54580-6
Deprecated Minimum Data Set - version 3.0
Deprecated
Status Information
- Status
- DEPRECATED
Term Description
Recognizing the care implication and program importance of an improved Minimim Data Set (MDS), CMS initiated a national project to create a version of 3.0 of the MDS. The revision aimed to improve the clinical relevance and accuracy of MDS assessments, increase the voice of residents in assessments, improve user satisfaction, and increase the efficiency of reports.
Source: Centers for Medicare & Medicaid Services
Panel Hierarchy
Details for each LOINC in Panel LHC-Forms
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 54580-6 | Deprecated Minimum Data Set - version 3.0 | |||
| Indent54501-2 | Identification information | |||
| Indent Indent58198-3 | Type of record | |||
| Indent Indent54581-4 | Facility provider numbers | |||
| Indent Indent Indent76468-8 | National Provider Identifier (NPI) | |||
| Indent Indent Indent69417-4 | CMS Certification Number (CCN) | |||
| Indent Indent Indent45398-5 | State provider number for Facility | |||
| Indent Indent54582-2 | Type of Provider | |||
| Indent Indent54502-0 | Type of Assessment | |||
| Indent Indent Indent54583-0 | Federal OBRA reason for assessment | |||
| Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent54585-5 | PPS Other Medicare Required Assessment - OMRA | |||
| Indent Indent Indent58107-4 | Is this a Swing Bed clinical change assessment? | |||
| Indent Indent Indent54587-1 | Is this assessment the first assessment (OBRA, PPS, or Discharge) since the most recent admission? | |||
| Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent71440-2 | Type of discharge | |||
| Indent Indent54896-6 | Submission requirement [MDSv3] | |||
| Indent Indent54503-8 | Legal name of resident | |||
| Indent Indent Indent45392-8 | Patient First (Given) name | |||
| Indent Indent Indent45393-6 | Middle initial | |||
| Indent Indent Indent45394-4 | Patient Last (Family) name | |||
| Indent Indent Indent45395-1 | Suffix | |||
| Indent Indent45966-9 | Social Security and Medicare numbers | |||
| Indent Indent Indent45396-9 | Social Security number [Identifier] | |||
| Indent Indent Indent45397-7 | Medicare number (or comparable railroad insurance number) | |||
| Indent Indent45400-9 | Medicaid number | |||
| Indent Indent46098-0 | Gender | |||
| Indent Indent21112-8 | Birth date | {mm/dd/yyyy} | ||
| Indent Indent59362-4 | Race/Ethnicity | 1..6 | ||
| Indent Indent54505-3 | Language | |||
| Indent Indent Indent54588-9 | Does the resident need or want an interpreter to communicate with a doctor or health care staff? | |||
| Indent Indent Indent54899-0 | Preferred Language | |||
| Indent Indent45404-1 | Marital status | |||
| Indent Indent54506-1 | Optional resident items | |||
| Indent Indent Indent46106-1 | Medical record number | |||
| Indent Indent Indent45403-3 | Room number [Location] | |||
| Indent Indent Indent52462-9 | Name by which resident prefers to be addressed | |||
| Indent Indent Indent21843-8 | History of Usual occupation | |||
| Indent Indent54589-7 | Preadmission Screening and Resident Review (PASRR). Has the resident been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition? | |||
| Indent Indent71441-0 | Level II Preadmission Screening and Resident Review (PASRR) | |||
| Indent Indent71454-3 | Conditions related to ID/DD | |||
| Indent Indent Indent71452-7 | ID/DD with organic condition | |||
| Indent Indent Indent Indent45422-3 | Down's syndrome [Minimum Data Set] | |||
| Indent Indent Indent Indent45423-1 | Autism [Minimum Data Set] | |||
| Indent Indent Indent Indent45424-9 | Epilepsy [Minimum Data Set] | |||
| Indent Indent Indent Indent71455-0 | Other organic condition related to ID/DD | |||
| Indent Indent Indent Indent71453-5 | ID/DD with no organic condition | |||
| Indent Indent50786-3 | Entry Date (date of this admission/reentry into the facility) | {mm/dd/yyyy} | ||
| Indent Indent54590-5 | Type of Entry | |||
| Indent Indent85398-6 | Admitted from Facility | |||
| Indent Indent52525-3 | Discharge date | {mm/dd/yyyy} | ||
| Indent Indent55128-3 | Discharge disposition | |||
| Indent Indent54592-1 | Previous assessment reference date for significant correction | {mm/dd/yyyy} | ||
| Indent Indent54593-9 | Assessment reference date - observation end date | {mm/dd/yyyy} | ||
| Indent Indent54507-9 | Medicare stay | |||
| Indent Indent Indent54594-7 | Has resident had Medicare-covered stay since the most recent entry? | |||
| Indent Indent Indent54595-4 | Start date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent Indent Indent54596-2 | End date of most recent Medicare stay | {mm/dd/yyyy} | ||
| Indent54508-7 | Hearing, speech, and vision | |||
| Indent Indent54597-0 | Comatose | |||
| Indent Indent54598-8 | Hearing | |||
| Indent Indent54599-6 | Hearing Aid | |||
| Indent Indent54600-2 | Speech Clarity | |||
| Indent Indent54601-0 | Makes Self Understood | |||
| Indent Indent54602-8 | Ability to understand others | |||
| Indent Indent54603-6 | Vision | |||
| Indent Indent54604-4 | Corrective Lenses | |||
| Indent54509-5 | Cognitive patterns during assessment period [CMS Assessment] | |||
| Indent Indent54605-1 | Brief interview for mental status should be conducted | |||
| Indent Indent52491-8 | Brief interview for mental status [BIMS] | |||
| Indent Indent Indent52731-7 | Repetition of three words # [BIMS] | |||
| Indent Indent Indent54510-3 | Temporal orientation (orientation to year, month, and day) [BIMS] | |||
| Indent Indent Indent Indent52732-5 | Temporal orientation - current year [BIMS] | |||
| Indent Indent Indent Indent52733-3 | Temporal orientation - current month [BIMS] | |||
| Indent Indent Indent Indent54609-3 | Temporal orientation - current day of the week [BIMS] | |||
| Indent Indent Indent52493-4 | Recall [BIMS] | |||
| Indent Indent Indent Indent52735-8 | Able to recall "sock" | |||
| Indent Indent Indent Indent52736-6 | Able to recall "blue" | |||
| Indent Indent Indent Indent52737-4 | Able to recall "bed" | |||
| Indent Indent Indent54614-3 | Summary Score | {score} | ||
| Indent Indent54615-0 | Should the Staff Assessment for Mental Status C0700-C1000 be conducted? | |||
| Indent Indent54895-8 | Staff assessment for mental status [MDSv3] | |||
| Indent Indent Indent54616-8 | Short-term Memory OK | |||
| Indent Indent Indent54617-6 | Long-term memory OK | |||
| Indent Indent Indent54618-4 | Memory/Recall Ability | |||
| Indent Indent Indent Indent54619-2 | Current season | |||
| Indent Indent Indent Indent54620-0 | Location of own room | |||
| Indent Indent Indent Indent54621-8 | Staff names and faces | |||
| Indent Indent Indent Indent54622-6 | That he or she is in a nursing home | |||
| Indent Indent Indent Indent54623-4 | None of the above were recalled | |||
| Indent Indent Indent54624-2 | Cognitive skills for daily decision making | |||
| Indent Indent54626-7 | Delirium [MDSv3] | |||
| Indent Indent Indent54627-5 | Signs and symptoms of delirium (from CAM) [CAM.MDSv3] | |||
| Indent Indent Indent Indent54628-3 | Inattention. Did the resident have difficulty focusing attention (easily distracted, out of touch or difficulty following what was said)? | |||
| Indent Indent Indent Indent54629-1 | Disorganized thinking. Was the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)? | |||
| Indent Indent Indent Indent54630-9 | Altered level of consciousness. Did the resident have altered level of consciousness? | |||
| Indent Indent Indent Indent54631-7 | Psychomotor retardation. Did the resident have an unusually decreased level of ctivity such as sluggishness, staring into space, staying in one position, moving very slowly? | |||
