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Numeric Identifier___________________________________________________________

MINIMUM DATA SET (MDS) — VERSION 2.0


FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING

BASIC ASSESSMENT TRACKING FORM


SECTION AA. IDENTIFICATION INFORMATION
1. RESIDENT 9. Signatures of Persons who Completed a Portion of the Accompanying Assessment or
NAME* Tracking Form
a. (First) b. (Middle Initial) c. (Last) d. (Jr/Sr) I certify that the accompanying information accurately reflects resident assessment or tracking
information for this resident and that I collected or coordinated collection of this information on the
2. GENDER* 1. Male 2. Female dates specified. To the best of my knowledge, this information was collected in accordance with
applicable Medicare and Medicaid requirements. I understand that this information is used as a
3. BIRTHDATE* basis for ensuring that residents receive appropriate and quality care, and as a basis for payment
from federal funds. I further understand that payment of such federal funds and continued partici­
Month Day Year pation in the government-funded health care programs is conditioned on the accuracy and truthful­
4. RACE/ * 1. American Indian/Alaskan Native 4. Hispanic ness of this information, and that I may be personally subject to or may subject my organization to
ETHNICITY 2. Asian/Pacific Islander 5.White, not of substantial criminal, civil, and/or administrative penalties for submitting false information. I also
3. Black, not of Hispanic origin Hispanic origin certify that I am authorized to submit this information by this facility on its behalf.
5. SOCIAL a. Social Security Number Signature and Title Sections Date
SECURITY*
AND
MEDICARE b. Medicare number (or comparable railroad insurance number) a.
NUMBERS *
[C in 1st box if b.
non med. no.]
c.
6. FACILITY a. State No.
PROVIDER d.
NO.*
e.
b. Federal No. f.
7. MEDICAID
NO. ["+" if g.
pending, "N" *
if not a h.
Medicaid
recipient] * i.
8. REASONS [Note—Other codes do not apply to this form] j.
FOR
ASSESS­ a. Primary reason for assessment k.
MENT 1. Admission assessment (required by day 14)
2. Annual assessment
3. Significant change in status assessment l.
4. Significant correction of prior full assessment
5. Quarterly review assessment
10. Significant correction of prior quarterly assessment
0. NONE OF ABOVE
b. Codes for assessments required for Medicare PPS or the State
1. Medicare 5 day assessment
2. Medicare 30 day assessment
3. Medicare 60 day assessment
4. Medicare 90 day assessment
5. Medicare readmission/return assessment
6. Other state required assessment
7. Medicare 14 day assessment
8. Other Medicare required assessment

GENERAL INSTRUCTIONS

Complete this information for submission with all full and quarterly assessments
(Admission, Annual, Significant Change, State or Medicare required assessments, or
Quarterly Reviews, etc.)

* = Key items for computerized resident tracking

= When box blank, must enter number or letter a. = When letter in box, check if condition applies MDS 2.0 September, 2000
Resident ______________________________________________________________ Numeric Identifier___________________________________________________________

MINIMUM DATA SET (MDS) — VERSION 2.0


FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING
BACKGROUND (FACE SHEET) INFORMATION AT ADMISSION

SECTION AB. DEMOGRAPHIC INFORMATION SECTION AC. CUSTOMARY ROUTINE


1. DATE OF Date the stay began. Note — Does not include readmission if record was 1. CUSTOMARY (Check all that apply. If all information UNKNOWN, check last box only.)
ENTRY closed at time of temporary discharge to hospital, etc. In such cases, use prior ROUTINE
admission date CYCLE OF DAILY EVENTS
(In year prior
to DATE OF a.
ENTRY Stays up late at night (e.g., after 9 pm)
Month Day Year to this b.
2. ADMITTED 1. Private home/apt. with no home health services nursing Naps regularly during day (at least 1 hour)
FROM 2. Private home/apt. with home health services home, or year c.
last in Goes out 1+ days a week
(AT ENTRY) 3. Board and care/assisted living/group home
4. Nursing home community if d.
5. Acute care hospital now being Stays busy with hobbies, reading, or fixed daily routine
6. Psychiatric hospital, MR/DD facility admitted from e.
7. Rehabilitation hospital another Spends most of time alone or watching TV
8. Other nursing
home) Moves independently indoors (with appliances, if used) f.
3. LIVED 0. No
ALONE 1.Yes Use of tobacco products at least daily g.
(PRIOR TO
ENTRY) 2. In other facility
NONE OF ABOVE h.
4. ZIP CODE OF
PRIOR EATING PATTERNS
PRIMARY
RESIDENCE Distinct food preferences i.
5. RESIDEN­ (Check all settings resident lived in during 5 years prior to date of
TIAL entry given in item AB1 above) Eats between meals all or most days j.
HISTORY
5 YEARS Prior stay at this nursing home Use of alcoholic beverage(s) at least weekly k.
a.
PRIOR TO Stay in other nursing home
ENTRY NONE OF ABOVE l.
b.
Other residential facility—board and care home, assisted living, group ADL PATTERNS
home c.
In bedclothes much of day m.
MH/psychiatric setting d.
Wakens to toilet all or most nights n.
MR/DD setting e.
NONE OF ABOVE Has irregular bowel movement pattern o.
f.
6. LIFETIME Showers for bathing p.
OCCUPA­
TION(S) Bathing in PM q.
[Put "/"
between two NONE OF ABOVE r.
occupations]
INVOLVEMENT PATTERNS
7. EDUCATION 1. No schooling 5.Technical or trade school
(Highest 2. 8th grade/less 6. Some college Daily contact with relatives/close friends s.
Level 3. 9-11 grades 7. Bachelor's degree
Completed) 4. High school 8. Graduate degree Usually attends church, temple, synagogue (etc.) t.
8. LANGUAGE (Code for correct response)
a. Primary Language Finds strength in faith u.

0. English 1. Spanish 2. French 3. Other Daily animal companion/presence v.


b. If other, specify
Involved in group activities w.
9. MENTAL Does resident's RECORD indicate any history of mental retardation, NONE OF ABOVE x.
HEALTH mental illness, or developmental disability problem?
HISTORY 0. No 1.Yes UNKNOWN—Resident/family unable to provide information
y.
10. CONDITIONS (Check all conditions that are related to MR/DD status that were
RELATED TO manifested before age 22, and are likely to continue indefinitely)
MR/DD SECTION AD. FACE SHEET SIGNATURES

STATUS Not applicable—no MR/DD (Skip to AB11) a.


SIGNATURES OF PERSONS COMPLETING FACE SHEET:
MR/DD with organic condition
Down's syndrome b.
a. Signature of RN Assessment Coordinator Date
Autism c.
Epilepsy d. I certify that the accompanying information accurately reflects resident assessment or tracking
Other organic condition related to MR/DD information for this resident and that I collected or coordinated collection of this information on the
e. dates specified. To the best of my knowledge, this information was collected in accordance with
MR/DD with no organic condition f. applicable Medicare and Medicaid requirements. I understand that this information is used as a
basis for ensuring that residents receive appropriate and quality care, and as a basis for payment
11. DATE from federal funds. I further understand that payment of such federal funds and continued partici­
BACK- pation in the government-funded health care programs is conditioned on the accuracy and truthful­
GROUND ness of this information, and that I may be personally subject to or may subject my organization to
INFORMA­ substantial criminal, civil, and/or administrative penalties for submitting false information. I also
TION Month Day Year
certify that I am authorized to submit this information by this facility on its behalf.
COMPLETED
Signature and Title Sections Date

b.
c.

d.

e.

f.

g.

= When box blank, must enter number or letter a. = When letter in box, check if condition applies MDS 2.0 September, 2000
Resident ______________________________________________________________ Numeric Identifier___________________________________________________________
MINIMUM DATA SET (MDS) — VERSION 2.0

FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING

FULL ASSESSMENT FORM

(Status in last 7 days, unless other time frame indicated)


SECTION A. IDENTIFICATION AND BACKGROUND INFORMATION 3. MEMORY/ (Check all that resident was normally able to recall during
RECALL last 7 days)
1. RESIDENT
NAME ABILITY Current season a.
That he/she is in a nursing home d.
a. (First) b. (Middle Initial) c. (Last) d. (Jr/Sr) Location of own room b.
2. ROOM Staff names/faces c. NONE OF ABOVE are recalled e.
NUMBER 4. COGNITIVE (Made decisions regarding tasks of daily life)
SKILLS FOR
3. ASSESS­ a. Last day of MDS observation period DAILY 0. INDEPENDENT—decisions consistent/reasonable
MENT DECISION- 1. MODIFIED INDEPENDENCE—some difficulty in new situations
REFERENCE MAKING only
DATE 2. MODERATELY IMPAIRED—decisions poor; cues/supervision
Month Day Year required
3. SEVERELY IMPAIRED—never/rarely made decisions
b. Original (0) or corrected copy of form (enter number of correction)
5. INDICATORS (Code for behavior in the last 7 days.) [Note: Accurate assessment
4a. DATE OF Date of reentry from most recent temporary discharge to a hospital in OF requires conversations with staff and family who have direct knowledge
REENTRY last 90 days (or since last assessment or admission if less than 90 days) DELIRIUM— of resident's behavior over this time].
PERIODIC
DISOR­ 0. Behavior not present
DERED 1. Behavior present, not of recent onset
THINKING/ 2. Behavior present, over last 7 days appears different from resident's usual
Month Day Year AWARENESS functioning (e.g., new onset or worsening)
5. MARITAL 1. Never married 3.Widowed 5. Divorced a. EASILY DISTRACTED—(e.g., difficulty paying attention; gets
STATUS 2. Married 4. Separated sidetracked)
6. MEDICAL b. PERIODS OF ALTERED PERCEPTION OR AWARENESS OF
RECORD SURROUNDINGS—(e.g., moves lips or talks to someone not
NO. present; believes he/she is somewhere else; confuses night and
day)
7. CURRENT (Billing Office to indicate; check all that apply in last 30 days)
PAYMENT c. EPISODES OF DISORGANIZED SPEECH—(e.g., speech is
SOURCES Medicaid per diem VA per diem
a. f. incoherent, nonsensical, irrelevant, or rambling from subject to
FOR N.H. subject; loses train of thought)
STAY Medicare per diem Self or family pays for full per diem
b. g.
d. PERIODS OF RESTLESSNESS—(e.g., fidgeting or picking at skin,
Medicare ancillary Medicaid resident liability or Medicare clothing, napkins, etc; frequent position changes; repetitive physical
part A c. co-payment h. movements or calling out)
Medicare ancillary Private insurance per diem (including e. PERIODS OF LETHARGY—(e.g., sluggishness; staring into space;
d. co-payment) i.
part B difficult to arouse; little body movement)
CHAMPUS per diem e. Other per diem j.
f. MENTAL FUNCTION VARIES OVER THE COURSE OF THE
8. REASONS a. Primary reason for assessment DAY—(e.g., sometimes better, sometimes worse; behaviors
FOR 1. Admission assessment (required by day 14) sometimes present, sometimes not)
ASSESS­ 2. Annual assessment
MENT 3. Significant change in status assessment 6. CHANGE IN Resident's cognitive status, skills, or abilities have changed as
4. Significant correction of prior full assessment COGNITIVE compared to status of 90 days ago (or since last assessment if less
[Note—If this 5. Quarterly review assessment STATUS than 90 days)
0. No change 1. Improved 2.Deteriorated
is a discharge 6. Discharged—return not anticipated
or reentry 7. Discharged—return anticipated
assessment, 8. Discharged prior to completing initial assessment SECTION C. COMMUNICATION/HEARING PATTERNS
only a limited 9. Reentry
subset of 10. Significant correction of prior quarterly assessment 1. HEARING (With hearing appliance, if used)
MDS items 0. NONE OF ABOVE 0. HEARS ADEQUATELY—normal talk, TV, phone
need be 1. MINIMAL DIFFICULTY when not in quiet setting
completed] b. Codes for assessments required for Medicare PPS or the State 2. HEARS IN SPECIAL SITUATIONS ONLY—speaker has to adjust
1. Medicare 5 day assessment tonal quality and speak distinctly
2. Medicare 30 day assessment 3. HIGHLY IMPAIRED/absence of useful hearing
3. Medicare 60 day assessment
4. Medicare 90 day assessment 2. COMMUNI­ (Check all that apply during last 7 days)
5. Medicare readmission/return assessment CATION a.
Hearing aid, present and used
6. Other state required assessment DEVICES/ b.
7. Medicare 14 day assessment TECH­ Hearing aid, present and not used regularly
8. Other Medicare required assessment NIQUES Other receptive comm. techniques used (e.g., lip reading) c.

