SP item set v1.18.11 removed items

Resident

Identifier

Date

MINIMUM DATA SET (MDS) - Version 3.0

RESIDENT ASSESSMENT AND CARE SCREENING

Swing Bed PPS (SP) Item Set

Section A		Identification Information
A0050. Type of Record
Enter Code	Add new record Continue to A0100, Facility Provider Numbers Modify existing record Continue to A0100, Facility Provider Numbers Inactivate existing record Skip to X0150, Type of Provider
A0100. Facility Provider Numbers
	National Provider Identifier (NPI): CMS Certification Number (CCN): State Provider Number:
A0200. Type of Provider.
Enter Code	Type of provider Nursing home (SNF/NF) Swing Bed
A0310. Type of Assessment
Enter Code Enter Code Enter Code Enter Code Enter Code	A. Federal OBRA Reason for Assessment Admission assessment (required by day 14) Quarterly review assessment Annual assessment Significant change in status assessment Significant correction to prior comprehensive assessment Significant correction to prior quarterly assessment 99. None of the above
	B. PPS Assessment. PPS Scheduled Assessment for a Medicare Part A Stay 01. 5-day scheduled assessment PPS Unscheduled Assessment for a Medicare Part A Stay. 08. IPA - Interim Payment Assessment Not PPS Assessment 99. None of the above
	E. Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry? No Yes
	F. Entry/discharge reporting 01. Entry tracking record Discharge assessment-return not anticipated Discharge assessment-return anticipated Death in facility tracking record 99. None of the above
	G. Type of discharge - Complete only if A0310F = 10 or 11 Planned Unplanned
A0310 continued on next page

Section A		Identification Information
A0310. Type of Assessment - Continued
Enter Code Enter Code	G1. Is this a SNF Part A Interrupted Stay? No Yes
	H. Is this a SNF Part A PPS Discharge Assessment? No Yes
A0410. Unit Certification or Licensure Designation
Enter Code	Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State. Unit is neither Medicare nor Medicaid certified but MDS data is required by the State Unit is Medicare and/or Medicaid certified
A0500. Legal Name of Resident.
	A. First name: B. Middle initial: C. Last name: D. Suffix:
A0600. Social Security and Medicare Numbers
	A. Social Security Number: _ _ B. Medicare number:
A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid recipient
A0800. Gender
Enter Code	Male Female
A0900. Birth Date
	_ _ Month Day Year
A1000. Race/Ethnicity Replaced with A1005 Ethnicity and A1010 Race
Check all that apply.
	A. American Indian or Alaska Native
	B. Asian
	C. Black or African American
	D. Hispanic or Latino
	E. Native Hawaiian or Other Pacific Islander
	F. White

Section A		Identification Information
A1100. Language Replaced with A1110 Language
Enter Code	A. Does the resident need or want an interpreter to communicate with a doctor or health care staff? 0. No Skip to A1200, Marital Status 1. Yes Specify in A1100B, Preferred language 9. Unable to determine Skip to A1200, Marital Status B. Preferred language:
A1200. Marital Status
Enter Code	Never married Married Widowed Separated Divorced
A1300. Optional Resident Items
	Medical record number: Room number: Name by which resident prefers to be addressed: Lifetime occupation(s) - put "/" between two occupations:

Most Recent Admission/Entry or Reentry into this Facility
A1600. Entry Date
	_ _ Month Day Year
A1700. Type of Entry
Enter Code	Admission Reentry
A1800. Entered From replaced with A1805 Entered From
Enter Code	Community (private home/apt., board/care, assisted living, group home) Another nursing home or swing bed Acute hospital Psychiatric hospital Inpatient rehabilitation facility ID/DD facility Hospice 09. Long Term Care Hospital (LTCH) 99. Other

A1900. Admission Date (Date this episode of care in this facility began)
	_ _ Month Day Year

Section A

A2000. Discharge Date

Identification Information

Complete only if A0310F = 10, 11, or 12

_

Month

_

Day

Year

A2100. Discharge Status Replaced with A2105 Discharge Staus

Complete only if A0310F = 10, 11, or 12

Enter Code

1. Community (private home/apt., board/care, assisted living, group home)

2. Another nursing home or swing bed

3. Acute hospital

4. Psychiatric hospital

5. Inpatient rehabilitation facility

6. ID/DD facility.

7. Hospice

8. Deceased

9. Long Term Care Hospital (LTCH)

99. Other

A2300. Assessment Reference Date

Observation end date:

_

Month

A2400. Medicare Stay

_

Day

Year

Enter Code

1. Has the resident had a Medicare-covered stay since the most recent entry?

   0. No Skip to B0100, Comatose

   1. Yes Continue to A2400B, Start date of most recent Medicare stay

2. Start date of most recent Medicare stay:

_

Month

_

Day

Year

3. End date of most recent Medicare stay - Enter dashes if stay is ongoing:

_

Month

_

Day

Year

Section B		Hearing, Speech, and Vision
B0100. Comatose
Enter Code	Persistent vegetative state/no discernible consciousness No Continue to B0200, Hearing Yes Skip to G0110, Activities of Daily Living (ADL) Assistance.
B0200. Hearing
Enter Code	Ability to hear (with hearing aid or hearing appliances if normally used) Adequate - no difficulty in normal conversation, social interaction, listening to TV Minimal difficulty - difficulty in some environments (e.g., when person speaks softly or setting is noisy) Moderate difficulty - speaker has to increase volume and speak distinctly Highly impaired - absence of useful hearing
B0300. Hearing Aid
Enter Code	Hearing aid or other hearing appliance used in completing B0200, Hearing No Yes

Section B		Hearing, Speech, and Vision
B0600. Speech Clarity
Enter Code	Select best description of speech pattern Clear speech - distinct intelligible words Unclear speech - slurred or mumbled words No speech - absence of spoken words
B0700. Makes Self Understood
Enter Code	Ability to express ideas and wants, consider both verbal and non-verbal expression Understood Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time. Sometimes understood - ability is limited to making concrete requests Rarely/never understood
B0800. Ability To Understand Others
Enter Code	Understanding verbal content, however able (with hearing aid or device if used) Understands - clear comprehension Usually understands - misses some part/intent of message but comprehends most conversation Sometimes understands - responds adequately to simple, direct communication only Rarely/never understands
B1000. Vision
Enter Code	Ability to see in adequate light (with glasses or other visual appliances) Adequate - sees fine detail, such as regular print in newspapers/books Impaired - sees large print, but not regular print in newspapers/books Moderately impaired - limited vision; not able to see newspaper headlines but can identify objects Highly impaired - object identification in question, but eyes appear to follow objects Severely impaired - no vision or sees only light, colors or shapes; eyes do not appear to follow objects
B1200. Corrective Lenses
Enter Code	Corrective lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision No Yes

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted? Attempt to conduct interview with all residents
Enter Code	No (resident is rarely/never understood) Skip to and complete C0700-C1000, Staff Assessment for Mental Status Yes Continue to C0200, Repetition of Three Words

Brief Interview for Mental Status (BIMS)
C0200. Repetition of Three Words
Enter Code	Ask resident: “I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.” Number of words repeated after first attempt None One Two Three After the resident's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece of furniture"). You may repeat the words up to two more times.