| Indent Indent Indent54632-5 | Acute Onset Mental Status Change - Is there evidence of an acute change in mental status from the resident's baseline? | |||
| Indent54633-3 | Mood | |||
| Indent Indent54634-1 | Should resident mood interview be conducted | |||
| Indent Indent54635-8 | Resident mood interview (PHQ-9) | |||
| Indent Indent Indent86843-0 | Symptom Presence | |||
| Indent Indent Indent Indent54636-6 | Little interest or pleasure in doing things in last 2W.presence | |||
| Indent Indent Indent Indent54638-2 | Feeling down, depressed or hopeless in last 2W.presence | |||
| Indent Indent Indent Indent54640-8 | Trouble falling or staying asleep, or sleeping too much in last 2W.presence | |||
| Indent Indent Indent Indent54642-4 | Feeling tired or having little energy in last 2W.presence | |||
| Indent Indent Indent Indent54644-0 | Poor appetite or overeating in last 2W.presence | |||
| Indent Indent Indent Indent54646-5 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down in last 2W.presence | |||
| Indent Indent Indent Indent54648-1 | Trouble concentrating on things, such as reading the newspaper or watching television in last 2W.presence | |||
| 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 in last 2W.presence | |||
| Indent Indent Indent Indent54652-3 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent86844-8 | Symptom Frequency | |||
| Indent Indent Indent Indent54637-4 | Little interest or pleasure in doing things in last 2W.frequency | |||
| Indent Indent Indent Indent54639-0 | Feeling down, depressed or hopeless in last 2W.frequency | |||
| Indent Indent Indent Indent54641-6 | Trouble falling or staying asleep, or sleeping too much in last 2W.frequency | |||
| Indent Indent Indent Indent54643-2 | Feeling tired or having little energy in last 2W.frequency | |||
| Indent Indent Indent Indent54645-7 | Poor appetite or overeating in last 2W.frequency | |||
| Indent Indent Indent Indent54647-3 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down in last 2W.frequency | |||
| Indent Indent Indent Indent54649-9 | Trouble concentrating on things, such as reading the newspaper or watching television in last 2W.frequency | |||
| 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 in last 2W.frequency | |||
| Indent Indent Indent Indent54653-1 | Thoughts that you would be better off dead, or of hurting yourself in some way in last 2W.frequency | |||
| Indent Indent54654-9 | Total Severity Score | {score} | ||
| Indent Indent54655-6 | Safety Notification. Was a responsible staff or provider informed that there is a potential for resident self harm? | |||
| Indent Indent54657-2 | Staff assessment of resident mood (PHQ-9-OV) | |||
| Indent Indent Indent86833-1 | Staff assessment of resident mood (PHQ-9-OV) - symptom presence in the last 2W | |||
| Indent Indent Indent Indent54658-0 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent54660-6 | Feeling or appearing down, depressed, or hopeless.Presence | |||
| Indent Indent Indent Indent54662-2 | Trouble falling or staying asleep, or sleeping too much.Presence | |||
| Indent Indent Indent Indent54664-8 | Feeling tired or having little energy.Presence | |||
| Indent Indent Indent Indent54666-3 | Poor appetite or overeating.Presence | |||
| Indent Indent Indent Indent54668-9 | Indicating that s/he feels bad about self, is a failure, or has let self or family down.presence | |||
| Indent Indent Indent Indent54670-5 | Trouble concentrating on things, such as reading the newspaper or watching television.Presence | |||
| Indent Indent Indent Indent54672-1 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that s/he has been moving around a lot more than usual.presence | |||
| Indent Indent Indent Indent54673-9 | States that life isn't worth living, wishes for death, or attempts to harm self.Presence | |||
| Indent Indent Indent Indent54675-4 | Being short-tempered, easily annoyed.Presence | |||
| Indent Indent Indent86891-9 | Staff assessment of resident mood (PHQ-9-OV) - symptom frequency in the last 2W | |||
| Indent Indent Indent Indent54659-8 | Little interest or pleasure in doing things.Frequency | |||
| Indent Indent Indent Indent54661-4 | Feeling or appearing down, depressed, or hopeless.Frequency | |||
| Indent Indent Indent Indent54663-0 | Trouble falling or staying asleep, or sleeping too much.Frequency | |||
| Indent Indent Indent Indent54665-5 | Feeling tired or having little energy.Frequency | |||
| Indent Indent Indent Indent54667-1 | Poor appetite or overeating.Frequency | |||
| Indent Indent Indent Indent54669-7 | Indicating that s/he feels bad about self, is a failure, or has let self or family down.frequency | |||
| Indent Indent Indent Indent54671-3 | Trouble concentrating on things, such as reading the newspaper or watching television.Frequency | |||
| Indent Indent Indent Indent54904-8 | Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that s/he has been moving around a lot more than usual.frequency | |||
| Indent Indent Indent Indent54674-7 | States that life isn't worth living, wishes for death, or attempts to harm self.Frequency | |||
| Indent Indent Indent Indent54676-2 | Being short-tempered, easily annoyed.Frequency | |||
| Indent Indent54677-0 | Total Severity Score | {score} | ||
| Indent Indent54655-6 | Safety Notification. Was a responsible staff or provider informed that there is a potential for resident self harm? | |||
| Indent54511-1 | Behavior | |||
| Indent Indent54512-9 | Pyschosis | |||
| Indent Indent Indent54678-8 | Hallucinations | |||
| Indent Indent Indent54680-4 | Delusions | |||
| Indent Indent Indent54681-2 | None of the above | |||
| Indent Indent54513-7 | Behavioral symptoms | |||
| 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 | Put the resident at significant risk for physical illness or injury? | |||
| Indent Indent Indent Indent54687-9 | Significantly interfere with the resident's care? | |||
| Indent Indent Indent Indent54688-7 | Significantly interfere with the resident's participation in activities or social interactions? | |||
| Indent Indent Indent54516-0 | Impact on others | |||
| Indent Indent Indent Indent54689-5 | Put others at significant risk for physical injury? | |||
| Indent Indent Indent Indent54690-3 | Significantly intrude on the privacy or activity of others? | |||
| Indent Indent Indent Indent54691-1 | Significantly disrupt care or living environment? | |||
| 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 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 (e.g., stairs, outside of the facility)? | |||
| Indent Indent Indent Indent54695-2 | Does wandering significantly intrude on the privacy or activities of others? | |||
| Indent Indent Indent54696-0 | Change in behavioral or other symptoms - How does resident's current behavior status, care rejection, or wandering compare to prior assessment (OBRA or PPS)? | |||
| Indent54518-6 | Preferences for customary routine and activities | |||
| Indent Indent54697-8 | Should Interview for Daily and Activity Preferences be Conducted? | |||
| Indent Indent54519-4 | Interview for daily preferences | |||
| Indent Indent Indent54698-6 | How important is it to you to choose what clothes to wear? | |||
| Indent Indent Indent54699-4 | How important is it to you to take care of your personal belongings or things? | |||
| Indent Indent Indent54700-0 | How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? | |||
| Indent Indent Indent54701-8 | How important is it to you to have snacks available between meals? | |||
