Form Mds PDF Details

MDS, or the Minimum Data Set, is a core component of Medicare that is used to measure the quality of care in health care organizations. The MDS includes information on patient characteristics, diagnoses, and services received. This data is then analyzed to identify areas where improvements can be made in the delivery of care. Form MDS 3.0 is the latest version of this form, and it was released in October 2014. Health care organizations are required to use this form starting in January 2015. There are several changes to Form MDS 3.0 that affect providers and patients alike. In this blog post, we will explore some of these changes and how they may impact you.

You will find information about the type of form you intend to complete in the table. It can tell you the time you'll need to complete form mds, what fields you need to fill in and several further specific details.

QuestionAnswer
Form NameForm Mds
Form Length38 pages
Fillable?Yes
Fillable fields1616
Avg. time to fill out36 min 58 sec
Other namesmds 3 0, mds 3 0 cue cards pdf, form mds 3 0, mds forms

Form Preview Example

Resident

 

Identifier

 

Date

 

 

 

 

 

MINIMUM DATA SET (MDS) - Version 3.0

RESIDENT ASSESSMENT AND CARE SCREENING

ALL ITEM LISTING

Section A.

Identification Information.

A0100. Facility Provider Numbers.

A.National Provider Identifier (NPI):

B.CMS Certification Number (CCN):

C.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

Enter Code

Enter Code

Enter Code

Enter Code

Enter Code

A.Federal OBRA Reason for Assessment.

01.Admission assessment (required by day 14).

02.Quarterly review assessment.

03.Annual assessment.

04.Significant change in status assessment.

05.Significant correction to prior comprehensive assessment.

06.Significant correction to prior quarterly assessment.

99.Not OBRA required assessment.

B.PPS Assessment.

PPS Scheduled Assessments for a Medicare Part A Stay.

01.5-day scheduled assessment.

02.14-day scheduled assessment.

03.30-day scheduled assessment.

04.60-day scheduled assessment.

05.90-day scheduled assessment.

06.Readmission/return assessment.

PPS Unscheduled Assessments for a Medicare Part A Stay.

07.Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment).

Not PPS Assessment.

99.Not PPS assessment.

C.PPS Other Medicare Required Assessment - OMRA.

0.No...

1.Start of therapy assessment.

2.End of therapy assessment.

3.Both Start and End of therapy assessment.

D.Is this a Swing Bed clinical change assessment? Complete only if A0200 = 2.

0.No...

1.Yes.

E.Is this assessment the first assessment (OBRA, PPS, or Discharge) since the most recent admission?

0.No...

1.Yes.

F.Entry/discharge reporting

01.Entry record.

10.Discharge assessment-return not anticipated.

11.Discharge assessment-return anticipated.

12.Death in facility record.

99.Not entry/discharge record.

MDS 3.0 Item Listing-Version 1.00.2 10/01/2010

Page 1 of 38

Resident

 

Identifier

 

Date

 

 

 

 

 

Section A.

Identification Information.

A0410. Submission Requirement.

Enter Code

1.

Neither federal nor state required submission.

 

 

 

2.

State but not federal required submission (FOR NURSING HOMES ONLY).

 

 

 

3.

Federal required submission.

 

 

 

 

 

A0500. Legal Name of Resident.

 

A.

First name:

 

 

 

 

 

 

B.

Middle initial:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C.

Last name:

 

 

 

 

 

 

D.

Suffix:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A0600. Social Security and Medicare Numbers.

 

 

 

A. Social Security Number:

 

 

 

 

 

 

 

 

 

_

 

 

 

 

 

_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. Medicare number (or comparable railroad insurance number):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid recipient.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A0800. Gender.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter Code

1.

Male.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Female.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A0900. Birth Date.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day

 

 

 

 

Year

A1000. Race/Ethnicity.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check all that apply.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. American Indian or Alaska Native.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. Asian.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. Black or African American.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D. Hispanic or Latino.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E. Native Hawaiian or Other Pacific Islander.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F. White.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A1100. Language.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter Code

A. Does the resident need or want an interpreter to communicate with a doctor or health care staff?

0.

No...

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Yes Specify in A1100B, Preferred language.

