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MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
[90475-5]
Date Done
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Time Done
Where Done
Comment
Name
Value
Units
Identification Information
[90500-0]
Type of Record
[58198-3]
Facility Provider Numbers
[54581-4]
National Provider Identifier (NPI)
[76468-8]
CMS Certification Number (CCN)
[69417-4]
State Provider Number
[45398-5]
Type of Provider
[85632-8]
Optional State Assessment
[90521-6]
Is this assessment for state payment purposes only?
[90522-4]
Type of Assessment
[90489-6]
Federal OBRA Reason for Assessment
[54583-0]
PPS Assessment
[54584-8]
Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry?
[54587-1]
Entry/discharge reporting
[58108-2]
Type of discharge
[71440-2]
Is this a SNF Part A Interrupted Stay?
[90525-7]
Is this a SNF Part A PPS Discharge Assessment?
[86525-3]
Unit Certification or Licensure Designation
[86526-1]
Legal Name of Resident
[54503-8]
First name
[45392-8]
Middle initial
[45393-6]
Last name
[45394-4]
Suffix
[45395-1]
Social Security and Medicare Numbers
[45966-9]
Social Security Number
[45396-9]
Medicare number
[45397-7]
Medicaid Number
[45400-9]
Gender
[46098-0]
Birth Date
[21112-8]
Race/Ethnicity
[59362-4]
Language
[54505-3]
Does the resident need or want an interpreter to communicate with a doctor or health care staff?
[54588-9]
Preferred language
[54899-0]
Marital Status
[45404-1]
Optional Resident Items
[54506-1]
Medical record number
[46106-1]
Room number
[45403-3]
Name by which resident prefers to be addressed
[52462-9]
Lifetime occupation(s)
[21843-8]
Most Recent Admission/Entry or Reentry into this Facility
[86528-7]
Entry Date
[50786-3]
Type of Entry
[54590-5]
Entered From
[85398-6]
Admission Date
[52455-3]
Discharge Date
[52525-3]
Discharge Status
[55128-3]
Previous Assessment Reference Date for Significant Correction
[54592-1]
Assessment Reference Date. Observation end date
[54593-9]
Medicare Stay
[54507-9]
Has the resident had a Medicare-covered stay since the most recent entry?
[54594-7]
Start date of most recent Medicare stay
[54595-4]
End date of most recent Medicare stay
[54596-2]
Hearing, Speech, and Vision
[96902-2]
Comatose
[54597-0]
Hearing
[95744-9]
Hearing Aid
[54599-6]
Speech Clarity
[54600-2]
Makes Self Understood
[95737-3]
Ability to Understand Others
[54602-8]
Vision
[95745-6]
Corrective Lenses
[54604-4]
Cognitive Patterns
[96903-0]
Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
[54605-1]
Brief Interview for Mental Status (BIMS)
[103694-6]
Repetition of Three Words
[103696-1]
Temporal Orientation
[103702-7]
Able to report correct year
[103697-9]
Able to report correct month
[103698-7]
Able to report correct day of the week
[103703-5]
Recall
[103695-3]
Able to recall "sock"
[103699-5]
Able to recall "blue"
[103700-1]
Able to recall "bed"
[103701-9]
BIMS Summary Score
[103704-3]
Should the Staff Assessment for Mental Status (C0700-C1000) be Conducted?
[54615-0]
Staff Assessment for Mental Status
[96908-9]
Short-term Memory OK
[54616-8]
Long-term Memory OK
[54617-6]
Memory/Recall Ability
[95743-1]
Cognitive Skills for Daily Decision Making
[54624-2]
Delirium
[96901-4]
Signs and Symptoms of Delirium (from CAM)
[95816-5]
Acute Onset Mental Status Change. Is there evidence of an acute change in mental status from the resident's baseline?
[95813-2]
Inattention - Did the resident have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?
[95812-4]
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)?
[95814-0]
Altered Level of Consciousness - Did the resident have altered level of consciousness, as indicated by any of the following criteria?
[95815-7]
Mood
[90482-1]
Should Resident Mood Interview be Conducted?