| Indent Indent Indent54702-6 | How important is it to choose your own bedtime? | |||
| Indent Indent Indent54703-4 | How important is it to you to have your family or a close friend involved in discussions about your care? | |||
| Indent Indent Indent54704-2 | How important is it to you to be able to use the phone in private? | |||
| Indent Indent Indent54705-9 | How important is it to you to have a place to lock your things to keep them safe? | |||
| Indent Indent54520-2 | Interview for activity preferences | |||
| Indent Indent Indent54706-7 | How important is it to you to have books, newspapers, and magazines to read? | |||
| Indent Indent Indent54707-5 | How important is it to you to listen to music you like? | |||
| Indent Indent Indent54708-3 | How important is it to you to be around animals such as pets? | |||
| Indent Indent Indent54709-1 | How important is it to you to keep up with the news? | |||
| Indent Indent Indent54710-9 | How important is it to you to do things with groups of people? | |||
| Indent Indent Indent54711-7 | How important is it to you to do your favorite activities? | |||
| Indent Indent Indent54712-5 | How important is it to you to go outside to get fresh air when the weather is good? | |||
| Indent Indent Indent54713-3 | How important is it to you to participate in religious services or practices? | |||
| Indent Indent54714-1 | Primary respondent for daily and activity preferences | |||
| Indent Indent54715-8 | Should the Staff Assessment of Daily and Activity Preferences be Conducted? | |||
| Indent Indent54521-0 | Staff assessment of daily and activity preferences | |||
| Indent Indent Indent54716-6 | Resident prefers choosing clothes to wear [MDSv3] | |||
| Indent Indent Indent54717-4 | Resident prefers caring for personal belongings [MDSv3] | |||
| Indent Indent Indent54718-2 | Resident prefers receiving tub bath [MDSv3] | |||
| Indent Indent Indent54719-0 | Resident prefers receiving shower [MDSv3] | |||
| Indent Indent Indent54720-8 | Resident prefers receiving bed bath [MDSv3] | |||
| Indent Indent Indent54721-6 | Resident prefers receiving sponge bath [MDSv3] | |||
| Indent Indent Indent54722-4 | Resident prefers snacks between meals [MDSv3] | |||
| Indent Indent Indent54723-2 | Resident prefers staying up past 8:00 p.m. [MDSv3] | |||
| Indent Indent Indent54724-0 | Resident prefers family or significant other involvement in care discussions [MDSv3] | |||
| Indent Indent Indent54725-7 | Resident prefers use of phone in private [MDSv3] | |||
| Indent Indent Indent54726-5 | Resident prefers place to lock personal belongings [MDSv3] | |||
| Indent Indent Indent54727-3 | Resident prefers reading books, newspapers, magazines [MDSv3] | |||
| Indent Indent Indent54728-1 | Resident prefers listening to music [MDSv3] | |||
| Indent Indent Indent54729-9 | Resident prefers being around animals such as pets [MDSv3] | |||
| Indent Indent Indent54730-7 | Resident prefers keeping up with the news [MDSv3] | |||
| Indent Indent Indent54731-5 | Resident prefers doing things with groups of people [MDSv3] | |||
| Indent Indent Indent54732-3 | Resident prefers participating in favorite activities [MDSv3] | |||
| Indent Indent Indent54733-1 | Resident prefers spending time away from the nursing home [MDSv3] | |||
| Indent Indent Indent54734-9 | Resident prefers spending time outdoors [MDSv3] | |||
| Indent Indent Indent54735-6 | Resident prefers participating in religious activities or practices [MDSv3] | |||
| Indent Indent Indent54736-4 | Resident prefers none of the above [MDSv3] | |||
| Indent54522-8 | Functional status | |||
| Indent Indent54523-6 | Activities of Daily Living (ADL) Assistance | |||
| Indent Indent Indent45588-1 | Bed mobility - self-performance during assessment period | |||
| Indent Indent Indent45589-9 | Bed mobility - support provided during assessment period | |||
| Indent Indent Indent45590-7 | Transfer - self-performance during assessment period | |||
| Indent Indent Indent45591-5 | Transfer - support provided during assessment period | |||
| Indent Indent Indent45592-3 | Walk in room - self-performance during assessment period | |||
| Indent Indent Indent45593-1 | Walk in room - support provided during assessment period | |||
| Indent Indent Indent45594-9 | Walk in corridor - self-performance during assessment period | |||
| Indent Indent Indent45595-6 | Walk in corridor - support provided during assessment period | |||
| Indent Indent Indent45596-4 | Locomotion on unit - self-performance during assessment period | |||
| Indent Indent Indent45597-2 | Locomotion on unit - support provided during assessment period | |||
| Indent Indent Indent45598-0 | Locomotion off unit - self-performance during assessment period | |||
| Indent Indent Indent45599-8 | Locomotion off unit - support provided during assessment period | |||
| Indent Indent Indent45600-4 | Dressing - self-performance during assessment period | |||
| Indent Indent Indent45601-2 | Dressing - support provided during assessment period | |||
| Indent Indent Indent45602-0 | Eating - self-performance during assessment period | |||
| Indent Indent Indent45603-8 | Eating - support provided during assessment period | |||
| Indent Indent Indent45604-6 | Toilet use - self-performance during assessment period | |||
| Indent Indent Indent45605-3 | Toilet use - support provided during assessment period | |||
| Indent Indent Indent45606-1 | Personal hygiene - self-performance during assessment period | |||
| Indent Indent Indent45607-9 | Personal hygiene - support provided during assessment period | |||
| Indent Indent46008-9 | Bathing | |||
| Indent Indent Indent45608-7 | Bathing - self-performance during assessment period | |||
| Indent Indent Indent45609-5 | Bathing - support provided during assessment period | |||
| Indent Indent54524-4 | Balance during transitions and walking | |||
| Indent Indent Indent54749-7 | Moving from seated to standing position | |||
| Indent Indent Indent54750-5 | Walking (with assistive device if used) | |||
| Indent Indent Indent54751-3 | Turning around and facing the opposite direction while walking | |||
| Indent Indent Indent54752-1 | Moving on and off toilet | |||
| Indent Indent Indent54753-9 | Surface-to-surface transfer | |||
| Indent Indent54525-1 | Deprecated Functional limitation in range of motion [CMS Assessment] | |||
| Indent Indent Indent54754-7 | Upper extremity (shoulder, elbow, wrist, hand) | |||
| Indent Indent Indent54755-4 | Lower extremity (hip, knee, ankle, foot) | |||
| Indent Indent54526-9 | Mobility devices | |||
| Indent Indent Indent54756-2 | Cane/crutch | |||
| Indent Indent Indent54757-0 | Walker | |||
| Indent Indent Indent54758-8 | Wheelchair (manual or electric) | |||
| Indent Indent Indent54759-6 | Limb prosthesis | |||
| Indent Indent Indent54760-4 | None of the above were used | |||
| Indent Indent54527-7 | Functional rehabilitation potential | |||
| Indent Indent Indent55123-4 | Resident believes he or she is capable of increased independence in at least some ADLs | |||
| Indent Indent Indent45613-7 | Direct care staff believe resident is capable of increased independence in at least some ADLs | |||
| Indent54528-5 | Bladder and bowel | |||
| Indent Indent54529-3 | Appliances | |||
| Indent Indent Indent54762-0 | Indwelling catheter | |||
| Indent Indent Indent54763-8 | External catheter | |||
| Indent Indent Indent54764-6 | Ostomy (including suprapubic catheter, ileostomy, and colostomy) | |||
| Indent Indent Indent54765-3 | Intermittent catheterization | |||
| Indent Indent Indent54766-1 | None of the above | |||