9. RESPONSI­ (Check all that apply) Durable power attorney/financial NONE OF ABOVE d.
d.
BILITY/ Legal guardian 3. MODES OF (Check all used by resident to make needs known)
LEGAL a. Family member responsible EXPRESSION
e. Signs/gestures/sounds
GUARDIAN Other legal oversight b. Speech a.
d.
Patient responsible for self f.
Durable power of Writing messages to Communication board e.
attorney/health care c. NONE OF ABOVE g. express or clarify needs b.
Other
10. ADVANCED (For those items with supporting documentation in the medical American sign language
f.
DIRECTIVES record, check all that apply) or Braille NONE OF ABOVE g.
c.
Living will a. Feeding restrictions f. 4. MAKING (Expressing information content—however able)
Do not resuscitate b. Medication restrictions SELF 0. UNDERSTOOD
g. UNDER-
Do not hospitalize c. 1. USUALLY UNDERSTOOD—difficulty finding words or finishing
Other treatment restrictions STOOD thoughts
Organ donation h.
d. 2. SOMETIMES UNDERSTOOD—ability is limited to making concrete
Autopsy request e. NONE OF ABOVE i. requests
3. RARELY/NEVER UNDERSTOOD
5. SPEECH (Code for speech in the last 7 days)
CLARITY 0. CLEAR SPEECH—distinct, intelligible words
SECTION B. COGNITIVE PATTERNS
1. UNCLEAR SPEECH—slurred, mumbled words
1. COMATOSE (Persistent vegetative state/no discernible consciousness) 2. NO SPEECH—absence of spoken words
0. No 1.Yes (If yes, skip to Section G) 6. ABILITY TO (Understanding verbal information content—however able)
2. MEMORY (Recall of what was learned or known) UNDER- 0. UNDERSTANDS
STAND 1. USUALLY UNDERSTANDS—may miss some part/intent of
a. Short-term memory OK—seems/appears to recall after 5 minutes OTHERS
0. Memory OK 1. Memory problem message
2. SOMETIMES UNDERSTANDS—responds adequately to simple,
b. Long-term memory OK—seems/appears to recall long past direct communication
0. Memory OK 1. Memory problem 3. RARELY/NEVER UNDERSTANDS
7. CHANGE IN Resident's ability to express, understand, or hear information has
COMMUNI­ changed as compared to status of 90 days ago (or since last
CATION/ assessment if less than 90 days)
HEARING 0. No change 1. Improved 2.Deteriorated
= When box blank, must enter number or letter a. = When letter in box, check if condition applies MDS 2.0 September, 2000
Resident ______________________________________________________________ Numeric Identifier _______________________________________________________
SECTION D. VISION PATTERNS
1. VISION (Ability to see in adequate light and with glasses if used)
5. CHANGE IN Resident's behavior status has changed as compared to status of 90
0. ADEQUATE—sees fine detail, including regular print in BEHAVIORAL days ago (or since last assessment if less than 90 days)
newspapers/books SYMPTOMS 0. No change 1. Improved 2.Deteriorated
1. IMPAIRED—sees large print, but not regular print in newspapers/
books
2. MODERATELY IMPAIRED—limited vision; not able to see
newspaper headlines, but can identify objects SECTION F. PSYCHOSOCIAL WELL-BEING
3. HIGHLY IMPAIRED—object identification in question, but eyes 1. SENSE OF At ease interacting with others a.
appear to follow objects INITIATIVE/ At ease doing planned or structured activities b.
4. SEVERELY IMPAIRED—no vision or sees only light, colors, or INVOLVE­
shapes; eyes do not appear to follow objects MENT At ease doing self-initiated activities c.
2. VISUAL Side vision problems—decreased peripheral vision (e.g., leaves food Establishes own goals d.
LIMITATIONS/ on one side of tray, difficulty traveling, bumps into people and objects, Pursues involvement in life of facility (e.g., makes/keeps friends;
DIFFICULTIES misjudges placement of chair when seating self) a.
involved in group activities; responds positively to new activities;
assists at religious services) e.
Experiences any of following: sees halos or rings around lights; sees
flashes of light; sees "curtains" over eyes b. Accepts invitations into most group activities f.
NONE OF ABOVE g.
NONE OF ABOVE c. 2. UNSETTLED Covert/open conflict with or repeated criticism of staff a.
3. VISUAL Glasses; contact lenses; magnifying glass RELATION- Unhappy with roommate b.
APPLIANCES 0. No 1.Yes SHIPS
Unhappy with residents other than roommate c.
Openly expresses conflict/anger with family/friends d.
SECTION E. MOOD AND BEHAVIOR PATTERNS Absence of personal contact with family/friends e.
1. INDICATORS (Code for indicators observed in last 30 days, irrespective of the
assumed cause) Recent loss of close family member/friend f.
OF
DEPRES­ 0. Indicator not exhibited in last 30 days Does not adjust easily to change in routines g.
SION, 1. Indicator of this type exhibited up to five days a week NONE OF ABOVE h.
ANXIETY, 2. Indicator of this type exhibited daily or almost daily (6, 7 days a week)
3. PAST ROLES Strong identification with past roles and life status a.
SAD MOOD VERBAL EXPRESSIONS h. Repetitive health Expresses sadness/anger/empty feeling over lost roles/status
OF DISTRESS complaints—e.g., b.
persistently seeks medical Resident perceives that daily routine (customary routine, activities) is
a. Resident made negative attention, obsessive concern very different from prior pattern in the community c.
statements—e.g., "Nothing with body functions
matters;Would rather be NONE OF ABOVE d.
dead;What's the use; i. Repetitive anxious
Regrets having lived so complaints/concerns (non- SECTION G. PHYSICAL FUNCTIONING AND STRUCTURAL PROBLEMS
long; Let me die" health related) e.g.,
persistently seeks attention/ 1. (A) ADL SELF-PERFORMANCE—(Code for resident's PERFORMANCE OVER ALL
b. Repetitive questions—e.g., reassurance regarding SHIFTS during last 7 days—Not including setup)
"Where do I go;What do I schedules, meals, laundry,
do?" clothing, relationship issues 0. INDEPENDENT—No help or oversight —OR— Help/oversight provided only 1 or 2 times
during last 7 days
c. Repetitive verbalizations— SLEEP-CYCLE ISSUES
e.g., calling out for help, 1. SUPERVISION—Oversight, encouragement or cueing provided 3 or more times during
("God help me") j. Unpleasant mood in morning last7 days —OR— Supervision (3 or more times) plus physical assistance provided only
k. Insomnia/change in usual 1 or 2 times during last 7 days
d. Persistent anger with self or sleep pattern
others—e.g., easily 2. LIMITED ASSISTANCE—Resident highly involved in activity; received physical help in
annoyed, anger at SAD, APATHETIC, ANXIOUS guided maneuvering of limbs or other nonweight bearing assistance 3 or more times —
placement in nursing home; APPEARANCE OR—More help provided only 1 or 2 times during last 7 days
anger at care received
l. Sad, pained, worried facial 3. EXTENSIVE ASSISTANCE—While resident performed part of activity, over last 7-day
e. Self deprecation—e.g., "I expressions—e.g., furrowed period, help of following type(s) provided 3 or more times:
am nothing; I am of no use brows — Weight-bearing support
to anyone" — Full staff performance during part (but not all) of last 7 days
m. Crying, tearfulness
f. Expressions of what 4. TOTAL DEPENDENCE—Full staff performance of activity during entire 7 days
appear to be unrealistic n. Repetitive physical
movements—e.g., pacing, 8. ACTIVITY DID NOT OCCUR during entire 7 days
fears—e.g., fear of being
abandoned, left alone, hand wringing, restlessness, (B) ADL SUPPORT PROVIDED—(Code for MOST SUPPORT PROVIDED
fidgeting, picking (A) (B)
being with others OVER ALL SHIFTS during last 7 days; code regardless of resident's self-
performance classification)

SELF-PERF
LOSS OF INTEREST

SUPPORT
g. Recurrent statements that
something terrible is about o. Withdrawal from activities of 0.No setup or physical help from staff
to happen—e.g., believes interest—e.g., no interest in 1.Setup help only
he or she is about to die, long standing activities or 2.One person physical assist 8. ADL activity itself did not
have a heart attack being with family/friends 3.Two+ persons physical assist occur during entire 7 days
p. Reduced social interaction a. BED How resident moves to and from lying position, turns side to side,
MOBILITY and positions body while in bed
2. MOOD One or more indicators of depressed, sad or anxious mood were
PERSIS­ not easily altered by attempts to "cheer up", console, or reassure b. TRANSFER How resident moves between surfaces—to/from: bed, chair,
TENCE the resident over last 7 days wheelchair, standing position (EXCLUDE to/from bath/toilet)
0. No mood 1. Indicators present, 2. Indicators present,
indicators easily altered not easily altered c. WALK IN How resident walks between locations in his/her room
ROOM
3. CHANGE Resident's mood status has changed as compared to status of 90
days ago (or since last assessment if less than 90 days) d. WALK IN How resident walks in corridor on unit
IN MOOD CORRIDOR
0. No change 1. Improved 2.Deteriorated
e. LOCOMO­ How resident moves between locations in his/her room and
4. BEHAVIORAL (A) Behavioral symptom frequency in last 7 days TION adjacent corridor on same floor. If in wheelchair, self-sufficiency
SYMPTOMS 0. Behavior not exhibited in last 7 days ON UNIT once in chair
1. Behavior of this type occurred 1 to 3 days in last 7 days
2. Behavior of this type occurred 4 to 6 days, but less than daily f. LOCOMO­ How resident moves to and returns from off unit locations (e.g.,
3. Behavior of this type occurred daily TION areas set aside for dining, activities, or treatments). If facility has
OFF UNITonly one floor, how resident moves to and from distant areas on
(B) Behavioral symptom alterability in last 7 days the floor. If in wheelchair, self-sufficiency once in chair
0. Behavior not present OR behavior was easily altered
1. Behavior was not easily altered (A) (B) g. DRESSING How resident puts on, fastens, and takes off all items of street
clothing, including donning/removing prosthesis
a. WANDERING (moved with no rational purpose, seemingly
oblivious to needs or safety) h. EATING How resident eats and drinks (regardless of skill). Includes intake of
nourishment by other means (e.g., tube feeding, total parenteral
b. VERBALLY ABUSIVE BEHAVIORAL SYMPTOMS (others nutrition)
were threatened, screamed at, cursed at)
i. TOILET USE How resident uses the toilet room (or commode, bedpan, urinal);
c. PHYSICALLY ABUSIVE BEHAVIORAL SYMPTOMS (others transfer on/off toilet, cleanses, changes pad, manages ostomy or
were hit, shoved, scratched, sexually abused) catheter, adjusts clothes
d. SOCIALLY INAPPROPRIATE/DISRUPTIVE BEHAVIORAL j. PERSONAL How resident maintains personal hygiene, including combing hair,
SYMPTOMS (made disruptive sounds, noisiness, screaming, HYGIENE brushing teeth, shaving, applying makeup, washing/drying face,
self-abusive acts, sexual behavior or disrobing in public, hands, and perineum (EXCLUDE baths and showers)
smeared/threw food/feces, hoarding, rummaged through others'
belongings)
e. RESISTS CARE (resisted taking medications/ injections, ADL
assistance, or eating)
MDS 2.0 September, 2000
Resident Numeric Identifier _______________________________________________________

2. BATHING How resident takes full-body bath/shower, sponge bath, and 3. APPLIANCES Any scheduled toileting plan a. Did not use toilet room/
transfers in/out of tub/shower (EXCLUDE washing of back and hair.) AND commode/urinal f.
Code for most dependent in self-performance and support.
(A) (B)
PROGRAMS Bladder retraining program g.
(A) BATHING SELF-PERFORMANCE codes appear below b. Pads/briefs used
External (condom) catheter Enemas/irrigation h.
0. Independent—No help provided c.

1. Supervision—Oversight help only Indwelling catheter d. Ostomy present i.

2. Physical help limited to transfer only Intermittent catheter NONE OF ABOVE j.


e.
3. Physical help in part of bathing activity 4. CHANGE IN Resident's urinary continence has changed as compared to status of
4. Total dependence URINARY 90 days ago (or since last assessment if less than 90 days)
CONTI­
8. Activity itself did not occur during entire 7 days NENCE 0. No change 1.Improved 2.Deteriorated
(Bathing support codes are as defined in Item 1, code B above)
3. TEST FOR (Code for ability during test in the last 7 days) SECTION I. DISEASE DIAGNOSES
BALANCE 0. Maintained position as required in test Check only those diseases that have a relationship to current ADL status, cognitive status,
1. Unsteady, but able to rebalance self without physical support mood and behavior status, medical treatments, nursing monitoring, or risk of death. (Do not list
(see training 2. Partial physical support during test; inactive diagnoses)
manual) or stands (sits) but does not follow directions for test 1. DISEASES (If none apply, CHECK the NONE OF ABOVE box)
3. Not able to attempt test without physical help
ENDOCRINE/METABOLIC/ Hemiplegia/Hemiparesis v.
a. Balance while standing
NUTRITIONAL Multiple sclerosis w.
b. Balance while sitting—position, trunk control
Diabetes mellitus a. Paraplegia x.
4. FUNCTIONAL (Code for limitations during last 7 days that interfered with daily functions or
LIMITATION placed resident at risk of injury) Hyperthyroidism b. Parkinson's disease y.
IN RANGE OF (A) RANGE OF MOTION (B) VOLUNTARY MOVEMENT Hypothyroidism c. Quadriplegia z.
MOTION 0. No limitation 0. No loss
1. Limitation on one side 1. Partial loss HEART/CIRCULATION Seizure disorder aa.
(see training 2. Limitation on both sides 2. Full loss (A) (B) Transient ischemic attack (TIA) bb.
Arteriosclerotic heart disease
manual) a. Neck (ASHD) d. Traumatic brain injury cc.
b. Arm—Including shoulder or elbow Cardiac dysrhythmias e. PSYCHIATRIC/MOOD
c. Hand—Including wrist or fingers Congestive heart failure f. Anxiety disorder dd.
d. Leg—Including hip or knee Deep vein thrombosis g. Depression
e. Foot—Including ankle or toes ee.
Hypertension h. Manic depression (bipolar
f. Other limitation or loss Hypotension i. disease) ff.
5. MODES OF (Check all that apply during last 7 days) Peripheral vascular disease j. Schizophrenia gg.
LOCOMO- Cane/walker/crutch
TION a. Wheelchair primary mode of Other cardiovascular disease k. PULMONARY
d.
Wheeled self b.
locomotion MUSCULOSKELETAL Asthma hh.
Other person wheeled NONE OF ABOVE
c. e. Arthritis l. Emphysema/COPD ii.
6. MODES OF (Check all that apply during last 7 days) Hip fracture m. SENSORY
TRANSFER Missing limb (e.g., amputation) n. Cataracts
Bedfast all or most of time Lifted mechanically jj.
a. d.
Osteoporosis o. Diabetic retinopathy kk.
Bed rails used for bed mobility Transfer aid (e.g., slide board,
or transfer b. trapeze, cane, walker, brace) e. Pathological bone fracture p. Glaucoma ll.
NEUROLOGICAL Macular degeneration mm.
Lifted manually c. NONE OF ABOVE f.
Alzheimer's disease q. OTHER
7. TASK Some or all of ADL activities were broken into subtasks during last 7
SEGMENTA- days so that resident could perform them Aphasia r. Allergies nn.
TION 0. No 1.Yes Cerebral palsy s. Anemia oo.
8. ADL Resident believes he/she is capable of increased independence in at Cerebrovascular accident Cancer pp.
FUNCTIONAL least some ADLs a. (stroke)
REHABILITA- t. Renal failure qq.
TION Direct care staff believe resident is capable of increased independence b. Dementia other than NONE OF ABOVE rr.
POTENTIAL in at least some ADLs Alzheimer's disease u.
Resident able to perform tasks/activity but is very slow c. 2. INFECTIONS (If none apply, CHECK the NONE OF ABOVE box)
Difference in ADL Self-Performance or ADL Support, comparing Antibiotic resistant infection Septicemia g.
mornings to evenings d.
(e.g., Methicillin resistant a. Sexually transmitted diseases h.
NONE OF ABOVE staph)
e. Tuberculosis i.
Clostridium difficile (c. diff.) b.
9. CHANGE IN Resident's ADL self-performance status has changed as compared Urinary tract infection in last 30
ADL to status of 90 days ago (or since last assessment if less than 90 Conjunctivitis c. days j.
FUNCTION days)
0. No change 1. Improved 2.Deteriorated HIV infection d. Viral hepatitis k.
Pneumonia e. Wound infection l.
SECTION H. CONTINENCE IN LAST 14 DAYS Respiratory infection f. NONE OF ABOVE m.
1. CONTINENCE SELF-CONTROL CATEGORIES 3. OTHER
(Code for resident's PERFORMANCE OVER ALL SHIFTS) a. •
CURRENT
OR MORE b.
0. CONTINENT—Complete control [includes use of indwelling urinary catheter or ostomy DETAILED •
device that does not leak urine or stool] DIAGNOSES c.
AND ICD-9

1. USUALLY CONTINENT—BLADDER, incontinent episodes once a week or less; CODES d.

BOWEL, less than weekly
e.

2. OCCASIONALLY INCONTINENT—BLADDER, 2 or more times a week but not daily;
BOWEL, once a week SECTION J. HEALTH CONDITIONS
3. FREQUENTLY INCONTINENT—BLADDER, tended to be incontinent daily, but some 1. PROBLEM (Check all problems present in last 7 days unless other time frame is
control present (e.g., on day shift); BOWEL, 2-3 times a week CONDITIONS indicated)
INDICATORS OF FLUID Dizziness/Vertigo f.
4. INCONTINENT—Had inadequate control BLADDER, multiple daily episodes; STATUS Edema g.
BOWEL, all (or almost all) of the time Fever
Weight gain or loss of 3 or h.
a. BOWEL Control of bowel movement, with appliance or bowel continence more pounds within a 7 day Hallucinations
CONTI­ programs, if employed period a. i.
NENCE Internal bleeding
j.
b. BLADDER Control of urinary bladder function (if dribbles, volume insufficient to Inability to lie flat due to
shortness of breath Recurrent lung aspirations in
CONTI­ soak through underpants), with appliances (e.g., foley) or continence b. last 90 days k.
NENCE programs, if employed Dehydrated; output exceeds Shortness of breath l.
2. BOWEL Bowel elimination pattern Diarrhea c. input c.
ELIMINATION regular—at least one a. Syncope (fainting) m.
PATTERN movement every three days Fecal impaction d.
Insufficient fluid; did NOT Unsteady gait
consume all/almost all liquids n.
Constipation b.
NONE OF ABOVE e. provided during last 3 days d. Vomiting o.
OTHER NONE OF ABOVE p.

MDS 2.0 September, 2000 Delusions e.


