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pdfResident
Identifier
Date
MINIMUM DATA SET (MDS) - Version 3.0
RESIDENT ASSESSMENT AND CARE SCREENING
Nursing Home Part A PPS Discharge (NPE) Item Set
Section A - Identification Information
A0050.
Type of Record
Enter Code
A0100.
•
•
•
1.
2.
3.
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
Facility Provider Numbers
A.
B.
C.
National Provider Identifier (NPI):
CMS Certification Number (CCN):
State Provider Number:
A0200.
Type of Provider
Enter Code
Type of provider
•
1. Nursing home (SNF/NF)
•
2. Swing Bed
A0310.
Type of Assessment
Enter Code
A.
Federal OBRA Reason for Assessment
•
•
01.
02.
03.
04.
05.
06.
99.
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
•
•
•
•
•
Enter Code
•
•
•
•
•
Enter Code
Enter Code
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
None of the above
E.
Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry
or reentry?
•
•
0.
1.
F.
Entry/discharge reporting
•
01.
10.
11.
12.
99.
•
•
•
•
No
Yes
Entry tracking record
Discharge assessment - return not anticipated
Discharge assessment - return anticipated
Death in facility tracking record
None of the above
A0310 continued on next page
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 1 of 26
Resident
Identifier
Date
Section A - Identification Information
A0310.
Enter Code
Enter Code
A0410.
Type of Assessment - Continued
G.
Type of discharge
•
•
1.
2.
H.
Is this a SNF Part A PPS Discharge Assessment?
•
0.
1.
•
A0500.
•
•
•
C.
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
First name:
B.
Last name:
D.
Middle initial:
Suffix:
Social Security and Medicare Numbers
A.
B.
A0700.
1.
2.
3.
Legal Name of Resident
A.
A0600.
No
Yes
Unit Certification or Licensure Designation
Enter Code
Planned
Unplanned
Social Security Number:
-
-
Medicare Number:
Medicaid Number
Enter “+” if pending, “N” if not a Medicaid recipient
A0810.
Sex
Enter Code
A0900.
•
•
1.
2.
Male
Female
Birth Date
-
-
Month
Day
Year
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 2 of 26
Resident
Identifier
Date
Section A - Identification Information
A1005.
Ethnicity
Are you of Hispanic, Latino/a, or Spanish origin?
↓
□
□
□
□
□
□
□
A1010.
Check all that apply
A.
No, not of Hispanic, Latino/a, or Spanish origin
B.
Yes, Mexican, Mexican American, Chicano/a
C.
Yes, Puerto Rican
D.
Yes, Cuban
E.
Yes, another Hispanic, Latino/a, or Spanish origin
X.
Resident unable to respond
Y.
Resident declines to respond
Race
What is your race?
↓
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
A1200.
Check all that apply
A.
White
B.
Black or African American
C.
American Indian or Alaska Native
D.
Asian Indian
E.
Chinese
F.
Filipino
G.
Japanese
H.
Korean
I.
Vietnamese
J.
Other Asian
K.
Native Hawaiian
L.
Guamanian or Chamorro
M.
Samoan
N.
Other Pacific Islander
X.
Resident unable to respond
Y.
Resident declines to respond
Z.
None of the above
Marital Status
Enter Code
•
•
•
•
•
1.
2.
3.
4.
5.
Never married
Married
Widowed
Separated
Divorced
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 3 of 26
Resident
Identifier
Date
Section A - Identification Information
A1300.
Optional Resident Items
A.
Medical record number:
B.
Room number:
C.
Name by which resident prefers to be addressed:
D.
Lifetime occupation(s) - put “/” between two occupations:
Most Recent Admission/Entry or Reentry into this Facility
A1600.
Entry Date
-
-
Month
A1700.
•
•
A1805.
•
•
•
•
•
•
•
•
•
•
•
•
•
A1900.
1.
2.