 

 

 

 

9. Unable to determine.

 

 

 

 

 

 

 

B. Preferred language:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MDS 3.0 Item Listing-Version 1.00.2 10/01/2010

Page 2 of 38

Resident

 

Identifier

 

Date

 

 

 

 

 

Section A.

Identification Information.

A1200. Marital Status.

Enter Code

1.

Never married.

2.

Married.

 

 

 

 

 

 

3.

Widowed.

 

 

 

4.

Separated.

 

 

 

5.

Divorced.

 

 

 

 

 

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:

A1500. Preadmission Screening and Resident Review (PASRR).

Complete only if A0310A = 01

Enter Code

Has the resident been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a

 

 

 

related condition?

 

 

 

0.

No...

 

 

 

1.

Yes.

 

 

 

9.

Not a Medicaid certified unit.

 

 

 

 

 

A1550. Conditions Related to MR/DD Status.

If the resident is 22 years of age or older, complete only if A0310A = 01.

If the resident is 21 years of age or younger, complete only if A0310A = 01, 03, 04, or 05.

Check all conditions that are related to MR/DD status that were manifested before age 22, and are likely to continue indefinitely.

MR/DD With Organic Condition.

A. Down syndrome.

B. Autism.

C. Epilepsy.

D. Other organic condition related to MR/DD.

MR/DD Without Organic Condition.

E. MR/DD with no organic condition.

No MR/DD.

Z. None of the above.

A1600.

Entry Date (date of this admission/reentry into the facility).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_

 

 

 

 

 

 

 

 

 

 

 

 

 

_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A1700.

Type of Entry.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter Code

 

1.

Admission.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Reentry.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MDS 3.0 Item Listing-Version 1.00.2 10/01/2010

Page 3 of 38

Resident

 

Identifier

 

Date

 

 

 

 

 

Section A.

Identification Information.

A1800. Entered From.

Enter Code

01.Community (private home/apt., board/care, assisted living, group home).

02.Another nursing home or swing bed.

03.Acute hospital.

04.Psychiatric hospital.

05.Inpatient rehabilitation facility.

06.MR/DD facility.

07.Hospice.

99.Other.

A2000. Discharge Date.

Complete only if A0310F = 10, 11, or 12

 

 

 

_

 

 

_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

Day

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

A2100. Discharge Status.

Complete only if A0310F = 10, 11, or 12

Enter Code

01.Community (private home/apt., board/care, assisted living, group home).

02.Another nursing home or swing bed.

03.Acute hospital.

04.Psychiatric hospital.

05.Inpatient rehabilitation facility.

06.MR/DD facility.

07.Hospice.

08.Deceased.

99.Other.

A2200. Previous Assessment Reference Date for Significant Correction. Complete only if A0310A = 05 or 06.

_

_

Month

Day

Y ear

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.No Skip to B0100, Comatose.

1.Yes Continue to A2400B, Start date of most recent Medicare stay.

B. Start date of most recent Medicare stay:

 

 

_

 

 

_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

Day

 

 

Year

C. End date of most recent Medicare stay - Enter dashes if stay is ongoing:

 

 

_

 

 

_

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

Day

 

 

Year

MDS 3.0 Item Listing-Version 1.00.2 10/01/2010

Page 4 of 38

Resident

 

Identifier

 

Date

 

 

 

 

 

Look back period for all items is 7 days unless another time frame is indicated.

Section B.

Hearing, Speech, and Vision.

B0100. Comatose.

Enter Code

Persistent vegetative state/no discernible consciousness.

0.No Continue to B0200, Hearing.

1.Yes Skip to G0110, Activities of Daily Living (ADL) Assistance.

B0200. Hearing.

Enter Code

Ability to hear (with hearing aid or hearing appliances if normally used).

0.Adequate - no difficulty in normal conversation, social interaction, listening to TV.

1.Minimal difficulty - difficulty in some environments (e.g., when person speaks softly or setting is noisy).

2.Moderate difficulty - speaker has to increase volume and speak distinctly.

3.Highly impaired - absence of useful hearing.

B0300. Hearing Aid.

Enter Code

Hearing aid or other hearing appliance used in completing B0200, Hearing.

0.No...

1.Yes.

B0600. Speech Clarity.

Enter Code

Select best description of speech pattern.

