent Indent Indent95745-6 | Vision | |||
| Indent Indent Indent54604-4 | Corrective Lenses | |||
| Indent Indent Indent103709-2 | Health Literacy | |||
| Indent Indent101592-4 | Cognitive Patterns | |||
| Indent Indent Indent54605-1 | Should Brief Interview for Mental Status (C0200-C0500) be Conducted? | |||
| Indent Indent Indent103694-6 | Brief Interview for Mental Status (BIMS) | |||
| Indent Indent Indent Indent103696-1 | Repetition of Three Words | |||
| Indent Indent Indent Indent103702-7 | Temporal Orientation | |||
| Indent Indent Indent Indent Indent103697-9 | Able to report correct year | |||
| Indent Indent Indent Indent Indent103698-7 | Able to report correct month | |||
| Indent Indent Indent Indent Indent103703-5 | Able to report correct day of the week | |||
| Indent Indent Indent Indent103695-3 | Recall | |||
| Indent Indent Indent Indent Indent103699-5 | Able to recall "sock" | |||
| Indent Indent Indent Indent Indent103700-1 | Able to recall "blue" | |||
| Indent Indent Indent Indent Indent103701-9 | Able to recall "bed" | |||
| Indent Indent Indent Indent103704-3 | BIMS Summary Score | {score} | ||
| Indent Indent Indent54615-0 | Should the Staff Assessment for Mental Status (C0700 - C1000) be Conducted? | |||
| Indent Indent Indent83241-0 | Staff Assessment for Mental Status | |||
| Indent Indent Indent Indent54616-8 | Short-term Memory OK | |||
| Indent Indent Indent Indent54617-6 | Long-term Memory OK | |||
| Indent Indent Indent Indent95743-1 | Memory/Recall Ability | 1..4 | ||
| Indent Indent Indent Indent54624-2 | Cognitive Skills for Daily Decision Making | |||
| Indent Indent Indent101593-2 | Delirium | |||
| Indent Indent Indent95816-5 | Signs and Symptoms of Delirium (from CAM©) | |||
| Indent Indent Indent Indent95813-2 | Acute Onset Mental Change | |||
| Indent Indent Indent Indent95812-4 | Inattention | |||
| Indent Indent Indent Indent95814-0 | Disorganized Thinking | |||
| Indent Indent Indent Indent95815-7 | Altered Level of Consciousness | |||
| Indent Indent101594-0 | Mood | |||
| Indent Indent Indent54634-1 | Should Resident Mood Interview be Conducted? | |||
| Indent Indent Indent54635-8 | Resident Mood Interview (PHQ-2 to 9) | |||
| Indent Indent Indent Indent86843-0 | Symptom Presence | |||
| Indent Indent Indent Indent Indent54636-6 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54638-2 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54640-8 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54642-4 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54644-0 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54646-5 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54648-1 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54650-7 | 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 | |||
| Indent Indent Indent Indent Indent54652-3 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent Indent86844-8 | Symptom Frequency | |||
| Indent Indent Indent Indent Indent54637-4 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54639-0 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54641-6 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54643-2 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54645-7 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54647-3 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54649-9 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54651-5 | 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 | |||
| Indent Indent Indent Indent Indent54653-1 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent103705-0 | Total Severity Score | {score} | ||
| Indent Indent Indent103706-8 | Staff Assessment of Resident Mood (PHQ-9-OV) | |||
| Indent Indent Indent Indent86833-1 | Symptom Presence | |||
| Indent Indent Indent Indent Indent54658-0 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54660-6 | Feeling or appearing down, depressed, or hopeless | |||
| Indent Indent Indent Indent Indent54662-2 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54664-8 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54666-3 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54668-9 | Indicating that they feel bad about self, are a failure, or have let self or family down | |||
| Indent Indent Indent Indent Indent54670-5 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54672-1 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that they have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54673-9 | States that life isn't worth living, wishes for death, or attempts to harm self | |||
| Indent Indent Indent Indent Indent54675-4 | Being short-tempered, easily annoyed | |||
| Indent Indent Indent Indent86891-9 | Symptom Frequency | |||
| Indent Indent Indent Indent Indent54659-8 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54661-4 | Feeling or appearing down, depressed, or hopeless | |||
| Indent Indent Indent Indent Indent54663-0 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54665-5 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54667-1 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54669-7 | Indicating that they feel bad about self, are a failure, or have let self or family down | |||
| Indent Indent Indent Indent Indent54671-3 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54904-8 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that they have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54674-7 | States that life isn't worth living, wishes for death, or attempts to harm self | |||
| Indent Indent Indent Indent Indent54676-2 | Being short-tempered, easily annoyed | |||
| Indent Indent Indent103707-6 | Total Severity Score | {score} | ||
| Indent Indent Indent93159-2 | Social Isolation | |||
| Indent Indent86596-4 | Behavior | |||
| Indent Indent Indent86597-2 | Potential Indicators of Psychosis | 1..2 | ||
| Indent Indent54514-5 | Behavioral Symptom - Presence & Frequency | |||
| Indent Indent Indent54682-0 | Physical behavioral symptoms directed toward others | d/(7.d) | ||
| Indent Indent Indent54683-8 | Verbal behavioral symptoms directed toward others | d/(7.d) | ||
| Indent Indent Indent54684-6 | Other behavioral symptoms not directed toward others | d/(7.d) | ||
| Indent Indent54692-9 | Rejection of Care - Presence & Frequency | d/(7.d) | ||
| Indent Indent54693-7 | Wandering - Presence & Frequency | d/(7.d) | ||
| Indent Indent101595-7 | Functional Abilities and Goals | |||
| Indent Indent Indent92908-3 | Functional Limitation in Range of Motion | |||
| Indent Indent Indent Indent92850-7 | Upper extremity (shoulder, elbow, wrist, hand) | |||
| Indent Indent Indent Indent92851-5 | Lower extremity (hip, knee, ankle, foot) | |||
| Indent Indent Indent101596-5 | Prior Functioning: Everyday Activities | |||
| Indent Indent Indent Indent85070-1 | Self-Care | |||