| Indent Indent54530-1 | Urinary toileting program | |||
| Indent Indent Indent54767-9 | Has a trial of a toileting program (e.g. scheduled toileting, prompted voiding, or bladder training) been attempted on admission/reentry or since urinary incontinence was noted in this facility? | |||
| Indent Indent Indent54768-7 | Response. What was the resident's response to the trial program? | |||
| Indent Indent Indent54769-5 | Current toileting program or trial. Is a toileting program (e.g. scheduled toileting, prompted voiding, or bladder training) currently being used to manage the resident's urinary continence? | |||
| Indent Indent54770-3 | Urinary continence. Select the one category that best describes the resident | |||
| Indent Indent54771-1 | Bowel continence. Select the one category that best describes the resident | |||
| Indent Indent54772-9 | Bowel Toileting Program. Is a toileting program currently being used to manage the resident's bowel continence? | |||
| Indent Indent54773-7 | Bowel Patterns. Constipation present? | |||
| Indent54531-9 | Active disease diagnosis | |||
| Indent Indent54532-7 | Cancer | |||
| Indent Indent Indent54774-5 | Cancer | |||
| Indent Indent54533-5 | Heart/Circulation | |||
| Indent Indent Indent54775-2 | Anemia | |||
| Indent Indent Indent54776-0 | Atrial Fibrillation and Other Dysrhythmias | |||
| Indent Indent Indent54777-8 | Coronary Artery Disease (CAD) | |||
| Indent Indent Indent54778-6 | Deep Venous Thrombosis (DVT), Pulmonary Embolus (PE), or Pulmonary Thrombo-Embolism (PTE) | |||
| Indent Indent Indent54779-4 | Heart Failure | |||
| Indent Indent Indent54780-2 | Hypertension | |||
| Indent Indent Indent54781-0 | Orthostatic hypotension | |||
| Indent Indent Indent54782-8 | Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD) | |||
| Indent Indent54534-3 | Gastrointestinal | |||
| Indent Indent Indent54783-6 | Cirrhosis | |||
| Indent Indent Indent54784-4 | Gastroesophageal Reflux Disease (GERD) or Ulcer | |||
| Indent Indent Indent54785-1 | Ulcerative Colitis, Chrohn's Disease or Inflammatory Bowel Disease | |||
| Indent Indent54535-0 | Genitourinary | |||
| Indent Indent Indent54786-9 | Benign prostatic hyperplasia (BPH) | |||
| Indent Indent Indent54787-7 | Renal Insufficiency or Renal Failure, or End-Stage Renal Disease (ESRD) | |||
| Indent Indent Indent58111-6 | Neurogenic Bladder | |||
| Indent Indent Indent58112-4 | Obstructive Uropathy | |||
| Indent Indent54536-8 | Infections | |||
| Indent Indent Indent58109-0 | Multidrug-resistant organism (MDRO) | |||
| Indent Indent Indent54790-1 | Pneumonia | |||
| Indent Indent Indent54791-9 | Septicemia | |||
| Indent Indent Indent54792-7 | Tuberculosis | |||
| Indent Indent Indent45689-7 | Urinary tract infection (UTI) (LAST 30 DAYS) | |||
| Indent Indent Indent54794-3 | Viral Hepatitis | |||
| Indent Indent Indent58110-8 | Wound infection (other than foot) | |||
| Indent Indent54537-6 | Metabolic | |||
| Indent Indent Indent54795-0 | Diabetes Mellitus (DM) | |||
| Indent Indent Indent54796-8 | Hyponatremia | |||
| Indent Indent Indent54797-6 | Hyperkalemia | |||
| Indent Indent Indent54798-4 | Hyperlipidemia | |||
| Indent Indent Indent54799-2 | Thyroid Disorder | |||
| Indent Indent54538-4 | Musculoskeletal | |||
| Indent Indent Indent54800-8 | Arthritis | |||
| Indent Indent Indent54801-6 | Osteoporosis | |||
| Indent Indent Indent54802-4 | Hip Fracture | |||
| Indent Indent Indent54803-2 | Other Fracture | |||
| Indent Indent54539-2 | Neurological | |||
| Indent Indent Indent54804-0 | Alzheimer's Disease | |||
| Indent Indent Indent54805-7 | Aphasia | |||
| Indent Indent Indent54806-5 | Cerebral Palsy | |||
| Indent Indent Indent54807-3 | Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke | |||
| Indent Indent Indent54808-1 | Dementia | |||
| Indent Indent Indent54809-9 | Hemiplegia or Hemiparesis | |||
| Indent Indent Indent54810-7 | Paraplegia | |||
| Indent Indent Indent54811-5 | Quadriplegia | |||
| Indent Indent Indent54812-3 | Multiple Sclerosis (MS) | |||
| Indent Indent Indent58113-2 | Huntington's Disease | |||
| Indent Indent Indent54813-1 | Parkinson's Disease | |||
| Indent Indent Indent58114-0 | Tourette's Syndrome | |||
| Indent Indent Indent54814-9 | Seizure Disorder or Epilepsy | |||
| Indent Indent Indent54815-6 | Traumatic Brain Injury (TBI) | |||
| Indent Indent54540-0 | Nutritional | |||
| Indent Indent Indent54816-4 | Malnutrition (protein or calorie) or at risk for malnutrition | |||
| Indent Indent54541-8 | Psychiatric/Mood Disorder | |||
| Indent Indent Indent54817-2 | Anxiety Disorder | |||
| Indent Indent Indent54818-0 | Depression (other than Bipolar) | |||
| Indent Indent Indent54819-8 | Manic Depression (bipolar Disease) | |||
| Indent Indent Indent58115-7 | Psychotic Disorder (other than schizophrenia) | |||
| Indent Indent Indent54820-6 | Schizophrenia | |||
| Indent Indent Indent54821-4 | Post-Traumatic Stress Disorder (PTSD) | |||
| Indent Indent54542-6 | Pulmonary | |||
| Indent Indent Indent54822-2 | Asthma,Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease | |||
| Indent Indent Indent58116-5 | Respiratory Failure | |||
| Indent Indent54543-4 | Vision | |||
| Indent Indent Indent54823-0 | Cataracts, Glaucoma, or Macular Degeneration | |||
| Indent Indent54544-2 | None of Above | |||
| Indent Indent Indent54824-8 | None of the above active diagnoses within the last 7 days | |||
| Indent Indent54898-2 | Other | |||
| Indent Indent Indent54545-9 | Additional diagnoses | |||
| Indent Indent Indent Indent54546-7 | Additional Diagnosis A | |||
| Indent Indent Indent Indent54547-5 | Additional Diagnosis B | |||
| Indent Indent Indent Indent54548-3 | Additional Diagnosis C | |||
| Indent Indent Indent Indent54549-1 | Additional Diagnosis D | |||
| Indent Indent Indent Indent54550-9 | Additional Diagnosis E | |||
| Indent Indent Indent Indent54551-7 | Additional Diagnosis F | |||
| Indent Indent Indent Indent54552-5 | Additional Diagnosis G | |||
| Indent Indent Indent Indent54553-3 | Additional Diagnosis H | |||
| Indent Indent Indent Indent54554-1 | Additional Diagnosis I | |||
| Indent Indent Indent Indent54555-8 | Additional Diagnosis J | |||
| Indent54556-6 | Health conditions | |||
| Indent Indent54557-4 | Pain Management. Complete for all residents, regardless of current pain level. At any time in the last 7 days, has the resident: | |||
| Indent Indent Indent71447-7 | Received scheduled pain medication regimen? | |||
| Indent Indent Indent71448-5 | Received PRN pain medications or was offered and declined? | |||
| Indent Indent Indent71449-3 | Received non-medication intervention for pain? | |||
| Indent Indent54828-9 | Should Pain Assessment Interview be Conducted? | |||
| Indent Indent54558-2 | MDS v3.0 - RAI v1.17.1, 1.17.2 - Pain assessment interview during assessment period | |||
| Indent Indent Indent54829-7 | Pain Presence. Ask resident: "Have you had pain or hurting any time in the last 5 days?" | |||
| Indent Indent Indent54830-5 | Pain Frequency. Ask resident: "How much of the time have you experienced pain or hurting over the last 5 days?" | |||
| Indent Indent Indent54559-0 | Pain effect on function | |||
| Indent Indent Indent Indent54831-3 | Ask resident: "Over the past 5 days, has pain made it hard for you to sleep at night?" | |||
| Indent Indent Indent Indent54832-1 | Ask resident: "Over the past 7 days, have you limited your day-to-day activities because of pain?" | |||
| Indent Indent Indent54560-8 | Pain intensity | |||
| Indent Indent Indent Indent54833-9 | Numeric Rating Scale (00-10). Ask resident: "Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine." (Show resident 00-10 pain scale.) | |||