Admission
Reentry
Entered From
Enter Code
Year
Type of Entry
Enter Code
Day
01. Home/Community (e.g., private home/apt., board/care, assisted living, group home, transitional living, other residential
care arrangements)
02. Nursing Home (long-term care facility)
03. Skilled Nursing Facility (SNF, swing beds)
04. Short-Term General Hospital (acute hospital, IPPS)
05. Long-Term Care Hospital (LTCH)
06. Inpatient Rehabilitation Facility (IRF, free standing facility or unit)
07. Inpatient Psychiatric Facility (psychiatric hospital or unit)
08. Intermediate Care Facility (ID/DD facility)
09. Hospice (home/non-institutional)
10. Hospice (institutional facility)
11. Critical Access Hospital (CAH)
12. Home under care of organized home health service organization
99. Not listed
Admission Date (Date this episode of care in this facility began)
-
-
Month
A2300.
Day
Year
Assessment Reference Date
Observation end date:
-
-
Month
Day
Year
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 4 of 26
Resident
Identifier
Date
Section A - Identification Information
A2400.
Medicare Stay
Enter Code
A.
Has the resident had a Medicare-covered stay since the most recent entry?
•
•
0.
1.
B.
Start date of most recent Medicare stay:
No → Skip to B0100, Comatose
Yes → Continue to A2400B, Start date of most recent Medicare stay
-
-
Month
C.
Day
Year
End date of most recent Medicare stay - Enter dashes if stay is ongoing:
-
-
Month
Day
Year
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 5 of 26
Resident
Identifier
Date
Look back period for all items is 7 days unless another time frame is indicated
Section B - Hearing, Speech, and Vision
B0100.
Comatose
Enter Code
Persistent vegetative state/no discernible consciousness
•
0. No → Continue to B1300, Health Literacy
•
1. Yes → Skip to GG0130, Self-Care
B1300.
Health Literacy
Enter Code
How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor
or pharmacy?
•
0. Never
•
1. Rarely
•
2. Sometimes
•
3. Often
•
4. Always
•
7. Resident declines to respond
•
8. Resident unable to respond
The Single Item Literacy Screener is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 6 of 26
Resident
Identifier
Date
Section C - Cognitive Patterns
C0100.
Should Brief Interview for Mental Status (C0200–C0500) be Conducted?
Attempt to conduct interview with all residents
Enter Code
0.
1.
•
•
No (resident is rarely/never understood) → Skip to and complete C1310, Signs and Symptoms of Delirium (from CAM ©)
Yes → Continue to C0200, Repetition of Three Words
Brief Interview for Mental Status (BIMS)
C0200.
Enter Code
Repetition of Three Words
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
•
0. None
•
1. One
•
2. Two
•
3. 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.
C0300.
Temporal Orientation (orientation to year, month, and day)
Ask resident: “Please tell me what year it is right now.”
A. Able to report correct year
Enter Code
0.
1.
2.
3.
•
•
•
•
Ask resident: “What month are we in right now?”
B. Able to report correct month
Enter Code
0.
1.
2.
•
•
•
0.
1.
•
•
C0400.
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”
0.
1.
2.
•
•
•
B.
Enter Code
•
C.
Enter Code
•
•
•
C0500.
Enter Score
No - could not recall
Yes, after cueing (“something to wear”)
Yes, no cue required
Able to recall “blue”
0.
1.
2.
•
•
Incorrect or no answer
Correct
Recall
Enter Code
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
Enter Code
Missed by > 5 years or no answer
Missed by 2–5 years
Missed by 1 year
Correct
No - could not recall
Yes, after cueing (“a color”)
Yes, no cue required
Able to recall “bed”
0.
1.
2.
No - could not recall
Yes, after cueing (“a piece of furniture”)
Yes, no cue required
BIMS Summary 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
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 7 of 26
Resident
Identifier
Date
Section C - Cognitive Patterns
Delirium
C1310.