| Indent Indent Indent Indent85071-9 | Indoor Mobility (Ambulation) | |||
| Indent Indent Indent Indent85072-7 | Stairs | |||
| Indent Indent Indent Indent85073-5 | Functional Cognition | |||
| Indent Indent Indent83234-5 | Prior Device Use | 1..5 | ||
| Indent Indent Indent88482-5 | Functional Abilities and Goals - Admission | |||
| Indent Indent Indent Indent83233-7 | Self-Care - Admission Performance | |||
| Indent Indent Indent Indent Indent95019-6 | Eating | |||
| Indent Indent Indent Indent Indent95018-8 | Oral hygiene | |||
| Indent Indent Indent Indent Indent95017-0 | Toileting hygiene | |||
| Indent Indent Indent Indent Indent95015-4 | Shower/bathe self | |||
| Indent Indent Indent Indent Indent95014-7 | Upper body dressing | |||
| Indent Indent Indent Indent Indent95013-9 | Lower body dressing | |||
| Indent Indent Indent Indent Indent95012-1 | Putting on/taking off footwear | |||
| Indent Indent Indent Indent85054-5 | Self-Care - Discharge Goal (Assessment period is the first 3 days of the stay) | |||
| Indent Indent Indent Indent Indent89404-8 | Oral hygiene - functional goal | |||
| Indent Indent Indent Indent Indent89409-7 | Eating | |||
| Indent Indent Indent Indent Indent89389-1 | Toileting hygiene | |||
| Indent Indent Indent Indent Indent89396-6 | Shower/bathe self | |||
| Indent Indent Indent Indent Indent89387-5 | Upper body dressing | |||
| Indent Indent Indent Indent Indent89406-3 | Lower body dressing | |||
| Indent Indent Indent Indent Indent89400-6 | Putting on/taking off footwear | |||
| Indent Indent Indent Indent88330-6 | Mobility - Admission Performance (Assessment period is the first 3 days of the stay) | |||
| Indent Indent Indent Indent Indent95011-3 | Roll left and right | |||
| Indent Indent Indent Indent Indent95010-5 | Sit to lying | |||
| Indent Indent Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent Indent95008-9 | Sit to stand | |||
| Indent Indent Indent Indent Indent95007-1 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent Indent95006-3 | Toilet transfer | |||
| Indent Indent Indent Indent Indent95005-5 | Car transfer | |||
| Indent Indent Indent Indent Indent95004-8 | Walk 10 feet | |||
| Indent Indent Indent Indent Indent95003-0 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95002-2 | Walk 150 feet | |||
| Indent Indent Indent Indent Indent95001-4 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent Indent Indent94999-0 | 4 steps | |||
| Indent Indent Indent Indent Indent94998-2 | 12 steps | |||
| Indent Indent Indent Indent Indent94997-4 | Picking up object | |||
| Indent Indent Indent Indent Indent95738-1 | Does the resident use a wheelchair and/or scooter? | |||
| Indent Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent85056-0 | Mobility - Discharge Goal Assessment period is the first 3 days of stay) | |||
| Indent Indent Indent Indent Indent89398-2 | Roll left and right | |||
| Indent Indent Indent Indent Indent89394-1 | Sit to lying | |||
| Indent Indent Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent Indent89392-5 | Sit to stand | |||
| Indent Indent Indent Indent Indent89414-7 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent Indent89390-9 | Toilet transfer | |||
| Indent Indent Indent Indent Indent89412-1 | Car transfer | |||
| Indent Indent Indent Indent Indent89385-9 | Walk 10 feet | |||
| Indent Indent Indent Indent Indent89381-8 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent Indent89383-4 | Walk 150 feet | |||
| Indent Indent Indent Indent Indent89379-2 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent Indent Indent89416-2 | 4 steps | |||
| Indent Indent Indent Indent Indent89418-8 | 12 steps | |||
| Indent Indent Indent Indent Indent89402-2 | Picking up object | |||
| Indent Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent88483-3 | Functional Abilities and Goals - Discharge | |||
| Indent Indent Indent Indent83254-3 | Self-Care - Discharge Performance | |||
| Indent Indent Indent Indent Indent89409-7 | Eating | |||
| Indent Indent Indent Indent Indent89404-8 | Oral hygiene | |||
| Indent Indent Indent Indent Indent89389-1 | Toileting hygiene | |||
| Indent Indent Indent Indent Indent89396-6 | Shower/bathe self | |||
| Indent Indent Indent Indent Indent89387-5 | Upper body dressing | |||
| Indent Indent Indent Indent Indent89406-3 | Lower body dressing | |||
| Indent Indent Indent Indent Indent89400-6 | Putting on/taking off footwear | |||
| Indent Indent Indent Indent88331-4 | Mobility - Discharge Performance (Assessment period is the last 3 days of the stay) | |||
| Indent Indent Indent Indent Indent89398-2 | Roll left and right | |||
| Indent Indent Indent Indent Indent89394-1 | Sit to lying | |||
| Indent Indent Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent Indent89392-5 | Sit to stand | |||
| Indent Indent Indent Indent Indent89414-7 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent Indent89390-9 | Toilet transfer | |||
| Indent Indent Indent Indent Indent89412-1 | Car transfer | |||
| Indent Indent Indent Indent Indent89385-9 | Walk 10 feet | |||
| Indent Indent Indent Indent Indent89381-8 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent Indent89383-4 | Walk 150 feet | |||
| Indent Indent Indent Indent Indent89379-2 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent Indent Indent89416-2 | 4 steps | |||
| Indent Indent Indent Indent Indent89418-8 | 12 steps | |||
| Indent Indent Indent Indent Indent89402-2 | Picking up object | |||
| Indent Indent Indent Indent Indent95738-1 | Does the resident use a wheelchair and/or scooter? | |||
| Indent Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent83237-8 | Bladder and Bowel | |||
| Indent Indent Indent86624-4 | Appliances | 1..4 | ||
| Indent Indent Indent54530-1 | Urinary Toileting Program | |||
| Indent Indent Indent Indent54767-9 | Has a trial of a toileting program been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility? | |||
| Indent Indent Indent Indent54769-5 | Current toileting program or trial - Is a toileting program currently being used to manage the resident's urinary continence? | |||
| Indent Indent Indent95735-7 | Urinary Continence | 1..1 | ||
| Indent Indent Indent95736-5 | Bowel Continence | 1..1 | ||
| Indent Indent Indent88695-2 | Bowel Toileting Program | |||
| Indent Indent101601-3 | Active Diagnoses | |||
| Indent Indent Indent96095-5 | Indicate the resident's primary medical condition category | 1..1 | ||
| Indent Indent Indent52797-8 | ICD Code | |||
| Indent Indent Indent86671-5 | Active Diagnoses in the last 7 days | 1..* | ||
| Indent Indent Indent52797-8 | Additional active diagnoses | 0..10 | ||
| Indent Indent101602-1 | Health Conditions | |||
| Indent Indent Indent54557-4 | Pain Management | |||