| Indent Indent Indent Indent54834-7 | Verbal Descriptor Scale. Ask resident: " Please rate the intensity of your worst pain over the last 5 days." (Show resident verbal scale.) | |||
| Indent Indent58117-3 | Should the Staff Assessment for Pain be Conducted? | |||
| Indent Indent54561-6 | Staff assessment for pain | |||
| Indent Indent Indent54562-4 | Indicators of pain or possible pain | |||
| Indent Indent Indent Indent54835-4 | Non-verbal sounds (crying, whining, gasping, moaning, or groaning). | |||
| Indent Indent Indent Indent54836-2 | Vocal complaints of pain (that hurts, ouch, stop). | |||
| Indent Indent Indent Indent54837-0 | Facial expressions (grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw). | |||
| Indent Indent Indent Indent54838-8 | Protective body movements or postures (bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement). | |||
| Indent Indent Indent Indent54839-6 | None of these signs observed or documented | |||
| Indent Indent Indent58118-1 | Frequency of indicator of pain or possible pain | d/(5.d) | ||
| Indent Indent54563-2 | Other health conditions | |||
| Indent Indent Indent54564-0 | Shortness of Breath (dyspnea) | |||
| Indent Indent Indent Indent54841-2 | Shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring). | |||
| Indent Indent Indent Indent54842-0 | Shortness of breath or trouble breathing when sitting at rest | |||
| Indent Indent Indent Indent54843-8 | Shortness of breath or trouble breathing when lying flat | |||
| Indent Indent Indent Indent54844-6 | None of the above | |||
| Indent Indent Indent54845-3 | Tobacco Use | |||
| Indent Indent Indent54846-1 | Prognosis | |||
| Indent Indent Indent54847-9 | Problem conditions [MDSv3] | |||
| Indent Indent Indent Indent45701-0 | Fever [Minimum Data Set] | |||
| Indent Indent Indent Indent45708-5 | Vomiting [Minimum Data Set] | |||
| Indent Indent Indent Indent45696-2 | Dehydrated | |||
| Indent Indent Indent Indent45703-6 | Internal bleeding [Minimum Data Set] | |||
| Indent Indent Indent Indent54848-7 | None of the above | |||
| Indent Indent Indent54849-5 | Fall history on admission | |||
| Indent Indent Indent Indent54850-3 | Did the resident fall one or more times in the last month prior to admission? | |||
| Indent Indent Indent Indent54851-1 | Did the resident fall one or more times in the last 2 - 6 months prior to admission? | |||
| Indent Indent Indent Indent54852-9 | Did the resident have any fracture related to a fall in the 6 months prior to admission? | |||
| Indent Indent Indent54853-7 | Has the resident had any falls since admission or the prior assessment (OBRA or PPS), whichever is more recent? | |||
| Indent Indent Indent54854-5 | Number of Falls Since Admission or Prior Assessment (OBRA or 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 | |||
| Indent54565-7 | Swallowing/Nutritional Status | |||
| Indent Indent54566-5 | Swallowing disorder | |||
| Indent Indent Indent54858-6 | Loss of liquids/solids from mouth when eating or drinking | |||
| Indent Indent Indent54859-4 | Holding food in mouth/cheeks or residual food in mouth after meals | |||
| Indent Indent Indent54860-2 | Coughing or choking during meals or when swallowing medications | |||
| Indent Indent Indent54861-0 | Complaints of difficulty or pain with swallowing | |||
| Indent Indent Indent54862-8 | None of the above | |||
| Indent Indent54567-3 | Height and weight | |||
| Indent Indent Indent3137-7 | Height (in inches) | [in_us];cm;m | ||
| Indent Indent Indent3141-9 | Weight (in pounds) | [lb_av];kg | ||
| Indent Indent54863-6 | Weight loss of 5% or more in the last Mo or loss of 10% or more in last 6Mo | |||
| Indent Indent71442-8 | Weight gain [MDSv3] | |||
| Indent Indent54568-1 | Nutritional approaches panel | |||
| Indent Indent Indent71444-4 | Nutritional Approaches. While NOT a Resident | 1..5 | ||
| Indent Indent Indent71445-1 | Nutritional Approaches. While a Resident | 1..4 | ||
| Indent Indent54569-9 | Percent intake by artificial route | |||
| Indent Indent Indent54897-4 | Proportion of total calories the resident received through parenteral or tube feedings | % | ||
| Indent Indent Indent54869-3 | Average fluid intake per day by parenteral or tube feedings | mL/(7.d) | ||
| Indent54570-7 | Oral/Dental Status | |||
| Indent Indent54571-5 | Dental | |||
| Indent Indent Indent54871-9 | Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) | |||
| Indent Indent Indent54872-7 | No natural teeth or tooth fragment(s) (edentulous) | |||
| Indent Indent Indent54873-5 | Abnormal mouth tissue (ulcers, masses, oral lesions, including under denture or partial if one is worn) | |||
| Indent Indent Indent54874-3 | Obvious or likely cavity or broken natural teeth | |||
| Indent Indent Indent54875-0 | Inflamed or bleeding gums or loose natural teeth | |||
| Indent Indent Indent54876-8 | Mouth or facial pain, discomfort or difficulty with chewing | |||
| Indent Indent Indent58119-9 | Unable to examine | |||
| Indent Indent Indent54877-6 | None of the above were present | |||
| Indent54572-3 | Skin conditions during assessment period [CMS Assessment] | |||
| Indent Indent54573-1 | Determination of pressure injury risk | |||
| Indent Indent Indent54878-4 | Resident has a stage 1 or greater, a scar over bony prominence, or a non-removable dressing/device | |||
| Indent Indent Indent54879-2 | Formal assessment/tool (e.g., Braden, Norton, or other) | |||
| Indent Indent Indent54880-0 | Clinical assessment | |||
| Indent Indent Indent54881-8 | None of the above | |||
| Indent Indent57280-0 | Risk of developing pressure injuries | |||
| Indent Indent58214-8 | Unhealed Pressure Ulcer(s). Does this patient have one or more unhealed pressure ulcer(s) at Stage 1 or higher? | |||
| Indent Indent54575-6 | Current number of unhealed (non-epithelialized) pressure injuries at each stage | |||
| Indent Indent Indent58215-5 | Stage 1 [MDSv3] | |||
| Indent Indent Indent Indent54884-2 | Number of pressure injuries - stage 1 | {#} | ||
| Indent Indent Indent54576-4 | Stage 2 | |||
| 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/reentry | {#} | ||
| Indent Indent Indent Indent58123-1 | Date of oldest stage 2 pressure injury | {mm/dd/yyyy} | ||
| Indent Indent Indent54577-2 | Stage 3 | |||
| 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/reentry | {#} | ||
| Indent Indent Indent54578-0 | Stage 4 | |||
| 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/reentry | {#} | ||
| Indent Indent Indent54579-8 | Unstageable: Known or likely but not stageable due to non-removable dressing/device | |||
| Indent Indent Indent Indent54893-3 | Number of unstageable pressure ulcers due to non-removable dressing/device | {#} | ||
| Indent Indent Indent Indent54894-1 | Number of these unstageable pressure ulcers that were present upon admission/reentry | {#} | ||
| Indent Indent Indent55089-7 | Unstageable: Known or likely but not stageable due to coverage of wound bed by slough and/or eschar | |||
| 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/reentry | {#} | ||
| Indent Indent Indent55088-9 | Pressure injuries - unstageable with suspected deep tissue injury in evolution | |||
| Indent Indent Indent Indent54950-1 | Number of unstageable pressure ulcers with suspected deep tissue injury in evolution | {#} | ||
| Indent Indent Indent Indent54951-9 | Number of these unstageable ulcers that were present upon admission/reentry | {#} | ||
| Indent Indent Indent52477-7 | Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers Or Eschar | |||
