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pdfResident
Identifier
Date
MINIMUM DATA SET (MDS) - Version 3.0
RESIDENT ASSESSMENT AND CARE SCREENING
Swing Bed Discharge (SD) Item Set
Section A - Identification Information
A0050. Type of Record
Enter Code
•
•
•
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
A0100. 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?
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0.
1.
F.
Entry/discharge reporting
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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
Swing
Bed
Discharge
(SD)
Version
1.20.1
Effective
10/01/2025
Page 1 of 33
Resident
Identifier
Date
Section A - Identification Information
A0310. Type of Assessment - Continued
Enter Code
Enter Code
Enter Code
G.
Type of discharge - Complete only if A0310F = 10 or 11
•
1.
2.
•
Planned
Unplanned
G1. Is this a SNF Part A Interrupted Stay?
•
0.
1.
H.
Is this a SNF Part A PPS Discharge Assessment?
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0.
1.
•
•
No
Yes
No
Yes
A0410. Unit Certification or Licensure Designation
Enter Code
•
•
•
1.
2.
3.
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.
C.
First name:
B.
Last name:
D.
Middle initial:
Suffix:
A0600. Social Security and Medicare Numbers
A.
B.
Social Security Number:
-
-
Medicare Number:
A0700. Medicaid Number
Enter “+” if pending, “N” if not a Medicaid recipient
A0810. Sex
Enter Code
•
•
1.
2.
Male
Female
A0900. Birth Date
-
-
Month
Day
Year
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Resident
Identifier
Date
Section A - Identification Information
A1005. Ethnicity
Are you of Hispanic, Latino/a, or Spanish origin?
↓
□
□
□
□
□
□
□
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
A1010. Race
What is your race?
↓
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□
□
□
□
□
□
□
□
□
□
□
□
□
□
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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
A1200. Marital Status
Enter Code
•
•
•
•
•
1.
2.
3.
4.
5.
Never married
Married
Widowed
Separated
Divorced
MDS
3.0
Swing
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Version
1.20.1
Effective
10/01/2025
Page 3 of 33
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
Day
Year
A1700. Type of Entry
Enter Code
•
•
1.
2.
Admission
Reentry
A1805. Entered From
Enter Code
•
•
•
•
•
•
•
•
•
•
•
•
•
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
A1900. Admission Date (Date this episode of care in this facility began)
-
-
Month
Day
Year
A2000. Discharge Date
Complete only if A0310F = 10, 11, or 12
-
-
Month
Day
Year
MDS
3.0
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Version
1.20.1
Effective
10/01/2025
Page 4 of 33
Resident
Identifier
Date
Section A - Identification Information
A2105. Discharge Status
Complete only if A0310F = 10, 11, or 12
Enter Code
•
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•
•
•
•
•
•
•
•
•
•
•
01. Home/Community (e.g., private home/apt., board/care, assisted living, group home, transitional living, other residential care
arrangements) → Skip to A2123, Provision of Current Reconciled Medication List to Resident at Discharge
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
13. Deceased
99. Not listed → Skip to A2123, Provision of Current Reconciled Medication List to Resident at Discharge
A2121. Provision of Current Reconciled Medication List to Subsequent Provider at Discharge
Complete only if A0310H = 1 and A2105 = 02–12
Enter Code
At the time of discharge to another provider, did your facility provide the resident’s current reconciled medication list to the
subsequent provider?
•
0. No - Current reconciled medication list not provided to the subsequent provider → Skip to A2300, Assessment
Reference Date
•
1. Yes - Current reconciled medication list provided to the subsequent provider
A2122. Route of Current Reconciled Medication List Transmission to Subsequent Provider
Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider.
Complete only if A2121 = 1
↓
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□
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□
□
Check all that apply
Route of Transmission
A.
Electronic Health Record
B.
Health Information Exchange
C.
Verbal (e.g., in-person, telephone, video conferencing)
D.
Paper-based (e.g., fax, copies, printouts)
E.
Other methods (e.g., texting, email, CDs)
A2123. Provision of Current Reconciled Medication List to Resident at Discharge
Complete only if A0310H = 1 and A2105 = 01, 99
Enter Code
At the time of discharge, did your facility provide the resident’s current reconciled medication list to the resident, family
and/or caregiver?
