Long-Term Care Facilities - Virginia

Regulations

Federal

 

 

MINIMUM DATA SET (MDS) - Version 3.0       

RESIDENT ASSESSMENT AND CARE SCREENING              

Nursing Home Comprehensive (NC) Item Set

 

Section A.              Identification Information.

Section B.              Hearing, Speech, and Vision.

Section C.              Cognitive Patterns.

Section D.              Mood.

Section E.              Behavior.

Section F.              Preferences for Customary Routine and Activities.

Section G.              Functional Status.

Section GG.           Functional Abilities and Goals - Discharge (End of SNF PPS Stay).

Section H.              Bladder and Bowel.

Section I.               Active Diagnoses.

Section J.               Health Conditions.

Section K.              Swallowing/Nutritional Status.

Section L.              Oral/Dental Status.

Section M.             Skin Conditions.

Section N.             Medications.

Section O.             Special Treatments, Procedures, and Programs.

Section P.              Restraints and Alarms.

Section Q.             Participation in Assessment and Goal Setting.

Section V.              Care Area Assessment (CAA) Summary.

Section X.              Correction Request.

Section Z.              Assessment Administration.

 

Section A.  Identification Information.

A0050.  Type of Record.    

A0100.  Facility Provider Numbers. 

A0200.  Type of Provider. 

A0310.  Type of Assessment.            

A0410.  Unit Certification or Licensure Designation.   

A0500.  Legal Name of Resident.     

A0600.  Social Security and Medicare Numbers.          

A0700.  Medicaid Number

A0800.  Gender. 

A0900.  Birth Date.             

A1000.  Race/Ethnicity.     

A1100.  Language.              

A1200.  Marital Status.       

A1300.  Optional Resident Items.    

A1500.  Preadmission Screening and Resident Review (PASRR).              

A1510.  Level II Preadmission Screening and Resident Review (PASRR) Conditions.             

A1550.  Conditions Related to ID/DD Status. 

A1600.  Entry Date.            

A1700.  Type of Entry.       

A1800.  Entered From.      

A1900.  Admission Date    

A2000.  Discharge Date

A2100.  Discharge Status.

A2200.  Previous Assessment Reference Date for Significant Correction

A2300.  Assessment Reference Date.             

A2400.  Medicare Stay.     

Section B.  Hearing, Speech, and Vision.

B0100.  Comatose.              

B0200.  Hearing. 

B0300.  Hearing Aid.          

B0600.  Speech Clarity.      

B0700.  Makes Self Understood.      

B0800.  Ability To Understand Others.           

B1000.  Vision.     

B1200.  Corrective Lenses.               

Section C.  Cognitive Patterns.

C0100.  Should Brief Interview for Mental Status (C0200-C0500) be Conducted?

C0200.  Repetition of Three Words.

C0300.  Temporal Orientation (orientation to year, month, and day).      

C0400.  Recall.     

C0500.  BIMS Summary Score.         

C0600.  Should the Staff Assessment for Mental Status (C0700 - C1000) be Conducted?    

C0700.  Short-term Memory OK.     

C0800.  Long-term Memory OK.      

C0900.  Memory/Recall Ability.       

C1000.  Cognitive Skills for Daily Decision Making.       

C1310.  Signs and Symptoms of Delirium (from CAM©).             

Section D.  Mood.

D0100.  Should Resident Mood Interview be Conducted?

D0200.  Resident Mood Interview (PHQ-9©).               

D0300.  Total Severity Score

D0350.  Safety Notification

D0500.  Staff Assessment of Resident Mood (PHQ-9-OV*).

D0600.  Total Severity Score.           

D0650.  Safety Notification

Section E.  Behavior.

E0100.  Potential Indicators of Psychosis.      

E0200.  Behavioral Symptom - Presence & Frequency.              

E0300.  Overall Presence of Behavioral Symptoms.     

E0500.  Impact on Resident.             

E0600.  Impact on Others. 

E0800.  Rejection of Care - Presence & Frequency.    

E0900.  Wandering - Presence & Frequency.               

E1000.  Wandering - Impact.            

E1100.  Change in Behavior or Other Symptoms.         

Section F.  Preferences for Customary Routine and Activities.

F0300.  Should Interview for Daily and Activity Preferences be Conducted?

F0400.  Interview for Daily Preferences.       

F0500.  Interview for Activity Preferences.   