[54634-1]
Resident Mood Interview (PHQ-9)
[54635-8]
Symptom Presence
[86843-0]
Little interest or pleasure in doing things
[54636-6]
Feeling down, depressed or hopeless
[54638-2]
Trouble falling or staying asleep, or sleeping too much
[54640-8]
Feeling tired or having little energy
[54642-4]
Poor appetite or overeating
[54644-0]
Feeling bad about yourself - or that you are a failure or have let yourself or your family down
[54646-5]
Trouble concentrating on things, such as reading the newspaper or watching television
[54648-1]
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
[54650-7]
Thoughts that you would be better off dead, or of hurting yourself in some way
[54652-3]
Symptom Frequency
[86844-8]
Little interest or pleasure in doing things
[54637-4]
Feeling down, depressed or hopeless
[54639-0]
Trouble falling or staying asleep, or sleeping too much
[54641-6]
Feeling tired or having little energy
[54643-2]
Poor appetite or overeating
[54645-7]
Feeling bad about yourself - or that you are a failure or have let yourself or your family down
[54647-3]
Trouble concentrating on things, such as reading the newspaper or watching television
[54649-9]
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
[54651-5]
Thoughts that you would be better off dead, or of hurting yourself in some way
[54653-1]
Total Severity Score
[103705-0]
Staff Assessment of Resident Mood (PHQ-9-OV)
[103706-8]
Symptom Presence
[86833-1]
Little interest or pleasure in doing things
[54658-0]
Feeling or appearing down, depressed, or hopeless
[54660-6]
Trouble falling or staying asleep, or sleeping too much
[54662-2]
Feeling tired or having little energy
[54664-8]
Poor appetite or overeating
[54666-3]
Indicating that s/he feels bad about self, is a failure, or has let self or family down
[54668-9]
Trouble concentrating on things, such as reading the newspaper or watching television
[54670-5]
Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that s/he has been moving around a lot more than usual
[54672-1]
States that life isn't worth living, wishes for death, or attempts to harm self
[54673-9]
Being short-tempered, easily annoyed
[54675-4]
Symptom Frequency
[86891-9]
Little interest or pleasure in doing things
[54659-8]
Feeling or appearing down, depressed, or hopeless
[54661-4]
Trouble falling or staying asleep, or sleeping too much
[54663-0]
Feeling tired or having little energy
[54665-5]
Poor appetite or overeating
[54667-1]
Indicating that s/he feels bad about self, is a failure, or has let self or family down
[54669-7]
Trouble concentrating on things, such as reading the newspaper or watching television
[54671-3]
Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that s/he has been moving around a lot more than usual
[54904-8]
States that life isn't worth living, wishes for death, or attempts to harm self
[54674-7]
Being short-tempered, easily annoyed
[54676-2]
Total Severity Score
[103707-6]
Behavior
[86815-8]
Potential Indicators of Psychosis
[86597-2]
Behavioral Symptom - Presence & Frequency
[54514-5]
Physical behavioral symptoms directed toward others
[54682-0]
Verbal behavioral symptoms directed toward others
[54683-8]
Other behavioral symptoms not directed toward others
[54684-6]
Rejection of Care - Presence & Frequency. 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?
[54692-9]
Wandering - Presence & Frequency. Has the resident wandered?