•
0. No - Current reconciled medication list not provided to the resident, family and/or caregiver → Skip to A2300, Assessment
Reference Date
•
1. Yes - Current reconciled medication list provided to the resident, family and/or caregiver
MDS
3.0
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Version
1.20.1
Effective
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Resident
Identifier
Date
Section A - Identification Information
A2124. Route of Current Reconciled Medication List Transmission to Resident
Indicate the route(s) of transmission of the current reconciled medication list to the resident/family/caregiver.
Complete only if A2123 = 1
↓
□
□
□
□
□
Check all that apply
Route of Transmission
A.
Electronic Health Record (e.g., electronic access to patient portal)
B.
Health Information Exchange
C.
Verbal (e.g., in-person, telephone, video conferencing)
D.
Paper-based (e.g., fax, copies, printouts)
E.
Other methods (e.g., texting, email, CDs)
A2300. Assessment Reference Date
Observation end date:
-
-
Month
Day
Year
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
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3.0
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Bed
Discharge
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Version
1.20.1
Effective
10/01/2025
Page 6 of 33
Resident
Identifier
Date
Section BLook
- Hearing,
Speech,
andisVision
back period
for all items
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
Complete only if A0310B = 01 or A0310G = 1 and A0310H = 1
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?
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0. Never
•
1. Rarely
•
2. Sometimes
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3. Often
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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
Swing
Bed
Discharge
(SD)
Version
1.20.1
Effective
10/01/2025
Page 7 of 33
Resident
Identifier
Date
Section C - Cognitive Patterns
C0100. Should Brief Interview for Mental Status (C0200–C0500) be Conducted?
If A0310G = 2 skip to C0700. Otherwise, attempt to conduct interview with all residents
Enter Code
0.
1.
•
•
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
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0. None
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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.
•
•
•
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
0.
1.
•
•
Incorrect or no answer
Correct
C0400. Recall
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”
Enter Code
0.
1.
2.
•
•
•
B.
Enter Code
•
•
C.
Enter Code
•
•
•
Able to recall “blue”
0.
1.
2.
•
No - could not recall
Yes, after cueing (“something to wear”)
Yes, no cue required
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
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
MDS
3.0
Swing
Bed
Discharge
(SD)
Version
1.20.1
Effective
10/01/2025
Page 8 of 33
Resident
Identifier
Date
Section C - Cognitive Patterns
C0600. Should the Staff Assessment for Mental Status (C0700–C1000) be Conducted?
Enter Code
0.
1.
•
•
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
Seems or appears to recall after 5 minutes
•
0. Memory OK
•
1. Memory problem
Enter Code
C1000. Cognitive Skills for Daily Decision Making
Made decisions regarding tasks of daily life
•
0. Independent - decisions consistent/reasonable
•
1. Modified independence - some difficulty in new situations only
•
2. Moderately impaired - decisions poor; cues/supervision required
•
3. Severely impaired - never/rarely made decisions
Enter Code
Delirium
C1310. Signs and Symptoms of Delirium (from CAM ©)
Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical record
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
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1.20.1
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Page 9 of 33
Resident
Identifier
Date
Section D - Mood
D0100. Should Resident Mood Interview be Conducted?
If A0310G = 2, skip to E0100. Otherwise, attempt to conduct interview with all residents
Enter Code
•
•
0.
1.
No (resident is rarely/never understood) → Skip to and complete D0500–D0600, Staff Assessment of Resident
Mood (PHQ-9-OV)
Yes → Continue to D0150, Resident Mood Interview (PHQ-2 to 9 ©)
D0150. 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. Total Severity Score
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 required items).
Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.
MDS
3.0
Swing
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Discharge
(SD)
Version
1.20.1
Effective
10/01/2025
Page 10 of 33
Resident
Identifier
Date
Section D - Mood
D0500. Staff Assessment of Resident Mood (PHQ-9-OV*)
Do not conduct if Resident Mood Interview (D0150–D0160) 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.
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)
•
•
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 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 they feel bad about self, are a failure, or have 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 they have 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
1. Symptom
Presence
2. Symptom
Frequency
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.