| Indent Indent Indent Indent71447-7 | At any time in the last 5 days, has the resident: Received scheduled pain medication regimen? | |||
| Indent Indent Indent Indent71448-5 | At any time in the last 5 days, has the resident: Received PRN pain medications OR was offered and declined? | |||
| Indent Indent Indent Indent71449-3 | At any time in the last 5 days, has the resident: Received non-medication intervention for pain? | |||
| Indent Indent Indent54828-9 | Should Pain Assessment Interview be Conducted? | |||
| Indent Indent Indent101603-9 | Pain Assessment Interview | |||
| Indent Indent Indent Indent54829-7 | Pain Presence | |||
| Indent Indent Indent Indent54830-5 | Pain Frequency | |||
| Indent Indent Indent Indent93156-8 | Pain Effect on Sleep | |||
| Indent Indent Indent Indent93160-0 | Pain Interference with Therapy Activities | |||
| Indent Indent Indent Indent93158-4 | Pain Interference with Day-to-Day Activities | |||
| Indent Indent Indent Indent54560-8 | Pain Intensity | |||
| Indent Indent Indent Indent Indent54833-9 | Numeric Rating Scale (00-10) | |||
| Indent Indent Indent Indent Indent54834-7 | Verbal Descriptor Scale | |||
| Indent Indent Indent58117-3 | Should the Staff Assessment for Pain be Conducted? | |||
| Indent Indent Indent86672-3 | Staff Assessment for Pain | |||
| Indent Indent Indent Indent86673-1 | Indicators of Pain or Possible Pain in the last 5 days | 1..4 | ||
| Indent Indent Indent Indent58118-1 | Frequency of Indicator of Pain or Possible Pain in the last 5 days | d/(5.d) | ||
| Indent Indent Indent86674-9 | Other Health Conditions | |||
| Indent Indent Indent Indent86675-6 | Shortness of Breath (dyspnea) | 1..3 | ||
| Indent Indent Indent Indent54846-1 | Prognosis | |||
| Indent Indent Indent Indent86676-4 | Problem Conditions | 1..4 | ||
| Indent Indent Indent Indent54849-5 | Fall History on Admission/Entry or Reentry | |||
| Indent Indent Indent Indent Indent54850-3 | Did the resident have a fall any time in the last month prior to admission/entry or reentry? | |||
| Indent Indent Indent Indent Indent54851-1 | Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry? | |||
| Indent Indent Indent Indent Indent54852-9 | Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry? | |||
| Indent Indent Indent Indent54853-7 | Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent | |||
| Indent Indent Indent Indent54854-5 | Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent | |||
| Indent Indent Indent Indent Indent54855-2 | No injury | |||
| Indent Indent Indent Indent Indent54856-0 | Injury (except major) | |||
| Indent Indent Indent Indent Indent54857-8 | Major injury | |||
| Indent Indent Indent83274-1 | Prior Surgery | |||
| Indent Indent Indent90542-2 | Recent Surgery Requiring Active SNF Care | |||
| Indent Indent Indent90745-1 | Surgical Procedures | 1..* | ||
| Indent Indent101604-7 | Swallowing &or Nutritional Status | |||
| Indent Indent Indent86677-2 | Swallowing Disorder | 1..4 | ||
| Indent Indent Indent54567-3 | Height and Weight | |||
| Indent Indent Indent Indent103692-0 | Height (in inches) | [in_us];cm;m | ||
| Indent Indent Indent Indent103693-8 | Weight (in pounds) | [lb_av];kg | ||
| Indent Indent Indent54863-6 | Weight Loss | |||
| Indent Indent Indent86678-0 | Weight Gain | |||
| Indent Indent Indent54568-1 | Nutritional Approaches | |||
| Indent Indent Indent Indent101632-8 | Nutritional Approaches. On Admission | 1..4 | ||
| Indent Indent Indent Indent71444-4 | Nutritional Approaches. While NOT a Resident | 1..2 | ||
| Indent Indent Indent Indent71445-1 | Nutritional Approaches. While a Resident | 1..4 | ||
| Indent Indent Indent Indent101605-4 | Nutritional Approaches. At Discharge | 1..4 | ||
| Indent Indent Indent90543-0 | Percent Intake by Artificial Route | |||
| Indent Indent Indent Indent86681-4 | Proportion of total calories the resident received through parenteral or tube feeding. While a Resident | |||
| Indent Indent Indent Indent86687-1 | Proportion of total calories the resident received through parenteral or tube feeding. During Entire 7 Days | |||
| Indent Indent Indent Indent86683-0 | Average fluid intake per day by IV or tube feeding. While a Resident | mL/d;L/d | ||
| Indent Indent Indent Indent86684-8 | Average fluid intake per day by IV or tube feeding. During Entire 7 Days | mL/d;L/d | ||
| Indent Indent101607-0 | Skin Conditions | |||
| Indent Indent Indent101333-3 | Determination of Pressure Ulcer/Injury Risk | 1..3 | ||
| Indent Indent Indent57280-0 | Risk of Pressure Ulcers/Injuries | |||
| Indent Indent Indent58214-8 | Unhealed Pressure Ulcers/Injuries | |||
| Indent Indent Indent101611-2 | Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage | |||
| Indent Indent Indent Indent54884-2 | Number of Stage 1 pressure injuries | {#} | ||
| Indent Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54886-7 | Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent55125-9 | Number of Stage 3 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54887-5 | Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent55126-7 | Number of Stage 4 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54890-9 | Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54893-3 | Number of unstageable pressure ulcers/injuries due to non-removable dressing/device | {#} | ||
| Indent Indent Indent Indent54894-1 | Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54946-9 | Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar | {#} | ||
| Indent Indent Indent Indent54947-7 | Number of these unstageable pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54950-1 | Number of unstageable pressure injuries presenting as deep tissue injury | {#} | ||
| Indent Indent Indent Indent54951-9 | Number of these unstageable pressure injuries that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent101609-6 | Number of Venous and Arterial Ulcers | {#} | ||
| Indent Indent Indent101610-4 | Other Ulcers, Wounds and Skin Problems | 1..8 | ||
| Indent Indent Indent86748-1 | Skin and Ulcer/Injury Treatments | 1..9 | ||
| Indent Indent86749-9 | Medications | |||
| Indent Indent Indent54982-4 | Injections | d/(7.d) | ||
| Indent Indent Indent58217-1 | Insulin | |||
| Indent Indent Indent Indent58127-2 | Insulin injections | d/(7.d) | ||
| Indent Indent Indent Indent58128-0 | Orders for insulin | d/(7.d) | ||
| Indent Indent Indent101612-0 | High-Risk Drug Classes: Use and Indication | |||
| Indent Indent Indent Indent93153-5 | Is taking | 1..10 | ||
| Indent Indent Indent Indent93154-3 | Indication noted | 0..10 | ||
| Indent Indent Indent57255-2 | Drug Regimen Review | |||
| Indent Indent Indent57281-8 | Medication Follow-up | |||
| Indent Indent Indent57256-0 | Medication Intervention | |||
| Indent Indent101613-8 | Special Treatments, Procedures, and Programs | |||