Brief Interview for Mental Status (BIMS)
C0300. Temporal Orientation (orientation to year, month, and day)
Enter Code Enter Code Enter Code	Ask resident: "Please tell me what year it is right now." A. Able to report correct year Missed by > 5 years or no answer Missed by 2-5 years Missed by 1 year Correct
	Ask resident: "What month are we in right now?" B. Able to report correct month Missed by > 1 month or no answer Missed by 6 days to 1 month Accurate within 5 days
	Ask resident: "What day of the week is today?" C. Able to report correct day of the week Incorrect or no answer. Correct
C0400. Recall
Enter Code Enter Code Enter Code	Ask resident: "Let's go back to an earlier question. What were those three words that I asked you to repeat?" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word. A. Able to recall "sock" No - could not recall Yes, after cueing ("something to wear") Yes, no cue required
	B. Able to recall "blue" No - could not recall Yes, after cueing ("a color") Yes, no cue required
	C. Able to recall "bed" No - could not recall Yes, after cueing ("a piece of furniture") Yes, no cue required
C0500. BIMS Summary Score
Enter Score	Add scores for questions C0200-C0400 and fill in total score (00-15) Enter 99 if the resident was unable to complete the interview

C0600. Should the Staff Assessment for Mental Status (C0700 - C1000) be Conducted?
Enter Code	No (resident was able to complete Brief Interview for Mental Status) Skip to C1310, Signs and Symptoms of Delirium Yes (resident was unable to complete Brief Interview for Mental Status) Continue to C0700, Short-term Memory OK.

Staff Assessment for Mental Status
Do not conduct if Brief Interview for Mental Status (C0200-C0500) was completed
C0700. Short-term Memory OK
Enter Code	Seems or appears to recall after 5 minutes Memory OK. Memory problem
C0800. Long-term Memory OK
Enter Code	Seems or appears to recall long past Memory OK. Memory problem
C0900. Memory/Recall Ability
Check all that the resident was normally able to recall
	A. Current season
	B. Location of own room
	C. Staff names and faces
	D. That he or she is in a nursing home/hospital swing bed
	Z. None of the above were recalled
C1000. Cognitive Skills for Daily Decision Making
Enter Code	Made decisions regarding tasks of daily life Independent - decisions consistent/reasonable. Modified independence - some difficulty in new situations only Moderately impaired - decisions poor; cues/supervision required Severely impaired - never/rarely made decisions

Delirium
C1310. Signs and Symptoms of Delirium (from CAM©)
Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical record
A. Acute Onset Mental Status Change
Enter Code	Is there evidence of an acute change in mental status from the resident's baseline? No Yes
Coding: Behavior not present Behavior continuously present, does not fluctuate Behavior present, fluctuates (comes and goes, changes in severity)		Enter Codes in Boxes
			B. Inattention - Did the resident have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?
			C. Disorganized Thinking - Was the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?
			D. Altered Level of Consciousness - Did the resident have altered level of consciousness, as indicated by any of the following criteria? vigilant - startled easily to any sound or touch lethargic - repeatedly dozed off when being asked questions, but responded to voice or touch stuporous - very difficult to arouse and keep aroused for the interview comatose - could not be aroused
Confusion Assessment Method. ©1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Used with permission.

D0100. Should Resident Mood Interview be Conducted? - Attempt to conduct interview with all residents
Enter Code	No (resident is rarely/never understood) Skip to and complete D0500-D0600, Staff Assessment of Resident Mood (PHQ-9-OV) Yes Continue to D0200, Resident Mood Interview (PHQ-9©)

D0200. Resident Mood Interview (PHQ-9©) Replaced by D0150
Say to resident: "Over the last 2 weeks, have you been bothered by any of the following problems?"
If symptom is present, enter 1 (yes) in column 1, Symptom Presence. If yes in column 1, then ask the resident: "About how often have you been bothered by this?" Read and show the resident a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
Symptom Presence 2. Symptom Frequency. No (enter 0 in column 2) 0. Never or 1 day Yes (enter 0-3 in column 2) 1. 2-6 days (several days) 9. No response (leave column 2 2. 7-11 days (half or more of the days) blank) 3. 12-14 days (nearly every day)		1. Symptom Presence	2. Symptom Frequency
		Enter Scores in Boxes
A. Little interest or pleasure in doing things
B. Feeling down, depressed, or hopeless
C. Trouble falling or staying asleep, or sleeping too much
D. Feeling tired or having little energy
E. Poor appetite or overeating
F. Feeling bad about yourself - or that you are a failure or have let yourself or your family down
G. Trouble concentrating on things, such as reading the newspaper or watching television
H. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
I. Thoughts that you would be better off dead, or of hurting yourself in some way
D0300.	Total Severity Score Replaced by D0160
Enter Score	Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 27. Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more items).

Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.

D0500. Staff Assessment of Resident Mood (PHQ-9-OV*) Do not conduct if Resident Mood Interview (D0200-D0300) was completed
Over the last 2 weeks, did the resident have any of the following problems or behaviors?
If symptom is present, enter 1 (yes) in column 1, Symptom Presence. Then move to column 2, Symptom Frequency, and indicate symptom frequency.
Symptom Presence 2. Symptom Frequency. No (enter 0 in column 2) 0. Never or 1 day Yes (enter 0-3 in column 2) 1. 2-6 days (several days) 7-11 days (half or more of the days) 12-14 days (nearly every day)		1. Symptom Presence	2. Symptom Frequency
		Enter Scores in Boxes
A. Little interest or pleasure in doing things
B. Feeling or appearing down, depressed, or hopeless
C. Trouble falling or staying asleep, or sleeping too much
D. Feeling tired or having little energy
E. Poor appetite or overeating
F. Indicating that s/he feels bad about self, is a failure, or has let self or family down
G. Trouble concentrating on things, such as reading the newspaper or watching television
H. Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety or restless that s/he has been moving around a lot more than usual
I. States that life isn't worth living, wishes for death, or attempts to harm self
J. Being short-tempered, easily annoyed
D0600. Total Severity Score
Enter Score	Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 30.

* Copyright © Pfizer Inc. All rights reserved.

Section E		Behavior
E0100. Potential Indicators of Psychosis
Check all that apply
	A. Hallucinations (perceptual experiences in the absence of real external sensory stimuli)
	B. Delusions (misconceptions or beliefs that are firmly held, contrary to reality)
	Z. None of the above
Behavioral Symptoms
E0200. Behavioral Symptom - Presence & Frequency
Note presence of symptoms and their frequency.
Coding: Behavior not exhibited Behavior of this type occurred 1 to 3 days Behavior of this type occurred 4 to 6 days, but less than daily Behavior of this type occurred daily			Enter Codes in Boxes
				A. Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually)
				B. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others)
				C. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds)
E0800. Rejection of Care - Presence & Frequency
Enter Code	Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? Do not include behaviors that have already been addressed (e.g., by discussion or care planning with the resident or family), and determined to be consistent with resident values, preferences, or goals. Behavior not exhibited Behavior of this type occurred 1 to 3 days Behavior of this type occurred 4 to 6 days, but less than daily Behavior of this type occurred daily
E0900. Wandering - Presence & Frequency
Enter Code	Has the resident wandered? Behavior not exhibited Behavior of this type occurred 1 to 3 days Behavior of this type occurred 4 to 6 days, but less than daily. Behavior of this type occurred daily