[54693-7]
Functional status
[86816-6]
Activities of Daily Living (ADL) Assistance. Self-Performance
[86880-2]
Bed mobility
[45588-1]
Transfer
[45590-7]
Walk in room
[45592-3]
Walk in corridor
[45594-9]
Locomotion on unit
[45596-4]
Locomotion off unit
[45598-0]
Dressing
[45600-4]
Eating
[45602-0]
Toilet use
[45604-6]
Personal hygiene
[45606-1]
Activities of Daily Living (ADL) Assistance. Support Provided
[86881-0]
Bed mobility
[45589-9]
Transfer
[45591-5]
Walk in room
[45593-1]
Walk in corridor
[45595-6]
Locomotion on unit
[45597-2]
Locomotion off unit
[45599-8]
Dressing
[45601-2]
Eating
[45603-8]
Toilet use
[45605-3]
Personal hygiene
[45607-9]
Bathing
[46008-9]
Self-performance
[45608-7]
Support provided
[45609-5]
Balance During Transitions and Walking
[54524-4]
Moving from seated to standing position
[54749-7]
Walking (with assistive device if used)
[54750-5]
Turning around and facing the opposite direction while walking
[54751-3]
Moving on and off toilet
[54752-1]
Surface-to-surface transfer (transfer between bed and chair or wheelchair)
[54753-9]
Functional Limitation in Range of Motion
[92908-3]
Upper extremity (shoulder, elbow, wrist, hand)
[92850-7]
Lower extremity (hip, knee, ankle, foot)
[92851-5]
Mobility Devices
[86602-0]
Functional Abilities and Goals - Start of SNF PPS Stay or State PDPM
[95811-6]
Prior Functioning: Everyday Activities
[83239-4]
Self-Care
[85070-1]
Indoor Mobility (Ambulation)
[85071-9]
Stairs
[85072-7]
Functional Cognition
[85073-5]
Prior Device Use
[83234-5]
Self-Care - Admission Performance
[95732-4]
Eating
[95019-6]
Oral hygiene
[95018-8]
Toileting hygiene
[95017-0]
Shower/bathe self
[95015-4]
Upper body dressing
[95014-7]
Lower body dressing
[95013-9]
Putting on/taking off footwear
[95012-1]
Self-Care - Discharge Goal
[89478-2]
Oral hygiene - functional goal
[89404-8]
Eating
[89409-7]
Toileting hygiene
[89389-1]
Shower/bathe self
[89396-6]
Upper body dressing
[89387-5]
Lower body dressing
[89406-3]
Putting on/taking off footwear
[89400-6]
Mobility - Admission Performance
[95741-5]
Roll left and right
[95011-3]
Sit to lying
[95010-5]
Lying to sitting on side of bed
[95009-7]
Sit to stand
[95008-9]
Chair/bed-to-chair transfer
[95007-1]
Toilet transfer
[95006-3]
Car transfer
[95005-5]
Walk 10 feet
[95004-8]
Walk 50 feet with two turns
[95003-0]
Walk 150 feet
[95002-2]
Walking 10 feet on uneven surfaces
[95001-4]
1 step (curb)
[95000-6]
4 steps
[94999-0]
12 steps
[94998-2]
Picking up object
[94997-4]
Does the resident use a wheelchair and/or scooter?
[95738-1]
Wheel 50 feet with two turns
[94992-5]
Indicate the type of wheelchair or scooter used
[95739-9]
-
Wheel 150 feet
[94991-7]
Indicate the type of wheelchair or scooter used
[95739-9]
-
Mobility - Discharge Goal
[89476-6]
Roll left and right
[89398-2]
Sit to lying
[89394-1]
Lying to sitting on side of bed
[85927-2]
Sit to stand
[89392-5]
Chair/bed-to-chair transfer
[89414-7]
Toilet transfer
[89390-9]
Car transfer
[89412-1]
Walk 10 feet
[89385-9]
Walk 50 feet with two turns
[89381-8]
Walk 150 feet
[89383-4]
Walking 10 feet on uneven surfaces
[89379-2]
1 step (curb)
[89420-4]
4 steps
[89416-2]
12 steps
[89418-8]
Picking up object
[89402-2]
Wheel 50 feet with two turns
[89375-0]
Wheel 150 feet
[89377-6]
Functional Abilities and Goals - Discharge (End of SNF PPS Stay)
[95810-8]
Self-Care - Discharge Performance
[95734-0]
Eating
[95019-6]
Oral hygiene
[95018-8]
Toileting hygiene
[95017-0]
Shower/bathe self
[95015-4]
Upper body dressing
[95014-7]
Lower body dressing
[95013-9]
Putting on/taking off footwear
[95012-1]
Mobility - Discharge Performance
[95742-3]
Roll left and right
[95011-3]
Sit to lying
[95010-5]
Lying to sitting on side of bed
[95009-7]
Sit to stand
[95008-9]
Chair/bed-to-chair transfer
[95007-1]
Toilet transfer
[95006-3]
Car transfer
[95005-5]
Walk 10 feet
[95004-8]
Walk 50 feet with two turns
[95003-0]
Walk 150 feet
[95002-2]
Walking 10 feet on uneven surfaces
[95001-4]
1 step (curb)
[95000-6]
4 steps
[94999-0]
12 steps
[94998-2]
Picking up object
[94997-4]
Does the resident use a wheelchair and/or scooter?