Resident ______________________________________________________________ Numeric Identifier _______________________________________________________
SECTION M. SKIN CONDITION
2. PAIN (Code the highest level of pain present in the last 7 days)

at Stage
Number
1. ULCERS (Record the number of ulcers at each ulcer stage—regardless of
SYMPTOMS cause. If none present at a stage, record "0" (zero). Code all that apply
a. FREQUENCY with which b. INTENSITY of pain
resident complains or (Due to any during last 7 days. Code 9 = 9 or more.) [Requires full body exam.]
1. Mild pain cause)
shows evidence of pain
2. Moderate pain a. Stage 1. A persistent area of skin redness (without a break in the
0. No pain (skip to J4) skin) that does not disappear when pressure is relieved.
3. Times when pain is
1. Pain less than daily horrible or excruciating b. Stage 2. A partial thickness loss of skin layers that presents
2. Pain daily clinically as an abrasion, blister, or shallow crater.
3. PAIN SITE (If pain present, check all sites that apply in last 7 days) c. Stage 3. A full thickness
12 of skin is lost, exposing the subcutaneous
Back pain a. Incisional pain f. tissues - presents as a deep crater with or without
undermining adjacent tissue.
Bone pain b. Joint pain (other than hip) g.
Chest pain while doing usual d. Stage 4. A full thickness of skin and subcutaneous
12 tissue is lost,
Soft tissue pain (e.g., lesion, exposing muscle or bone.
activities c. muscle) h.
2. TYPE OF (For each type of ulcer, code for the highest stage in the last 7 days
Headache d. Stomach pain i. using scale in item M1—i.e., 0=none; stages 1, 2, 3, 4)
ULCER
Hip pain e. Other j.
a. Pressure ulcer—any lesion caused by pressure resulting in damage
4. ACCIDENTS (Check all that apply) of underlying tissue
Fell in past 30 days Hip fracture in last 180 days
a. c. b. Stasis ulcer—open lesion caused by poor circulation in the lower
Fell in past 31-180 days Other fracture in last 180 days
b. d. extremities
NONE OF ABOVE e. 3. HISTORY OF Resident had an ulcer that was resolved or cured in LAST 90 DAYS
5. STABILITY Conditions/diseases make resident's cognitive, ADL, mood or behavior RESOLVED
OF patterns unstable—(fluctuating, precarious, or deteriorating) a. ULCERS 0. No 1.Yes
CONDITIONS 4. OTHER SKIN (Check all that apply during last 7 days)
Resident experiencing an acute episode or a flare-up of a recurrent or
b. PROBLEMS Abrasions, bruises
chronic problem a.
OR LESIONS
End-stage disease, 6 or fewer months to live c. PRESENT Burns (second or third degree) b.
NONE OF ABOVE d. Open lesions other than ulcers, rashes, cuts (e.g., cancer lesions) c.
Rashes—e.g., intertrigo, eczema, drug rash, heat rash, herpes zoster d.
Skin desensitized to pain or pressure e.
SECTION K. ORAL/NUTRITIONAL STATUS Skin tears or cuts (other than surgery) f.
1. ORAL Chewing problem a.
Surgical wounds g.
PROBLEMS Swallowing problem b.
NONE OF ABOVE h.
Mouth pain c.
5. SKIN (Check all that apply during last 7 days)
NONE OF ABOVE d. TREAT- Pressure relieving device(s) for chair a.
2. HEIGHT Record (a.) height in inches and (b.) weight in pounds.Base weight on most MENTS
Pressure relieving device(s) for bed
AND recent measure in last 30 days; measure weight consistently in accord with b.
WEIGHT standard facility practice—e.g., in a.m.after voiding, before meal, with shoes Turning/repositioning program c.
off, and in nightclothes Nutrition or hydration intervention to manage skin problems d.
a. HT (in.) b. WT (lb.) Ulcer care e.
3. WEIGHT a.Weight loss—5 % or more in last 30 days; or 10 % or more in last Surgical wound care
180 days f.
CHANGE
0. No 1.Yes Application of dressings (with or without topical medications) other than
to feet g.
b.Weight gain—5 % or more in last 30 days; or 10 % or more in last
180 days Application of ointments/medications (other than to feet) h.
0. No 1.Yes Other preventative or protective skin care (other than to feet) i.

4. NUTRI- Complains about the taste of Leaves 25% or more of food NONE OF ABOVE j.
TIONAL many foods a. uneaten at most meals c. 6. FOOT (Check all that apply during last 7 days)
PROBLEMS PROBLEMS Resident has one or more foot problems—e.g., corns, callouses,
Regular or repetitive NONE OF ABOVE
complaints of hunger b. d.
AND CARE bunions, hammer toes, overlapping toes, pain, structural problems
a.
5. NUTRI- (Check all that apply in last 7 days) Infection of the foot—e.g., cellulitis, purulent drainage b.
TIONAL Parenteral/IV Dietary supplement between Open lesions on the foot
a. c.
APPROACH- meals
ES Feeding tube f. Nails/calluses trimmed during last 90 days
b. d.
Mechanically altered diet Plate guard, stabilized built-up Received preventative or protective foot care (e.g., used special shoes,
c. utensil, etc. inserts, pads, toe separators) e.
g.
Syringe (oral feeding) d. On a planned weight change Application of dressings (with or without topical medications) f.
Therapeutic diet program h. NONE OF ABOVE
e. g.
NONE OF ABOVE i.
6. PARENTERAL (Skip to Section L if neither 5a nor 5b is checked)
OR ENTERAL a. Code the proportion of total calories the resident received through SECTION N. ACTIVITY PURSUIT PATTERNS
INTAKE parenteral or tube feedings in the last 7 days 1. TIME (Check appropriate time periods over last 7 days)
0. None 3. 51% to 75% AWAKE Resident awake all or most of time (i.e., naps no more than one hour
1. 1% to 25% 4. 76% to 100% per time period) in the:
Evening c.
2. 26% to 50% Morning a.
Afternoon b. NONE OF ABOVE d.
b. Code the average fluid intake per day by IV or tube in last 7 days
0. None 3. 1001 to 1500 cc/day (If resident is comatose, skip to Section O)
1. 1 to 500 cc/day 4. 1501 to 2000 cc/day 2. (When awake and not receiving treatments or ADL care)
2. 501 to 1000 cc/day 5. 2001 or more cc/day AVERAGE
TIME
INVOLVED IN 0. Most—more than 2/3 of time 2. Little—less than 1/3 of time
ACTIVITIES 1. Some—from 1/3 to 2/3 of time 3. None
SECTION L. ORAL/DENTAL STATUS 3. PREFERRED (Check all settings in which activities are preferred)
1. ORAL Debris (soft, easily movable substances) present in mouth prior to ACTIVITY Own room a.
STATUS AND going to bed at night a. SETTINGS Day/activity room Outside facility d.
b.
DISEASE Has dentures or removable bridge
PREVENTION b. Inside NH/off unit c. NONE OF ABOVE e.
Some/all natural teeth lost—does not have or does not use dentures 4. GENERAL (Check all PREFERENCES whether or not activity is currently
(or partial plates) c. ACTIVITY available to resident) Trips/shopping g.
PREFER­ Cards/other games a.
Broken, loose, or carious teeth d. ENCES Walking/wheeling outdoors
Crafts/arts h.
(adapted to b.
Inflamed gums (gingiva); swollen or bleeding gums; oral abcesses; Watching TV i.
ulcers or rashes e. resident's Exercise/sports c.
current Music d.
Gardening or plants j.
Daily cleaning of teeth/dentures or daily mouth care—by resident or f. abilities)
staff Reading/writing e.
Talking or conversing k.
NONE OF ABOVE g. Spiritual/religious Helping others l.
activities f. NONE OF ABOVE m.
MDS 2.0 September, 2000
Resident Numeric Identifier _______________________________________________________

5. PREFERS Code for resident preferences in daily routines 4. DEVICES (Use the following codes for last 7 days:)
CHANGE IN 0. No change 1. Slight change 2. Major change AND 0. Not used
DAILY a. Type of activities in which resident is currently involved RESTRAINTS 1. Used less than daily
ROUTINE 2. Used daily
b. Extent of resident involvement in activities Bed rails
a. — Full bed rails on all open sides of bed
SECTION O. MEDICATIONS
b. — Other types of side rails used (e.g., half rail, one side)
1. NUMBER OF (Record the number of different medications used in the last 7 days;
MEDICA­ enter "0" if none used) c.Trunk restraint
TIONS d. Limb restraint
2. NEW (Resident currently receiving medications that were initiated during the e. Chair prevents rising
MEDICA­ last 90 days) 5. HOSPITAL Record number of times resident was admitted to hospital with an
TIONS 0. No 1.Yes STAY(S) overnight stay in last 90 days (or since last assessment if less than 90
3. INJECTIONS (Record the number of DAYS injections of any type received during days). (Enter 0 if no hospital admissions)
the last 7 days; enter "0" if none used) 6. EMERGENCY Record number of times resident visited ER without an overnight stay
4. DAYS (Record the number of DAYS during last 7 days; enter "0" if not ROOM (ER) in last 90 days (or since last assessment if less than 90 days).
RECEIVED used. Note—enter "1" for long-acting meds used less than weekly) VISIT(S) (Enter 0 if no ER visits)
THE a. Antipsychotic 7. PHYSICIAN In the LAST 14 DAYS (or since admission if less than 14 days in
FOLLOWING d. Hypnotic
VISITS facility) how many days has the physician (or authorized assistant or
MEDICATION b. Antianxiety practitioner) examined the resident? (Enter 0 if none)
e. Diuretic
c. Antidepressant
8. PHYSICIAN In the LAST 14 DAYS (or since admission if less than 14 days in
ORDERS facility) how many days has the physician (or authorized assistant or
SECTION P. SPECIALTREATMENTS AND PROCEDURES practitioner) changed the resident's orders? Do not include order
renewals without change. (Enter 0 if none)
1. SPECIAL a. SPECIAL CARE—Check treatments or programs received during
TREAT- the last 14 days 9. ABNORMAL Has the resident had any abnormal lab values during the last 90 days
MENTS, LAB VALUES (or since admission)?
PROCE­ TREATMENTS Ventilator or respirator
DURES, AND l. 0. No 1.Yes
PROGRAMS Chemotherapy a. PROGRAMS
Dialysis b. Alcohol/drug treatment SECTION Q. DISCHARGE POTENTIAL AND OVERALL STATUS
IV medication c.
program m.
1. DISCHARGE a. Resident expresses/indicates preference to return to the community
Intake/output d. Alzheimer's/dementia special POTENTIAL
care unit n. 0. No 1.Yes
Monitoring acute medical
condition e. Hospice care o. b. Resident has a support person who is positive towards discharge
Pediatric unit p.
Ostomy care f. 0. No 1.Yes
Respite care q.
Oxygen therapy g. c. Stay projected to be of a short duration— discharge projected within
Training in skills required to 90 days (do not include expected discharge due to death)
Radiation h. return to the community (e.g., 0. No 2.Within 31-90 days
Suctioning i. taking medications, house r. 1.Within 30 days 3. Discharge status uncertain
work, shopping, transportation,
Tracheostomy care j. ADLs) 2. OVERALL Resident's overall self sufficiency has changed significantly as
CHANGE IN compared to status of 90 days ago (or since last assessment if less
Transfusions k. NONE OF ABOVE s. CARE NEEDS than 90 days)
0. No change 1. Improved—receives fewer 2. Deteriorated—receives
b.THERAPIES - Record the number of days and total minutes each of the supports, needs less more support
following therapies was administered (for at least 15 minutes a day) in restrictive level of care
the last 7 calendar days (Enter 0 if none or less than 15 min. daily)
[Note—count only post admission therapies]
(A) = # of days administered for 15 minutes or more DAYS MIN
(B) = total # of minutes provided in last 7 days (A) (B)
SECTION R. ASSESSMENT INFORMATION
1. PARTICIPA­ a. Resident: 0. No 1.Yes
a. Speech - language pathology and audiology services TION IN b. Family: 0. No 1.Yes 2. No family
b. Occupational therapy ASSESS­
MENT c. Significant other: 0. No 1.Yes 2. None
c. Physical therapy 2. SIGNATURE OF PERSON COORDINATINGTHE ASSESSMENT:
d. Respiratory therapy
e. Psychological therapy (by any licensed mental a. Signature of RN Assessment Coordinator (sign on above line)
health professional) b. Date RN Assessment Coordinator
2. INTERVEN­ (Check all interventions or strategies used in last 7 days—no signed as complete
TION matter where received) Month Day Year
PROGRAMS Special behavior symptom evaluation program
FOR MOOD, a.
BEHAVIOR, Evaluation by a licensed mental health specialist in last 90 days
COGNITIVE Group therapy b.
LOSS c.
Resident-specific deliberate changes in the environment to address
mood/behavior patterns—e.g., providing bureau in which to rummage d.
Reorientation—e.g., cueing e.
NONE OF ABOVE f.
3. NURSING Record the NUMBER OF DAYS each of the following rehabilitation or
REHABILITA­ restorative techniques or practices was provided to the resident for
TION/ more than or equal to 15 minutes per day in the last 7 days
RESTOR­ (Enter 0 if none or less than 15 min. daily.)
ATIVE CARE a. Range of motion (passive) f. Walking
b. Range of motion (active) g. Dressing or grooming
c. Splint or brace assistance
h. Eating or swallowing
TRAINING AND SKILL
PRACTICE IN: i. Amputation/prosthesis care
d. Bed mobility j. Communication
e. Transfer k. Other

MDS 2.0 September, 2000


Resident ______________________________________________________________ Numeric Identifier _______________________________________________________
SECTIONT.THERAPY SUPPLEMENT FOR MEDICARE PPS
1. SPECIAL a. RECREATION THERAPY—Enter number of days and total minutes of
TREAT- recreation therapy administered (for at least 15 minutes a day) in the
MENTS AND last 7 days (Enter 0 if none) DAYS MIN
PROCE­
DURES (A) (B)
(A) = # of days administered for 15 minutes or more
(B) = total # of minutes provided in last 7 days
Skip unless this is a Medicare 5 day or Medicare readmission/
return assessment.

b. ORDERED THERAPIES—Has physician ordered any of


following therapies to begin in FIRST 14 days of stay—physical
therapy, occupational therapy, or speech pathology service?
0. No 1. Yes

If not ordered, skip to item 2

c. Through day 15, provide an estimate of the number of days


when at least 1 therapy service can be expected to have been
delivered.

d. Through day 15, provide an estimate of the number of


therapy minutes (across the therapies) that can be
expected to be delivered?
2. WALKING Complete item 2 if ADL self-performance score forTRANSFER
WHEN MOST (G.1.b.A) is 0,1,2, or 3 AND at least one of the following are
SELF present:
SUFFICIENT • Resident received physical therapy involving gait training (P.1.b.c)
• Physical therapy was ordered for the resident involving gait
training (T.1.b)
• Resident received nursing rehabilitation for walking (P.3.f)
• Physical therapy involving walking has been discontinued within
the past 180 days

Skip to item 3 if resident did not walk in last 7 days


(FOR FOLLOWING FIVE ITEMS, BASE CODING ONTHE
EPISODE WHENTHE RESIDENT WALKEDTHE FARTHEST
WITHOUT SITTING DOWN. INCLUDEWALKING DURING
REHABILITATION SESSIONS.)
a. Furthest distance walked without sitting down during this
episode.

0. 150+ feet 3. 10-25 feet


1. 51-149 feet 4. Less than 10 feet
2. 26-50 feet

b. Time walked without sitting down during this episode.

0. 1-2 minutes 3. 11-15 minutes


1. 3-4 minutes 4. 16-30 minutes
2. 5-10 minutes 5. 31+ minutes

c. Self-Performance in walking during this episode.

0. INDEPENDENT—No help or oversight


1. SUPERVISION—Oversight, encouragement or cueing
provided
2. LIMITED ASSISTANCE—Resident highly involved in walking;
received physical help in guided maneuvering of limbs or other
nonweight bearing assistance
3. EXTENSIVE ASSISTANCE—Resident received weight
bearing assistance while walking

d. Walking support provided associated with this episode (code


regardless of resident's self-performance classification).
0. No setup or physical help from staff
1. Setup help only
2. One person physical assist
3. Two+ persons physical assist

e. Parallel bars used by resident in association with this episode.