| Indent Indent Indent101614-6 | Special Treatments, Procedures, and Programs | |||
| Indent Indent Indent Indent83252-7 | Special Treatments, Procedures, and Programs - On Admission | 1..30 | ||
| Indent Indent Indent Indent86761-4 | Special Treatments, Procedures, and Programs - While a Resident | 1..13 | ||
| Indent Indent Indent Indent93185-7 | Special Treatments, Procedures, and Programs - At Discharge | 1..30 | ||
| Indent Indent Indent69339-0 | Influenza Vaccine | |||
| Indent Indent Indent Indent55019-4 | Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? | |||
| Indent Indent Indent Indent58131-4 | Date influenza vaccine received | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent55020-2 | If influenza vaccine not received, state reason: | |||
| Indent Indent Indent55021-0 | Pneumococcal Vaccine | |||
| Indent Indent Indent Indent55022-8 | Is the resident's Pneumococcal vaccination up to date? | |||
| Indent Indent Indent Indent45956-0 | If Pneumococcal vaccine not received, state reason: | |||
| Indent Indent Indent86762-2 | Therapies | |||
| Indent Indent Indent Indent86763-0 | Speech-Language Pathology and Audiology Services | |||
| Indent Indent Indent Indent Indent58218-9 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent58133-0 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent58134-8 | Group minutes | min | ||
| Indent Indent Indent Indent Indent86765-5 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent45760-6 | Days | d/(7.d) | ||
| Indent Indent Indent Indent Indent55025-1 | Therapy start date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent Indent55026-9 | Therapy end date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent86767-1 | Occupational Therapy | |||
| Indent Indent Indent Indent Indent58219-7 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent58136-3 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent58137-1 | Group minutes | min | ||
| Indent Indent Indent Indent Indent86764-8 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent45762-2 | Days | d/(7.d) | ||
| Indent Indent Indent Indent Indent55027-7 | Therapy start date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent Indent55028-5 | Therapy end date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent86768-9 | Physical Therapy | |||
| Indent Indent Indent Indent Indent58220-5 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent58139-7 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent58140-5 | Group minutes | min | ||
| Indent Indent Indent Indent Indent86766-3 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent45764-8 | Days | d/(7.d) | ||
| Indent Indent Indent Indent Indent55029-3 | Therapy start date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent Indent55030-1 | Therapy end date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent58141-3 | Respiratory Therapy | |||
| Indent Indent Indent Indent Indent45766-3 | Days | d/(7.d) | ||
| Indent Indent Indent90544-8 | Part A Therapies | |||
| Indent Indent Indent Indent90545-5 | Speech-Language Pathology and Audiology Services | |||
| Indent Indent Indent Indent Indent90539-8 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90536-4 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90538-0 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90537-2 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90551-3 | Days | d/{#} | ||
| Indent Indent Indent Indent90546-3 | Occupational Therapy | |||
| Indent Indent Indent Indent Indent90531-5 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90527-3 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90529-9 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90528-1 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90530-7 | Days | d/{#} | ||
| Indent Indent Indent Indent90547-1 | Physical Therapy | |||
| Indent Indent Indent Indent Indent90535-6 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90532-3 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90534-9 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90533-1 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90550-5 | Days | d/{#} | ||
| Indent Indent Indent90548-9 | Distinct Calendar Days of Part A Therapy | {#} | ||
| Indent Indent Indent86773-9 | Restorative Nursing Programs | |||
| Indent Indent Indent Indent86774-7 | Technique. Range of motion (passive) | d/(7.d) | ||
| Indent Indent Indent Indent86775-4 | Technique. Range of motion (active) | d/(7.d) | ||
| Indent Indent Indent Indent86776-2 | Technique. Splint or brace assistance | d/(7.d) | ||
| Indent Indent Indent Indent86777-0 | Training and Skill Practice In: Bed mobility | d/(7.d) | ||
| Indent Indent Indent Indent86778-8 | Training and Skill Practice In: Transfer | d/(7.d) | ||
| Indent Indent Indent Indent86779-6 | Training and Skill Practice In: Walking | d/(7.d) | ||
| Indent Indent Indent Indent86780-4 | Training and Skill Practice In: Dressing and/or grooming | d/(7.d) | ||
| Indent Indent Indent Indent86781-2 | Training and Skill Practice In: Eating and/or swallowing | d/(7.d) | ||
| Indent Indent Indent Indent86782-0 | Training and Skill Practice In: Amputation/prostheses care | d/(7.d) | ||
| Indent Indent Indent Indent86783-8 | Training and Skill Practice In: Communication | d/(7.d) | ||
| Indent Indent88307-4 | Restraints and Alarms | |||
| Indent Indent Indent86785-3 | Physical Restraints | |||
| Indent Indent Indent Indent86786-1 | Used in Bed. Bed rail | d/(7.d) | ||
| Indent Indent Indent Indent86787-9 | Used in Bed. Trunk restraint | d/(7.d) | ||
| Indent Indent Indent Indent86788-7 | Used in Bed. Limb restraint | d/(7.d) | ||
| Indent Indent Indent Indent86789-5 | Used in Bed. Other | d/(7.d) | ||
| Indent Indent Indent Indent86790-3 | Used in Chair or Out of Bed. Trunk restraint | d/(7.d) | ||
| Indent Indent Indent Indent86791-1 | Used in Chair or Out of Bed. Limb restraint | d/(7.d) | ||
| Indent Indent Indent Indent86792-9 | Used in Chair or Out of Bed. Chair prevents rising | d/(7.d) | ||
| Indent Indent Indent Indent86793-7 | Used in Chair or Out of Bed. Other | d/(7.d) | ||
| Indent Indent101615-3 | Participation in Assessment and Goal Setting | |||
| Indent Indent Indent101616-1 | Participation in Assessment and Goal Setting | 1..5 | ||
| Indent Indent Indent55056-6 | Resident's Overall Goal | |||
| Indent Indent Indent Indent55057-4 | Resident's overall goal for discharge established during the assessment process. | |||
| Indent Indent Indent Indent55058-2 | Indicate information source for Q0310A | |||
| Indent Indent Indent101617-9 | Discharge Plan | |||
| Indent Indent Indent Indent58146-2 | Is active discharge planning already occurring for the resident to return to the community? | |||
| Indent Indent Indent86795-2 | Resident's Documented Preference to Avoid Being Asked Question Q0500B | |||