[95738-1]
Wheel 50 feet with two turns
[94992-5]
Indicate the type of wheelchair or scooter used
[95739-9]
-
Wheel 150 feet
[94991-7]
Indicate the type of wheelchair or scooter used
[95739-9]
-
Bladder and Bowel
[96906-3]
Appliances
[86624-4]
Urinary Toileting Program
[86866-1]
Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility?
[54767-9]
Current toileting program or trial - Is a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) currently being used to manage the resident's urinary continence?
[54769-5]
Urinary Continence
[95735-7]
Bowel Continence
[95736-5]
Bowel Toileting Program
[88695-2]
Active Diagnoses
[90485-4]
Indicate the resident's primary medical condition category
[96095-5]
ICD Code
[52797-8]
-
Active Diagnoses in the last 7 days
[86671-5]
Additional active diagnoses
[52797-8]
-
Health Conditions
[90487-0]
Pain Management
[54557-4]
At any time in the last 5 days, has the resident: Received scheduled pain medication regimen?
[71447-7]
At any time in the last 5 days, has the resident: Received PRN pain medications OR was offered and declined?
[71448-5]
At any time in the last 5 days, has the resident: Received non-medication intervention for pain?
[71449-3]
Should Pain Assessment Interview be Conducted?
[54828-9]
Pain Assessment Interview
[54558-2]
Pain Presence. Have you had pain or hurting at any time in the last 5 days?
[54829-7]
Pain Frequency. How much of the time have you experienced pain or hurting over the last 5 days?
[54830-5]
Pain Effect on Function
[54559-0]
Over the past 5 days, has pain made it hard for you to sleep at night?
[54831-3]
Over the past 5 days, have you limited your day-to-day activities because of pain?
[54832-1]
Pain Intensity
[54560-8]
Numeric Rating Scale (00-10)
[54833-9]
Verbal Descriptor Scale
[54834-7]
Should the Staff Assessment for Pain be Conducted?
[58117-3]
Staff Assessment for Pain
[86672-3]
Indicators of Pain or Possible Pain in the last 5 days
[86673-1]
Frequency of Indicator of Pain or Possible Pain in the last 5 days. Frequency with which resident complains or shows evidence of pain or possible pain
[58118-1]
Other Health Conditions
[86868-7]
Shortness of Breath (dyspnea)
[86675-6]
Prognosis
[54846-1]
Problem Conditions
[86676-4]
Fall History on Admission/Entry or Reentry
[54849-5]
Did the resident have a fall any time in the last month prior to admission/entry or reentry?
[54850-3]
Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry?
[54851-1]
Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry?
[54852-9]
Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent?
[54853-7]
Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent
[54854-5]
No injury
[54855-2]
Injury (except major)
[54856-0]
Major injury
[54857-8]
Prior Surgery
[83274-1]
Recent Surgery Requiring Active SNF Care
[90542-2]
Surgical Procedures
[90745-1]
Swallowing/Nutritional Status
[90483-9]
Swallowing Disorder. Signs and symptoms of possible swallowing disorder
[86677-2]
Height and Weight
[54567-3]
Height (in inches)
[103692-0]
Weight (in pounds)
[103693-8]
Weight Loss. Loss of 5% or more in the last month or loss of 10% or more in last 6 months
[54863-6]
Weight Gain. Gain of 5% or more in the last month or gain of 10% or more in last 6 months
[86678-0]
Nutritional Approaches
[54568-1]
Nutritional Approaches. While NOT a Resident
[71444-4]
Nutritional Approaches. While a Resident
[71445-1]
Percent Intake by Artificial Route
[90543-0]
Proportion of total calories the resident received through parenteral or tube feeding. While a Resident
[86681-4]
Proportion of total calories the resident received through parenteral or tube feeding. During Entire 7 Days
[86687-1]
Average fluid intake per day by IV or tube feeding. While a Resident
[86683-0]
Average fluid intake per day by IV or tube feeding. During Entire 7 Days
[86684-8]
Oral/Dental Status
[86685-5]
Dental
[86706-9]
Skin Conditions
[88960-0]
Determination of Pressure Ulcer/Injury Risk
[86708-5]
Risk of Pressure Ulcers/Injuries
[57280-0]
Unhealed Pressure Ulcers/Injuries
[58214-8]
Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
[88961-8]
Number of Stage 1 pressure injuries
[54884-2]
Number of Stage 2 pressure ulcers
[55124-2]
Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry
[54886-7]
Number of Stage 3 pressure ulcers
[55125-9]
Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry
[54887-5]
Number of Stage 4 pressure ulcers
[55126-7]
Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry
[54890-9]
Number of unstageable pressure ulcers/injuries due to non-removable dressing/device
[54893-3]
Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry
[54894-1]
Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar
[54946-9]
Number of these unstageable pressure ulcers that were present upon admission/entry or reentry
[54947-7]
Number of unstageable pressure injuries presenting as deep tissue injury
[54950-1]
Number of these unstageable pressure injuries that were present upon admission/entry or reentry
[54951-9]
Number of Venous and Arterial Ulcers
[54970-9]
Other Ulcers, Wounds and Skin Problems
[88696-0]
Skin and Ulcer/Injury Treatments
[86748-1]
Medications
[88962-6]
Injections. Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days.