0. No 1.Yes
3. CASE MIX
GROUP Medicare State

MDS 2.0 September, 2000


Numeric Identifier _______________________________________________________
SECTION V. RESIDENT ASSESSMENT PROTOCOL SUMMARY
Resident's Name: Medical Record No.:
1. Check if RAP is triggered.
2. For each triggered RAP, use the RAP guidelines to identify areas needing further assessment. Document relevant assessment information
regarding the resident's status.
• Describe:
— Nature of the condition (may include presence or lack of objective data and subjective complaints).
— Complications and risk factors that affect your decision to proceed to care planning.
— Factors that must be considered in developing individualized care plan interventions.
— Need for referrals/further evaluation by appropriate health professionals.
• Documentation should support your decision-making regarding whether to proceed with a care plan for a triggered RAP and the type(s)
of care plan interventions that are appropriate for a particular resident.
• Documentation may appear anywhere in the clinical record (e.g., progress notes, consults, flowsheets, etc.).
3. Indicate under the Location of RAP Assessment Documentation column where information related to the RAP assessment can be found.
4. For each triggered RAP, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address
the problem(s) identified in your assessment.The Care Planning Decision column must be completed within 7 days of completing the RAI
(MDS and RAPs).
(b) Care Planning
Decision—check
(a) Check if Location and Date of if addressed in
A. RAP PROBLEM AREA triggered RAP Assessment Documentation care plan

1. DELIRIUM

2. COGNITIVE LOSS

3.VISUAL FUNCTION

4. COMMUNICATION
5. ADL FUNCTIONAL/
REHABILITATION POTENTIAL
6. URINARY INCONTINENCE AND
INDWELLING CATHETER
7. PSYCHOSOCIAL WELL-BEING

8. MOOD STATE

9. BEHAVIORAL SYMPTOMS

10. ACTIVITIES

11. FALLS

12. NUTRITIONAL STATUS

13. FEEDINGTUBES

14. DEHYDRATION/FLUID MAINTENANCE

15. DENTAL CARE

16. PRESSURE ULCERS

17. PSYCHOTROPIC DRUG USE

18. PHYSICAL RESTRAINTS

B._____________________________________________________________________________
1. Signature of RN Coordinator for RAP Assessment Process 2. Month Day Year

_____________________________________________________________________________
3. Signature of Person Completing Care Planning Decision 4. Month Day Year

MDS 2.0 September, 2000


RESIDENT ASSESSMENT PROTOCOL TRIGGER LEGEND FOR REVISED RAPS (FOR MDS VERSION 2.0)

Key:

r
� = One item required to trigger

ete
ath
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gC
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MDS ITEM CODE

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RESIDENT ASSESSMENT PROTOCOL TRIGGER LEGEND FOR REVISED RAPS (FOR MDS VERSION 2.0)

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MDS 2.0 September, 2000


Numeric Identifier _______________________________________________________
MDS QUARTERLY ASSESSMENT FORM
A1. RESIDENT E1. INDICATORS VERBAL EXPRESSIONS SLEEP-CYCLE ISSUES
NAME OF OF DISTRESS j. Unpleasant mood in morning
a. (First) b. (Middle Initial) c. (Last) d. (Jr/Sr) DEPRES­
SION, f. Expressions of what k. Insomnia/change in usual
A2. ROOM ANXIETY, appear to be unrealistic sleep pattern
NUMBER SAD MOOD fears—e.g., fear of being
(cont.) abandoned, left alone, SAD, APATHETIC, ANXIOUS
being with others APPEARANCE
A3. ASSESS­ a. Last day of MDS observation period
MENT g. Recurrent statements that l. Sad, pained, worried facial
REFERENCE something terrible is about expressions—e.g., furrowed
DATE to happen—e.g., believes brows
Month Day Year he or she is about to die, m. Crying, tearfulness
b. Original (0) or corrected copy of form (enter number of correction) have a heart attack
n. Repetitive physical
A4a DATE OF Date of reentry from most recent temporary discharge to a hospital in h. Repetitive health movements—e.g., pacing,
REENTRY last 90 days (or since last assessment or admission if less than 90 days) complaints—e.g., hand wringing, restlessness,
persistently seeks medical fidgeting, picking
attention, obsessive
concern with body LOSS OF INTEREST
functions o. Withdrawal from activities of
Month Day Year interest—e.g., no interest in
i. Repetitive anxious
A6. MEDICAL complaints/concerns (non- long standing activities or
RECORD health related) e.g., being with family/friends
NO. persistently seeks attention/ p. Reduced social interaction
B1. COMATOSE (Persistent vegetative state/no discernible consciousness) reassurance regarding
0. No 1.Yes (Skip to Section G) schedules, meals, laundry,
clothing, relationship issues
B2. MEMORY (Recall of what was learned or known) One or more indicators of depressed, sad or anxious mood were
E2. MOOD
a. Short-term memory OK—seems/appears to recall after 5 minutes PERSIS­ not easily altered by attempts to "cheer up", console, or reassure
0. Memory OK 1. Memory problem TENCE the resident over last 7 days
0. No mood 1. Indicators present, 2.Indicators present,
b. Long-term memory OK—seems/appears to recall long past indicators easily altered not easily altered
0. Memory OK 1. Memory problem
E4. BEHAVIORAL (A) Behavioral symptom frequency in last 7 days
B4. COGNITIVE (Made decisions regarding tasks of daily life) SYMPTOMS 0. Behavior not exhibited in last 7 days
SKILLS FOR 1. Behavior of this type occurred 1 to 3 days in last 7 days
DAILY 0. INDEPENDENT—decisions consistent/reasonable 2. Behavior of this type occurred 4 to 6 days, but less than daily
DECISION- 1. MODIFIED INDEPENDENCE—some difficulty in new situations 3. Behavior of this type occurred daily
MAKING only
2. MODERATELY IMPAIRED—decisions poor; cues/supervision (B) Behavioral symptom alterability in last 7 days
required 0. Behavior not present OR behavior was easily altered
3. SEVERELY IMPAIRED—never/rarely made decisions 1. Behavior was not easily altered (A) (B)
B5. INDICATORS (Code for behavior in the last 7 days.) [Note: Accurate assessment a. WANDERING (moved with no rational purpose, seemingly
OF requires conversations with staff and family who have direct knowledge oblivious to needs or safety)
DELIRIUM— of resident's behavior over this time]. b. VERBALLY ABUSIVE BEHAVIORAL SYMPTOMS (others
PERIODIC 0. Behavior not present were threatened, screamed at, cursed at)
DISOR­ 1. Behavior present, not of recent onset
DERED c. PHYSICALLY ABUSIVE BEHAVIORAL SYMPTOMS (others
THINKING/ 2. Behavior present, over last 7 days appears different from resident's usual
were hit, shoved, scratched, sexually abused)
AWARENESS functioning (e.g., new onset or worsening)
a. EASILY DISTRACTED—(e.g., difficulty paying attention; gets d. SOCIALLY INAPPROPRIATE/DISRUPTIVE BEHAVIORAL
sidetracked) SYMPTOMS (made disruptive sounds, noisiness, screaming,
self-abusive acts, sexual behavior or disrobing in public,
b.PERIODS OF ALTERED PERCEPTION OR AWARENESS OF smeared/threw food/feces, hoarding, rummaged through others'
SURROUNDINGS—(e.g., moves lips or talks to someone not belongings)
present; believes he/she is somewhere else; confuses night and
day) e. RESISTS CARE (resisted taking medications/ injections, ADL
assistance, or eating)
c. EPISODES OF DISORGANIZED SPEECH—(e.g., speech is
incoherent, nonsensical, irrelevant, or rambling from subject to G1. (A) ADL SELF-PERFORMANCE—(Code for resident's PERFORMANCE OVER ALL
subject; loses train of thought) SHIFTS during last 7 days—Not including setup)

d.PERIODS OF RESTLESSNESS—(e.g., fidgeting or picking at skin, 0. INDEPENDENT—No help or oversight —OR— Help/oversight provided only 1 or 2 times
clothing, napkins, etc; frequent position changes; repetitive physical during last 7 days
movements or calling out) 1. SUPERVISION—Oversight, encouragement or cueing provided 3 or more times during
e. PERIODS OF LETHARGY—(e.g., sluggishness; staring into space; last7 days —OR— Supervision (3 or more times) plus physical assistance provided only
difficult to arouse; little body movement) 1 or 2 times during last 7 days

f. MENTAL FUNCTION VARIES OVER THE COURSE OF THE 2. LIMITED ASSISTANCE—Resident highly involved in activity; received physical help in
DAY—(e.g., sometimes better, sometimes worse; behaviors guided maneuvering of limbs or other nonweight bearing assistance 3 or more times —
sometimes present, sometimes not) OR—More help provided only 1 or 2 times during last 7 days
C4. MAKING (Expressing information content—however able) 3. EXTENSIVE ASSISTANCE—While resident performed part of activity, over last 7-day
SELF 0. UNDERSTOOD period, help of following type(s) provided 3 or more times:
UNDER- 1. USUALLY UNDERSTOOD—difficulty finding words or finishing — Weight-bearing support
STOOD thoughts — Full staff performance during part (but not all) of last 7 days
2. SOMETIMES UNDERSTOOD—ability is limited to making concrete 4. TOTAL DEPENDENCE—Full staff performance of activity during entire 7 days
requests (A)
3. RARELY/NEVER UNDERSTOOD 8. ACTIVITY DID NOT OCCUR during entire 7 days
C6. ABILITY TO (Understanding verbal information content—however able) a. BED How resident moves to and from lying position, turns side to side, and
UNDER- MOBILITY positions body while in bed
STAND 0. UNDERSTANDS
OTHERS 1. USUALLY UNDERSTANDS—may miss some part/intent of b. TRANSFER How resident moves between surfaces—to/from: bed, chair,
message wheelchair, standing position (EXCLUDE to/from bath/toilet)
2. SOMETIMES UNDERSTANDS—responds adequately to simple,
direct communication c. WALK IN How resident walks between locations in his/her room.
3. RARELY/NEVER UNDERSTANDS ROOM
E1. INDICATORS (Code for indicators observed in last 30 days, irrespective of the d. WALK IN How resident walks in corridor on unit.
OF assumed cause) CORRIDOR
DEPRES­ 0. Indicator not exhibited in last 30 days e. LOCOMO­
SION, 1. Indicator of this type exhibited up to five days a week How resident moves between locations in his/her room and adjacent
TION
ANXIETY, 2. Indicator of this type exhibited daily or almost daily (6, 7 days a week) ON UNIT
corridor on same floor. If in wheelchair, self-sufficiency once in chair
SAD MOOD VERBAL EXPRESSIONS c. Repetitive verbalizations—
OF DISTRESS e.g., calling out for help, f. LOCOMO­ How resident moves to and returns from off unit locations (e.g., areas
("God help me") TION set aside for dining, activities, or treatments). If facility has only one
a. Resident made negative OFF UNIT floor, how resident moves to and from distant areas on the floor. If in
statements—e.g., "Nothing d. Persistent anger with self or wheelchair, self-sufficiency once in chair
matters;Would rather be others—e.g., easily annoyed, g. DRESSING How resident puts on, fastens, and takes off all items of street
dead;What's the use; anger at placement in clothing, including donning/removing prosthesis
Regrets having lived so nursing home; anger at care
long; Let me die" received h. EATING How resident eats and drinks (regardless of skill). Includes intake of
nourishment by other means (e.g., tube feeding, total parenteral
b. Repetitive questions—e.g., e. Self deprecation—e.g., "I am nutrition).
"Where do I go;What do I nothing; I am of no use to
do?" anyone" MDS 2.0 September, 2000
Resident_______________________________________________________________ Numeric Identifier _______________________________________________________

i. TOILET USE How resident uses the toilet room (or commode, bedpan, urinal); J5. STABILITY Conditions/diseases make resident's cognitive, ADL, mood or behavior
transfer on/off toilet, cleanses, changes pad, manages ostomy or OF status unstable—(fluctuating, precarious, or deteriorating) a.
catheter, adjusts clothes CONDITIONS
Resident experiencing an acute episode or a flare-up of a recurrent or
b.
j. PERSONAL How resident maintains personal hygiene, including combing hair, chronic problem
HYGIENE brushing teeth, shaving, applying makeup, washing/drying face, hands, End-stage disease, 6 or fewer months to live c.
and perineum (EXCLUDE baths and showers)
NONE OF ABOVE d.
G2. BATHING How resident takes full-body bath/shower, sponge bath, and
transfers in/out of tub/shower (EXCLUDE washing of back and hair.) K3. WEIGHT a.Weight loss—5 % or more in last 30 days; or 10 % or more in last
Code for most dependent in self-performance. CHANGE 180 days
(A) BATHING SELF PERFORMANCE codes appear below 0. No 1.Yes
(A)
0. Independent—No help provided b.Weight gain—5 % or more in last 30 days; or 10 % or more in last
1. Supervision—Oversight help only 180 days
2. Physical help limited to transfer only 0. No 1.Yes
3. Physical help in part of bathing activity K5. NUTRI­ Feeding tube b.
TIONAL On a planned weight change program
4. Total dependence APPROACH­ h.
8. Activity itself did not occur during entire 7 days ES NONE OF ABOVE i.

at Stage
Number
G4. FUNCTIONAL (Code for limitations during last 7 days that interfered with daily functions or M1. ULCERS (Record the number of ulcers at each ulcer stage—regardless of
LIMITATION placed residents at risk of injury) cause. If none present at a stage, record "0" (zero). Code all that apply
IN RANGE OF (A) RANGE OF MOTION (B) VOLUNTARY MOVEMENT (Due to any during last 7 days. Code 9 = 9 or more.) [Requires full body exam.]
MOTION 0. No limitation 0. No loss cause)
1. Limitation on one side 1. Partial loss a. Stage 1. A persistent area of skin redness (without a break in the
2. Limitation on both sides 2. Full loss (A) (B) skin) that does not disappear when pressure is relieved.
a. Neck b. Stage 2. A partial thickness loss of skin layers that presents
b. Arm—Including shoulder or elbow clinically as an abrasion, blister, or shallow crater.
c. Hand—Including wrist or fingers c. Stage 3. A full thickness of skin is lost, exposing the subcutaneous
d. Leg—Including hip or knee tissues - presents as a deep crater with or without
undermining adjacent tissue.
e. Foot—Including ankle or toes
f. Other limitation or loss d. Stage 4. A full thickness of skin and subcutaneous tissue is lost,
exposing muscle or bone.
G6. MODES OF (Check all that apply during last 7 days) (For each type of ulcer, code for the highest stage in the last 7 days using
TRANSFER Bedfast all or most of time M2. TYPE OF
NONE OF ABOVE ULCER scale in item M1—i.e., 0=none; stages 1, 2, 3, 4)
a. f.
Bed rails used for bed mobility a. Pressure ulcer—any lesion caused by pressure resulting in damage
or transfer b.
of underlying tissue
H1. CONTINENCE SELF-CONTROL CATEGORIES b. Stasis ulcer—open lesion caused by poor circulation in the lower
(Code for resident's PERFORMANCE OVER ALL SHIFTS) extremities
N1. TIME (Check appropriate time periods over last 7 days)
0. CONTINENT—Complete control [includes use of indwelling urinary catheter or ostomy AWAKE Resident awake all or most of time (i.e., naps no more than one hour
device that does not leak urine or stool] per time period) in the:
Evening c.
Morning a.
1. USUALLY CONTINENT—BLADDER, incontinent episodes once a week or less;
BOWEL, less than weekly Afternoon b. NONE OF ABOVE d.
(If resident is comatose, skip to Section O)
2. OCCASIONALLY INCONTINENT—BLADDER, 2 or more times a week but not daily;
BOWEL, once a week N2. AVERAGE (When awake and not receiving treatments or ADL care)
TIME
3. FREQUENTLY INCONTINENT—BLADDER, tended to be incontinent daily, but some INVOLVED IN 0. Most—more than 2/3 of time 2. Little—less than 1/3 of time
control present (e.g., on day shift); BOWEL, 2-3 times a week ACTIVITIES 1. Some—from 1/3 to 2/3 of time 3. None
O1. NUMBER OF (Record the number of different medications used in the last 7 days;
4. INCONTINENT—Had inadequate control BLADDER, multiple daily episodes; MEDICA­ enter "0" if none used)
BOWEL, all (or almost all) of the time TIONS
a. BOWEL Control of bowel movement, with appliance or bowel continence O4. DAYS (Record the number of DAYS during last 7 days; enter "0" if not
CONTI­ programs, if employed RECEIVED used. Note—enter "1" for long-acting meds used less than weekly)
NENCE THE a. Antipsychotic d. Hypnotic
b. BLADDER Control of urinary bladder function (if dribbles, volume insufficient to FOLLOWING
CONTI­ soak through underpants), with appliances (e.g., foley) or continence MEDICATION b. Antianxiety
NENCE programs, if employed e. Diuretic
c. Antidepressant
H2. BOWEL Fecal impaction NONE OF ABOVE P4. DEVICES Use the following codes for last 7 days:
ELIMINATION d. e.
AND 0. Not used
PATTERN RESTRAINTS 1. Used less than daily
H3. APPLIANCES Any scheduled toileting plan a. Indwelling catheter 2. Used daily
d.
AND Bed rails
PROGRAMS Bladder retraining program b. Ostomy present i. a. — Full bed rails on all open sides of bed
External (condom) catheter NONE OF ABOVE b. — Other types of side rails used (e.g., half rail, one side)
c. j.
I2. INFECTIONS Urinary tract infection in last NONE OF ABOVE c. Trunk restraint
30 days j. m. d. Limb restraint
I3. OTHER (Include only those diseases diagnosed in the last 90 days that have a
relationship to current ADL status, cognitive status, mood or behavior status, e. Chair prevents rising
CURRENT
DIAGNOSES medical treatments, nursing monitoring, or risk of death) Q2. OVERALL Resident's overall level of self sufficiency has changed significantly as
AND ICD-9 CHANGE IN compared to status of 90 days ago (or since last assessment if less
CODES CARE NEEDS than 90 days)
a. • 0. No change 1. Improved—receives fewer 2. Deteriorated—receives
supports, needs less more support
b.
• restrictive level of care
J1. PROBLEM (Check all problems present in last 7 days ) R2. SIGNATURE OF PERSON COORDINATINGTHE ASSESSMENT:
CONDITIONS Dehydrated; output exceeds Hallucinations i.
input c.
NONE OF ABOVE p.
a. Signature of RN Assessment Coordinator (sign on above line)
J2. PAIN (Code the highest level of pain present in the last 7 days)
SYMPTOMS b. Date RN Assessment Coordinator
a. FREQUENCY with which b. INTENSITY of pain signed as complete
resident complains or 1. Mild pain
shows evidence of pain Month Day Year
2. Moderate pain
0. No pain (skip to J4)
3.Times when pain is horrible
1. Pain less than daily or excrutiating
2. Pain daily
J4. ACCIDENTS (Check all that apply) Hip fracture in last 180 days c.
Fell in past 30 days a. Other fracture in last 180 days d.
Fell in past 31-180 days b. NONE OF ABOVE e.