| Indent Indent Indent101618-7 | Return to Community | |||
| Indent Indent Indent Indent58149-6 | Do you want to talk to someone about the possiblity of leaving this facility and returning to live and receive services in the community? | |||
| Indent Indent Indent Indent86798-6 | Indicate information source for Q0500B | |||
| Indent Indent Indent86796-0 | Resident's Preference to Avoid Being Asked Question Q0500B Again | |||
| Indent Indent Indent Indent86797-8 | Does resident (or family or significant other or guardian or legally authorized representative only if resident is unable to understand or respond) want to be asked about returning to the community on all assessments? | |||
| Indent Indent Indent Indent86798-6 | Indicate information source for Q0550A | |||
| Indent Indent Indent101619-5 | Referral | |||
| Indent Indent Indent Indent101620-3 | Has a referral been made to the Local Contact Agency (LCA)? | |||
| Indent Indent Indent101621-1 | Reason Referral to Local Contact Agency (LCA) Not Made | |||
| Indent Indent101622-9 | Correction Request | |||
| Indent Indent Indent85632-8 | Type of Provider | |||
| Indent Indent Indent87226-7 | Name of Resident | |||
| Indent Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent86524-6 | Type of Assessment | |||
| Indent Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent Indent86525-3 | Is this a SNF Part A PPS Discharge Assessment? | |||
| Indent Indent Indent87216-8 | Date on existing record to be modified/inactivated | |||
| Indent Indent Indent Indent54593-9 | Assessment Reference Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent52525-3 | Discharge Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent87209-3 | Correction Attestation Section | |||
| Indent Indent Indent58200-7 | Correction Number | {#} | ||
| Indent Indent Indent87217-6 | Reasons for Modification | 1..5 | ||
| Indent Indent Indent87225-9 | Reasons for Inactivation | 1..2 | ||
| Indent Indent Indent87218-4 | RN Assessment Coordinator Attestation of Completion | |||
| Indent Indent Indent Indent87219-2 | Attesting individual's first name | |||
| Indent Indent Indent Indent87220-0 | Attesting individual's last name | |||
| Indent Indent Indent Indent87221-8 | Attesting individual's title | |||
| Indent Indent Indent Indent87222-6 | Attestation date | {mm/dd/yyyy} | ||
| Indent Indent87223-4 | Assessment Administration | |||
| Indent Indent Indent55064-0 | Medicare Part A Billing | |||
| Indent Indent Indent Indent55065-7 | Medicare Part A HIPPS code | |||
| Indent Indent Indent Indent55081-4 | Version code | |||
| Indent Indent Indent55070-7 | Insurance Billing | |||
| Indent Indent Indent Indent55071-5 | Billing code | |||
| Indent Indent Indent Indent55081-4 | Billing version | |||
| Indent Indent Indent85648-4 | Signature of Persons Completing the Assessment or Entry/Death Reporting | |||
| Indent Indent Indent70127-6 | Signature of RN Assessment Coordinator Verifying Assessment Completion | |||
| Indent Indent Indent Indent70127-6 | Signature: | |||
| Indent Indent Indent Indent30947-6 | Date RN Assessment Coordinator signed assessment as complete: | {mm/dd/yyyy} | ||
| Indent101113-9 | MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set | |||
| Indent Indent101591-6 | Identification Information | |||
| Indent Indent Indent58198-3 | Type of Record | |||
| Indent Indent Indent54581-4 | Facility Provider Numbers | |||
| Indent Indent Indent Indent76468-8 | National Provider Identifier (NPI) | |||
| Indent Indent Indent Indent69417-4 | CMS Certification Number (CCN) | |||
| Indent Indent Indent Indent45398-5 | State Provider Number | |||
| Indent Indent Indent85632-8 | Type of Provider | |||
| Indent Indent Indent86524-6 | Type of Assessment | |||
| Indent Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent Indent54587-1 | Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry? | |||
| Indent Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent Indent71440-2 | Type of discharge | |||
| Indent Indent Indent Indent90525-7 | Is this a SNF Part A Interrupted Stay? | |||
| Indent Indent Indent Indent86525-3 | Is this a SNF Part A PPS Discharge Assessment? | |||
| Indent Indent Indent86526-1 | Unit Certification or Licensure Designation | |||
| Indent Indent Indent54503-8 | Legal Name of Resident | |||
| Indent Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent Indent45393-6 | Middle initial | |||
| Indent Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent Indent45395-1 | Suffix | |||
| Indent Indent Indent45966-9 | Social Security and Medicare Numbers | |||
| Indent Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent Indent45397-7 | Medicare number | |||
| Indent Indent Indent45400-9 | Medicaid Number | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent69854-8 | Ethnicity. Are you of Hispanic, Latino/a, or Spanish origin? | 1..4 | ||
| Indent Indent Indent103708-4 | Race. What is your race? | 1..14 | ||
| Indent Indent Indent45404-1 | Marital Status | |||
| Indent Indent Indent101351-5 | Transportation (from NACHC©) | |||
| Indent Indent Indent54506-1 | Optional Resident Items | |||
| Indent Indent Indent Indent46106-1 | Medical record number | |||
| Indent Indent Indent Indent45403-3 | Room number | |||
| Indent Indent Indent Indent52462-9 | Name by which resident prefers to be addressed | |||
| Indent Indent Indent Indent21843-8 | Lifetime occupation(s) | |||
| Indent Indent Indent86528-7 | Most Recent Admission/Entry or Reentry into this Facility | |||
| Indent Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent54590-5 | Type of Entry | |||
| Indent Indent Indent Indent85398-6 | Entered From | |||
| Indent Indent Indent52455-3 | Admission Date | {mm/dd/yyyy} | ||
| Indent Indent Indent52525-3 | Discharge Date | {mm/dd/yyyy} | ||
| Indent Indent Indent55128-3 | Discharge Status | |||
| Indent Indent Indent93182-4 | Provision of Current Reconciled Medication List to Subsequent Provider at Discharge | |||
| Indent Indent Indent93184-0 | Route of Current Reconciled Medication List Transmission to Subsequent Provider | 1..5 | ||
| Indent Indent Indent93181-6 | Provision of Current Reconciled Medication List to Resident at Discharge | |||
| Indent Indent Indent93183-2 | Route of Current Reconciled Medication List Transmission to Resident | 1..5 | ||
| Indent Indent Indent54593-9 | Assessment Reference Date. Observation end date | {mm/dd/yyyy} | ||
| Indent Indent Indent54507-9 | Medicare Stay | |||
| Indent Indent Indent Indent54594-7 | Has the resident had a Medicare-covered stay since the most recent entry? | |||
| Indent Indent Indent Indent54595-4 | Start date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent54596-2 | End date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent54508-7 | Hearing, Speech, and Vision | |||