[54982-4]
Insulin
[58217-1]
Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days
[58127-2]
Orders for insulin - Record the number of days the physician (or authorized assistant or practitioner) changed the resident's insulin orders during the last 7 days or since admission/entry or reentry if less than 7 days
[58128-0]
Medications Received
[88290-2]
Antipsychotic
[86751-5]
Antianxiety
[86752-3]
Antidepressant
[86753-1]
Hypnotic
[86754-9]
Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin)
[86755-6]
Antibiotic
[86756-4]
Diuretic
[86757-2]
Opioid
[88291-0]
Antipsychotic Medication Review
[88295-1]
Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent?
[88296-9]
Has a gradual dose reduction (GDR) been attempted?
[88297-7]
Date of last attempted GDR
[88298-5]
Physician documented GDR as clinically contraindicated
[88299-3]
Date physician documented GDR as clinically contraindicated
[88300-9]
Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?
[57255-2]
Medication Follow-up: Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?
[57281-8]
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?
[57256-0]
Special Treatments, Procedures, and Programs
[90515-8]
Special Treatments, Procedures, and Programs
[86759-8]
While NOT a Resident
[86760-6]
While a Resident
[86761-4]
Influenza Vaccine
[69339-0]
Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season?
[55019-4]
Date influenza vaccine received
[58131-4]
If influenza vaccine not received, state reason:
[55020-2]
Pneumococcal Vaccine
[55021-0]
Is the resident's Pneumococcal vaccination up to date?
[55022-8]
If Pneumococcal vaccine not received, state reason:
[45956-0]
Therapies
[86841-4]
Speech-Language Pathology and Audiology Services
[86763-0]
Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the last 7 days
[58218-9]
Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the last 7 days
[58133-0]
Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days
[58134-8]
Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment sessions in the last 7 days
[86765-5]
Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days
[45760-6]
Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started
[55025-1]
Therapy end date - record the date the most recent therapy regimen (since the most recent entry) ended
[55026-9]
Occupational Therapy
[86767-1]
Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the last 7 days
[58219-7]
Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the last 7 days
[58136-3]
Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days
[58137-1]
Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment sessions in the last 7 days
[86764-8]
Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days
[45762-2]
Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started
[55027-7]
Therapy end date - record the date the most recent therapy regimen (since the most recent entry) ended
[55028-5]
Physical Therapy
[86768-9]
Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the last 7 days
[58220-5]
Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the last 7 days
[58139-7]
Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days
[58140-5]
Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment sessions in the last 7 days
[86766-3]
Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days
[45764-8]
Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started
[55029-3]
Therapy end date - record the date the most recent therapy regimen (since the most recent entry) ended
[55030-1]
Respiratory therapy
[86849-7]
Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days
[45766-3]
Psychological therapy
[86850-5]
Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.
[45768-9]
Distinct Calendar Days of Therapy. 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 in the past 7 days.
[86769-7]
Part A Therapies
[90544-8]
Speech-Language Pathology and Audiology Services
[90545-5]
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)
[90539-8]
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)
[90536-4]
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)
[90538-0]
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)
[90537-2]
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)
[90551-3]
Occupational Therapy
[90546-3]
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)
[90531-5]
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)
[90527-3]
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)
[90529-9]
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)
[90528-1]
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)
[90530-7]
Physical Therapy
[90547-1]
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)
[90535-6]
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)
[90532-3]
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)
[90534-9]
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)
[90533-1]
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)
[90550-5]
Distinct Calendar Days of Part A Therapy
[90548-9]
Restorative Nursing Programs
[86773-9]
Technique. Range of motion (passive)
[86774-7]
Technique. Range of motion (active)
[86775-4]
Technique. Splint or brace assistance
[86776-2]
Training and Skill Practice In: Bed mobility
[86777-0]
Training and Skill Practice In: Transfer
[86778-8]
Training and Skill Practice In: Walking
[86779-6]
Training and Skill Practice In: Dressing and/or grooming
[86780-4]
Training and Skill Practice In: Eating and/or swallowing
[86781-2]
Training and Skill Practice In: Amputation/prostheses care
[86782-0]
Training and Skill Practice In: Communication
[86783-8]
Physician Examinations. Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) examine the resident?