Section G	Functional Status
G0110. Activities of Daily Living (ADL) Assistance Refer to the ADL flow chart in the RAI manual to facilitate accurate coding
Instructions for Rule of 3 When an activity occurs three times at any one given level, code that level. When an activity occurs three times at multiple levels, code the most dependent, exceptions are total dependence (4), activity must require full assist every time, and activity did not occur (8), activity must not have occurred at all. Example, three times extensive assistance (3) and three times limited assistance (2), code extensive assistance (3). When an activity occurs at various levels, but not three times at any given level, apply the following: ￮ When there is a combination of full staff performance, and extensive assistance, code extensive assistance. ￮ When there is a combination of full staff performance, weight bearing assistance and/or non-weight bearing assistance code limited assistance (2). If none of the above are met, code supervision.
ADL Self-Performance 2. ADL Support Provided Code for resident's performance over all shifts - not including setup. If the ADL activity Code for most support provided over all occurred 3 or more times at various levels of assistance, code the most dependent - except for shifts; code regardless of resident's self- total dependence, which requires full staff performance every time. performance classification Coding: Coding: Activity Occurred 3 or More Times 0. No setup or physical help from staff. Independent - no help or staff oversight at any time 1. Setup help only. Supervision - oversight, encouragement or cueing 2. One person physical assist Limited assistance - resident highly involved in activity; staff provide guided maneuvering 3. Two+ persons physical assist. of limbs or other non-weight-bearing assistance 8. ADL activity itself did not occur or family Extensive assistance - resident involved in activity, staff provide weight-bearing support and/or non-facility staff provided care Total dependence - full staff performance every time during entire 7-day period 100% of the time for that activity over the Activity Occurred 2 or Fewer Times entire 7-day period
7. Activity occurred only once or twice - activity did occur but only once or twice 8. Activity did not occur - activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period		1. Self-Performance	2. Support
		Enter Codes in Boxes
A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture
B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet)
C. Walk in room - how resident walks between locations in his/her room
D. Walk in corridor - how resident walks in corridor on unit.
E. Locomotion on unit - how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair
F. Locomotion off unit - how resident moves to and returns from off-unit locations (e.g., areas set aside for dining, activities or treatments). If facility has only one floor, how resident moves to and from distant areas on the floor. If in wheelchair, self-sufficiency once in chair
G. Dressing - how resident puts on, fastens and takes off all items of clothing, including donning/removing a prosthesis or TED hose. Dressing includes putting on and changing pajamas and housedresses
H. Eating - how resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. Includes intake of nourishment by other means (e.g., tube feeding, total parenteral nutrition, IV fluids administered for nutrition or hydration)
I. Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag or ostomy bag
J. Personal hygiene - how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers)

Section G		Functional Status
G0120. Bathing
How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair). Code for most dependent in self-performance and support.
Enter Code Enter Code	A. Self-performance Independent - no help provided Supervision - oversight help only. Physical help limited to transfer only Physical help in part of bathing activity Total dependence 8. Activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period
	B. Support provided (Bathing support codes are as defined in item G0110 column 2, ADL Support Provided, above)
G0300. Balance During Transitions and Walking
After observing the resident, code the following walking and transition items for most dependent.
Coding: Steady at all times Not steady, but able to stabilize without staff assistance Not steady, only able to stabilize with staff assistance 8. Activity did not occur			Enter Codes in Boxes
				A. Moving from seated to standing position
				B. Walking (with assistive device if used)
				C. Turning around and facing the opposite direction while walking
				D. Moving on and off toilet
				E. Surface-to-surface transfer (transfer between bed and chair or wheelchair)
G0400. Functional Limitation in Range of Motion
Code for limitation that interfered with daily functions or placed resident at risk of injury
Coding: No impairment Impairment on one side. Impairment on both sides			Enter Codes in Boxes
				A. Upper extremity (shoulder, elbow, wrist, hand)
				B. Lower extremity (hip, knee, ankle, foot)
G0600. Mobility Devices
Check all that were normally used
	A. Cane/crutch
	B. Walker
	C. Wheelchair (manual or electric)
	D. Limb prosthesis
	Z. None of the above were used

Section GG Functional Abilities and Goals - Admission (Start of SNF PPS Stay)

GG0100. Prior Functioning: Everyday Activities. Indicate the resident’s usual ability with everyday activities prior to the current illness, exacerbation, or injury

Complete only if A0310B = 01

Coding:

3. Independent - Resident completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.

2. Needed Some Help - Resident needed partial assistance from another person to complete activities.

1. Dependent - A helper completed the activities for the resident.

8. Unknown.

9. Not Applicable.

Enter Codes in Boxes

1. Self-Care: Code the resident's need for assistance with bathing, dressing, using the toilet, or eating prior to the current illness, exacerbation, or injury.

2. Indoor Mobility (Ambulation): Code the resident's need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.

3. Stairs: Code the resident's need for assistance with internal or external stairs (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury.

4. Functional Cognition: Code the resident's need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury.

GG0110. Prior Device Use. Indicate devices and aids used by the resident prior to the current illness, exacerbation, or injury Complete only if A0310B = 01

Check all that apply.

1. Manual wheelchair

2. Motorized wheelchair and/or scooter

3. Mechanical lift.

4. Walker

5. Orthotics/Prosthetics

Z. None of the above

Section GG			Functional Abilities and Goals - Admission (Start of SNF PPS Stay)
GG0130. Self-Care (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B) Complete only if A0310B = 01
Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code end of SNF PPS stay (discharge) goal(s).
Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices. 06. Independent - Resident completes the activity by him/herself with no assistance from a helper. 05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. 04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. 03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. 02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. If activity was not attempted, code reason: 07. Resident refused 09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. 10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) 88. Not attempted due to medical condition or safety concerns
1. Admission Performance	2. Discharge Goal
Enter Codes in Boxes
		A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident.
		B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.
		C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment.
		E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower.
		F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.
		G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear.
		H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable.

Section GG			Functional Abilities and Goals - Admission (Start of SNF PPS Stay)
GG0170. Mobility (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B) Complete only if A0310B = 01
Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code end of SNF PPS stay (discharge) goal(s).
Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices. 06. Independent - Resident completes the activity by him/herself with no assistance from a helper. 05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. 04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. 03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. 02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. If activity was not attempted, code reason: 07. Resident refused 09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. 10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) 88. Not attempted due to medical condition or safety concerns
1. Admission Performance	2. Discharge Goal
Enter Codes in Boxes
		A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed.
		B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
		C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support.
		D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.
		E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
		F. Toilet transfer: The ability to get on and off a toilet or commode.
		G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt.
		I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. If admission performance is coded 07, 09, 10, or 88 Skip to GG0170M, 1 step (curb)
		J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.
		K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.