| Indent Indent Indent54597-0 | Comatose | |||
| Indent Indent Indent103709-2 | Health Literacy | |||
| Indent Indent101592-4 | Cognitive Patterns | |||
| Indent Indent Indent54605-1 | Should Brief Interview for Mental Status (C0200-C0500) be Conducted? | |||
| Indent Indent Indent103694-6 | Brief Interview for Mental Status (BIMS) | |||
| Indent Indent Indent Indent103696-1 | Repetition of Three Words | |||
| Indent Indent Indent Indent103702-7 | Temporal Orientation | |||
| Indent Indent Indent Indent Indent103697-9 | Able to report correct year | |||
| Indent Indent Indent Indent Indent103698-7 | Able to report correct month | |||
| Indent Indent Indent Indent Indent103703-5 | Able to report correct day of the week | |||
| Indent Indent Indent Indent103695-3 | Recall | |||
| Indent Indent Indent Indent Indent103699-5 | Able to recall "sock" | |||
| Indent Indent Indent Indent Indent103700-1 | Able to recall "blue" | |||
| Indent Indent Indent Indent Indent103701-9 | Able to recall "bed" | |||
| Indent Indent Indent Indent103704-3 | BIMS Summary Score | {score} | ||
| Indent Indent Indent54615-0 | Should the Staff Assessment for Mental Status (C0700 - C1000) be Conducted? | |||
| Indent Indent Indent83241-0 | Staff Assessment for Mental Status | |||
| Indent Indent Indent Indent54616-8 | Short-term Memory OK | |||
| Indent Indent Indent Indent54624-2 | Cognitive Skills for Daily Decision Making | |||
| Indent Indent Indent101593-2 | Delirium | |||
| Indent Indent Indent95816-5 | Signs and Symptoms of Delirium (from CAM©) | |||
| Indent Indent Indent Indent95813-2 | Acute Onset Mental Change | |||
| Indent Indent Indent Indent95812-4 | Inattention | |||
| Indent Indent Indent Indent95814-0 | Disorganized Thinking | |||
| Indent Indent Indent Indent95815-7 | Altered Level of Consciousness | |||
| Indent Indent101594-0 | Mood | |||
| Indent Indent Indent54634-1 | Should Resident Mood Interview be Conducted? | |||
| Indent Indent Indent54635-8 | Resident Mood Interview (PHQ-2 to 9) | |||
| Indent Indent Indent Indent86843-0 | Symptom Presence | |||
| Indent Indent Indent Indent Indent54636-6 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54638-2 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54640-8 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54642-4 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54644-0 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54646-5 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54648-1 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54650-7 | 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 | |||
| Indent Indent Indent Indent Indent54652-3 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent Indent86844-8 | Symptom Frequency | |||
| Indent Indent Indent Indent Indent54637-4 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54639-0 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent Indent54641-6 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54643-2 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54645-7 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54647-3 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent Indent54649-9 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54651-5 | 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 | |||
| Indent Indent Indent Indent Indent54653-1 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent103705-0 | Total Severity Score | {score} | ||
| Indent Indent Indent103706-8 | Staff Assessment of Resident Mood (PHQ-9-OV) | |||
| Indent Indent Indent Indent86833-1 | Symptom Presence | |||
| Indent Indent Indent Indent Indent54658-0 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54660-6 | Feeling or appearing down, depressed, or hopeless | |||
| Indent Indent Indent Indent Indent54662-2 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54664-8 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54666-3 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54668-9 | Indicating that they feel bad about self, are a failure, or have let self or family down | |||
| Indent Indent Indent Indent Indent54670-5 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54672-1 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that they have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54673-9 | States that life isn't worth living, wishes for death, or attempts to harm self | |||
| Indent Indent Indent Indent Indent54675-4 | Being short-tempered, easily annoyed | |||
| Indent Indent Indent Indent86891-9 | Symptom Frequency | |||
| Indent Indent Indent Indent Indent54659-8 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent Indent54661-4 | Feeling or appearing down, depressed, or hopeless | |||
| Indent Indent Indent Indent Indent54663-0 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent Indent54665-5 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent Indent54667-1 | Poor appetite or overeating | |||
| Indent Indent Indent Indent Indent54669-7 | Indicating that they feel bad about self, are a failure, or have let self or family down | |||
| Indent Indent Indent Indent Indent54671-3 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent Indent54904-8 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that they have been moving around a lot more than usual | |||
| Indent Indent Indent Indent Indent54674-7 | States that life isn't worth living, wishes for death, or attempts to harm self | |||
| Indent Indent Indent Indent Indent54676-2 | Being short-tempered, easily annoyed | |||
| Indent Indent Indent103707-6 | Total Severity Score | {score} | ||
| Indent Indent Indent93159-2 | Social Isolation | |||
| Indent Indent86596-4 | Behavior | |||
| Indent Indent Indent86597-2 | Potential Indicators of Psychosis | 1..2 | ||
| Indent Indent54514-5 | Behavioral Symptom - Presence & Frequency | |||
| Indent Indent Indent54682-0 | Physical behavioral symptoms directed toward others | d/(7.d) | ||
| Indent Indent Indent54683-8 | Verbal behavioral symptoms directed toward others | d/(7.d) | ||
| Indent Indent Indent54684-6 | Other behavioral symptoms not directed toward others | d/(7.d) | ||
| Indent Indent54692-9 | Rejection of Care - Presence & Frequency | d/(7.d) | ||
| Indent Indent54693-7 | Wandering - Presence & Frequency | d/(7.d) | ||
| Indent Indent101595-7 | Functional Abilities and Goals | |||
| Indent Indent Indent88483-3 | Functional Abilities and Goals - Discharge | |||
| Indent Indent Indent Indent83254-3 | Self-Care - Discharge Performance | |||
| Indent Indent Indent Indent Indent95019-6 | Eating | |||
| Indent Indent Indent Indent Indent95018-8 | Oral hygiene | |||
| Indent Indent Indent Indent Indent95017-0 | Toileting hygiene | |||
| Indent Indent Indent Indent Indent95015-4 | Shower/bathe self | |||