[55040-0]
Physician Orders. Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) change the resident's orders?
[55041-8]
Restraints and Alarms
[88307-4]
Physical Restraints
[86785-3]
Used in Bed. Bed rail
[86786-1]
Used in Bed. Trunk restraint
[86787-9]
Used in Bed. Limb restraint
[86788-7]
Used in Bed. Other
[86789-5]
Used in Chair or Out of Bed. Trunk restraint
[86790-3]
Used in Chair or Out of Bed. Limb restraint
[86791-1]
Used in Chair or Out of Bed. Chair prevents rising
[86792-9]
Used in Chair or Out of Bed. Other
[86793-7]
Alarms
[88309-0]
Bed alarm
[88310-8]
Chair alarm
[88311-6]
Floor mat alarm
[88312-4]
Motion sensor alarm
[88313-2]
Wander/elopement alarm
[88314-0]
Other alarm
[88308-2]
Participation in Assessment and Goal Setting
[86794-5]
Participation in Assessment
[55053-3]
Resident participated in assessment
[55054-1]
Family or significant other participated in assessment
[55074-9]
Guardian or legally authorized representative participated in assessment
[58221-3]
Resident's Overall Expectation
[55056-6]
Select one for resident's overall goal established during assessment process
[55057-4]
Indicate information source for Q0300A
[55058-2]
Discharge Plan. Is active discharge planning already occurring for the resident to return to the community?
[58146-2]
Resident's Preference to Avoid Being Asked Question Q0500B
[86795-2]
Return to Community. Do you want to talk to someone about the possiblity of leaving this facility and returning to live and receive services in the community?
[58149-6]
Resident's Preference to Avoid Being Asked Question Q0500B Again
[86796-0]
Does the resident (or family or significant other or guardian or legally authorized representative if resident is unable to understand or respond) want to be asked about returning to the community on all assessments?
[86797-8]
Indicate information source for Q0550A
[86798-6]
Referral. Has a referral been made to the Local Contact Agency?
[58150-4]
Correction Request
[90490-4]
Type of Provider
[85632-8]
Name of Resident
[87226-7]
Patient First name
[45392-8]
Patient Last name
[45394-4]
Gender
[46098-0]
Birth Date
[21112-8]
Social Security Number
[45396-9]
Optional State Assessment. Is this assessment for state payment purposes only?
[90522-4]
Type of Assessment
[90492-0]
Federal OBRA Reason for Assessment
[54583-0]
PPS Assessment
[54584-8]
Entry/discharge reporting
[58108-2]
Is this a SNF Part A PPS Discharge Assessment?
[86525-3]
Date on existing record to be modified/inactivated
[87216-8]
Assessment Reference Date
[54593-9]
Discharge Date
[52525-3]
Entry Date
[50786-3]
Correction Attestation Section
[87209-3]
Correction Number
[58200-7]
Reasons for Modification
[87217-6]
Reasons for Inactivation
[87225-9]
RN Assessment Coordinator Attestation of Completion
[87218-4]
Attesting individual's first name
[87219-2]
Attesting individual's last name
[87220-0]
Attesting individual's title
[87221-8]
Attestation date
[87222-6]
Assessment Administration
[90497-9]
Medicare Part A Billing
[90498-7]
Medicare Part A HIPPS code
[55065-7]
Version code
[55081-4]
State Medicaid Billing (if required by the state)
[93053-7]
Case Mix group
[55068-1]
Version code
[55081-4]
Alternate State Medicaid Billing (if required by the state)
[93052-9]
Case Mix group
[58212-2]
Version code
[55081-4]
Insurance Billing
[93051-1]
Billing code
[55071-5]
Billing version
[55081-4]
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