F0600.  Daily and Activity Preferences Primary Respondent.    

F0700.  Should the Staff Assessment of Daily and Activity Preferences be Conducted?      

F0800.  Staff Assessment of Daily and Activity Preferences.      

Section G.  Functional Status.

G0110.  Activities of Daily Living (ADL) Assistance..     

G0120.  Bathing.  

G0300.  Balance During Transitions and Walking.         

G0400.  Functional Limitation in Range of Motion.       

G0600.  Mobility Devices. 

G0900.  Functional Rehabilitation Potential.  

Section GG.  Functional Abilities and Goals - Discharge (End of SNF PPS Stay).

GG0100.  Prior Functioning: Everyday Activities.         

GG0110.  Prior Device Use

GG0130.  Self-Care

GG0170.  Mobility               

Section H.  Bladder and Bowel.

H0100.  Appliances.           

H0200.  Urinary Toileting Program. 

H0300.  Urinary Continence.            

H0400.  Bowel Continence.              

H0500.  Bowel Toileting Program.   

H0600.  Bowel Patterns.

Section I.  Active Diagnoses.

I0020.  Indicate the resident’s primary medical condition category.        

I0100.  Cancer     

I0200.  Anemia    

I0300.  Atrial Fibrillation or Other Dysrhythmias

I0400.  Coronary Artery Disease (CAD)          

I0700.  Hypertension         

I0800.  Orthostatic Hypotension      

I0900.  Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD) Gastrointestinal.     

I1100.  Cirrhosis  

I1200.  Gastroesophageal Reflux Disease (GERD) or Ulcer

I1300.  Ulcerative Colitis, Crohn's Disease, or Inflammatory Bowel Disease Genitourinary. 

I1400.  Benign Prostatic Hyperplasia (BPH)    

I1500.  Renal Insufficiency, Renal Failure, or End-Stage Renal Disease (ESRD)

I1550.  Neurogenic Bladder              

I1650.  Obstructive Uropathy Infections.       

I1700.  Multidrug-Resistant Organism (MDRO)

I2000.  Pneumonia             

I2100.  Septicemia

I2200.  Tuberculosis           

I2300.  Urinary Tract Infection (UTI) (LAST 30 DAYS)

I2400.  Viral Hepatitis (e.g., Hepatitis A, B, C, D, and E)

I2500.  Wound Infection (other than foot)    

I2900.  Diabetes Mellitus (DM)

I3100.  Hyponatremia

I3200.  Hyperkalemia         

I3300.  Hyperlipidemia

I3400.  Thyroid Disorder   

I3700.  Arthritis

I3800.  Osteoporosis          

I3900.  Hip Fracture –

I4000.  Other Fracture Neurological.              

I4200.  Alzheimer's Disease

I4300.  Aphasia    

I4400.  Cerebral Palsy        

I4500.  Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke            

I4800.  Non-Alzheimer's Dementia  

I4900.  Hemiplegia or Hemiparesis

I5000.  Paraplegia               

I5100.  Quadriplegia           

I5200.  Multiple Sclerosis (MS)

I5250.  Huntington's Disease

I5300.  Parkinson's Disease

I5350.  Tourette's Syndrome            

I5400.  Seizure Disorder or Epilepsy

I5500. Traumatic Brain Injury (TBI) Nutritional.             

I5600.  Malnutrition (protein or calorie) or at risk for malnutrition          

I5800.  Depression             

I5900.  Manic Depression

I5950.  Psychotic Disorder

I6000.  Schizophrenia        

I6100.  Post Traumatic Stress Disorder (PTSD) Pulmonary.         

I6200.  Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease

I6300.  Respiratory Failure Vision.   

I6500.  Cataracts, Glaucoma, or Macular Degeneration              

I7900.  None of the above active diagnoses within the last 7 days            

I8000.  Additional active diagnoses 

Section J.  Health Conditions.

J0100.  Pain Management 

J0200.  Should Pain Assessment Interview be Conducted?        

J0300.  Pain Presence.       

J0400.  Pain Frequency.    

J0500.  Pain Effect on Function.       

J0600.  Pain Intensity

J0700. Should the Staff Assessment for Pain be Conducted?     

J0800.  Indicators of Pain or Possible Pain in the last 5 days.     

J0850.  Frequency of Indicator of Pain or Possible Pain in the last 5 days.              