| Indent Indent Indent Indent Indent95014-7 | Upper body dressing | |||
| Indent Indent Indent Indent Indent95013-9 | Lower body dressing | |||
| Indent Indent Indent Indent Indent95012-1 | Putting on/taking off footwear | |||
| Indent Indent Indent Indent88331-4 | Mobility - Discharge Performance (Assessment period is the last 3 days of the stay) | |||
| Indent Indent Indent Indent Indent95011-3 | Roll left and right | |||
| Indent Indent Indent Indent Indent95010-5 | Sit to lying | |||
| Indent Indent Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent Indent Indent95008-9 | Sit to stand | |||
| Indent Indent Indent Indent Indent95007-1 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent Indent Indent95006-3 | Toilet transfer | |||
| Indent Indent Indent Indent Indent95005-5 | Car transfer | |||
| Indent Indent Indent Indent Indent95004-8 | Walk 10 feet | |||
| Indent Indent Indent Indent Indent95003-0 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95002-2 | Walk 150 feet | |||
| Indent Indent Indent Indent Indent95001-4 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent Indent Indent94999-0 | 4 steps | |||
| Indent Indent Indent Indent Indent94998-2 | 12 steps | |||
| Indent Indent Indent Indent Indent94997-4 | Picking up object | |||
| Indent Indent Indent Indent Indent95738-1 | Does the resident use a wheelchair and/or scooter? | |||
| Indent Indent Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent83237-8 | Bladder and Bowel | |||
| Indent Indent Indent86624-4 | Appliances | 1..4 | ||
| Indent Indent Indent95735-7 | Urinary Continence | |||
| Indent Indent Indent95736-5 | Bowel Continence | |||
| Indent Indent101601-3 | Active Diagnoses | |||
| Indent Indent Indent86671-5 | Active Diagnoses in the last 7 days | 1..* | ||
| Indent Indent Indent52797-8 | Additional active diagnoses | 0..10 | ||
| Indent Indent101602-1 | Health Conditions | |||
| Indent Indent Indent54557-4 | Pain Management | |||
| Indent Indent Indent Indent71447-7 | At any time in the last 5 days, has the resident: Received scheduled pain medication regimen? | |||
| Indent Indent Indent Indent71448-5 | At any time in the last 5 days, has the resident: Received PRN pain medications OR was offered and declined? | |||
| Indent Indent Indent Indent71449-3 | At any time in the last 5 days, has the resident: Received non-medication intervention for pain? | |||
| Indent Indent Indent54828-9 | Should Pain Assessment Interview be Conducted? | |||
| Indent Indent Indent101603-9 | Pain Assessment Interview | |||
| Indent Indent Indent Indent54829-7 | Pain Presence | |||
| Indent Indent Indent Indent93156-8 | Pain Effect on Sleep | |||
| Indent Indent Indent Indent93160-0 | Pain Interference with Therapy Activities | |||
| Indent Indent Indent Indent93158-4 | Pain Interference with Day-to-Day Activities | |||
| Indent Indent Indent86674-9 | Other Health Conditions | |||
| Indent Indent Indent Indent86675-6 | Shortness of Breath (dyspnea) | 1..3 | ||
| Indent Indent Indent Indent54846-1 | Prognosis | |||
| Indent Indent Indent Indent86676-4 | Problem Conditions | 1..4 | ||
| Indent Indent Indent Indent54853-7 | Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent | |||
| Indent Indent Indent Indent54854-5 | Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent | |||
| Indent Indent Indent Indent Indent54855-2 | No injury | |||
| Indent Indent Indent Indent Indent54856-0 | Injury (except major) | |||
| Indent Indent Indent Indent Indent54857-8 | Major injury | |||
| Indent Indent101604-7 | Swallowing &or Nutritional Status | |||
| Indent Indent Indent54567-3 | Height and Weight | |||
| Indent Indent Indent Indent103692-0 | Height (in inches) | [in_us];cm;m | ||
| Indent Indent Indent Indent103693-8 | Weight (in pounds) | [lb_av];kg | ||
| Indent Indent Indent54863-6 | Weight Loss | |||
| Indent Indent Indent86678-0 | Weight Gain | |||
| Indent Indent Indent54568-1 | Nutritional Approaches | |||
| Indent Indent Indent Indent101605-4 | Nutritional Approaches. At Discharge | 1..4 | ||
| Indent Indent101607-0 | Skin Conditions | |||
| Indent Indent Indent101333-3 | Determination of Pressure Ulcer/Injury Risk | 1..3 | ||
| Indent Indent Indent58214-8 | Unhealed Pressure Ulcers/Injuries | |||
| Indent Indent Indent101611-2 | Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage | |||
| Indent Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54886-7 | Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent55125-9 | Number of Stage 3 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54887-5 | Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent55126-7 | Number of Stage 4 pressure ulcers | {#} | ||
| Indent Indent Indent Indent54890-9 | Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54893-3 | Number of unstageable pressure ulcers/injuries due to non-removable dressing/device | {#} | ||
| Indent Indent Indent Indent54894-1 | Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54946-9 | Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar | {#} | ||
| Indent Indent Indent Indent54947-7 | Number of these unstageable pressure ulcers that were present upon admission/entry or reentry | {#} | ||
| Indent Indent Indent Indent54950-1 | Number of unstageable pressure injuries presenting as deep tissue injury | {#} | ||
| Indent Indent Indent Indent54951-9 | Number of these unstageable pressure injuries that were present upon admission/entry or reentry | {#} | ||
| Indent Indent86749-9 | Medications | |||
| Indent Indent Indent101612-0 | High-Risk Drug Classes: Use and Indication | |||
| Indent Indent Indent Indent93153-5 | Is taking | 1..10 | ||
| Indent Indent Indent Indent93154-3 | Indication noted | 0..10 | ||
| Indent Indent Indent57256-0 | Medication Intervention | |||
| Indent Indent101613-8 | Special Treatments, Procedures, and Programs | |||
| Indent Indent Indent101614-6 | Special Treatments, Procedures, and Programs | |||
| Indent Indent Indent Indent93185-7 | Special Treatments, Procedures, and Programs - At Discharge | 1..30 | ||
| Indent Indent Indent69339-0 | Influenza Vaccine | |||
| Indent Indent Indent Indent55019-4 | Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? | |||
| Indent Indent Indent Indent58131-4 | Date influenza vaccine received | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent55020-2 | If influenza vaccine not received, state reason: | |||
| Indent Indent Indent55021-0 | Pneumococcal Vaccine | |||
| Indent Indent Indent Indent55022-8 | Is the resident's Pneumococcal vaccination up to date? | |||
| Indent Indent Indent Indent45956-0 | If Pneumococcal vaccine not received, state reason: | |||
| Indent Indent Indent90544-8 | Part A Therapies | |||
| Indent Indent Indent Indent90545-5 | Speech-Language Pathology and Audiology Services | |||