| Indent Indent Indent Indent52728-3 | Pressure ulcer length | cm | ||
| Indent Indent Indent Indent52729-1 | Pressure ulcer width | cm | ||
| Indent Indent Indent Indent57228-9 | Pressure ulcer depth | cm | ||
| Indent Indent Indent55073-1 | Most Severe Tissue Type for Any Pressure Ulcer | |||
| Indent Indent Indent54952-7 | Worsening in pressure injury status since last assessment (OBRA, PPS, or Discharge) | |||
| Indent Indent Indent Indent54953-5 | Stage 2 | {#} | ||
| Indent Indent Indent Indent54954-3 | Stage 3 | {#} | ||
| Indent Indent Indent Indent54955-0 | Stage 4 | {#} | ||
| Indent Indent Indent54956-8 | Healed pressure injuries | |||
| Indent Indent Indent Indent54957-6 | Were pressure ulcers present on the prior assessment (OBRA or PPS)? | |||
| Indent Indent Indent Indent54958-4 | Stage 2 | {#} | ||
| Indent Indent Indent Indent54959-2 | Stage 3 | {#} | ||
| Indent Indent Indent Indent54960-0 | Stage 4 | {#} | ||
| Indent Indent Indent54970-9 | Number of venous and arterial ulcers. Enter the total number of venous and arterial ulcers present. | {#} | ||
| Indent Indent Indent54961-8 | Other ulcers, wounds and skin problems | |||
| Indent Indent Indent Indent58228-8 | Infection of the foot [MDSv3] | |||
| Indent Indent Indent Indent54963-4 | Diabetic foot ulcer(s) | |||
| Indent Indent Indent Indent58125-6 | Other open lesion(s) on the foot [MDSv3] | |||
| Indent Indent Indent Indent54967-5 | Open lesion(s) other than ulcers, rashes, cuts | |||
| Indent Indent Indent Indent54966-7 | Surgical wound(s) | |||
| Indent Indent Indent Indent54968-3 | Burn(s) (second or third degree) | |||
| Indent Indent Indent Indent71450-1 | Skin tear(s) [MDSv3] | |||
| Indent Indent Indent Indent71451-9 | Moisture associated skin damage (MASD) [MDSv3] | |||
| Indent Indent Indent Indent54969-1 | None of the above were present | |||
| Indent Indent Indent54971-7 | Skin and Ulcer Treatments | |||
| Indent Indent Indent Indent54972-5 | Pressure reducing device for chair | |||
| Indent Indent Indent Indent54973-3 | Pressure reducing device for bed | |||
| Indent Indent Indent Indent54974-1 | Turning/repositioning program | |||
| Indent Indent Indent Indent54975-8 | Nutrition or hydration intervention to manage skin problems | |||
| Indent Indent Indent Indent54976-6 | Pressure ulcer care | |||
| Indent Indent Indent Indent54977-4 | Surgical wound care | |||
| Indent Indent Indent Indent54978-2 | Application of nonsurgical dressings (with or without topical medications) other than to feet | |||
| Indent Indent Indent Indent54979-0 | Applications of ointments/medications other than to feet | |||
| Indent Indent Indent Indent54980-8 | Application of dressings to feet (with or without topical medications) | |||
| Indent Indent Indent Indent54981-6 | None of the above were provided | |||
| Indent55094-7 | Medications [MDSv3] | |||
| Indent Indent54982-4 | Injections | d/(7.d) | ||
| Indent Indent58217-1 | Insulin | |||
| Indent Indent Indent58127-2 | Insulin injections | d/(7.d) | ||
| Indent Indent Indent58128-0 | Orders for insulin | d/(7.d) | ||
| Indent Indent54983-2 | Medications Received | |||
| Indent Indent Indent54984-0 | Antipsychotic received in last 7D | |||
| Indent Indent Indent54985-7 | Antianxiety received in last 7D | |||
| Indent Indent Indent54986-5 | Antidepressant received in last 7D | |||
| Indent Indent Indent54987-3 | Hypnotic received in last 7D | |||
| Indent Indent Indent54988-1 | Anticoagulant received in last 7D | |||
| Indent Indent Indent58129-8 | Antibiotic recieved in last 7D | |||
| Indent Indent Indent58130-6 | Diuretic received in last 7D | |||
| Indent54990-7 | Special treatments and procedures | |||
| Indent Indent54991-5 | Special Treatments and Programs | |||
| Indent Indent Indent55086-3 | Cancer Treatments | |||
| Indent Indent Indent Indent54992-3 | Chemotherapy - while NOT a resident | |||
| Indent Indent Indent Indent54993-1 | Chemotherapy - while a resident | |||
| Indent Indent Indent Indent54994-9 | Radiation - while NOT a resident | |||
| Indent Indent Indent Indent54995-6 | Radiation - while a resident | |||
| Indent Indent Indent55085-5 | Respiratory Treatments | |||
| Indent Indent Indent Indent54996-4 | Oxygen therapy - while NOT a resident | |||
| Indent Indent Indent Indent54997-2 | Oxygen therapy - while a resident | |||
| Indent Indent Indent Indent54998-0 | Suctioning - while NOT a resident | |||
| Indent Indent Indent Indent54999-8 | Suctioning - while a resident | |||
| Indent Indent Indent Indent55000-4 | Tracheostomy care - while NOT a resident | |||
| Indent Indent Indent Indent55001-2 | Tracheostomy care - while a resident | |||
| Indent Indent Indent Indent55002-0 | Ventilator or respirator - while NOT a resident | |||
| Indent Indent Indent Indent55003-8 | Ventilator or respirator - while a resident | |||
| Indent Indent Indent Indent55004-6 | BIPAP/CPAP machine - while NOT a resident | |||
| Indent Indent Indent Indent55005-3 | BIPAP/CPAP machine - while a resident | |||
| Indent Indent Indent55084-8 | Other | |||
| Indent Indent Indent Indent55006-1 | IV medications - while NOT a resident | |||
| Indent Indent Indent Indent55007-9 | IV medications - while a resident | |||
| Indent Indent Indent Indent55008-7 | Transfusions - while NOT a resident | |||
| Indent Indent Indent Indent55009-5 | Transfusions - while a resident | |||
| Indent Indent Indent Indent55010-3 | Dialysis - while NOT a resident | |||
| Indent Indent Indent Indent55011-1 | Dialysis - while a resident | |||
| Indent Indent Indent Indent55012-9 | Hospice care - while NOT a resident | |||
| Indent Indent Indent Indent55013-7 | Hospice care - while a resident | |||
| Indent Indent Indent Indent55015-2 | Respite care in last 14 days - while a resident [MDSv3] | |||
| Indent Indent Indent Indent55016-0 | Isolation or quarantine for active infectious disease - while NOT a resident | |||
| Indent Indent Indent Indent55017-8 | Isolation or quarantine for active infectious disease - while a resident | |||
| Indent Indent Indent75795-5 | None of the above | |||
| Indent Indent Indent Indent59374-9 | None of above - while NOT a resident | |||
| Indent Indent Indent Indent59373-1 | None of above - while a resident | |||
| Indent Indent55018-6 | Influenza vaccine | |||
| Indent Indent Indent55019-4 | Influenza virus vaccine received in facility | |||
| Indent Indent Indent58131-4 | Date of influenza vaccination | {mm/dd/yyyy} | ||
| Indent Indent Indent55020-2 | If influenza vaccine not received, state reason | |||
| Indent Indent55021-0 | Pneumococcal vaccine | |||
| Indent Indent Indent55022-8 | Is the resident's Pneumococcal Vaccination up to date? | |||
| Indent Indent Indent45956-0 | Reason pneumococcal vaccine not received | |||
| Indent Indent55024-4 | Therapies | |||
| Indent Indent Indent58132-2 | Speech-language pathology and audiology services [MDSv3] | |||
| Indent Indent Indent Indent58218-9 | Speech-language pathology and audiology services - individual minutes in the last 7D | min | ||
| Indent Indent Indent Indent58133-0 | Speech-language pathology and audiology services - concurrent minutes in the last 7D | min | ||
| Indent Indent Indent Indent58134-8 | Speech-language pathology and audiology services - group minutes in the last 7D | min | ||
| Indent Indent Indent Indent45760-6 | Speech/language pathology and audiology services - Days | d/(7.d) | ||
| Indent Indent Indent Indent55025-1 | Speech/language pathology and audiology services - Therapy Start Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent55026-9 | Speech/language pathology and audiology services - Therapy End Date | {mm/dd/yyyy} | ||