Signs and Symptoms of Delirium (from CAM ©)
Enter Code
A.
Acute Onset Mental Status Change
Is there evidence of an acute change in mental status from the resident’s baseline?
•
•
0.
1.
No
Yes
Coding:
•
0. Behavior not present
•
1. Behavior continuously present, does
not fluctuate
•
2. 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
Adapted from: Inouye, S. K., et al. Ann Intern Med. 1990; 113: 941–948. Confusion Assessment Method. © 2003, Hospital Elder Life Program, LLC. Not to be
reproduced without permission.
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 8 of 26
Resident
Identifier
Date
Section D - Mood
D0100.
Should Resident Mood Interview be Conducted?
Attempt to conduct interview with all residents
Enter Code
D0150.
•
•
0.
1.
No (resident is rarely/never understood) → Skip to and complete D0700, Social Isolation
Yes → Continue to D0150, Resident Mood Interview (PHQ-2 to 9 ©)
Resident Mood Interview (PHQ-2 to 9 ©)
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.
1. Symptom Presence
2. Symptom Frequency
•
0. No (enter 0 in column 2)
•
0. Never or 1 day
•
1. Yes (enter 0–3 in column 2)
•
1. 2–6 days (several days)
•
9. No response (leave column 2 blank)
•
2. 7–11 days (half or more of the days)
•
3. 12–14 days (nearly every day)
•
Enter Scores in Boxes
A.
Little interest or pleasure in doing things
B.
Feeling down, depressed, or hopeless
1. Symptom
Presence
2. Symptom
Frequency
If both D0150A1 and D0150B1 are coded 9, OR both D0150A2 and D0150B2 are coded 0 or 1, END the PHQ interview; otherwise, continue.
C.
Trouble falling or staying asleep, or sleeping too much
D.
Feeling tired or having little energy
E.
Poor appetite or overeating
F.
Feeling bad about yourself - or that you are a failure or have let yourself or your family down
G.
Trouble concentrating on things, such as reading the newspaper or watching television
H.
Moving or speaking so slowly that other people could have noticed.
Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
I.
Thoughts that you would be better off dead, or of hurting yourself in some way
D0160.
Enter Score
Total Severity Score
Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more required items).
Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 9 of 26
Resident
Identifier
Date
Section D - Mood
D0700.
Social Isolation
Enter Code
How often do you feel lonely or isolated from those around you?
•
0. Never
•
1. Rarely
•
2. Sometimes
•
3. Often
•
4. Always
•
7. Resident declines to respond
•
8. Resident unable to respond
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 10 of 26
Resident
Identifier
Date
Section GG - Functional Abilities - Discharge
GG0130. Self-Care (Assessment period is the last 3 days of the Stay)
Complete when A2400C minus A2400B is greater than 2.
Code the resident’s usual performance at the end of the stay for each activity using the 6-point scale. If an activity was not attempted
at the end of the 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.
If activity was not attempted, code reason:
•
06.
Independent - Resident completes the activity by themself with no assistance from a helper.
•
07. Resident refused
•
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.
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
•
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.
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.
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 11 of 26
Resident
Identifier
Date
Section GG - Functional Abilities - Discharge
GG0170. Mobility (Assessment period is the last 3 days of the Stay)
Complete when A2400C minus A2400B is greater than 2.
Code the resident’s usual performance at the end of the stay for each activity using the 6-point scale. If an activity was not attempted
at the end of the 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.
If activity was not attempted, code reason:
•
06.
Independent - Resident completes the activity by themself with no assistance from a helper.
•
07. Resident refused
•
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.
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
•
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.
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 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.
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 12 of 26
Resident
Identifier
Date
Section GG - Functional Abilities - Discharge
GG0170. Mobility (Assessment period is the last 3 days of the Stay)
Complete when A2400C minus A2400B is greater than 2.
Code the resident’s usual performance at the end of the stay for each activity using the 6-point scale. If an activity was not attempted
at the end of the 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.