J1100.  Shortness of Breath (dyspnea).          

J1300.  Current Tobacco Use.           

J1400.  Prognosis.               

J1550.  Problem Conditions.             

J1700.  Fall History on Admission/Entry or Reentry.

J1800.  Any Falls Since Admission/Entry or Reentry or Prior Assessment

J1900.  Number of Falls Since Admission/Entry or Reentry or Prior Assessment   

J2000.  Prior Surgery         

Section K.  Swallowing/Nutritional Status.

K0100.  Swallowing Disorder.           

K0200.  Height and Weight               

K0300.  Weight Loss.          

K0310.  Weight Gain.         

K0510.  Nutritional Approaches.      

K0710.  Percent Intake by Artificial Route     

Section L.  Oral/Dental Status.

L0200. Dental      

Section M.  Skin Conditions.

M0100.  Determination of Pressure Ulcer/Injury Risk.

M0150.  Risk of Pressure Ulcers/Injuries.      

M0210.  Unhealed Pressure Ulcers/Injuries.

M0300.  Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage - Continued.               

M0300.  Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.     

M1030.  Number of Venous and Arterial Ulcers.          

M1040.  Other Ulcers, Wounds and Skin Problems.    

M1200.  Skin and Ulcer/Injury Treatments.   

Section N.  Medications.

N0300.  Injections.              

N0350.  Insulin.   

N0410.  Medications Received.       

N0450.  Antipsychotic Medication Review    

N0450.  Antipsychotic Medication Review.   

N2001.  Drug Regimen Review.        

N2003.  Medication Follow-up         

N2005.  Medication Intervention

Section O.  Special Treatments, Procedures, and Programs.

O0100.  Special Treatments, Procedures, and Programs.           

O0250.  Influenza Vaccine

O0300.  Pneumococcal Vaccine.     

O0400.  Therapies.             

O0420.  Distinct Calendar Days of Therapy.   

O0450.  Resumption of Therapy      

O0500.  Restorative Nursing Programs.          

O0600.  Physician Examinations.      

O0700.  Physician Orders.

Section P.  Restraints and Alarms.

P0100.  Physical Restraints.              

P0200.  Alarms.   

Section Q.  Participation in Assessment and Goal Setting.

Q0100.  Participation in Assessment.              

Q0300.  Resident's Overall Expectation.

Q0400.  Discharge Plan.    

Q0490.  Resident's Preference to Avoid Being Asked Question Q0500B.

Q0500.  Return to Community.        

Q0550.  Resident's Preference to Avoid Being Asked Question Q0500B Again.    

Q0600.  Referral.

Section V.  Care Area Assessment (CAA) Summary.

V0100.  Items From the Most Recent Prior OBRA or Scheduled PPS Assessment. 

V0200.  CAAs and Care Planning. (No mandated format or content)

01. Delirium.

02. Cognitive Loss/Dementia.

03. Visual Function.

04. Communication.

05. ADL Functional/Rehabilitation Potential.

06. Urinary Incontinence and Indwelling Catheter.

07. Psychosocial Well-Being.

08. Mood State.

09. Behavioral Symptoms.

10. Activities.

11. Falls.

12. Nutritional Status.

13. Feeding Tube.

14. Dehydration/Fluid Maintenance.

15. Dental Care.

16. Pressure Ulcer.

17. Psychotropic Drug Use.

18. Physical Restraints.

19. Pain.

20. Return to Community Referral.               

Section X.  Correction Request.

X0150.  Type of Provider

X0200.  Name of Resident 

X0300.  Gender   

X0400.  Birth Date              

X0500.  Social Security Number       

X0600.  Type of Assessment             

X0700.  Date on existing record to be modified/inactivated

X0800.  Correction Number.            

X0900.  Reasons for Modification    

X1050.  Reasons for Inactivation      

X1100.  RN Assessment Coordinator Attestation of Completion.               

Section Z.  Assessment Administration.

Z0100.  Medicare Part A Billing.       

Z0150.  Medicare Part A Non-Therapy Billing.              

Z0200.  State Medicaid Billing          

Z0250.  Alternate State Medicaid Billing        

Z0300.  Insurance Billing.  

Z0400.  Signature of Persons Completing the Assessment or Entry/Death Reporting.          

Z0500.  Signature of RN Assessment Coordinator Verifying Assessment Completion.