| Indent Indent Indent58135-5 | Occupational therapy [MDSv3] | |||
| Indent Indent Indent Indent58219-7 | Occupational therapy - individual minutes in the last 7D | min | ||
| Indent Indent Indent Indent58136-3 | Occupational therapy - concurrent minutes in the last 7D | min | ||
| Indent Indent Indent Indent58137-1 | Occupational therapy - group minutes in the last 7D | min | ||
| Indent Indent Indent Indent45762-2 | Occupational Therapy - Days | d/(7.d) | ||
| Indent Indent Indent Indent55027-7 | Occupational Therapy - Therapy Start Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent55028-5 | Occupational Therapy - Therapy End Date | {mm/dd/yyyy} | ||
| Indent Indent Indent58138-9 | Physical therapy [MDSv3] | |||
| Indent Indent Indent Indent58220-5 | Physical therapy - individual minutes in the last 7D | min | ||
| Indent Indent Indent Indent58139-7 | Physical therapy - concurrent minutes in the last 7D | min | ||
| Indent Indent Indent Indent58140-5 | Physical therapy - group minutes in the last 7D | min | ||
| Indent Indent Indent Indent45764-8 | Physical Therapy - Days | d/(7.d) | ||
| Indent Indent Indent Indent55029-3 | Physical Therapy - Therapy Start Date | {mm/dd/yyyy} | ||
| Indent Indent Indent Indent55030-1 | Physical Therapy - Therapy End Date | {mm/dd/yyyy} | ||
| Indent Indent Indent58141-3 | Respiratory therapy | |||
| Indent Indent Indent Indent45767-1 | Respiratory Therapy - Minutes | min | ||
| Indent Indent Indent Indent45766-3 | Respiratory Therapy - Days | d/(7.d) | ||
| Indent Indent Indent58142-1 | Psychological therapy | |||
| Indent Indent Indent Indent45852-1 | Psychological Therapy (by any licensed mental health professional) - Minutes | min | ||
| Indent Indent Indent Indent45768-9 | Psychological Therapy (by any licensed mental health professional) - Days | d/(7.d) | ||
| Indent Indent Indent58143-9 | Recreational therapy | |||
| Indent Indent Indent Indent55035-0 | Recreational Therapy (includes recreational and music therapy) - Minutes | min | ||
| Indent Indent Indent Indent55036-8 | Recreational Therapy (includes recreational and music therapy) - Days | d/(7.d) | ||
| Indent Indent55039-2 | Restorative Nursing Programs | |||
| Indent Indent Indent55131-7 | Technique | |||
| Indent Indent Indent Indent45859-6 | Range of motion (passive) | d | ||
| Indent Indent Indent Indent45860-4 | Technique. Range of motion (active) | d | ||
| Indent Indent Indent Indent45861-2 | Splint or brace assistance | d | ||
| Indent Indent Indent55132-5 | Training and skill practice in | |||
| Indent Indent Indent Indent45862-0 | Bed mobility | d | ||
| Indent Indent Indent Indent45863-8 | Transfer | d | ||
| Indent Indent Indent Indent45864-6 | Walking | d | ||
| Indent Indent Indent Indent45865-3 | Dressing and/or grooming | d | ||
| Indent Indent Indent Indent45866-1 | Eating and/or swallowing | d | ||
| Indent Indent Indent Indent45867-9 | Amputation/prostheses care | d | ||
| Indent Indent Indent Indent45868-7 | Communication | d | ||
| Indent Indent55040-0 | Physician Examinations. Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) examine the resident? | d/(14.d) | ||
| Indent Indent55041-8 | Physician Orders. Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) change the resident's orders? | d/(14.d) | ||
| Indent55042-6 | Restraints | |||
| Indent Indent55043-4 | Physical restraints | |||
| Indent Indent Indent55129-1 | Used in Bed | |||
| Indent Indent Indent Indent55044-2 | Bed rail | |||
| Indent Indent Indent Indent55045-9 | Trunk restraint | |||
| Indent Indent Indent Indent55046-7 | Limb restraint | |||
| Indent Indent Indent Indent55047-5 | Other | |||
| Indent Indent Indent55130-9 | Used in Chair or Out of Bed | |||
| Indent Indent Indent Indent55048-3 | Trunk restraint | |||
| Indent Indent Indent Indent55049-1 | Limb restraint | |||
| Indent Indent Indent Indent55050-9 | Chair prevents rising | |||
| Indent Indent Indent Indent55051-7 | Other | |||
| Indent55052-5 | Participation in assessment and goal setting | |||
| Indent Indent55053-3 | Participation in assessment | |||
| Indent Indent Indent55054-1 | Resident participated in assessment | |||
| Indent Indent Indent55074-9 | Family or significant other participated in assessment | |||
| Indent Indent Indent58221-3 | Guardian or legally authorized representative participated in assessment | |||
| Indent Indent55056-6 | Resident's Overall Expectation | |||
| Indent Indent Indent55057-4 | Resident's overall goal established during assessment process | |||
| Indent Indent Indent55058-2 | Indicate information source for Q0300A | |||
| Indent Indent58222-1 | Discharge plan | |||
| Indent Indent Indent58146-2 | Active discharge planning already occurring for the resident to return to the community | |||
| Indent Indent Indent58147-0 | What determination was made by the resident and the care planning team regarding discharge to the community? | |||
| Indent Indent58223-9 | Return to community | |||
| Indent Indent Indent58148-8 | Has the resident been asked about returning to the community? | |||
| Indent Indent Indent58149-6 | Ask the resident (or family or significant other if resident is unable to respond): "Do you want to talk to someone about the possibility of returning to the community?" | |||
| Indent Indent58150-4 | Referral. Has a referral been made to the Local Contact Agency? | |||
| Indent58154-6 | Care Area Assessment (CAA) Summary [MDSv3] | |||
| Indent Indent58224-7 | Items from most recent prior OBRA or scheduled PPS assessment | |||
| Indent Indent Indent54583-0 | Prior Assessment Federal OBRA Reason for Assessment | |||
| Indent Indent Indent54584-8 | Prior Assessment PPS Reason for Assessment | |||
| Indent Indent Indent54593-9 | Prior Assessment Reference Date | {mm/dd/yyyy} | ||
| Indent Indent Indent58151-2 | Prior assessment Brief Interview for Mental Status (BIMS) summary score [MDSv3] | {score} | ||
| Indent Indent Indent58152-0 | Prior assessment resident mood interview (PHQ-9) total severity score [MDSv3] | {score} | ||
| Indent Indent Indent58153-8 | Prior assessment staff assessment of resident mood interview (PHQ-9) total severity score [MDSv3] | {score} | ||
| Indent Indent58155-3 | CAAs and Care Planning | |||
| Indent Indent Indent58156-1 | CAA Results | |||
| Indent Indent Indent Indent58157-9 | Delirium - care area triggered [MDSv3] | |||
| Indent Indent Indent Indent58158-7 | Delirium - addressed in care plan [MDSv3] | |||
| Indent Indent Indent Indent58159-5 | Cognitive loss/dementia - care area triggered | |||
| Indent Indent Indent Indent58160-3 | Cognitive loss/dementia - addressed in care plan | |||
| Indent Indent Indent Indent58226-2 | Visual function - care area triggered [MDSv3] | |||
| Indent Indent Indent Indent58225-4 | Visual function - addressed in care plan [MDSv3] | |||
| Indent Indent Indent Indent58161-1 | Communication - care area triggered [MDSv3] | |||
| Indent Indent Indent Indent58162-9 | Communication - addressed in care plan [MDSv3] | |||
| Indent Indent Indent Indent58163-7 | ADL functional/rehabilitation potential - care area triggered | |||
| Indent Indent Indent Indent58164-5 | ADL functional/rehabilitation potential - addressed in care plan | |||
| Indent Indent Indent Indent58165-2 | Urinary incontinence and indwelling catheter - care area triggered [MDSv3] | |||
| Indent Indent Indent Indent58166-0 | Urinary incontinence and indwelling catheter - addressed in care plan [MDSv3] | |||
| Indent Indent Indent Indent58167-8 | Psychosocial well-being - care area triggered [MDSv3] | |||