D0700. Social Isolation
Complete only if A0310G = 1
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
* Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.
MDS
3.0
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Discharge
(SD)
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1.20.1
Effective
10/01/2025
Page 11 of 33
Resident
Identifier
Date
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 and Frequency
Note presence of symptoms and their frequency
Coding:
•
0. Behavior not exhibited
•
1. Behavior of this type occurred 1 to
3 days
•
2. Behavior of this type occurred 4 to 6
days, but less than daily
•
3. 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 and 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.
•
0. Behavior not exhibited
•
1. Behavior of this type occurred 1 to 3 days
•
2. Behavior of this type occurred 4 to 6 days, but less than daily
•
3. Behavior of this type occurred daily
E0900. Wandering - Presence and Frequency
Enter Code
Has the resident wandered?
•
0. Behavior not exhibited
•
1. Behavior of this type occurred 1 to 3 days
•
2. Behavior of this type occurred 4 to 6 days, but less than daily
•
3. Behavior of this type occurred daily
MDS
3.0
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Version
1.20.1
Effective
10/01/2025
Page 12 of 33
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 and A2105 is not = 04.
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.
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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 and A2105 is not = 04.
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.
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Resident
Identifier
Date
Section GG - Functional Abilities - Discharge
Admission
GG0170. Mobility (Assessment period is the last 3 days of the stay)
Complete when A2400C minus A2400B is greater than 2 and A2105 is not = 04.
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 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.
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
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Resident
Identifier
Date
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
H0300. Urinary Continence
Enter Code
Urinary continence - Select the one category that best describes the resident
•
0. Always continent
•
1. Occasionally incontinent (less than 7 episodes of incontinence)
•
2. Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding)
•
3. 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
•
0. Always continent
•
1. Occasionally incontinent (one episode of bowel incontinence)
•
2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement)
•
3. 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
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Resident
Identifier
Date
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
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Heart/Circulation
I0900.
Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
Genitourinary
I1550.
Neurogenic Bladder
I1650.
Obstructive Uropathy
Infections
I2300.
Urinary Tract Infection (UTI) (LAST 30 DAYS)
Metabolic
I2900.
Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)
Neurological
I5250.
Huntington’s Disease
I5350.
Tourette’s Syndrome
Nutritional
I5600.
Malnutrition (protein or calorie) or at risk for malnutrition
Psychiatric/Mood Disorder
I5700.
Anxiety Disorder
I5900.
Bipolar Disorder
I5950.
Psychotic Disorder (other than schizophrenia)
I6000.
Schizophrenia (e.g., schizoaffective and schizophreniform disorders)
I6100.
Post Traumatic Stress Disorder (PTSD)
None of Above
I7900.
None of the above active diagnoses within the last 7 days
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.
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Resident
Identifier
Date
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?
•
•
0.
1.
B.
Received PRN pain medications OR was offered and declined?
•
•
0.
1.
C.
Received non-medication intervention for pain?
•
0.
1.
•
No
Yes
No
Yes
No
Yes
J0200. Should Pain Assessment Interview be Conducted?
If resident is comatose or if A0310G = 2, skip to J1100, Shortness of Breath (dyspnea). Otherwise, attempt to conduct
interview with all residents.
Enter Code
0.
1.
•
•
No (resident is rarely/never understood) → Skip to and complete J1100, Shortness of Breath
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?”
0. No → Skip to J1100, Shortness of Breath (dyspnea)
•
1. Yes → Continue to J0510, Pain Effect on Sleep
•
9. Unable to answer → Skip to J1100, Shortness of Breath (dyspnea)
•
J0510. Pain Effect on Sleep
Enter Code
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
•
J0520. Pain Interference with Therapy Activities
Enter Code
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
J0530. Pain Interference with Day-to-Day Activities
Enter Code
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
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Resident
Identifier
Date
Section J - Health Conditions
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)
•
0. No
•
1. Yes
J1550. Problem Conditions
↓
□
□
□
□
□
Check all that apply
A.
Fever
B.
Vomiting
C.
Dehydrated
D.
Internal bleeding
Z.
None of the above
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?