MDS 2.0 September, 2000


Numeric Identifier _______________________________________________________
MDS QUARTERLY ASSESSMENT FORM
E1. INDICATORS VERBAL EXPRESSIONS h. Repetitive health
(OPTIONALVERSION FOR RUG-III) OF OF DISTRESS complaints—e.g.,
DEPRES­ persistently seeks medical
A1. RESIDENT SION, a. Resident made negative
NAME attention, obsessive concern
ANXIETY, statements—e.g., "Nothing with body functions
a. (First) b. (Middle Initial) c. (Last) d. (Jr/Sr) SAD MOOD matters;Would rather be
dead;What's the use; i. Repetitive anxious
A2. ROOM Regrets having lived so complaints/concerns (non-
NUMBER long; Let me die" health related) e.g.,
persistently seeks attention/
A3. ASSESS­ a. Last day of MDS observation period b. Repetitive questions—e.g., reassurance regarding
MENT "Where do I go;What do I schedules, meals, laundry,
REFERENCE do?" clothing, relationship issues
DATE c. Repetitive verbalizations—
Month Day Year SLEEP-CYCLE ISSUES
e.g., calling out for help,
("God help me") j. Unpleasant mood in morning
b. Original (0) or corrected copy of form (enter number of correction)
k. Insomnia/change in usual
A4. DATE OF Date of reentry from most recent temporary discharge to a hospital in d. Persistent anger with self or sleep pattern
REENTRY last 90 days (or since last assessment or admission if less than 90 days) others—e.g., easily
annoyed, anger at SAD, APATHETIC, ANXIOUS
placement in nursing home; APPEARANCE
anger at care received
l. Sad, pained, worried facial
Month Day Year e. Self deprecation—e.g., "I expressions—e.g., furrowed
am nothing; I am of no use brows
A6. MEDICAL to anyone"
RECORD m. Crying, tearfulness
NO. f. Expressions of what
appear to be unrealistic n. Repetitive physical
B1. COMATOSE (Persistent vegetative state/no discernible consciousness) movements—e.g., pacing,
fears—e.g., fear of being
0. No 1.Yes (Skip to Section G) abandoned, left alone, hand wringing, restlessness,
fidgeting, picking
B2. MEMORY (Recall of what was learned or known) being with others
a. Short-term memory OK—seems/appears to recall after 5 minutes LOSS OF INTEREST
g. Recurrent statements that
0. Memory OK 1. Memory problem something terrible is about o. Withdrawal from activities of
to happen—e.g., believes interest—e.g., no interest in
b. Long-term memory OK—seems/appears to recall long past he or she is about to die, long standing activities or
0. Memory OK 1. Memory problem have a heart attack being with family/friends
B3. MEMORY/ (Check all that resident was normally able to recall during p. Reduced social interaction
RECALL last 7 days)
ABILITY Current season E2. One or more indicators of depressed, sad or anxious mood were
MOOD
a.
That he/she is in a nursing home not easily altered by attempts to "cheer up", console, or reassure
PERSIS­
Location of own room b. d. the resident over last 7 days
TENCE
Staff names/faces c. NONE OF ABOVE are recalled e. 0. No mood 1. Indicators present, 2.Indicators present,
indicators easily altered not easily altered
B4. COGNITIVE (Made decisions regarding tasks of daily life)
SKILLS FOR E4. BEHAVIORAL (A) Behavioral symptom frequency in last 7 days
DAILY 0. INDEPENDENT—decisions consistent/reasonable SYMPTOMS 0. Behavior not exhibited in last 7 days
DECISION- 1. MODIFIED INDEPENDENCE—some difficulty in new situations 1. Behavior of this type occurred 1 to 3 days in last 7 days
MAKING only 2. Behavior of this type occurred 4 to 6 days, but less than daily
2. MODERATELY IMPAIRED—decisions poor; cues/supervision 3. Behavior of this type occurred daily
required (B) Behavioral symptom alterability in last 7 days
3. SEVERELY IMPAIRED—never/rarely made decisions 0. Behavior not present OR behavior was easily altered
B5. INDICATORS (Code for behavior in the last 7 days.) [Note: Accurate assessment 1. Behavior was not easily altered (A) (B)
OF requires conversations with staff and family who have direct knowledge a. WANDERING (moved with no rational purpose, seemingly
DELIRIUM— of resident's behavior over this time]. oblivious to needs or safety)
PERIODIC 0. Behavior not present
DISOR­ b. VERBALLY ABUSIVE BEHAVIORAL SYMPTOMS (others
DERED 1. Behavior present, not of recent onset were threatened, screamed at, cursed at)
THINKING/ 2. Behavior present, over last 7 days appears different from resident's usual
AWARENESS functioning (e.g., new onset or worsening) c. PHYSICALLY ABUSIVE BEHAVIORAL SYMPTOMS (others
were hit, shoved, scratched, sexually abused)
a. EASILY DISTRACTED—(e.g., difficulty paying attention; gets
sidetracked) d. SOCIALLY INAPPROPRIATE/DISRUPTIVE BEHAVIORAL
SYMPTOMS (made disruptive sounds, noisiness, screaming,
b.PERIODS OF ALTERED PERCEPTION OR AWARENESS OF self-abusive acts, sexual behavior or disrobing in public,
SURROUNDINGS—(e.g., moves lips or talks to someone not smeared/threw food/feces, hoarding, rummaged through others'
present; believes he/she is somewhere else; confuses night and belongings)
day)
e. RESISTS CARE (resisted taking medications/ injections, ADL
c. EPISODES OF DISORGANIZED SPEECH—(e.g., speech is assistance, or eating)
incoherent, nonsensical, irrelevant, or rambling from subject to
subject; loses train of thought) G1. (A) ADL SELF-PERFORMANCE—(Code for resident's PERFORMANCE OVER ALL
SHIFTS during last 7 days—Not including setup)
d.PERIODS OF RESTLESSNESS—(e.g., fidgeting or picking at skin,
clothing, napkins, etc; frequent position changes; repetitive physical 0. INDEPENDENT—No help or oversight —OR— Help/oversight provided only 1 or 2 times
movements or calling out) during last 7 days
e. PERIODS OF LETHARGY—(e.g., sluggishness; staring into space; 1. SUPERVISION—Oversight, encouragement or cueing provided 3 or more times during
difficult to arouse; little body movement) last7 days —OR— Supervision (3 or more times) plus physical assistance provided only
1 or 2 times during last 7 days
f. MENTAL FUNCTION VARIES OVER THE COURSE OF THE
DAY—(e.g., sometimes better, sometimes worse; behaviors 2. LIMITED ASSISTANCE—Resident highly involved in activity; received physical help in
sometimes present, sometimes not) guided maneuvering of limbs or other nonweight bearing assistance 3 or more times —
C4. MAKING (Expressing information content—however able) OR—More help provided only 1 or 2 times during last 7 days
SELF 0. UNDERSTOOD
UNDER- 3. EXTENSIVE ASSISTANCE—While resident performed part of activity, over last 7-day
1. USUALLY UNDERSTOOD—difficulty finding words or finishing period, help of following type(s) provided 3 or more times:
STOOD thoughts — Weight-bearing support
2. SOMETIMES UNDERSTOOD—ability is limited to making concrete — Full staff performance during part (but not all) of last 7 days
requests
3. RARELY/NEVER UNDERSTOOD 4. TOTAL DEPENDENCE—Full staff performance of activity during entire 7 days
C6. ABILITY TO (Understanding verbal information content—however able) 8. ACTIVITY DID NOT OCCUR during entire 7 days
UNDER-
STAND 0. UNDERSTANDS (B) ADL SUPPORT PROVIDED—(Code for MOST SUPPORT PROVIDED
OTHERS 1. USUALLY UNDERSTANDS—may miss some part/intent of OVER ALL SHIFTS during last 7 days; code regardless of resident's self- (A) (B)
message performance classification)
SELF-PERF

2. SOMETIMES UNDERSTANDS—responds adequately to simple,


SUPPORT

direct communication 0. No setup or physical help from staff


3. RARELY/NEVER UNDERSTANDS 1. Setup help only
E1. INDICATORS (Code for indicators observed in last 30 days, irrespective of the 2. One person physical assist 8. ADL activity itself did not
OF assumed cause) 3. Two+ persons physical assist occur during entire 7 days
DEPRES­ 0. Indicator not exhibited in last 30 days BED
SION, 1. Indicator of this type exhibited up to five days a week a. How resident moves to and from lying position, turns side to side,
MOBILITY and positions body while in bed
ANXIETY, 2. Indicator of this type exhibited daily or almost daily (6, 7 days a week)
SAD MOOD
b. TRANSFER How resident moves between surfaces—to/from: bed, chair,
wheelchair, standing position (EXCLUDE to/from bath/toilet)
MDS 2.0 September, 2000
Resident_______________________________________________________________ Numeric Identifier _______________________________________________________

G1. (A) (B) H3. APPLIANCES Any scheduled toileting plan Indwelling catheter
a. d.
c. WALK IN AND
How resident walks between locations in his/her room PROGRAMS Bladder retraining program Ostomy present
ROOM b. i.
d. WALK IN How resident walks in corridor on unit External (condom) catheter NONE OF ABOVE
CORRIDOR c. j.
e. LOCOMO­ How resident moves between locations in his/her room and Check only those diseases that have a relationship to current ADL status, cognitive status,
TION adjacent corridor on same floor. If in wheelchair, self-sufficiency mood and behavior status, medical treatments, nursing monitoring, or risk of death. (Do not list
ON UNIT once in chair inactive diagnoses)
f. LOCOMO­ How resident moves to and returns from off unit locations (e.g., I1. DISEASES (If none apply, CHECK the NONE OF ABOVE box)
TION areas set aside for dining, activities, or treatments). If facility has MUSCULOSKELETAL Multiple sclerosis
OFF UNITonly one floor, how resident moves to and from distant areas on w.
the floor. If in wheelchair, self-sufficiency once in chair Hip fracture m. Quadriplegia z.
g. DRESSING How resident puts on, fastens, and takes off all items of street NEUROLOGICAL PSYCHIATRIC/MOOD
clothing, including donning/removing prosthesis Aphasia r. Depression ee.
h. EATING How resident eats and drinks (regardless of skill). Includes intake of Cerebral palsy s. Manic depressive (bipolar
nourishment by other means (e.g., tube feeding, total parenteral disease)
nutrition) Cerebrovascular accident ff.
(stroke) t.OTHER
i. TOILET USE How resident uses the toilet room (or commode, bedpan, urinal);
transfer on/off toilet, cleanses, changes pad, manages ostomy or Hemiplegia/Hemiparesis v. NONE OF ABOVE rr.
catheter, adjusts clothes I2. INFECTIONS (If none apply, CHECK the NONE OF ABOVE box)
j. PERSONAL How resident maintains personal hygiene, including combing hair, Antibiotic resistant infection Septicemia g.
HYGIENE brushing teeth, shaving, applying makeup, washing/drying face, (e.g., Methicillin resistant
hands, and perineum (EXCLUDE baths and showers) a. Sexually transmitted diseases h.
staph)
Tuberculosis
G2. BATHING How resident takes full-body bath/shower, sponge bath, and Clostridium difficile (c. diff.) b.
i.
transfers in/out of tub/shower (EXCLUDE washing of back and hair.) Urinary tract infection in last 30
Code for most dependent in self-performance. Conjunctivitis c. days j.
(A) BATHING SELF PERFORMANCE codes appear below
(A) HIV infection d. Viral hepatitis k.
0. Independent—No help provided Pneumonia e. Wound infection l.
1. Supervision—Oversight help only
Respiratory infection f. NONE OF ABOVE m.
2. Physical help limited to transfer only
I3. OTHER (Include only those diseases diagnosed in the last 90 days that have a
3. Physical help in part of bathing activity CURRENT relationship to current ADL status, cognitive status, mood or behavior status,
4. Total dependence DIAGNOSES medical treatments, nursing monitoring, or risk of death)
AND ICD-9
8. Activity itself did not occur during entire 7 days CODES a. •
G3. TEST FOR (Code for ability during test in the last 7 days)
BALANCE 0. Maintained position as required in test b. •
J1. PROBLEM (Check all problems present in last 7 days unless other time frame is
(see training 1. Unsteady, but able to rebalance self without physical support
manual) 2. Partial physical support during test; CONDITIONS indicated)
or stands (sits) but does not follow directions for test INDICATORS OF FLUID OTHER
3. Not able to attempt test without physical help STATUS Delusions e.
a. Balance while standing
Weight gain or loss of 3 or Edema g.
b. Balance while sitting—position, trunk control more pounds within a 7 day Fever h.
G4. FUNCTIONAL (Code for limitations during last 7 days that interfered with daily functions or period a.
LIMITATION placed residents at risk of injury) Hallucinations i.
IN RANGE OF (A) RANGE OF MOTION (B) VOLUNTARY MOVEMENT Inability to lie flat due to Internal bleeding j.
MOTION 0. No limitation 0. No loss shortness of breath b.
1. Limitation on one side 1. Partial loss Recurrent lung aspirations in
2. Limitation on both sides 2. Full loss (A) (B) Dehydrated; output exceeds last 90 days k.
input c.
a. Neck Shortness of breath l.
b. Arm—Including shoulder or elbow Insufficient fluid; did NOT Unsteady gait n.
consume all/almost all liquids
c. Hand—Including wrist or fingers provided during last 3 days d. Vomiting o.
d. Leg—Including hip or knee NONE OF ABOVE p.
e. Foot—Including ankle or toes J2. PAIN (Code the highest level of pain present in the last 7 days)
f. Other limitation or loss SYMPTOMS
a. FREQUENCY with which b. INTENSITY of pain
G6. MODES OF (Check all that apply during last 7 days) resident complains or 1. Mild pain
TRANSFER Bedfast all or most of time shows evidence of pain
NONE OF ABOVE 2. Moderate pain
a. f. 0. No pain (skip to J4)
Bed rails used for bed mobility 3.Times when pain is horrible
or transfer b. 1. Pain less than daily or excrutiating
G7. TASK Some or all of ADL activities were broken into subtasks during last 7 2. Pain daily
SEGMENTA­ days so that resident could perform them J4. ACCIDENTS (Check all that apply)
TION 0. No 1.Yes Hip fracture in last 180 days c.
Fell in past 30 days a. Other fracture in last 180 days
H1. CONTINENCE SELF-CONTROL CATEGORIES d.
(Code for resident's PERFORMANCE OVER ALL SHIFTS) Fell in past 31-180 days b. NONE OF ABOVE e.
J5. STABILITY Conditions/diseases make resident's cognitive, ADL, mood or behavior
0. CONTINENT—Complete control [includes use of indwelling urinary catheter or ostomy OF status unstable—(fluctuating, precarious, or deteriorating) a.
device that does not leak urine or stool] CONDITIONS
Resident experiencing an acute episode or a flare-up of a recurrent or
1. USUALLY CONTINENT—BLADDER, incontinent episodes once a week or less; chronic problem b.
BOWEL, less than weekly c.
End-stage disease, 6 or fewer months to live
2. OCCASIONALLY INCONTINENT—BLADDER, 2 or more times a week but not daily; NONE OF ABOVE d.
BOWEL, once a week K1. ORAL Chewing problem a.
PROBLEMS Swallowing problem b.
3. FREQUENTLY INCONTINENT—BLADDER, tended to be incontinent daily, but some
control present (e.g., on day shift); BOWEL, 2-3 times a week NONE OF ABOVE d.

