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MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
[90480-5]
Date Done
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Time Done
Where Done
Comment
Name
Value
Units
Identification Information
[90503-4]
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
[90571-1]
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]
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]
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
[90505-9]
Comatose
[54597-0]
Makes Self Understood
[95737-3]
Cognitive Patterns
[93050-3]
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
[86814-1]
Short-term Memory OK
[54616-8]
Cognitive Skills for Daily Decision Making
[54624-2]
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 Abilities and Goals - Interim Payment Assessment
[90526-5]
Self-Care - Interim Performance
[90540-6]
Eating
[95019-6]
Oral hygiene
[95018-8]
Toileting hygiene
[95017-0]
Mobility - Interim Performance
[90541-4]
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]
Walk 10 feet
[95004-8]
Walk 50 feet with two turns
[95003-0]
Walk 150 feet
[95002-2]
Bladder and Bowel
[90507-5]
Appliances
[86624-4]
Urinary Toileting Program. 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]
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
[90488-8]
Other Health Conditions
[86889-3]
Shortness of Breath (dyspnea)
[86675-6]
Problem Conditions
[86676-4]
Recent Surgery Requiring Active SNF Care
[90542-2]
Surgical Procedures
[90745-1]
Swallowing/Nutritional Status
[90509-1]
Swallowing Disorder. Signs and symptoms of possible swallowing disorder
[86677-2]
Weight Loss. Loss of 5% or more in the last month or loss of 10% or more in last 6 months
[54863-6]
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]
Skin Conditions
[89051-7]
Unhealed Pressure Ulcers/Injuries
[58214-8]
Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
[86892-7]
Number of Stage 2 pressure ulcers
[55124-2]
Number of Stage 3 pressure ulcers
[55125-9]
Number of Stage 4 pressure ulcers
[55126-7]
Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar
[54946-9]
Number of Venous and Arterial Ulcers
[54970-9]
Other Ulcers, Wounds and Skin Problems
[88696-0]
Skin and Ulcer/Injury Treatments
[86748-1]
Medications
[90513-3]
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]
Special Treatments, Procedures, and Programs
[90519-0]
While a Resident
[86761-4]
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]
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]
Correction Request
[91579-3]
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
[91580-1]
Federal OBRA Reason for Assessment
[54583-0]
PPS Assessment
[54584-8]
Entry/discharge reporting
[58108-2]
Date on existing record to be modified/inactivated. Assessment Reference Date
[54593-9]
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
[90495-3]
Medicare Part A Billing
[90498-7]
Medicare Part A HIPPS code
[55065-7]
Version code
[55081-4]
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