Section GG			Functional Abilities and Goals - Admission (Start of SNF PPS Stay)
GG0170. Mobility (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B) - Continued Complete only if A0310B = 01
Code the resident's usual performance at the start of the SNF PPS stay (admission) for each activity using the 6-point scale. If activity was not attempted at the start of the SNF PPS stay (admission), code the reason. Code the resident's end of SNF PPS stay (discharge) goal(s) using the 6-point scale. Use of codes 07, 09, 10, or 88 is permissible to code end of SNF PPS stay (discharge) goal(s).
Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices. 06. Independent - Resident completes the activity by him/herself with no assistance from a helper. 05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. 04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. 03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. 02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. If activity was not attempted, code reason: 07. Resident refused 09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. 10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) 88. Not attempted due to medical condition or safety concerns
1. Admission Performance	2. Discharge Goal
Enter Codes in Boxes
		L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel.
		M. 1 step (curb): The ability to go up and down a curb and/or up and down one step. If admission performance is coded 07, 09, 10, or 88 Skip to GG0170P, Picking up object.
		N. 4 steps: The ability to go up and down four steps with or without a rail. If admission performance is coded 07, 09, 10, or 88 Skip to GG0170P, Picking up object.
		O. 12 steps: The ability to go up and down 12 steps with or without a rail.
		P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor.
				Q1. Does the resident use a wheelchair and/or scooter? No Skip to GG0130, Self Care (Discharge) Yes Continue to GG0170R, Wheel 50 feet with two turns
		R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns.
				RR1. Indicate the type of wheelchair or scooter used. Manual Motorized
		S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.
				SS1. Indicate the type of wheelchair or scooter used. Manual Motorized

Section GG		Functional Abilities and Goals - Discharge (End of SNF PPS Stay)
GG0130. Self-Care (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C) Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03
Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted at the end of the SNF PPS stay, code the reason.
Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices. 06. Independent - Resident completes the activity by him/herself with no assistance from a helper. 05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. 04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. 03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. 02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. If activity was not attempted, code reason: 07. Resident refused 09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. 10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) 88. Not attempted due to medical condition or safety concerns
3. Discharge Performance
Enter Codes in Boxes
	A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident.
	B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.
	C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment.
	E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower.
	F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.
	G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear.
	H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable.

Section GG		Functional Abilities and Goals - Discharge (End of SNF PPS Stay)
GG0170. Mobility (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C) Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03
Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted at the end of the SNF PPS stay, code the reason.
Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices. 06. Independent - Resident completes the activity by him/herself with no assistance from a helper. 05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. 04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. 03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. 02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. If activity was not attempted, code reason: 07. Resident refused 09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. 10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) 88. Not attempted due to medical condition or safety concerns
3. Discharge Performance
Enter Codes in Boxes
	A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed.
	B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
	C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support.
	D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.
	E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
	F. Toilet transfer: The ability to get on and off a toilet or commode.
	G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/ close door or fasten seat belt.
	I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. If discharge performance is coded 07, 09, 10, or 88 Skip to GG0170M, 1 step (curb)
	J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.
	K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.

Section GG			Functional Abilities and Goals - Discharge (End of SNF PPS Stay)
GG0170. Mobility (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C) - Continued Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03
Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted at the end of the SNF PPS stay, code the reason.
Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices. 06. Independent - Resident completes the activity by him/herself with no assistance from a helper. 05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. 04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. 03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. 02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. If activity was not attempted, code reason: 07. Resident refused 09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury. 10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) 88. Not attempted due to medical condition or safety concerns
3. Discharge Performance
Enter Codes in Boxes
	L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel.
	M. 1 step (curb): The ability to go up and down a curb and/or up and down one step. If discharge performance is coded 07, 09, 10, or 88 Skip to GG0170P, Picking up object.
	N. 4 steps: The ability to go up and down four steps with or without a rail. If discharge performance is coded 07, 09, 10, or 88 Skip to GG0170P, Picking up object.
	O. 12 steps: The ability to go up and down 12 steps with or without a rail.
	P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor.
		Q3. Does the resident use a wheelchair and/or scooter? No Skip to H0100, Appliances Yes Continue to GG0170R, Wheel 50 feet with two turns
	R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns.
		RR3. Indicate the type of wheelchair or scooter used. Manual Motorized
	S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.
		SS3. Indicate the type of wheelchair or scooter used. Manual Motorized

Section H		Bladder and Bowel
H0100. Appliances
Check all that apply
	A. Indwelling catheter (including suprapubic catheter and nephrostomy tube)
	B. External catheter
	C. Ostomy (including urostomy, ileostomy, and colostomy)
	D. Intermittent catheterization
	Z. None of the above
H0200. Urinary Toileting Program
Enter Code Enter Code	A. Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility? No Skip to H0300, Urinary Continence Yes Continue to H0200C, Current toileting program or trial 9. Unable to determine Continue to H0200C, Current toileting program or trial
	C. Current toileting program or trial - Is a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) currently being used to manage the resident's urinary continence? No Yes
H0300. Urinary Continence.
Enter Code	Urinary continence - Select the one category that best describes the resident Always continent. Occasionally incontinent (less than 7 episodes of incontinence) Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding) Always incontinent (no episodes of continent voiding) 9. Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days
H0400. Bowel Continence
Enter Code	Bowel continence - Select the one category that best describes the resident Always continent. Occasionally incontinent (one episode of bowel incontinence) Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement) Always incontinent (no episodes of continent bowel movements) 9. Not rated, resident had an ostomy or did not have a bowel movement for the entire 7 days
H0500. Bowel Toileting Program
Enter Code	Is a toileting program currently being used to manage the resident's bowel continence? 0. No 1. Yes

Section I		Active Diagnoses
I0020. Indicate the resident’s primary medical condition category Complete only if A0310B = 01 or 08
Enter Code	Indicate the resident's primary medical condition category that best describes the primary reason for admission Stroke Non-Traumatic Brain Dysfunction Traumatic Brain Dysfunction Non-Traumatic Spinal Cord Dysfunction Traumatic Spinal Cord Dysfunction Progressive Neurological Conditions Other Neurological Conditions Amputation Hip and Knee Replacement Fractures and Other Multiple Trauma Other Orthopedic Conditions Debility, Cardiorespiratory Conditions Medically Complex Conditions I0020B. ICD Code

Section I			Active Diagnoses
Active Diagnoses in the last 7 days - Check all that apply Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists
	Cancer
	I0100.	Cancer (with or without metastasis)
	Heart/Circulation
	I0200.	Anemia (e.g., aplastic, iron deficiency, pernicious, and sickle cell)
	I0400.	Coronary Artery Disease (CAD) (e.g., angina, myocardial infarction, and atherosclerotic heart disease (ASHD))
	I0600.	Heart Failure (e.g., congestive heart failure (CHF) and pulmonary edema)
	I0700.	Hypertension
	I0800.	Orthostatic Hypotension
	I0900.	Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
	Gastrointestinal
	I1300.	Ulcerative Colitis, Crohn's Disease, or Inflammatory Bowel Disease
	Genitourinary
	I1500.	Renal Insufficiency, Renal Failure, or End-Stage Renal Disease (ESRD)
	I1550.	Neurogenic Bladder
	I1650.	Obstructive Uropathy
	Infections
	I1700.	Multidrug-Resistant Organism (MDRO)
	I2000.	Pneumonia
	I2100.	Septicemia
	I2200.	Tuberculosis
	I2300.	Urinary Tract Infection (UTI) (LAST 30 DAYS)
	I2500.	Wound Infection (other than foot)
	Metabolic
	I2900.	Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)
	I3100.	Hyponatremia
	I3200.	Hyperkalemia
	I3300.	Hyperlipidemia (e.g., hypercholesterolemia)
	Musculoskeletal
	I3900.	Hip Fracture - any hip fracture that has a relationship to current status, treatments, monitoring (e.g., sub-capital fractures, and
		fractures of the trochanter and femoral neck)
	I4000.	Other Fracture
	Neurological
	I4300.	Aphasia
	I4400.	Cerebral Palsy
	I4500.	Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke
	I4800.	Non-Alzheimer's Dementia (e.g. Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia
		such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-Jakob diseases)
	I4900.	Hemiplegia or Hemiparesis
	I5000.	Paraplegia
	I5100.	Quadriplegia
	I5200.	Multiple Sclerosis (MS)
	I5250.	Huntington's Disease
	I5300.	Parkinson's Disease
	I5350.	Tourette's Syndrome
	I5400.	Seizure Disorder or Epilepsy
	I5500.	Traumatic Brain Injury (TBI)