4. INCONTINENT—Had inadequate control BLADDER, multiple daily episodes; K2. HEIGHT Record (a.) height in inches and (b.) weight in pounds.Base weight on most
AND recent measure in last 30 days; measure weight consistently in accord with
BOWEL, all (or almost all) of the time
WEIGHT standard facility practice—e.g., in a.m.after voiding, before meal, with shoes
a. BOWEL Control of bowel movement, with appliance or bowel continence off, and in nightclothes
CONTI­ programs, if employed
NENCE a. HT (in.) b. WT (lb.)
K3. WEIGHT a.Weight loss—5 % or more in last 30 days; or 10 % or more in last
b. BLADDER Control of urinary bladder function (if dribbles, volume insufficient to
CONTI­ soak through underpants), with appliances (e.g., foley) or continence CHANGE 180 days
NENCE programs, if employed 0. No 1.Yes
H2. BOWEL Diarrhea c. NONE OF ABOVE e.
b.Weight gain—5 % or more in last 30 days; or 10 % or more in last
ELIMINATION 180 days
PATTERN Fecal impaction d. 0. No 1.Yes

MDS 2.0 September, 2000


Resident_______________________________________________________________ Numeric Identifier _______________________________________________________

K5. NUTRI­ (Check all that apply in last 7 days) P1. SPECIAL a. SPECIAL CARE—Check treatments or programs received during
TIONAL TREAT- the last 14 days
Parenteral/IV a. On a planned weight change MENTS,
APPROACH­ program
ES h. PROCE­ TREATMENTS
Feeding tube b. Ventilator or respirator l.
NONE OF ABOVE DURES, AND
i.
PROGRAMS Chemotherapy a. PROGRAMS

at Stage
Number
M1. ULCERS (Record the number of ulcers at each ulcer stage—regardless of Dialysis
cause. If none present at a stage, record "0" (zero). Code all that apply b. Alcohol/drug treatment
(Due to any during last 7 days. Code 9 = 9 or more.) [Requires full body exam.] IV medication c.
program m.
cause) Alzheimer's/dementia special
a. Stage 1. A persistent area of skin redness (without a break in the Intake/output d.
care unit n.
skin) that does not disappear when pressure is relieved. Monitoring acute medical
e. Hospice care o.
b. Stage 2. A partial thickness loss of skin layers that presents condition
Pediatric unit p.
clinically as an abrasion, blister, or shallow crater. Ostomy care f.
Respite care q.
c. Stage 3. A full thickness
12 of skin is lost, exposing the subcutaneous Oxygen therapy g.
tissues - presents as a deep crater with or without Training in skills required to
undermining adjacent tissue. Radiation h. return to the community (e.g.,
Suctioning i. taking medications, house r.
d. Stage 4. A full thickness of skin and subcutaneous
12 tissue is lost, work, shopping, transportation,
exposing muscle or bone. Tracheostomy care j. ADLs)
M2. TYPE OF (For each type of ulcer, code for the highest stage in the last 7 days Transfusions k. NONE OF ABOVE s.
ULCER using scale in item M1—i.e., 0=none; stages 1, 2, 3, 4)
b.THERAPIES - Record the number of days and total minutes each of
a. Pressure ulcer—any lesion caused by pressure resulting in damage the following therapies was administered (for at least 15 minutes a day)
of underlying tissue in the last 7 calendar days (Enter 0 if none or less than 15 min. daily)
[Note—count only post admission therapies]
b. Stasis ulcer—open lesion caused by poor circulation in the lower
extremities (A) = # of days administered for 15 minutes or more DAYS MIN
(B) = total # of minutes provided in last 7 days (A) (B)
M4. OTHER SKIN (Check all that apply during last 7 days)
PROBLEMS Abrasions, bruises a. Speech - language pathology and audiology services
a.
OR LESIONS b. Occupational therapy
PRESENT Burns (second or third degree) b.
Open lesions other than ulcers, rashes, cuts (e.g., cancer lesions) c. c. Physical therapy
Rashes—e.g., intertrigo, eczema, drug rash, heat rash, herpes zoster d.
d. Respiratory therapy
Skin desensitized to pain or pressure e.
Skin tears or cuts (other than surgery) f. e. Psychological therapy (by any licensed mental
health professional)
Surgical wounds g.
P3. NURSING Record the NUMBER OF DAYS each of the following rehabilitation or
NONE OF ABOVE h. REHABILITA­ restorative techniques or practices was provided to the resident for
M5. SKIN (Check all that apply during last 7 days) TION/ more than or equal to 15 minutes per day in the last 7 days
TREAT- Pressure relieving device(s) for chair RESTOR­ (Enter 0 if none or less than 15 min. daily.)
a.
MENTS ATIVE CARE a. Range of motion (passive) f. Walking
Pressure relieving device(s) for bed b.
b. Range of motion (active) g. Dressing or grooming
Turning/repositioning program c.
c. Splint or brace assistance
Nutrition or hydration intervention to manage skin problems d. h. Eating or swallowing
Ulcer care TRAINING AND SKILL
e. PRACTICE IN: i. Amputation/prosthesis care
Surgical wound care f. j. Communication
d. Bed mobility
Application of dressings (with or without topical medications) other than e. Transfer k. Other
to feet g.
P4. DEVICES Use the following codes for last 7 days:
Application of ointments/medications (other than to feet) h.
AND 0. Not used
Other preventative or protective skin care (other than to feet) i. RESTRAINTS 1. Used less than daily
2. Used daily
NONE OF ABOVE j.
Bed rails
M6. FOOT (Check all that apply during last 7 days)
PROBLEMS Resident has one or more foot problems—e.g., corns, callouses, a. — Full bed rails on all open sides of bed
AND CARE bunions, hammer toes, overlapping toes, pain, structural problems b. — Other types of side rails used (e.g., half rail, one side)
a.
Infection of the foot—e.g., cellulitis, purulent drainage c. Trunk restraint
b.
Open lesions on the foot c.
d. Limb restraint
Nails/calluses trimmed during last 90 days e. Chair prevents rising
d.
Received preventative or protective foot care (e.g., used special shoes, P7. PHYSICIAN In the LAST 14 DAYS (or since admission if less than 14 days in
inserts, pads, toe separators) e. VISITS facility) how many days has the physician (or authorized assistant or
practitioner) examined the resident? (Enter 0 if none)
Application of dressings (with or without topical medications) f.
P8. PHYSICIAN In the LAST 14 DAYS (or since admission if less than 14 days in
NONE OF ABOVE g. ORDERS facility) how many days has the physician (or authorized assistant or
(Check appropriate time periods over last 7 days) practitioner) changed the resident's orders? Do not include order
N1. TIME renewals without change. (Enter 0 if none)
AWAKE Resident awake all or most of time (i.e., naps no more than one hour
per time period) in the:
Evening Q2. OVERALL Resident's overall level of self sufficiency has changed significantly as
Morning c. CHANGE IN compared to status of 90 days ago (or since last assessment if less
a.
Afternoon b. NONE OF ABOVE d. CARE NEEDS than 90 days)
0. No change 1. Improved—receives fewer 2. Deteriorated—receives
(If resident is comatose, skip to Section O) supports, needs less more support
restrictive level of care
N2. AVERAGE (When awake and not receiving treatments or ADL care)
TIME R2. SIGNATURE OF PERSON COORDINATINGTHE ASSESSMENT:
INVOLVED IN 0. Most—more than 2/3 of time 2. Little—less than 1/3 of time
ACTIVITIES 1. Some—from 1/3 to 2/3 of time 3. None
O1. NUMBER OF (Record the number of different medications used in the last 7 days; a. Signature of RN Assessment Coordinator (sign on above line)
MEDICA­ enter "0" if none used)
TIONS b. Date RN Assessment Coordinator
signed as complete
O3. INJECTIONS (Record the number of DAYS injections of any type received during Month Day Year
the last 7 days; enter "0" if none used)
O4. DAYS (Record the number of DAYS during last 7 days; enter "0" if not
RECEIVED used. Note—enter "1" for long-acting meds used less than weekly)
THE a. Antipsychotic
FOLLOWING d. Hypnotic
MEDICATION b. Antianxiety
e. Diuretic
c. Antidepressant

MDS 2.0 September, 2000


MDS QUARTERLY ASSESSMENT FORM Numeric Identifier _______________________________________________________
(OPTIONAL VERSION FOR RUG-III 1997 Update)
E1. INDICATORS VERBAL EXPRESSIONS h. Repetitive health
A1. RESIDENT OF OF DISTRESS complaints—e.g.,
NAME DEPRES­ persistently seeks medical
a. (First) b. (Middle Initial) c. (Last) d. (Jr/Sr) SION, a. Resident made negative attention, obsessive concern
ANXIETY, statements—e.g., "Nothing with body functions
A2. ROOM SAD MOOD matters;Would rather be
NUMBER dead;What's the use; i. Repetitive anxious
Regrets having lived so complaints/concerns (non-
A3. ASSESS­ a. Last day of MDS observation period long; Let me die" health related) e.g.,
MENT persistently seeks attention/
b. Repetitive questions—e.g., reassurance regarding
REFERENCE "Where do I go;What do I
DATE schedules, meals, laundry,
Month Day Year do?" clothing, relationship issues
b. Original (0) or corrected copy of form (enter number of correction) c. Repetitive verbalizations— SLEEP-CYCLE ISSUES
e.g., calling out for help,
("God help me") j. Unpleasant mood in morning
A4a. DATE OF Date of reentry from most recent temporary discharge to a hospital in
REENTRY last 90 days (or since last assessment or admission if less than 90 days) k. Insomnia/change in usual
d. Persistent anger with self or sleep pattern
others—e.g., easily
annoyed, anger at SAD, APATHETIC, ANXIOUS
placement in nursing home; APPEARANCE
Month Day Year anger at care received
l. Sad, pained, worried facial
A6. MEDICAL e. Self deprecation—e.g., "I expressions—e.g., furrowed
RECORD am nothing; I am of no use brows
NO. to anyone"
m. Crying, tearfulness
B1. COMATOSE (Persistent vegetative state/no discernible consciousness) f. Expressions of what
0. No 1.Yes (Skip to Section G) appear to be unrealistic n. Repetitive physical
fears—e.g., fear of being movements—e.g., pacing,
B2. MEMORY (Recall of what was learned or known) hand wringing, restlessness,
abandoned, left alone,
a. Short-term memory OK—seems/appears to recall after 5 minutes being with others fidgeting, picking
0. Memory OK 1. Memory problem LOSS OF INTEREST
g. Recurrent statements that
b. Long-term memory OK—seems/appears to recall long past something terrible is about o. Withdrawal from activities of
0. Memory OK 1. Memory problem to happen—e.g., believes interest—e.g., no interest in
B3. MEMORY/ (Check all that resident was normally able to recall during he or she is about to die, long standing activities or
RECALL last 7 days) have a heart attack being with family/friends
ABILITY Current season a. p. Reduced social interaction
That he/she is in a nursing home d. One or more indicators of depressed, sad or anxious mood were
Location of own room b. E2. MOOD
not easily altered by attempts to "cheer up", console, or reassure
PERSIS­
Staff names/faces c. NONE OF ABOVE are recalled e. the resident over last 7 days
TENCE
B4. COGNITIVE (Made decisions regarding tasks of daily life) 0. No mood 1. Indicators present, 2.Indicators present,
SKILLS FOR indicators easily altered not easily altered
DAILY 0. INDEPENDENT—decisions consistent/reasonable E4. BEHAVIORAL (A) Behavioral symptom frequency in last 7 days
DECISION- 1. MODIFIED INDEPENDENCE—some difficulty in new situations SYMPTOMS 0. Behavior not exhibited in last 7 days
MAKING only 1. Behavior of this type occurred 1 to 3 days in last 7 days
2. MODERATELY IMPAIRED—decisions poor; cues/supervision 2. Behavior of this type occurred 4 to 6 days, but less than daily
required 3. Behavior of this type occurred daily
3. SEVERELY IMPAIRED—never/rarely made decisions
B5. INDICATORS (Code for behavior in the last 7 days.) [Note: Accurate assessment (B) Behavioral symptom alterability in last 7 days
OF requires conversations with staff and family who have direct knowledge 0. Behavior not present OR behavior was easily altered
1. Behavior was not easily altered (A) (B)
DELIRIUM— of resident's behavior over this time].
PERIODIC a. WANDERING (moved with no rational purpose, seemingly
DISOR­ 0. Behavior not present oblivious to needs or safety)
DERED 1. Behavior present, not of recent onset
THINKING/ 2. Behavior present, over last 7 days appears different from resident's usual b. VERBALLY ABUSIVE BEHAVIORAL SYMPTOMS (others
AWARENESS functioning (e.g., new onset or worsening) were threatened, screamed at, cursed at)
a. EASILY DISTRACTED—(e.g., difficulty paying attention; gets c. PHYSICALLY ABUSIVE BEHAVIORAL SYMPTOMS (others
sidetracked) were hit, shoved, scratched, sexually abused)
b.PERIODS OF ALTERED PERCEPTION OR AWARENESS OF d. SOCIALLY INAPPROPRIATE/DISRUPTIVE BEHAVIORAL
SURROUNDINGS—(e.g., moves lips or talks to someone not SYMPTOMS (made disruptive sounds, noisiness, screaming,
present; believes he/she is somewhere else; confuses night and self-abusive acts, sexual behavior or disrobing in public,
day) smeared/threw food/feces, hoarding, rummaged through others'
belongings)
c. EPISODES OF DISORGANIZED SPEECH—(e.g., speech is
incoherent, nonsensical, irrelevant, or rambling from subject to e. RESISTS CARE (resisted taking medications/ injections, ADL
subject; loses train of thought) assistance, or eating)
d.PERIODS OF RESTLESSNESS—(e.g., fidgeting or picking at skin, G1. (A) ADL SELF-PERFORMANCE—(Code for resident's PERFORMANCE OVER ALL
clothing, napkins, etc; frequent position changes; repetitive physical SHIFTS during last 7 days—Not including setup)
movements or calling out)
0. INDEPENDENT—No help or oversight —OR— Help/oversight provided only 1 or 2 times
e. PERIODS OF LETHARGY—(e.g., sluggishness; staring into space; during last 7 days
difficult to arouse; little body movement)
1. SUPERVISION—Oversight, encouragement or cueing provided 3 or more times during
f. MENTAL FUNCTION VARIES OVER THE COURSE OF THE last7 days —OR— Supervision (3 or more times) plus physical assistance provided only
DAY—(e.g., sometimes better, sometimes worse; behaviors 1 or 2 times during last 7 days
sometimes present, sometimes not)
C4. MAKING (Expressing information content—however able) 2. LIMITED ASSISTANCE—Resident highly involved in activity; received physical help in
SELF guided maneuvering of limbs or other nonweight bearing assistance 3 or more times —
0. UNDERSTOOD OR—More help provided only 1 or 2 times during last 7 days
UNDER-1. USUALLY UNDERSTOOD—difficulty finding words or finishing
STOOD thoughts 3. EXTENSIVE ASSISTANCE—While resident performed part of activity, over last 7-day
2. SOMETIMES UNDERSTOOD—ability is limited to making concrete period, help of following type(s) provided 3 or more times:
requests — Weight-bearing support
3. RARELY/NEVER UNDERSTOOD — Full staff performance during part (but not all) of last 7 days
C6. ABILITY TO (Understanding verbal information content—however able) 4. TOTAL DEPENDENCE—Full staff performance of activity during entire 7 days
UNDER-
STAND 0. UNDERSTANDS 8. ACTIVITY DID NOT OCCUR during entire 7 days
OTHERS 1. USUALLY UNDERSTANDS—may miss some part/intent of (B) ADL SUPPORT PROVIDED—(Code for MOST SUPPORT PROVIDED
message
2. SOMETIMES UNDERSTANDS—responds adequately to simple, OVER ALL SHIFTS during last 7 days; code regardless of resident's self- (A) (B)
direct communication performance classification)
SELF-PERF