| Indent Indent Indent Indent Indent90539-8 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90536-4 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90538-0 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90537-2 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90551-3 | Days | d/{#} | ||
| Indent Indent Indent Indent90546-3 | Occupational Therapy | |||
| Indent Indent Indent Indent Indent90531-5 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90527-3 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90529-9 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90528-1 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90530-7 | Days | d/{#} | ||
| Indent Indent Indent Indent90547-1 | Physical Therapy | |||
| Indent Indent Indent Indent Indent90535-6 | Individual minutes | min | ||
| Indent Indent Indent Indent Indent90532-3 | Concurrent minutes | min | ||
| Indent Indent Indent Indent Indent90534-9 | Group minutes | min | ||
| Indent Indent Indent Indent Indent90533-1 | Co-treatment minutes | min | ||
| Indent Indent Indent Indent Indent90550-5 | Days | d/{#} | ||
| Indent Indent Indent90548-9 | Distinct Calendar Days of Part A Therapy | {#} | ||
| Indent Indent88307-4 | Restraints and Alarms | |||
| Indent Indent Indent86785-3 | Physical Restraints | |||
| Indent Indent Indent Indent86786-1 | Used in Bed. Bed rail | d/(7.d) | ||
| Indent Indent Indent Indent86787-9 | Used in Bed. Trunk restraint | d/(7.d) | ||
| Indent Indent Indent Indent86788-7 | Used in Bed. Limb restraint | d/(7.d) | ||
| Indent Indent Indent Indent86789-5 | Used in Bed. Other | d/(7.d) | ||
| Indent Indent Indent Indent86790-3 | Used in Chair or Out of Bed. Trunk restraint | d/(7.d) | ||
| Indent Indent Indent Indent86791-1 | Used in Chair or Out of Bed. Limb restraint | d/(7.d) | ||
| Indent Indent Indent Indent86792-9 | Used in Chair or Out of Bed. Chair prevents rising | d/(7.d) | ||
| Indent Indent Indent Indent86793-7 | Used in Chair or Out of Bed. Other | d/(7.d) | ||
| Indent Indent101615-3 | Participation in Assessment and Goal Setting | |||
| Indent Indent Indent101617-9 | Discharge Plan | |||
| Indent Indent Indent Indent58146-2 | Is active discharge planning already occurring for the resident to return to the community? | |||
| Indent Indent Indent101619-5 | Referral | |||
| Indent Indent Indent Indent101620-3 | Has a referral been made to the Local Contact Agency (LCA)? | |||
| Indent Indent Indent101621-1 | Reason Referral to Local Contact Agency (LCA) Not Made | |||
| Indent Indent101622-9 | Correction Request | |||
| Indent Indent Indent85632-8 | Type of Provider | |||
| Indent Indent Indent87226-7 | Name of Resident | |||
| Indent Indent Indent Indent45392-8 | First name | |||
| Indent Indent Indent Indent45394-4 | Last name | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent86524-6 | Type of Assessment | |||
| Indent Indent Indent Indent54583-0 | Federal OBRA Reason for Assessment | |||
| Indent Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent Indent86525-3 | Is this a SNF Part A PPS Discharge Assessment? | |||
| Indent Indent Indent87216-8 | Date on existing record to be modified/inactivated | |||
| Indent Indent Indent Indent54593-9 | Assessment Reference Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent52525-3 | Discharge Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent87209-3 | Correction Attestation Section | |||
| Indent Indent Indent58200-7 | Correction Number | {#} | ||
| Indent Indent Indent87217-6 | Reasons for Modification | 1..5 | ||
| Indent Indent Indent87225-9 | Reasons for Inactivation | 1..2 | ||
| Indent Indent Indent87218-4 | RN Assessment Coordinator Attestation of Completion | |||
| Indent Indent Indent Indent87219-2 | Attesting individual's first name | |||
| Indent Indent Indent Indent87220-0 | Attesting individual's last name | |||
| Indent Indent Indent Indent87221-8 | Attesting individual's title | |||
| Indent Indent87223-4 | Assessment Administration | |||
| Indent Indent Indent55070-7 | Insurance Billing | |||
| Indent Indent Indent Indent55071-5 | Billing code | |||
| Indent Indent Indent Indent55081-4 | Billing version | |||
| Indent Indent Indent85648-4 | Signature of Persons Completing the Assessment or Entry/Death Reporting | |||
| Indent Indent Indent70127-6 | Signature of RN Assessment Coordinator Verifying Assessment Completion | |||
| Indent Indent Indent Indent70127-6 | Signature: | |||
| Indent Indent Indent Indent30947-6 | Date RN Assessment Coordinator signed assessment as complete: | {mm/dd/yyyy} |
LOINC Names Get Info
- Fully-Specified Name
- Minimum Data Set (MDS) - version 3.0 - Resident Assessment Instrument (RAI) version 1.18.11:
-: RptPeriod: ^Patient: -: CMS Assessment - Long Common Name
- Minimum Data Set (MDS) - version 3.0 - Resident Assessment Instrument (RAI) version 1.18.11 during assessment period [CMS Assessment]
Part Model Get Info
- Component
- Minimum Data Set (MDS) - version 3.0 - Resident Assessment Instrument (RAI) version 1.18.11
LP434012-3
- Analyte
- Minimum Data Set (MDS) - version 3.0 - Resident Assessment Instrument (RAI) version 1.18.11
LP434012-3
- Component Numerator
- Minimum Data Set (MDS) - version 3.0 - Resident Assessment Instrument (RAI) version 1.18.11
LP434012-3
- Component Numerator Core
- Minimum Data Set (MDS) - version 3.0 - Resident Assessment Instrument (RAI) version 1.18.11
LP434012-3
- Component Numerator Core Suffix
- NULL
- Component Denominator
- NULL
- Component Denominator Core
- NULL
- Component Denominator Core Suffix
- NULL
- Challenge
- NULL
- Adjustment
- NULL
- Count
- NULL
- Property
- -
LP6769-6
- Time
- RptPeriod
LP190654-6
- Time Core
- RptPeriod
LP190654-6
- Time Modifier
- NULL
- System
- ^Patient
LP310005-6
- System Core
- NULL
- Super System
- Patient
LP6985-8
- Scale
- -
LP7747-1
- Method
- CMS Assessment
LP230524-3
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.74
- Last Updated
- Version 2.77 (PANEL)
- Change Reason
- Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;
- Order vs. Observation
- Order
- Panel Type
- Convenience group
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 100997-6 | Respiratory Allergen Panel, Area 5 - Serum |
LOINC Terminology Service (API) using HL7® FHIR® Get Info
Requests to this service require a free LOINC username and password. Below is a sample of the possible capabilities. See the LOINC Terminology Service documentation for more information.
- CodeSystem lookup
- https:
//fhir.loinc.org/CodeSystem/$lookup?system=http: //loinc.org&code=101104-8 - Questionnaire definition
- https:
//fhir.loinc.org/Questionnaire/?url=http: //loinc.org/q/101104-8
LOINC Copyright
Copyright © Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright © Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee. See https://