If activity was not attempted, code reason:
•
06.
Independent - Resident completes the activity by themself with no assistance from a helper.
•
07. Resident refused
•
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.
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
•
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.
3. Discharge
Performance
Enter Codes in Boxes
L.
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.
Does the resident use a wheelchair and/or scooter?
•
0.
•
1.
No → Skip to J1800, Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS),
whichever is more recent
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.
Enter Code
Enter Code
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.
Enter Code
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.
•
•
S.
1.
2.
Manual
Motorized
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.
•
•
1.
2.
Manual
Motorized
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 13 of 26
Resident
Identifier
Date
Section J - Health Conditions
J0200.
Should Pain Assessment Interview be Conducted?
Attempt to conduct interview with all residents.
Enter Code
0.
•
1.
•
No (resident is rarely/never understood) → Skip to J1800, Any Falls Since Admission/Entry or Reentry or Prior Assessment
(OBRA or Scheduled PPS), whichever is more recent
Yes → Continue to J0300, Pain Presence
Pain Assessment Interview
J0300.
Enter Code
Pain Presence
Ask resident: “Have you had pain or hurting at any time in the last 5 days?”
0. No → Skip to J1800, Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS),
whichever is more recent
•
1. Yes → Continue to J00510, Pain Effect on Sleep
•
9. Unable to answer → Skip to J1800, Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or
Scheduled PPS), whichever is more recent
•
J0510.
Enter Code
J0520.
Enter Code
J0530.
Enter Code
Pain Effect on Sleep
Ask resident: “Over the past 5 days, how much of the time has pain made it hard for you to sleep at night?”
1. Rarely or not at all
•
2. Occasionally
•
3. Frequently
•
4. Almost constantly
•
8. Unable to answer
•
Pain Interference with Therapy Activities
Ask resident: “Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due
to pain?”
•
0. Does not apply - I have not received rehabilitation therapy in the past 5 days
•
1. Rarely or not at all
•
2. Occasionally
•
3. Frequently
•
4. Almost constantly
•
8. Unable to answer
Pain Interference with Day-to-Day Activities
Ask resident: “Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy
sessions) because of pain?”
•
1. Rarely or not at all
•
2. Occasionally
•
3. Frequently
•
4. Almost constantly
•
8. Unable to answer
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 14 of 26
Resident
Identifier
Date
Section J - Health Conditions
J1800.
Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS),
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?
•
0. No → Skip to K0520, Nutritional Approaches
•
1. 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
whichever is more recent
Coding:
•
0. None
•
1. One
•
2. 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
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 15 of 26
Resident
Identifier
Date
Section K - Swallowing/Nutritional Status
K0520.
Nutritional Approaches
Check all of the following nutritional approaches that apply
4. At Discharge
Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C
Check all that apply
•
A.
Parenteral/IV feeding
•
B.
Feeding tube (e.g., nasogastric or abdominal (PEG))
•
C.
Mechanically altered diet - require change in texture of food or liquids
(e.g., pureed food, thickened liquids)
•
D.
Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
•
Z.
None of the above
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
4. At
Discharge
□
□
□
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Page 16 of 26
Resident
Identifier
Date
Section M - Skin Conditions
Report based on highest stage of existing ulcers/injuries at their worst; do not “reverse” stage
M0210.
Unhealed Pressure Ulcers/Injuries
Enter Code
Does this resident have one or more unhealed pressure ulcers/injuries?
•
0. No → Skip to N0415, High-Risk Drug Classes: Use and Indication
•
1. 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
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
Enter Number
1.
Number of Stage 2 pressure ulcers - If 0 → Skip to M0300C, Stage 3
Enter Number
2.
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
Enter Number
1.
Number of Stage 3 pressure ulcers - If 0 → Skip to M0300D, Stage 4
Enter Number
2.
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
Enter Number
1.