•
0. No → Skip to K0200, Height and Weight
•
1. Yes → Continue to J1900, Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS)
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Resident
Identifier
Date
Section J - Health Conditions
J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS),
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
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Resident
Identifier
Date
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
A.
Height (in inches)
Record most recent height measure since the most recent admission/entry or reentry
Pounds
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
•
0. No or unknown
•
1. Yes, on physician-prescribed weight-loss regimen
•
2. 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
•
0. No or unknown
•
1. Yes, on physician-prescribed weight-gain regimen
•
2. Yes, not on physician-prescribed weight-gain regimen
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
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4. At
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Page 21 of 33
Resident
Identifier
Date
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
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
M0300 continued on next page
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Resident
Identifier
Date
Section M - Skin Conditions
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage - Continued
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
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
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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
N2005. Medication Intervention
1. Is
taking
□
□
□
□
□
□
□
□
□
□
□
□
2. Indication
noted
□
□
□
□
□
□
□
□
□
□
□
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. N/A - There were no potential clinically significant medication issues identified since admission or resident is not taking
any medications
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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
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c. At
Discharge
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
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□
□
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Page 25 of 33
Resident
Identifier
Date
Section O - Special Treatments, Procedures, and Programs
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.
1.
B.
Date influenza vaccine received → Complete date and skip to O0300A, Is the resident’s Pneumococcal vaccination up to date?
No → Skip to O0250C, If influenza vaccine not received, state reason
Yes → Continue to O0250B, Date influenza vaccine received
-
-
Month
Enter Code
Day
Year
C.
If influenza vaccine not received, state reason:
•
1.
2.
3.
4.
5.
6.
9.
•
•
•
•
•
•
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
None of the above
O0300. Pneumococcal Vaccine
Enter Code
Enter Code
A.
Is the resident’s Pneumococcal vaccination up to date?
•
•
0.
1.
B.
If Pneumococcal vaccine not received, state reason:
•
1.
2.
3.
•
•
No → Continue to O0300B, If Pneumococcal vaccine not received, state reason
Yes → Skip to O0350, Resident’s COVID-19 vaccination is up to date
Not eligible - medical contraindication
Offered and declined
Not offered
O0350. Resident’s COVID-19 vaccination is up to date
Enter Code
•
•
0.
1.
No, resident is not up to date
Yes, resident is up to date
O0425. Part A Therapies
Complete only if A0310H = 1
A.
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
• 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
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Resident
Identifier
Date
Section O - Special Treatments, Procedures, and Programs
O0425. Part A Therapies - Continued
B.
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
C.
• 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)
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
• 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)
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Resident
Identifier
Date
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:
•
0. Not used
•
1. Used less than daily
•
2. 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
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Resident
Identifier
Date
Section Q - Participation in Assessment and Goal Setting
Q0400. Discharge Plan
Enter Code
A.
Is active discharge planning already occurring for the resident to return to the community?
•
0.
1.
•
No
Yes
Q0610. Referral
Enter Code
A.
Has a referral been made to the Local Contact Agency (LCA)?
•
0.
1.
•
No
Yes
Q0620. Reason Referral to Local Contact Agency (LCA) Not Made
Complete only if Q0610 = 0
Enter Code
Indicate reason why referral to LCA was not made
•
1. LCA unknown
•
2. Referral previously made
•
3. Referral not wanted
•
4. Discharge date 3 or fewer months away
•
5. Discharge date more than 3 months away
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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.
First name:
Last name:
X0310. Sex (A0810 on existing record to be modified/inactivated)
Enter Code
•
•
1.
2.
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)
-
-
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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
•
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
X0700. 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
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Resident
Identifier
Date
Section X - Correction Request
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
X0900. 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: _____________________________________________________________________________
X1050. 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: _____________________________________________________________________________
X1100. 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
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Resident
Identifier
Date
Section Z - Assessment Administration
Z0300. Insurance Billing
A.
B.
Billing code:
Billing version:
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. 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
Swing
Bed
Discharge
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Version
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Page 33 of 33
| File Type | application/pdf |
| File Title | MDS 3.0 Nursing Home Swing Bed (SD) Item Set |
| Author | Centers for Medicare & Medicaid Services |
| File Modified | 2025-03-28 |
| File Created | 2024-11-07 |