Section I		Active Diagnoses
Active Diagnoses in the last 7 days - Check all that apply Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists
	Nutritional
	I5600. Malnutrition (protein or calorie) or at risk for malnutrition
	Psychiatric/Mood Disorder
	I5700. Anxiety Disorder I5800. Depression (other than bipolar) I5900. Bipolar Disorder I5950. Psychotic Disorder (other than schizophrenia) I6000. Schizophrenia (e.g., schizoaffective and schizophreniform disorders) I6100. Post Traumatic Stress Disorder (PTSD)
	Pulmonary
	I6200. Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease (e.g., chronic bronchitis and restrictive lung diseases such as asbestosis) I6300. Respiratory Failure
	Other
	I8000. Additional active diagnoses Enter diagnosis on line and ICD code in boxes. Include the decimal for the code in the appropriate box. A. B. C. D. E. F. G. H. I. J.

Section J		Health Conditions
J0100. Pain Management - Complete for all residents, regardless of current pain level
At any time in the last 5 days, has the resident:
Enter Code Enter Code Enter Code	A. Received scheduled pain medication regimen? No Yes
	B. Received PRN pain medications OR was offered and declined? No Yes
	C. Received non-medication intervention for pain? No Yes

J0200. Should Pain Assessment Interview be Conducted? Attempt to conduct interview with all residents. If resident is comatose, skip to J1100, Shortness of Breath (dyspnea)
Enter Code	No (resident is rarely/never understood) Skip to and complete J0800, Indicators of Pain or Possible Pain Yes Continue to J0300, Pain Presence

Pain Assessment Interview
J0300. Pain Presence
Enter Code	Ask resident: "Have you had pain or hurting at any time in the last 5 days?" No Skip to J1100, Shortness of Breath Yes Continue to J0400, Pain Frequency 9. Unable to answer Skip to J0800, Indicators of Pain or Possible Pain
J0400. Pain Frequency replaced by J0410
Enter Code	Ask resident: "How much of the time have you experienced pain or hurting over the last 5 days?" Almost constantly Frequently. Occasionally Rarely 9. Unable to answer
J0500. Pain Effect on Function
Enter Code Enter Code	A. Ask resident: "Over the past 5 days, has pain made it hard for you to sleep at night?" 0. No 1. Yes 9. Unable to answer
	B. Ask resident: "Over the past 5 days, have you limited your day-to-day activities because of pain?" 0. No 1. Yes 9. Unable to answer
J0600. Pain Intensity - Administer ONLY ONE of the following pain intensity questions (A or B)
Enter Rating Enter Code	A. Numeric Rating Scale (00-10) Ask resident: "Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine." (Show resident 00 -10 pain scale) Enter two-digit response. Enter 99 if unable to answer.
	B. Verbal Descriptor Scale Ask resident: "Please rate the intensity of your worst pain over the last 5 days." (Show resident verbal scale) Mild Moderate Severe Very severe, horrible 9. Unable to answer

J0700. Should the Staff Assessment for Pain be Conducted?
Enter Code	No (J0400 = 1 thru 4) Skip to J1100, Shortness of Breath (dyspnea) Yes (J0400 = 9) Continue to J0800, Indicators of Pain or Possible Pain

Staff Assessment for Pain
J0800. Indicators of Pain or Possible Pain in the last 5 days
Check all that apply.
	A. Non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning)
	B. Vocal complaints of pain (e.g., that hurts, ouch, stop)
	C. Facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw)
	D. Protective body movements or postures (e.g., bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement)
	Z. None of these signs observed or documented If checked, skip to J1100, Shortness of Breath (dyspnea)
J0850. Frequency of Indicator of Pain or Possible Pain in the last 5 days
Enter Code	Frequency with which resident complains or shows evidence of pain or possible pain Indicators of pain or possible pain observed 1 to 2 days Indicators of pain or possible pain observed 3 to 4 days. Indicators of pain or possible pain observed daily

Other Health Conditions
J1100. Shortness of Breath (dyspnea)
Check all that apply
	A. Shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring)
	B. Shortness of breath or trouble breathing when sitting at rest.
	C. Shortness of breath or trouble breathing when lying flat
	Z. None of the above
J1400. Prognosis
Enter Code	Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? (Requires physician documentation) No. Yes
J1550. Problem Conditions
Check all that apply
	A. Fever
	B. Vomiting
	C. Dehydrated
	D. Internal bleeding
	Z. None of the above

Section J		Health Conditions
J1700. Fall History on Admission/Entry or Reentry Complete only if A0310A = 01 or A0310E = 1
Enter Code Enter Code Enter Code	A. Did the resident have a fall any time in the last month prior to admission/entry or reentry? 0. No. 1. Yes 9. Unable to determine
	B. Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry? 0. No. 1. Yes 9. Unable to determine
	C. Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry? 0. No. 1. Yes 9. Unable to determine
J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent
Enter Code	Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent? No Skip to J2000, Prior Surgery Yes Continue to J1900, Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS)
J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent.
Coding: None One Two or more		Enter Codes in Boxes
			A. No injury - no evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the resident; no change in the resident's behavior is noted after the fall
			B. Injury (except major) - skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the resident to complain of pain
			C. Major injury - bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma
J2000. Prior Surgery - Complete only if A0310B = 01
Enter Code	Did the resident have major surgery during the 100 days prior to admission? 0. No. 1. Yes 8. Unknown
J2100. Recent Surgery Requiring Active SNF Care - Complete only if A0310B = 01 or 08
Enter Code	Did the resident have a major surgical procedure during the prior inpatient hospital stay that requires active care during the SNF stay? 0. No. 1. Yes 8. Unknown

Section J			Health Conditions
Surgical Procedures - Complete only if J2100 = 1
Check all that apply
	Major Joint Replacement
	J2300.	Knee Replacement - partial or total
	J2310.	Hip Replacement - partial or total
	J2320.	Ankle Replacement - partial or total
	J2330.	Shoulder Replacement - partial or total
	Spinal Surgery
	J2400.	Involving the spinal cord or major spinal nerves
	J2410.	Involving fusion of spinal bones
	J2420.	Involving Iamina, discs, or facets
	J2499.	Other major spinal surgery
	Other Orthopedic Surgery.
	J2500.	Repair fractures of the shoulder (including clavicle and scapula) or arm (but not hand)
	J2510.	Repair fractures of the pelvis, hip, leg, knee, or ankle (not foot)
	J2520.	Repair but not replace joints
	J2530.	Repair other bones (such as hand, foot, jaw)
	J2599.	Other major orthopedic surgery
	Neurological Surgery
	J2600.	Involving the brain, surrounding tissue or blood vessels (excludes skull and skin but includes cranial nerves)
	J2610.	Involving the peripheral or autonomic nervous system - open or percutaneous
	J2620.	Insertion or removal of spinal or brain neurostimulators, electrodes, catheters, or CSF drainage devices
	J2699.	Other major neurological surgery
	Cardiopulmonary Surgery.
	J2700.	Involving the heart or major blood vessels - open or percutaneous procedures
	J2710.	Involving the respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords - open or endoscopic
	J2799.	Other major cardiopulmonary surgery
	Genitourinary Surgery
	J2800.	Involving male or female organs (such as prostate, testes, ovaries, uterus, vagina, external genitalia)
	J2810.	Involving the kidneys, ureters, adrenal glands, or bladder - open or laparoscopic (includes creation or removal of
		nephrostomies or urostomies)
	J2899.	Other major genitourinary surgery
	Other Major Surgery.
	J2900.	Involving tendons, ligaments, or muscles
	J2910.	Involving the gastrointestinal tract or abdominal contents from the esophagus to the anus, the biliary tree, gall bladder, liver,
		pancreas, or spleen - open or laparoscopic (including creation or removal of ostomies or percutaneous feeding tubes, or hernia repair)
	J2920.	Involving the endocrine organs (such as thyroid, parathyroid), neck, lymph nodes, or thymus - open
	J2930.	Involving the breast
	J2940.	Repair of deep ulcers, internal brachytherapy, bone marrow or stem cell harvest or transplant
	J5000.	Other major surgery not listed above