3. RARELY/NEVER UNDERSTANDS
SUPPORT

0. No setup or physical help from staff


E1. INDICATORS (Code for indicators observed in last 30 days, irrespective of the 1. Setup help only
OF assumed cause) 2. One person physical assist 8. ADL activity itself did not
DEPRES­ 0. Indicator not exhibited in last 30 days 3. Two+ persons physical assist occur during entire 7 days
SION, 1. Indicator of this type exhibited up to five days a week
ANXIETY, 2. Indicator of this type exhibited daily or almost daily (6, 7 days a week) a. BED How resident moves to and from lying position, turns side to side,
SAD MOOD MOBILITY and positions body while in bed
b. TRANSFER How resident moves between surfaces—to/from: bed, chair,
wheelchair, standing position (EXCLUDE to/from bath/toilet)
MDS 2.0 September, 2000
Resident_______________________________________________________________ Numeric Identifier _______________________________________________________

G1. (A) (B) H3. APPLIANCES Any scheduled toileting plan Indwelling catheter
a. d.
c. WALK IN AND
How resident walks between locations in his/her room PROGRAMS Bladder retraining program Ostomy present
ROOM b. i.
d. WALK IN How resident walks in corridor on unit External (condom) catheter NONE OF ABOVE
CORRIDOR c. j.
e. LOCOMO­ How resident moves between locations in his/her room and Check only those diseases that have a relationship to current ADL status, cognitive status,
TION adjacent corridor on same floor. If in wheelchair, self-sufficiency mood and behavior status, medical treatments, nursing monitoring, or risk of death. (Do not list
ON UNIT once in chair inactive diagnoses)
f. LOCOMO­ How resident moves to and returns from off unit locations (e.g., I1. DISEASES (If none apply, CHECK the NONE OF ABOVE box)
TION areas set aside for dining, activities, or treatments). If facility has ENDOCRINE/METABOLIC/ Hemiplegia/Hemiparesis v.
OFF UNITonly one floor, how resident moves to and from distant areas on NUTRITIONAL
the floor. If in wheelchair, self-sufficiency once in chair Multiple sclerosis w.
Diabetes mellitus a. Quadriplegia
g. DRESSING How resident puts on, fastens, and takes off all items of street z.
clothing, including donning/removing prosthesis MUSCULOSKELETAL PSYCHIATRIC/MOOD
h. EATING How resident eats and drinks (regardless of skill). Includes intake of Hip fracture m. Depression
nourishment by other means (e.g., tube feeding, total parenteral ee.
NEUROLOGICAL
nutrition) Manic depressive (bipolar
Aphasia r. disease) ff.
i. TOILET USE How resident uses the toilet room (or commode, bedpan, urinal);
transfer on/off toilet, cleanses, changes pad, manages ostomy or Cerebral palsy s. OTHER
catheter, adjusts clothes Cerebrovascular accident NONE OF ABOVE rr.
j. PERSONAL How resident maintains personal hygiene, including combing hair, (stroke) t.
HYGIENE brushing teeth, shaving, applying makeup, washing/drying face, I2. INFECTIONS (If none apply, CHECK the NONE OF ABOVE box)
hands, and perineum (EXCLUDE baths and showers)
Antibiotic resistant infection Septicemia g.
G2. BATHING How resident takes full-body bath/shower, sponge bath, and (e.g., Methicillin resistant
transfers in/out of tub/shower (EXCLUDE washing of back and hair.) a. Sexually transmitted diseases h.
Code for most dependent in self-performance. staph)
Tuberculosis i.
(A) BATHING SELF PERFORMANCE codes appear below Clostridium difficile (c. diff.) b.
(A) Urinary tract infection in last 30
0. Independent—No help provided Conjunctivitis c. days j.
1. Supervision—Oversight help only HIV infection d. Viral hepatitis k.
2. Physical help limited to transfer only Pneumonia e. Wound infection l.
3. Physical help in part of bathing activity Respiratory infection NONE OF ABOVE
f. m.
4. Total dependence (Include only those diseases diagnosed in the last 90 days that have a
I3. OTHER
8. Activity itself did not occur during entire 7 days CURRENT relationship to current ADL status, cognitive status, mood or behavior status,
(Code for ability during test in the last 7 days) DIAGNOSES medical treatments, nursing monitoring, or risk of death)
G3. TEST FOR AND ICD-9
BALANCE 0. Maintained position as required in test CODES a. •
(see training 1. Unsteady, but able to rebalance self without physical support
manual) 2. Partial physical support during test; b. •
or stands (sits) but does not follow directions for test
3. Not able to attempt test without physical help J1. PROBLEM (Check all problems present in last 7 days unless other time frame is
CONDITIONS indicated)
a. Balance while standing OTHER
INDICATORS OF FLUID
b. Balance while sitting—position, trunk control STATUS Delusions e.
G4. FUNCTIONAL (Code for limitations during last 7 days that interfered with daily functions or
LIMITATION placed residents at risk of injury) Weight gain or loss of 3 or Edema g.
IN RANGE OF (A) RANGE OF MOTION (B) VOLUNTARY MOVEMENT more pounds within a 7 day Fever h.
MOTION 0. No limitation 0. No loss period a.
Hallucinations i.
1. Limitation on one side 1. Partial loss Inability to lie flat due to
2. Limitation on both sides 2. Full loss (A) (B) Internal bleeding j.
shortness of breath b.
a. Neck Recurrent lung aspirations in
b. Arm—Including shoulder or elbow Dehydrated; output exceeds last 90 days k.
input c.
c. Hand—Including wrist or fingers Shortness of breath l.
Insufficient fluid; did NOT Unsteady gait
d. Leg—Including hip or knee consume all/almost all liquids n.
e. Foot—Including ankle or toes provided during last 3 days d. Vomiting o.
f. Other limitation or loss NONE OF ABOVE p.
G6. MODES OF (Check all that apply during last 7 days) J2. PAIN (Code the highest level of pain present in the last 7 days)
TRANSFER Bedfast all or most of time SYMPTOMS
NONE OF ABOVE a. FREQUENCY with which b. INTENSITY of pain
a. f. resident complains or
Bed rails used for bed mobility 1. Mild pain
shows evidence of pain
or transfer b. 2. Moderate pain
G7. TASK Some or all of ADL activities were broken into subtasks during last 7 0. No pain (skip to J4)
3.Times when pain is horrible
SEGMENTA­ days so that resident could perform them 1. Pain less than daily or excrutiating
TION 0. No 1.Yes 2. Pain daily
H1. CONTINENCE SELF-CONTROL CATEGORIES
(Code for resident's PERFORMANCE OVER ALL SHIFTS) J4. ACCIDENTS (Check all that apply) Hip fracture in last 180 days c.
Fell in past 30 days a. Other fracture in last 180 days d.
0. CONTINENT—Complete control [includes use of indwelling urinary catheter or ostomy Fell in past 31-180 days
device that does not leak urine or stool] b.NONE OF ABOVE e.
J5. STABILITY Conditions/diseases make resident's cognitive, ADL, mood or behavior
1. USUALLY CONTINENT—BLADDER, incontinent episodes once a week or less; OF status unstable—(fluctuating, precarious, or deteriorating) a.
BOWEL, less than weekly CONDITIONS
Resident experiencing an acute episode or a flare-up of a recurrent or
chronic problem b.
2. OCCASIONALLY INCONTINENT—BLADDER, 2 or more times a week but not daily;
BOWEL, once a week End-stage disease, 6 or fewer months to live c.

3. FREQUENTLY INCONTINENT—BLADDER, tended to be incontinent daily, but some NONE OF ABOVE d.


control present (e.g., on day shift); BOWEL, 2-3 times a week K1. ORAL Chewing problem a.
PROBLEMS Swallowing problem b.
4. INCONTINENT—Had inadequate control BLADDER, multiple daily episodes;
BOWEL, all (or almost all) of the time NONE OF ABOVE d.
a. BOWEL Control of bowel movement, with appliance or bowel continence
K2. HEIGHT Record (a.) height in inches and (b.) weight in pounds.Base weight on most
CONTI­ AND recent measure in last 30 days; measure weight consistently in accord with
programs, if employed WEIGHT standard facility practice—e.g., in a.m.after voiding, before meal, with shoes
NENCE
off, and in nightclothes
b. BLADDER Control of urinary bladder function (if dribbles, volume insufficient to
CONTI­ soak through underpants), with appliances (e.g., foley) or continence a. HT (in.) b. WT (lb.)
NENCE programs, if employed K3. WEIGHT a.Weight loss—5 % or more in last 30 days; or 10 % or more in last
H2. BOWEL Diarrhea c. NONE OF ABOVE e. CHANGE 180 days
ELIMINATION 0. No 1.Yes
PATTERN Fecal impaction d. b.Weight gain—5 % or more in last 30 days; or 10 % or more in last
180 days
0. No 1.Yes
MDS 2.0 September, 2000
Resident_______________________________________________________________ Numeric Identifier _______________________________________________________

K5. NUTRI­ (Check all that apply in last 7 days) P1. SPECIAL a. SPECIAL CARE—Check treatments or programs received during
TIONAL TREAT- the last 14 days
Parenteral/IV a. On a planned weight change
APPROACH­ program MENTS,
ES h. PROCE­
Feeding tube b. TREATMENTS Ventilator or respirator
DURES, AND l.
NONE OF ABOVE i.
PROGRAMS Chemotherapy a. PROGRAMS
K6. PARENTERAL (Skip to Section M if neither 5a nor 5b is checked)
OR ENTERAL a. Code the proportion of total calories the resident received through Dialysis b. Alcohol/drug treatment
INTAKE parenteral or tube feedings in the last 7 days IV medication c.
program m.
0. None 3. 51% to 75% Intake/output Alzheimer's/dementia special
1. 1% to 25% 4. 76% to 100% d.
care unit n.
2. 26% to 50% Monitoring acute medical
e. Hospice care o.
condition
b. Code the average fluid intake per day by IV or tube in last 7 days Pediatric unit p.
0. None 3. 1001 to 1500 cc/day Ostomy care f.
1. 1 to 500 cc/day 4. 1501 to 2000 cc/day Respite care q.
2. 501 to 1000 cc/day 5. 2001 or more cc/day Oxygen therapy g.
Training in skills required to
Radiation

at Stage
Number
M1. ULCERS (Record the number of ulcers at each ulcer stage—regardless of h. return to the community (e.g.,
cause. If none present at a stage, record "0" (zero). Code all that apply Suctioning i. taking medications, house r.
(Due to any during last 7 days. Code 9 = 9 or more.) [Requires full body exam.] work, shopping, transportation,
cause) Tracheostomy care j. ADLs)
a. Stage 1. A persistent area of skin redness (without a break in the Transfusions NONE OF ABOVE
skin) that does not disappear when pressure is relieved. k. s.
b.THERAPIES - Record the number of days and total minutes each of
b. Stage 2. A partial thickness loss of skin layers that presents the following therapies was administered (for at least 15 minutes a day)
clinically as an abrasion, blister, or shallow crater. in the last 7 calendar days (Enter 0 if none or less than 15 min. daily)
c. Stage 3. A full thickness
12 of skin is lost, exposing the subcutaneous [Note—count only post admission therapies]
tissues - presents as a deep crater with or without (A) = # of days administered for 15 minutes or more DAYS MIN
undermining adjacent tissue. (B) = total # of minutes provided in last 7 days (A) (B)