| Indent Indent Indent Indent58168-6 | Psychosocial well-being - addressed in care plan [MDSv3] | |||
| Indent Indent Indent Indent58169-4 | Mood state - care area triggered [MDSv3] | |||
| Indent Indent Indent Indent58170-2 | Mood state - addressed in care plan [MDSv3] | |||
| Indent Indent Indent Indent58171-0 | Behavioral symptoms - care area triggered [MDSv3] | |||
| Indent Indent Indent Indent58172-8 | Behavioral symptoms - addressed in care plan [MDSv3] | |||
| Indent Indent Indent Indent58173-6 | Activities - care area triggered [MDSv3] | |||
| Indent Indent Indent Indent58174-4 | Activities - addressed in care plan [MDSv3] | |||
| Indent Indent Indent Indent58175-1 | Falls - care area triggered [MDSv3] | |||
| Indent Indent Indent Indent58176-9 | Falls - addressed in care plan [MDSv3] | |||
| Indent Indent Indent Indent58177-7 | Nutritional status - care area triggered [MDSv3] | |||
| Indent Indent Indent Indent58178-5 | Nutritional status - addressed in care plan [MDSv3] | |||
| Indent Indent Indent Indent58179-3 | Feeding tube - care area triggered [MDSv3] | |||
| Indent Indent Indent Indent58180-1 | Feeding tube - addressed in care plan [MDSv3] | |||
| Indent Indent Indent Indent58181-9 | Dehydration/fluid maintenance - care area triggered | |||
| Indent Indent Indent Indent58182-7 | Dehydration/fluid maintenance - addressed in care plan | |||
| Indent Indent Indent Indent58183-5 | Dental care - care area triggered [MDSv3] | |||
| Indent Indent Indent Indent58184-3 | Dental care - addressed in care plan [MDSv3] | |||
| Indent Indent Indent Indent58185-0 | Pressure injury - care area triggered [MDSv3] | |||
| Indent Indent Indent Indent58186-8 | Pressure injury - addressed in care plan [MDSv3] | |||
| Indent Indent Indent Indent58187-6 | Psychotropic drug use - care area triggered [MDSv3] | |||
| Indent Indent Indent Indent58188-4 | Psychotropic drug use - addressed in care plan [MDSv3] | |||
| Indent Indent Indent Indent58189-2 | Physical restraints - care area triggered [MDSv3] | |||
| Indent Indent Indent Indent58190-0 | Physical restraints - addressed in care plan [MDSv3] | |||
| Indent Indent Indent Indent58191-8 | Pain - care area triggered [MDSv3] | |||
| Indent Indent Indent Indent58192-6 | Pain - addressed in care plan [MDSv3] | |||
| Indent Indent Indent Indent58193-4 | Return to community referral - care area triggered [MDSv3] | |||
| Indent Indent Indent Indent58194-2 | Return to community referral - addressed in care plan [MDSv3] | |||
| Indent Indent Indent Indent58195-9 | Date of Care Area Assessment (CAA) information [MDSv3] | R | 0..20 | |
| Indent Indent Indent Indent58196-7 | Location of Care Area Assessment (CAA) information [MDSv3] | R | 0..20 | |
| Indent58197-5 | Correction request [MDSv3] | |||
| Indent Indent54582-2 | Provider type [MDSv3] | |||
| Indent Indent54503-8 | Name of Resident on existing record to be modified/inactivated | |||
| Indent Indent Indent45392-8 | Patient First (Given) name | |||
| Indent Indent Indent45393-6 | Middle initial | |||
| Indent Indent Indent45394-4 | Patient Last (Family) name | |||
| Indent Indent Indent45395-1 | Suffix | |||
| Indent Indent46098-0 | Gender on existing record to be modified/inactivated | |||
| Indent Indent21112-8 | Birth Date on existing record to be modified/inactived | {mm/dd/yyyy} | ||
| Indent Indent45396-9 | Social Security Number on existing record to be modified/inactivated | |||
| Indent Indent54502-0 | Type of Assessment on existing record to be modified/inactivated | |||
| Indent Indent Indent54583-0 | Federal OBRA reason for assessment | |||
| Indent Indent Indent54584-8 | PPS Assessment | |||
| Indent Indent Indent54585-5 | PPS Other Medicare Required Assessment - OMRA | |||
| Indent Indent Indent58107-4 | Is this a Swing Bed clinical change assessment? | |||
| Indent Indent Indent54587-1 | Is this assessment the first assessment (OBRA, PPS, or Discharge) since the most recent admission? | |||
| Indent Indent Indent58108-2 | Entry/discharge reporting | |||
| Indent Indent Indent71440-2 | Type of discharge | |||
| Indent Indent75794-8 | Date on existing record to be modified/inactivated | |||
| Indent Indent54593-9 | Assessment reference date - observation end date | {mm/dd/yyyy} | ||
| Indent Indent Indent52525-3 | Discharge date | {mm/dd/yyyy} | ||
| Indent Indent Indent50786-3 | Entry Date | {mm/dd/yyyy} | ||
| Indent Indent Indent58200-7 | Correction number | {#} | ||
| Indent Indent58199-1 | Reasons for modification [MDSv3] | |||
| Indent Indent Indent58201-5 | Transcription error [MDSv3] | |||
| Indent Indent Indent58202-3 | Data entry error [MDSv3] | |||
| Indent Indent Indent58203-1 | Item coding error [MDSv3] | |||
| Indent Indent Indent58227-0 | Software product error [MDSv3] | |||
| Indent Indent Indent58204-9 | Other error requiring modification [MDSv3] | |||
| Indent Indent Indent58205-6 | Other error requiring modification.other specified [MDSv3] | |||
| Indent Indent58206-4 | Reasons for inactivation [MDSv3] | |||
| Indent Indent Indent58207-2 | Reasons for inactivation - event did not occur [MDSv3] | |||
| Indent Indent Indent58208-0 | Other error requiring error requiring inactivation [MDSv3] | |||
| Indent Indent Indent58209-8 | Other error requiring error requiring inactivation.other specified [MDSv3] | |||
| Indent55063-2 | Assessment administration | |||
| Indent Indent55064-0 | Medicare part A billing | |||
| Indent Indent Indent55065-7 | Medicare part A - HIPPS code for billing | |||
| Indent Indent Indent55066-5 | RUG version code | |||
| Indent Indent Indent58421-9 | Medicare short stay assessment | |||
| Indent Indent59375-6 | Medicare non-therapy Part A billing | |||
| Indent Indent Indent58210-6 | Medicare non-therapy Part A HIPPS code | |||
| Indent Indent Indent58211-4 | RUG version code | |||
| Indent Indent55067-3 | State Medicaid billing | |||
| Indent Indent Indent55068-1 | RUG Case Mix group | |||
| Indent Indent Indent55069-9 | RUG version code | |||
| Indent Indent58422-7 | Alternate state Medicaid billing | |||
| Indent Indent Indent58212-2 | RUG Case Mix Group | |||
| Indent Indent Indent58213-0 | RUG version code | |||
| Indent Indent55070-7 | Insurance billing | |||
| Indent Indent Indent55071-5 | RUG Case Mix group | |||
| Indent Indent Indent55072-3 | RUG version code | |||
| Indent Indent55083-0 | Item subset code | |||
| Indent Indent55075-6 | Version code Specifications | |||
| Indent Indent55082-2 | Transaction code Transaction [MDSv3] | |||
| Indent Indent55076-4 | Production or test indicator Submission [MDSv3] | |||
| Indent Indent55077-2 | State assigned facility submission ID | |||
| Indent Indent55078-0 | Federal employer tax ID Software vendor | |||
| Indent Indent55079-8 | Vendor company name Software | |||
| Indent Indent55093-9 | Vendor email address Software | |||
| Indent Indent55080-6 | Product name Software | |||
| Indent Indent55081-4 | Product version code Software |
LOINC Names Get Info
- Fully-Specified Name
- Minimum Data Set - version 3.0:
-: Pt: ^Patient: -: - Long Common Name
- Deprecated Minimum Data Set - version 3.0
Part Model Get Info
Basic Attributes
- Class
- PANEL.SURVEY.MDS
- Type
- Surveys
- First Released
- Version 2.27
- Last Updated
- Version 2.75 (PANEL)
- Change Reason
- Release 2.73: Status: LOINC will keep most current version and one prior version of CMS assessments active and discourage all older versions.;
- Panel Type
- Panel
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=54580-6 - Questionnaire definition
- https:
//fhir.loinc.org/Questionnaire/?url=http: //loinc.org/q/54580-6
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://