Section K		Swallowing/Nutritional Status
K0100. Swallowing Disorder Signs and symptoms of possible swallowing disorder
Check all that apply
	A. Loss of liquids/solids from mouth when eating or drinking
	B. Holding food in mouth/cheeks or residual food in mouth after meals
	C. Coughing or choking during meals or when swallowing medications
	D. Complaints of difficulty or pain with swallowing
	Z. None of the above

Section K			Swallowing/Nutritional Status
K0200. Height and Weight - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up
inches pounds		A. Height (in inches). Record most recent height measure since the most recent admission/entry or reentry
		B. Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight consistently, according to standard facility practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.)
K0300. Weight Loss
Enter Code	Loss of 5% or more in the last month or loss of 10% or more in last 6 months No or unknown Yes, on physician-prescribed weight-loss regimen Yes, not on physician-prescribed weight-loss regimen
K0310. Weight Gain
Enter Code	Gain of 5% or more in the last month or gain of 10% or more in last 6 months No or unknown Yes, on physician-prescribed weight-gain regimen Yes, not on physician-prescribed weight-gain regimen
K0510. Nutritional Approaches Replaced by K0520 Check all of the following nutritional approaches that were performed during the last 7 days
While NOT a Resident Performed while NOT a resident of this facility and within the last 7 days. Only check column 1 if resident entered (admission or reentry) IN THE LAST 7 DAYS. If resident last entered 7 or more days ago, leave column 1 blank While a Resident. Performed while a resident of this facility and within the last 7 days				1. While NOT a Resident.	2. While a Resident
				Check all that apply
A. Parenteral/IV feeding
B. Feeding tube - nasogastric or abdominal (PEG)
C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids)
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
Z. None of the above
K0710. Percent Intake by Artificial Route - Complete K0710 only if Column 1 and/or Column 2 are checked for K0510A and/or K0510B
While a Resident. Performed while a resident of this facility and within the last 7 days During Entire 7 Days Performed during the entire last 7 days				2. While a Resident.	3. During Entire 7 Days
				Enter Codes
A. Proportion of total calories the resident received through parenteral or tube feeding 25% or less 26-50% 51% or more
B. Average fluid intake per day by IV or tube feeding 500 cc/day or less 501 cc/day or more

Section M		Skin Conditions
Report based on highest stage of existing ulcers/injuries at their worst; do not "reverse" stage
M0100. Determination of Pressure Ulcer/Injury Risk.
Check all that apply
	A. Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device.
	B. Formal assessment instrument/tool (e.g., Braden, Norton, or other)
	C. Clinical assessment
	Z. None of the above
M0150. Risk of Pressure Ulcers/Injuries
Enter Code	Is this resident at risk of developing pressure ulcers/injuries? No. Yes
M0210. Unhealed Pressure Ulcers/Injuries
Enter Code	Does this resident have one or more unhealed pressure ulcers/injuries? No Skip to M1030, Number of Venous and Arterial Ulcers Yes Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
Enter Number Enter Number Enter Number Enter Number Enter Number Enter Number Enter Number	A. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues 1. Number of Stage 1 pressure injuries
	B. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister Number of Stage 2 pressure ulcers - If 0 Skip to M0300C, Stage 3 Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry
	C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling Number of Stage 3 pressure ulcers - If 0 Skip to M0300D, Stage 4 Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling Number of Stage 4 pressure ulcers - If 0 Skip to M0300E, Unstageable - Non-removable dressing/device Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry
M0300 continued on next page

Section M		Skin Conditions
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage - Continued
Enter Number Enter Number Enter Number Enter Number Enter Number Enter Number	E. Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device Number of unstageable pressure ulcers/injuries due to non-removable dressing/device - If 0 Skip to M0300F, Unstageable - Slough and/or eschar Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry
	F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar - If 0 Skip to M0300G, Unstageable - Deep tissue injury Number of these unstageable pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry
	G. Unstageable - Deep tissue injury: Number of unstageable pressure injuries presenting as deep tissue injury - If 0 Skip to M1030, Number of Venous and Arterial Ulcers Number of these unstageable pressure injuries that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry
M1030. Number of Venous and Arterial Ulcers
Enter Number	Enter the total number of venous and arterial ulcers present.
M1040. Other Ulcers, Wounds and Skin Problems
Check all that apply
	Foot Problems
	A. Infection of the foot (e.g., cellulitis, purulent drainage)
	B. Diabetic foot ulcer(s)
	C. Other open lesion(s) on the foot
	Other Problems
	D. Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion)
	E. Surgical wound(s)
	F. Burn(s) (second or third degree)
	G. Skin tear(s).
	H. Moisture Associated Skin Damage (MASD) (e.g., incontinence-associated dermatitis [IAD], perspiration, drainage)
	None of the Above
	Z. None of the above were present

Section M		Skin Conditions
M1200. Skin and Ulcer/Injury Treatments
Check all that apply
	A. Pressure reducing device for chair
	B. Pressure reducing device for bed
	C. Turning/repositioning program
	D. Nutrition or hydration intervention to manage skin problems
	E. Pressure ulcer/injury care
	F. Surgical wound care
	G. Application of nonsurgical dressings (with or without topical medications) other than to feet
	H. Applications of ointments/medications other than to feet
	I. Application of dressings to feet (with or without topical medications)
	Z. None of the above were provided

Section N		Medications
N0300. Injections
Enter Days	Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days. If 0 Skip to N0410, Medications Received
N0350. Insulin
Enter Days Enter Days	A. Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days
	B. Orders for insulin - Record the number of days the physician (or authorized assistant or practitioner) changed the resident's insulin orders during the last 7 days or since admission/entry or reentry if less than 7 days
N0410. Medications Received Replaced by N0415
Indicate the number of DAYS the resident received the following medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. Enter "0" if medication was not received by the resident during the last 7 days
Enter Days Enter Days Enter Days Enter Days Enter Days Enter Days Enter Days Enter Days	A. Antipsychotic.
	B. Antianxiety
	C. Antidepressant.
	D. Hypnotic.
	E. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin)
	F. Antibiotic
	G. Diuretic.
	H. Opioid
N2001. Drug Regimen Review - Complete only if A0310B = 01
Enter Code	Did a complete drug regimen review identify potential clinically significant medication issues? 0. No - No issues found during review. 1. Yes - Issues found during review. 9. NA - Resident is not taking any medications
N2003. Medication Follow-up - Complete only if N2001 =1
Enter Code	Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/ recommended actions in response to the identified potential clinically significant medication issues? 0. No 1. Yes
N2005. Medication Intervention - Complete only if A0310H = 1
Enter Code	Did the facility contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the admission? 0. No 1. Yes 9. NA - There were no potential clinically significant medication issues identified since admission or resident is not taking any medications