d. Stage 4. A full thickness of skin and subcutaneous


12 tissue is lost, a. Speech - language pathology and audiology services
exposing muscle or bone.
b. Occupational therapy
M2. TYPE OF (For each type of ulcer, code for the highest stage in the last 7 days
ULCER using scale in item M1—i.e., 0=none; stages 1, 2, 3, 4) c. Physical therapy
a. Pressure ulcer—any lesion caused by pressure resulting in damage d. Respiratory therapy
of underlying tissue
e. Psychological therapy (by any licensed mental
b. Stasis ulcer—open lesion caused by poor circulation in the lower health professional)
extremities
P3. NURSING Record the NUMBER OF DAYS each of the following rehabilitation or
M4. OTHER SKIN Abrasions, bruises a. REHABILITA­ restorative techniques or practices was provided to the resident for
PROBLEMS Burns (second or third degree) b. TION/ more than or equal to 15 minutes per day in the last 7 days
OR LESIONS RESTOR­ (Enter 0 if none or less than 15 min. daily.)
PRESENT Open lesions other than ulcers, rashes, cuts (e.g., cancer lesions) c. ATIVE CARE a. Range of motion (passive) f. Walking
Rashes—e.g., intertrigo, eczema, drug rash, heat rash, herpes zoster d.
(Check all b. Range of motion (active) g. Dressing or grooming
that apply Skin desensitized to pain or pressure e.
c. Splint or brace assistance
during last 7 Skin tears or cuts (other than surgery) f. h. Eating or swallowing
days) TRAINING AND SKILL
Surgical wounds g. PRACTICE IN: i. Amputation/prosthesis care
NONE OF ABOVE h. d. Bed mobility j. Communication
M5. SKIN Pressure relieving device(s) for chair a. e. Transfer k. Other
TREAT- Pressure relieving device(s) for bed
MENTS b. P4. DEVICES Use the following codes for last 7 days:
Turning/repositioning program c. AND 0. Not used
(Check all Nutrition or hydration intervention to manage skin problems RESTRAINTS 1. Used less than daily
d. 2. Used daily
that apply Ulcer care
during last 7 e. Bed rails
days) Surgical wound care f. a. — Full bed rails on all open sides of bed
Application of dressings (with or without topical medications) other than b. — Other types of side rails used (e.g., half rail, one side)
to feet g.
c. Trunk restraint
Application of ointments/medications (other than to feet) h.
d. Limb restraint
Other preventative or protective skin care (other than to feet) i.
e. Chair prevents rising
NONE OF ABOVE j.
P7. PHYSICIAN In the LAST 14 DAYS (or since admission if less than 14 days in
M6. FOOT Resident has one or more foot problems—e.g., corns, callouses, VISITS facility) how many days has the physician (or authorized assistant or
PROBLEMS bunions, hammer toes, overlapping toes, pain, structural problems a. practitioner) examined the resident? (Enter 0 if none)
AND CARE Infection of the foot—e.g., cellulitis, purulent drainage b. P8. PHYSICIAN In the LAST 14 DAYS (or since admission if less than 14 days in
(Check all Open lesions on the foot c. ORDERS facility) how many days has the physician (or authorized assistant or
that apply practitioner) changed the resident's orders? Do not include order
Nails/calluses trimmed during last 90 days d.
during last 7 renewals without change. (Enter 0 if none)
days) Received preventative or protective foot care (e.g., used special shoes, e. Q2. OVERALL Resident's overall level of self sufficiency has changed significantly as
inserts, pads, toe separators) CHANGE IN compared to status of 90 days ago (or since last assessment if less
Application of dressings (with or without topical medications)
f. CARE NEEDS than 90 days)
0. No change 1. Improved—receives fewer 2. Deteriorated—receives
NONE OF ABOVE g. supports, needs less more support
N1. TIME (Check appropriate time periods over last 7 days) restrictive level of care
AWAKE Resident awake all or most of time (i.e., naps no more than one hour R2. SIGNATURE OF PERSON COORDINATINGTHE ASSESSMENT:
per time period) in the:
Evening c.
Morning a.
Afternoon b. NONE OF ABOVE d. a. Signature of RN Assessment Coordinator (sign on above line)
(If resident is comatose, skip to Section O) b. Date RN Assessment Coordinator
N2. AVERAGE (When awake and not receiving treatments or ADL care) signed as complete
TIME Month Day Year
INVOLVED IN 0. Most—more than 2/3 of time 2. Little—less than 1/3 of time
ACTIVITIES 1. Some—from 1/3 to 2/3 of time 3. None
O1. NUMBER OF (Record the number of different medications used in the last 7 days;
MEDICA­ enter "0" if none used)
TIONS
O3. INJECTIONS (Record the number of DAYS injections of any type received during
the last 7 days; enter "0" if none used)
O4. DAYS (Record the number of DAYS during last 7 days; enter "0" if not
RECEIVED used. Note—enter "1" for long-acting meds used less than weekly)
THE a. Antipsychotic
FOLLOWING d. Hypnotic
MEDICATION b. Antianxiety
e. Diuretic
c. Antidepressant MDS 2.0 September, 2000
Numeric Identifier___________________________________________________________

MINIMUM DATA SET (MDS) — VERSION 2.0


FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING
DISCHARGE TRACKING FORM [do not use for temporary visits home]
SECTION AB. DEMOGRAPHIC INFORMATION
SECTION AA. IDENTIFICATION INFORMATION [Complete only for stays less than 14 days] (AA8a=8)
1. RESIDENT 1. DATE OF Date the stay began. Note — Does not include readmission if record was
NAME * ENTRY closed at time of temporary discharge to hospital, etc. In such cases, use prior
a. (First) b. (Middle Initial) c. (Last) d. (Jr/Sr) admission date
2. GENDER * 1. Male 2. Female
3. BIRTHDATE * Month Day Year
2. ADMITTED 1. Private home/apt. with no home health services
Month Day Year FROM 2. Private home/apt. with home health services
4. RACE/ 1. American Indian/Alaskan Native 4. Hispanic (AT ENTRY) 3. Board and care/assisted living/group home
ETHNICITY * 2. Asian/Pacific Islander 5.White, not of 4. Nursing home
3. Black, not of Hispanic origin Hispanic origin 5. Acute care hospital
5. SOCIAL a. Social Security Number 6. Psychiatric hospital, MR/DD facility
SECURITY* 7. Rehabilitation hospital
AND 8. Other
MEDICARE
NUMBERS * b. Medicare number (or comparable railroad insurance number)
[C in 1st box if SECTION A. IDENTIFICATION AND BACKGROUND INFORMATION
non med. no.]
6. MEDICAL
6. FACILITY a. State No. RECORD
PROVIDER NO.
NO. *

b. Federal No.
SECTION R. ASSESSMENT/DISCHARGE INFORMATION
7. MEDICAID 3. DISCHARGE a. Code for resident disposition upon discharge
NO. ["+" if STATUS
1. Private home/apartment with no home health services
pending, "N" *
if not a 2. Private home/apartment with home health services
Medicaid 3. Board and care/assisted living
recipient] * 4. Another nursing facility
8. REASONS [Note—Other codes do not apply to this form] 5. Acute care hospital
FOR
ASSESS­ a. Primary reason for assessment 6. Psychiatric hopital, MR/DD facility
MENT 7. Rehabilitation hospital
6. Discharged—return not anticipated
7.Discharged—return anticipated 8. Deceased
8. Discharged prior to completing initial assessment 9. Other
9. Signatures of Persons who Completed a Portion of the Accompanying Assessment or
Tracking Form b. Optional State Code
4. DISCHARGE Date of death or discharge
I certify that the accompanying information accurately reflects resident assessment or tracking DATE
information for this resident and that I collected or coordinated collection of this information on the
dates specified. To the best of my knowledge, this information was collected in accordance with
applicable Medicare and Medicaid requirements. I understand that this information is used as a Month Day Year
basis for ensuring that residents receive appropriate and quality care, and as a basis for payment
from federal funds. I further understand that payment of such federal funds and continued partici­
pation in the government-funded health care programs is conditioned on the accuracy and truthful­
ness of this information, and that I may be personally subject to or may subject my organization to
substantial criminal, civil, and/or administrative penalties for submitting false information. I also
certify that I am authorized to submit this information by this facility on its behalf.
Signature and Title Sections Date

a.

b.

c.

* = Key items for computerized resident tracking

= When box blank, must enter number or letter a. = When letter in box, check if condition applies MDS 2.0 September, 2000
Numeric Identifier___________________________________________________________

MINIMUM DATA SET (MDS) — VERSION 2.0


FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING
REENTRY TRACKING FORM

SECTION AA. IDENTIFICATION INFORMATION SECTION A. IDENTIFICATION AND BACKGROUND INFORMATION


1. RESIDENT 4a. DATE OF Date of reentry
NAME * REENTRY
a. (First) b. (Middle Initial) c. (Last) d. (Jr/Sr)
2. GENDER * 1. Male 2. Female Month Day Year
4b. ADMITTED 1. Private home/apt. with no home health services
3. BIRTHDATE * FROM 2. Private home/apt. with home health services
(AT 3. Board and care/assisted living/group home
Month Day Year REENTRY) 4. Nursing home
4. RACE/ 1. American Indian/Alaskan Native 4. Hispanic 5. Acute care hospital
ETHNICITY * 2. Asian/Pacific Islander 5.White, not of 6. Psychiatric hospital, MR/DD facility
3. Black, not of Hispanic origin Hispanic origin 7. Rehabilitation hospital
8. Other
5. SOCIAL a. Social Security Number
SECURITY* 6. MEDICAL
AND RECORD
MEDICARE NO.
NUMBERS * b. Medicare number (or comparable railroad insurance number)
[C in 1st box if
non med. no.]
6. FACILITY a. State No.
PROVIDER
NO. *

b. Federal No.
7. MEDICAID
NO. ["+" if
pending, "N" *
if not a
Medicaid
recipient] *
8. REASONS [Note—Other codes do not apply to this form]
FOR a. Primary reason for assessment
ASSESS­
MENT 9. Reentry
9. Signatures of Persons who Completed a Portion of the Accompanying Assessment or
Tracking Form
I certify that the accompanying information accurately reflects resident assessment or tracking
information for this resident and that I collected or coordinated collection of this information on the
dates specified. To the best of my knowledge, this information was collected in accordance with
applicable Medicare and Medicaid requirements. I understand that this information is used as a
basis for ensuring that residents receive appropriate and quality care, and as a basis for payment
from federal funds. I further understand that payment of such federal funds and continued partici­
pation in the government-funded health care programs is conditioned on the accuracy and truthful­
ness of this information, and that I may be personally subject to or may subject my organization to
substantial criminal, civil, and/or administrative penalties for submitting false information. I also
certify that I am authorized to submit this information by this facility on its behalf.
Signature and Title Sections Date

a.

b.

c.

* = Key items for computerized resident tracking

= When box blank, must enter number or letter a. = When letter in box, check if condition applies MDS 2.0 September, 2000
MINIMUM DATA SET (MDS) — VERSION 2.0
FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING
Correction Request Form
Use this form (1) to request correction of error(s) in an MDS assessment record or error(s) in an MDS Discharge or Reentry Tracking form record that has been
previously accepted into the State MDS database, (2) to identify the inaccurate record, and (3) to attest to the correction request. A correction request can be
made to either MODIFY or INACTIVATE a record.
TO MODIFY A RECORD IN THE STATE DATABASE:
1. Complete a new corrected assessment form or tracking form. Include all the items on the form, not just those in need of correction;
2. Complete and attach this Correction Request Form to the corrected assessment or tracking form;
3. Create a new electronic record including the corrected assessment or tracking form AND the Correction Request Form; and
4. Electronically submit the new record (as in #3) to the MDS database at the State.
TO INACTIVATE A RECORD IN THE STATE DATABASE:
1. Complete this correction request form;
2. Create an electronic record of the Correction Request Form; and
3. Electronically submit this Correction Request record to the MDS database at the State.
AT3. REASONS (If AT2=1, check at least one of the following reasons; check all
PRIOR RECORD SECTION. FOR that apply,then skip to AT5)
THIS SECTION IDENTIFIES THE ASSESSMENT OR TRACKING FORM THAT IS IN MODIFICA-
ERROR. (In this section, reproduce the information EXACTLY as it appeared in TION a. Transcription error
the erroneous record, even if the information is wrong. This information is
necessary in order to locate the record in the State database.) b. Data entry error
Prior RESIDENT c . Software product error
AA1. NAME
a. (First) b. (Middle Initial) c. (Last) d. (Jr/Sr) d. Item coding error
Prior GENDER 1. Male 2. Female e. Other error
AA2. If "Other" checked, please specify: _________________________
Prior BIRTHDATE
AA3. ______________________________________________________
Month Day Year AT4. REASONS (If AT2=2, check at least one of the following reasons;check all
Prior SOCIAL a. Social Security Number FOR that apply.)
AA5. SECURITY INACTIVATION
a. Test record submitted as production record
Prior REASONS a. Primary reason for assessment b. Event did not occur
AA8. FOR ASSESSMENT (Complete Prior Date item Prior A3a ONLY)
ASSESSMENT 1. Admission assessment (required by day 14) c . Inadvertent submission of inappropriate record
2. Annual assessment
3. Significant change in status assessment d. Other reason requiring inactivation
4. Significant correction of prior full assessment If "Other" checked, please specify: _________________________
5. Quarterly review assessment
10. Significant correction of prior quarterly assessment ______________________________________________________
0. NONE OF ABOVE
DISCHARGE TRACKING (Complete Prior Date item Prior R4 ONLY)
6. Discharged—return not anticipated RN COORDINATOR ATTESTATION OF COMPLETION
7. Discharged—return anticipated AT5. ATTESTING
8. DIscharged prior ro completing initial assessment INDIVIDUAL
REENTRYTRACKING (Complete Prior Date item Prior A4a ONLY) NAME
9. Rentry a. (First) b. (Last) c. (Title)
b. Codes for assessments required for Medicare PPS or the State SIGNATURE
1. Medicare 5 day assessment
2. Medicare 30 day assessment
3. Medicare 60 day assessment AT6. ATTESTATION
4. Medicare 90 day assessment DATE
5. Medicare readmission/return assessment Month Day Year
6. Other state required assessment
7. Medicare 14 day assessment AT7. ATTESTATION OF ACCURACY AND SIGNATURES OF PERSONSWHO CORRECT A
8. Other Medicare required assessment PORTION OF ASSESSMENT ORTRACKING INFORMATION
PRIOR DATE (Complete one only) I certify that the accompanying information accurately reflects resident assessment or tracking
Complete Prior A3a if Primary Reason (Prior AA8a) equals 1, 2, 3, 4, information for this resident and that I collected or coordinated collection of this information on the
5, 10, or 0. dates specified. To the best of my knowledge, this information was collected in accordance with
Complete Prior R4 if Primary Reason (Prior AA8a) equals 6, 7, or 8. applicable Medicare and Medicaid requirements. I understand that this information is used as a
Complete Prior A4a if Primary Reason (Prior AA8a) equals 9. basis for ensuring that residents receive appropriate and quality care, and as a basis for payment
from federal funds. I further understand that payment of such federal funds and continued partici­
Prior ASSESSMENT a. Last day of MDS observation period pation in the government-funded health care programs is conditioned on the accuracy and truthful­
A3. REFERENCE ness of this information, and that I may be personally subject to or may subject my organization to
DATE substantial criminal, civil, and/or administrative penalties for submitting false information. I also
certify that I am authorized to submit this information by this facility on its behalf.
Month Day Year
Signature and Title Attestation Date
Prior DISCHARGE Date of discharge
R4. DATE
a.
Month Day Year b.
Prior DATE OF Date of reentry c.
A4a. REENTRY
d.
Month Day Year
e.

f.
CORRECTION ATTESTATION SECTION.
COMPLETE THIS SECTION TO EXPLAIN AND ATTEST TO THE CORRECT
REQUEST
AT1. ATTESTATION (Enter total number of attestations for this record, including the
SEQUENCE present one)
NUMBER
AT2. ACTION 1. MODIFY record in error (Attach and submit a COMPLETE assess­
REQUESTED ment or tracking form. Do NOT submit the corrected items ONLY.
Proceed to item AT3 below.)
2. INACTIVE record in error. (Do NOT submit an assessment or track­
ing form. Submit the correction request only. Skip to item AT4.)

MDS 2.0 September, 2000


SECTION U. MEDICATIONS—CASE MIX DEMO

List all medications that the resident received during the last 7 days. Include scheduled medications that are used
regularly, but less than weekly .

1. Medication Name and Dose Ordered. Record the name of the medication and dose ordered.
2. Route of Administration (RA). Code the Route of Administration using the following list:
1=by mouth (PO) 5=subcutaneous (SQ) 8=inhalation
2=sub lingual (SL) 6=rectal (R) 9=enteral tube
3=intramuscular (IM) 7=topical 10=other
4=intravenous (IV)
3. Frequency. Code the number of times per day, week, or month the medication is administered using the following

list:

PR=(PRN) as necessary 2D=(BID) two times daily QO=every other day

1H=(QH) every hour (includes every 12 hrs) 4W=4 times each week

2H=(Q2H) every two hours 3D=(TID) three times daily 5W=five times each week

3H=(Q3H) every three hours 4D=(QID) four times daily 6W=six times each week

4H=(Q4H) every four hours 5D=five times daily 1M=(Q month) once every month

6H=(Q6H) every six hours 1W=(Q week) once each wk 2M=twice every month

8H=(Q8H) every eight hours 2W=two times every week C=continuous

1D=(QD or HS) once daily 3W=three times every week O=other

4. Amount Administered (AA). Record the number of tablets, capsules, suppositories, or liquid (any route) per dose

administered to the resident. Code 999 for topicals, eye drops, inhalants and oral medications that need to be dissolved

in water..

5. PRN-number of days (PRN-n). If the frequency code for the medication is "PR", record the number of times during

the last 7 days each PRN medication was given. Code STAT medications as PRNs given once.

6. NDC Codes. Enter the National Drug Code for each medication given. Be sure to enter the correct NDC code for

the drug name, strength , and form. The NDC code must match the drug dispensed by the pharmacy.

1. Medication Name and Dose Ordered 2. RA 3. Freq 4. AA 5. PRN-n 6. NDC Codes

MDS 2.0 September, 2000