Number of Stage 4 pressure ulcers - If 0 → Skip to M0300E, Unstageable - Non-removable dressing/device
Enter Number
2.
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
E.
Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device
Enter Number
1.
Number of unstageable pressure ulcers/injuries due to non-removable dressing/device - If 0 → Skip to M0300F,
Unstageable - Slough and/or eschar
Enter Number
2.
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
Enter Number
1.
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
Enter Number
2.
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
M0300 continued on next page
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 17 of 26
Resident
Identifier
Date
Section M - Skin Conditions
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage - Continued
G.
Unstageable - Deep tissue injury:
Enter Number
1.
Number of unstageable pressure injuries presenting as deep tissue injury - If 0 → Skip to N0415, High-Risk Drug Classes:
Use and Indication
Enter Number
2.
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
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 18 of 26
Resident
Identifier
Date
Section N - Medications
N0415.
High-Risk Drug Classes: Use and Indication
1. Is taking
Check if the resident is taking any 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
2. Indication noted
If Column 1 is checked, check if there is an indication noted for all
medications in the drug class
Check all that apply
•
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
•
I.
Antiplatelet
•
J.
Hypoglycemic (including insulin)
•
K.
Anticonvulsant
•
Z.
None of the above
1. Is
taking
□
□
□
□
□
□
□
□
□
□
□
□
2. Indication
noted
□
□
□
□
□
□
□
□
□
□
□
N2005.
Medication Intervention
Enter Code
Did the facility contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the
next calendar day each time potential clinically significant medication issues were identified since the admission?
•
0. No
•
1. Yes
•
9. N/A - There were no potential clinically significant medication issues identified since admission or resident is not taking
any medications
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 19 of 26
Resident
Identifier
Date
Section O - Special Treatments, Procedures, and Programs
O0110.
Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that were performed
c. At Discharge
Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C
Check all that apply
Cancer Treatments
•
A1. Chemotherapy
•
A2. IV
•
A3. Oral
A10. Other
•
•
B1. Radiation
Respiratory Treatments
•
C1. Oxygen therapy
•
C2. Continuous
•
C3. Intermittent
C4. High-concentration
•
•
D1. Suctioning
D2. Scheduled
•
D3. As needed
•
•
E1.
Tracheostomy care
•
F1.
Invasive Mechanical Ventilator (ventilator or respirator)
•
G1. Non-invasive Mechanical Ventilator
G2. BiPAP
•
G3. CPAP
•
Other
•
H1. IV Medications
•
H2. Vasoactive medications
•
H3. Antibiotics
•
H4. Anticoagulant
•
H10. Other
•
I1.
Transfusions
•
J1.
Dialysis
J2. Hemodialysis
•
J3. Peritoneal dialysis
•
•
K1. Hospice care
•
M1. Isolation or quarantine for active infectious disease (does not include standard body/fluid precautions)
•
O1. IV Access
•
O2. Peripheral
•
O3. Midline
•
O4. Central (e.g., PICC, tunneled, port)
None of the Above
•
Z1.
None of the above
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
c. At
Discharge
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
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Page 20 of 26
Resident
Identifier
Date
Section O - Special Treatments, Procedures, and Programs
O0350.
Resident’s COVID-19 vaccination is up to date
Enter Code
O0425.
A.
•
•
0.
1.
No, resident is not up to date
Yes, resident is up to date
Part A Therapies
Speech-Language Pathology and Audiology Services
Enter Number of Minutes
Enter Number of Minutes
Enter Number of Minutes
• 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
Enter Number of Minutes
Enter Number of Days
B.
• 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)
Occupational Therapy
Enter Number of Minutes
Enter Number of Minutes
Enter Number of Minutes
• 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
Enter Number of Minutes
Enter Number of Days
• 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)
O0425 continued on next page
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 21 of 26
Resident
Identifier
Section
Special- Continued
Treatments,
O0425.
PartOA -Therapies
C.