Section O		Special Treatments, Procedures, and Programs
O0100. Special Treatments, Procedures, and Programs Replaced by O0110 Check all of the following treatments, procedures, and programs that were performed during the last 14 days
While NOT a Resident Performed while NOT a resident of this facility and within the last 14 days. Only check column 1 if resident entered (admission or reentry) IN THE LAST 14 DAYS. If resident last entered 14 or more days ago, leave column 1 blank While a Resident. Performed while a resident of this facility and within the last 14 days			1. While NOT a Resident.	2. While a Resident
			Check all that apply
Cancer Treatments
A. Chemotherapy
B. Radiation
Respiratory Treatments.
C. Oxygen therapy
D. Suctioning
E. Tracheostomy care
F. Invasive Mechanical Ventilator (ventilator or respirator)
Other.
H. IV medications
I. Transfusions
J. Dialysis
K. Hospice care.
M. Isolation or quarantine for active infectious disease (does not include standard body/fluid precautions)
O0250. Influenza Vaccine - Refer to current version of RAI manual for current influenza vaccination season and reporting period
Enter Code	A. Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season? 0. No Skip to O0250C, If influenza vaccine not received, state reason
	1. Yes Continue to O0250B, Date influenza vaccine received
Enter Code	B. Date influenza vaccine received Complete date and skip to O0300A, Is the resident's Pneumococcal vaccination up to date? _ _ Month Day Year
	C. If influenza vaccine not received, state reason: Resident not in this facility during this year's influenza vaccination season Received outside of this facility. Not eligible - medical contraindication Offered and declined. Not offered Inability to obtain influenza vaccine due to a declared shortage 9. None of the above.
O0300. Pneumococcal Vaccine
Enter Code	A. Is the resident's Pneumococcal vaccination up to date? No Continue to O0300B, If Pneumococcal vaccine not received, state reason Yes Skip to O0400, Therapies
Enter Code	B. If Pneumococcal vaccine not received, state reason: Not eligible - medical contraindication Offered and declined Not offered

Section O

O0400. Therapies

Special Treatments, Procedures, and Programs

1. Speech-Language Pathology and Audiology Services

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Days

1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually

in the last 7 days

2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident

concurrently with one other resident in the last 7 days

3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days

If the sum of individual, concurrent, and group minutes is zero, skip to O0400A5, Therapy start date

3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in

co-treatment sessions in the last 7 days

4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days

5. Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started

6. Therapy end date - record the date the most recent therapy regimen (since the most recent entry) ended

   • enter dashes if therapy is ongoing

_

Month

_

Day

Year

_

Month

_

Day

Year

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Days

2. Occupational Therapy

   1. 

      
      

      Individual minutes - record the total number of minutes this therapy was administered to the resident individually

in the last 7 days

2. 

   
   

   Concurrent minutes - record the total number of minutes this therapy was administered to the resident

concurrently with one other resident in the last 7 days

3. 

   
   

   Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days

If the sum of individual, concurrent, and group minutes is zero, skip to O0400B5, Therapy start date

3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in

co-treatment sessions in the last 7 days

4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days

5. Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started

6. Therapy end date - record the date the most recent therapy regimen (since the most recent entry) ended

   • enter dashes if therapy is ongoing

_

Month

O0400 continued on next page

_

Day

Year

_

Month

_

Day

Year

Section O		Special Treatments, Procedures, and Programs
O0400. Therapies - Continued
	C. Physical Therapy
Enter Number of Minutes Enter Number of Minutes Enter Number of Minutes Enter Number of Minutes Enter Number of Days Enter Number of Days	Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the last 7 days Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the last 7 days Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days If the sum of individual, concurrent, and group minutes is zero, skip to O0400C5, Therapy start date 3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment sessions in the last 7 days Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days Therapy start date - record the date the most recent 6. Therapy end date - record the date the most recent therapy regimen (since the most recent entry) started therapy regimen (since the most recent entry) ended - enter dashes if therapy is ongoing _ _ _ _ Month Day Year Month Day Year
	D. Respiratory Therapy
	2. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days

Section O

O0425. Part A Therapies

Complete only if A0310H = 1

Special Treatments, Procedures, and Programs

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Days

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Days

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Minutes

Enter Number of Days

1. Speech-Language Pathology and Audiology Services

   1. 

      
      

      Individual minutes - record the total number of minutes this therapy was administered to the resident individually

since the start date of the resident's most recent Medicare Part A stay (A2400B)

2. 

   
   

   Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident since the start date of the resident's most recent Medicare Part A stay (A2400B)

3. 

   
   

   Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents since the start date of the resident's most recent Medicare Part A stay (A2400B)

If the sum of individual, concurrent, and group minutes is zero, skip to O0425B, Occupational Therapy

4. 

   
   

   Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in

co-treatment sessions since the start date of the resident's most recent Medicare Part A stay (A2400B)

5. Days - record the number of days this therapy was administered for at least 15 minutes a day since the start date of the resident's most recent Medicare Part A stay (A2400B)

1. Occupational Therapy

   1. 

      
      

      Individual minutes - record the total number of minutes this therapy was administered to the resident individually

since the start date of the resident's most recent Medicare Part A stay (A2400B)

2. 

   
   

   Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident since the start date of the resident's most recent Medicare Part A stay (A2400B)

3. 

   
   

   Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents since the start date of the resident's most recent Medicare Part A stay (A2400B)

If the sum of individual, concurrent, and group minutes is zero, skip to O0425C, Physical Therapy

4. 

   
   

   Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in

co-treatment sessions since the start date of the resident's most recent Medicare Part A stay (A2400B)

5. Days - record the number of days this therapy was administered for at least 15 minutes a day since the start date of the resident's most recent Medicare Part A stay (A2400B)

1. Physical Therapy

   1. 

      
      

      Individual minutes - record the total number of minutes this therapy was administered to the resident individually

since the start date of the resident's most recent Medicare Part A stay (A2400B)

2. 

   
   

   Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident since the start date of the resident's most recent Medicare Part A stay (A2400B)

3. 

   
   

   Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents since the start date of the resident's most recent Medicare Part A stay (A2400B)

If the sum of individual, concurrent, and group minutes is zero, skip to O0430, Distinct Calendar Days of Part A Therapy

4. 

   
   

   Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in

co-treatment sessions since the start date of the resident's most recent Medicare Part A stay (A2400B)

5. Days - record the number of days this therapy was administered for at least 15 minutes a day since the start date of the resident's most recent Medicare Part A stay (A2400B)

O0430. Distinct Calendar Days of Part A Therapy

Complete only if A0310H = 1

Enter Number of Days

Record the number of calendar days that the resident received Speech-Language Pathology and Audiology Services, Occupational Therapy, or Physical Therapy for at least 15 minutes since the start date of the resident's most recent Medicare Part A stay (A2400B)

Section O		Special Treatments, Procedures, and Programs
O0500. Restorative Nursing Programs
Record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days (enter 0 if none or less than 15 minutes daily)
Number of Days	Technique.
	A. Range of motion (passive)
	B. Range of motion (active)
	C. Splint or brace assistance
Number of Days	Training and Skill Practice In:
	D. Bed mobility
	E. Transfer
	F. Walking
	G. Dressing and/or grooming
	H. Eating and/or swallowing
	I. Amputation/prostheses care
	J. Communication
O0600. Physician Examinations
Enter Days	Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) examine the resident?
O0700. Physician Orders
Enter Days	Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) change the resident's orders?

Section P	Restraints and Alarms
P0100. Physical Restraints
Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body
Coding: Not used Used less than daily Used daily		Enter Codes in Boxes
			Used in Bed
			A. Bed rail.
			B. Trunk restraint
			C. Limb restraint
			D. Other
			Used in Chair or Out of Bed
			E. Trunk restraint
			F. Limb restraint.
			G. Chair prevents rising.
			H. Other

Section Q		Participation in Assessment and Goal Setting
Q0100. Participation in Assessment replaced by Q0110 Participation in Assessment and Goal Setting
Enter Code Enter Code Enter Code	A. Resident participated in assessment No Yes
	B. Family or significant other participated in assessment 0. No 1. Yes 9. Resident has no family or significant other
	C. Guardian or legally authorized representative participated in assessment 0. No 1. Yes 9. Resident has no guardian or legally authorized representative
Q0300. Resident's Overall Expectation Replaced by Q0310 Resident’s Overall Goal Complete only if A0310E = 1
Enter Code Enter Code	A. Select one for resident's overall goal established during assessment process Expects to be discharged to the community Expects to remain in this facility Expects to be discharged to another facility/institution 9. Unknown or uncertain
	Indicate information source for Q0300A Resident. If not resident, then family or significant other If not resident, family, or significant other, then guardian or legally authorized representative 9. Unknown or uncertain
Q0400. Discharge Plan
Enter Code	A. Is active discharge planning already occurring for the resident to return to the community? No Yes Skip to Q0600, Referral

Section Q		Participation in Assessment and Goal Setting
Q0490. Resident's Preference to Avoid Being Asked Question Q0500B Complete only if A0310A = 02, 06, or 99
Enter Code	Does the resident's clinical record document a request that this question be asked only on comprehensive assessments? No Yes Skip to Q0600, Referral
Q0500. Return to Community
Enter Code	B. Ask the resident (or family or significant other or guardian or legally authorized representative if resident is unable to understand or respond): "Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community?" 0. No 1. Yes 9. Unknown or uncertain
Q0550. Resident's Preference to Avoid Being Asked Question Q0500B Again
Enter Code Enter Code	A. Does the resident (or family or significant other or guardian or legally authorized representative if resident is unable to understand or respond) want to be asked about returning to the community on all assessments? (Rather than only on comprehensive assessments.) 0. No - then document in resident's clinical record and ask again only on the next comprehensive assessment 1. Yes 8. Information not available
	B. Indicate information source for Q0550A. Resident If not resident, then family or significant other If not resident, family or significant other, then guardian or legally authorized representative 9. None of the above
Q0600. Referral Replaced by Q0610Referral
Enter Code	Has a referral been made to the Local Contact Agency? (Document reasons in resident's clinical record) No - referral not needed No - referral is or may be needed (For more information see Appendix C, Care Area Assessment Resources #20) Yes - referral made

Section X		Correction Request
Complete Section X only if A0050 = 2 or 3 Identification of Record to be Modified/Inactivated - The following items identify the existing assessment record that is in error. In this section, reproduce the information EXACTLY as it appeared on the existing erroneous record, even if the information is incorrect. This information is necessary to locate the existing record in the National MDS Database.
X0150. Type of Provider (A0200 on existing record to be modified/inactivated)
Enter Code	Type of provider Nursing home (SNF/NF) Swing Bed
X0200. Name of Resident (A0500 on existing record to be modified/inactivated)
	A. First name: C. Last name:
X0300. Gender (A0800 on existing record to be modified/inactivated)
Enter Code	Male Female

X0400. Birth Date (A0900 on existing record to be modified/inactivated)

_

Month

_

Day

Year

X0500. Social Security Number (A0600A on existing record to be modified/inactivated)

_ _

X0600. Type of Assessment (A0310 on existing record to be modified/inactivated)

Enter Code

Enter Code

Enter Code

Enter Code

1. Federal OBRA Reason for Assessment

   1. Admission assessment (required by day 14)

   2. Quarterly review assessment

   3. Annual assessment

   4. Significant change in status assessment

   5. Significant correction to prior comprehensive assessment

   6. Significant correction to prior quarterly assessment

99. None of the above

2. PPS Assessment.

PPS Scheduled Assessment for a Medicare Part A Stay

1. 5-day scheduled assessment

PPS Unscheduled Assessment for a Medicare Part A Stay.

08. IPA - Interim Payment Assessment

Not PPS Assessment

99. None of the above

6. Entry/discharge reporting

01. Entry tracking record

8. Discharge assessment-return not anticipated

9. Discharge assessment-return anticipated

10. Death in facility tracking record

99. None of the above

H. Is this a SNF Part A PPS Discharge Assessment?

0. No

1. Yes

X0700. Date on existing record to be modified/inactivated - Complete one only

1. Assessment Reference Date (A2300 on existing record to be modified/inactivated) - Complete only if X0600F = 99

_

Month

_

Day

Year

2. Discharge Date (A2000 on existing record to be modified/inactivated) - Complete only if X0600F = 10, 11, or 12

_

Month

_

Day

Year

3. Entry Date (A1600 on existing record to be modified/inactivated) - Complete only if X0600F = 01

_

Month

_

Day

Year

Correction Attestation Section - Complete this section to explain and attest to the modification/inactivation request

X0800. Correction Number

Enter Number

Enter the number of correction requests to modify/inactivate the existing record, including the present one

Section Z		Assessment Administration
Z0100. Medicare Part A Billing
	Medicare Part A HIPPS code: Version code:
Z0300. Insurance Billing
	Billing code: Billing version:

Section Z		Assessment Administration
Z0400. Signature of Persons Completing the Assessment or Entry/Death Reporting
	I certify that the accompanying information accurately reflects resident assessment 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 participation in the government-funded health care programs is conditioned on the accuracy and truthfulness of this information, and that I may be personally subject to or may subject my organization to substantial criminal, civil, and/or administrative penalties for submitting false information. I also certify that I am authorized to submit this information by this facility on its behalf.
	Signature		Title	Sections	Date Section Completed
	A.
	B.
	C.
	D.
	E.
	F.
	G.
	H.
	I.
	J.
	K.
	L.
Z0500. Signature of RN Assessment Coordinator Verifying Assessment Completion
	A. Signature: B. Date RN Assessment Coordinator signed assessment as complete: _ _ Month Day Year

Legal Notice Regarding MDS 3.0 - Copyright 2011 United States of America and interRAI. This work may be freely used and distributed solely within the United States. Portions of the MDS 3.0 are under separate copyright protections; Pfizer Inc. holds the copyright for the PHQ-9; Confusion Assessment Method. © 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Both Pfizer Inc. and the Hospital Elder Life Program, LLC have granted permission to use these instruments in association with the MDS 3.0.

MDS 3.0 Swing Bed PPS (SP) Version 1.17.2 Effective 10/01/2020

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