Date
Procedures, and Programs
Physical Therapy
Enter Number of Minutes
Enter Number of Minutes
Enter Number of Minutes
• 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
Enter Number of Minutes
Enter Number of Days
O0430.
• 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)
Distinct Calendar Days of Part A Therapy
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)
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 22 of 26
Resident
Identifier
Date
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
•
1. Nursing home (SNF/NF)
•
2. Swing Bed
X0200.
Name of Resident (A0500 on existing record to be modified/inactivated)
A.
C.
X0310.
X0400.
Last name:
Sex (A0810 on existing record to be modified/inactivated)
Enter Code
First name:
•
•
1.
2.
Male
Female
Birth Date (A0900 on existing record to be modified/inactivated)
-
-
Month
X0500.
Day
Year
Social Security Number (A0600A on existing record to be modified/inactivated)
-
-
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 23 of 26
Resident
Identifier
Date
Section X - Correction Request
X0600.
Type of Assessment (A0310 on existing record to be modified/inactivated)
Enter Code
A.
Federal OBRA Reason for Assessment
•
•
01.
02.
03.
04.
05.
06.
99.
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
F.
Entry/discharge reporting
•
•
01.
10.
11.
12.
99.
H.
Is this a SNF Part A PPS Discharge Assessment?
•
0.
1.
•
•
•
•
•
Enter Code
•
•
•
•
Enter Code
•
•
•
Enter Code
X0700.
•
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
None of the above
Entry tracking record
Discharge assessment - return not anticipated
Discharge assessment - return anticipated
Death in facility tracking record
None of the above
No
Yes
Date on existing record to be modified/inactivated
Complete one only
A.
Assessment Reference Date (A2300 on existing record to be modified/inactivated) - Complete only if X0600F = 99
-
-
Month
B.
Year
Discharge Date (A2000 on existing record to be modified/inactivated) - Complete only if X0600F = 10, 11, or 12
-
-
Month
C.
Day
Day
Year
Entry Date (A1600 on existing record to be modified/inactivated) - Complete only if X0600F = 01
-
-
Month
Day
Year
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 24 of 26
Resident
Identifier
Date
Section X - Correction Request
Correction Attestation Section
Complete this section to explain and attest to the modification/inactivation request
X0800.
Enter Number
X0900.
↓
□
□
□
□
□
X1050.
↓
□
□
X1100.
Correction Number
Enter the number of correction requests to modify/inactivate the existing record, including the present one
Reasons for Modification
Complete only if Type of Record is to modify a record in error (A0050 = 2)
Check all that apply
A.
Transcription error
B.
Data entry error
C.
Software product error
D.
Item coding error
Z.
Other error requiring modification
If “Other” checked, please specify: _____________________________________________________________________________
Reasons for Inactivation
Complete only if Type of Record is to inactivate a record in error (A0050 = 3)
Check all that apply
A.
Event did not occur
Z.
Other error requiring inactivation
If “Other” checked, please specify: _____________________________________________________________________________
RN Assessment Coordinator Attestation of Completion
A.
B.
Attesting individual’s first name:
Attesting individual’s last name:
C.
Attesting individual’s title:
D.
Signature
E.
Attestation date
-
-
Month
Day
Year
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 25 of 26
Resident
Identifier
Date
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.
A.
Signature of RN Assessment Coordinator Verifying Assessment Completion
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. Question on transportation has been derived from
the national PRAPARE® social drivers of health assessment tool (2016), for which the National Association of Community Health Centers (NACHC) holds the
copyright. Pfizer Inc., the Hospital Elder Life Program, LLC, and NACHC have granted permission to use these instruments in association with the MDS 3.0. All
rights reserved.
MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.20.1 Effective 10/01/2025
Page 26 of 26
| File Type | application/pdf |
| File Title | MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Item Set |
| Author | Centers for Medicare & Medicaid Services |
| File Modified | 2025-07-15 |
| File Created | 2024-10-21 |