0.Clear speech - distinct intelligible words.

1.Unclear speech - slurred or mumbled words.

2.No speech - absence of spoken words.

B0700. Makes Self Understood.

Enter Code

Ability to express ideas and wants, consider both verbal and non-verbal expression.

0.Understood.

1.Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time.

2.Sometimes understood - ability is limited to making concrete requests.

3.Rarely/never understood.

B0800. Ability To Understand Others.

Enter Code

Understanding verbal content, however able (with hearing aid or device if used).

0.Understands - clear comprehension.

1.Usually understands - misses some part/intent of message but comprehends most conversation.

2.Sometimes understands - responds adequately to simple, direct communication only.

3.Rarely/never understands.

B1000. Vision.

Enter Code

Ability to see in adequate light (with glasses or other visual appliances).

0.Adequate - sees fine detail, including regular print in newspapers/books.

1.Impaired - sees large print, but not regular print in newspapers/books.

2.Moderately impaired - limited vision; not able to see newspaper headlines but can identify objects.

3.Highly impaired - object identification in question, but eyes appear to follow objects.

4.Severely impaired - no vision or sees only light, colors or shapes; eyes do not appear to follow objects.

B1200. Corrective Lenses.

Enter Code

Corrective lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision.

0.No...

1.Yes.

MDS 3.0 Item Listing-Version 1.00.2 10/01/2010

Page 5 of 38

Resident

 

Identifier

 

Date

 

 

 

 

 

Section C.

Cognitive Patterns.

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted? Attempt to conduct interview with all residents.

Enter Code

0.No (resident is rarely/never understood) Skip to and complete C0700-C1000, Staff Assessment for Mental Status.

1.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.

0.None.

1.One.

2.Two.

3.Three.

After the resident's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece of furniture"). You may repeat the words up to two more times.

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

Enter Code

Enter Code

Enter Code

Ask resident: "Please tell me what year it is right now."

A.Able to report correct year.

0.Missed by > 5 years or no answer.

1.Missed by 2-5 years.

2.Missed by 1 year.

3.Correct.

Ask resident: "What month are we in right now?"

B.Able to report correct month.

0.Missed by > 1 month or no answer.

1.Missed by 6 days to 1 month.

2.Accurate within 5 days.

Ask resident: "What day of the week is today?"

C.Able to report correct day of the week.

0.Incorrect or no answer.

1.Correct.

C0400. Recall.

Enter Code

Enter Code

Enter Code

Ask resident: "Let's go back to an earlier question. What were those three words that I asked you to repeat?" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.

A.Able to recall "sock".

0.No - could not recall.

1.Yes, after cueing ("something to wear").

2.Yes, no cue required.

B.Able to recall "blue".

0.No - could not recall.

1.Yes, after cueing ("a color").

2.Yes, no cue required.

C.Able to recall "bed".

0.No - could not recall.

1.Yes, after cueing ("a piece of furniture").

2.Yes, no cue required.

C0500. 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 Item Listing-Version 1.00.2 10/01/2010

Page 6 of 38

Resident

 

Identifier

 

Date

 

 

 

 

 

Section C.

Cognitive Patterns.

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

Enter Code

0.No (resident was able to complete interview ) Skip to C1300, Signs and Symptoms of Delirium.

1.Yes (resident was unable to complete interview) 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.

Enter Code

Seems or appears to recall after 5 minutes.

0.Memory OK.

1.Memory problem.

C0800. Long-term Memory OK.

Enter Code

Seems or appears to recall long past.

0.Memory OK.

1.Memory problem.

C0900. Memory/Recall Ability.

Check all that the resident was normally able to recall.

A. Current season.

B. Location of own room.

C. Staff names and faces.

D. That he or she is in a nursing home.

Z. None of the above were recalled.

C1000. Cognitive Skills for Daily Decision Making.

Enter Code

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.

Delirium.

C1300. Signs and Symptoms of Delirium (from CAM©).

Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical record.

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.

A.Inattention - Did the resident have difficulty focusing attention (easily distracted, out of touch or difficulty following what was said)?

B.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)?

C.Altered level of consciousness - Did the resident have altered level of consciousness (e.g., 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)?

D.Psychomotor retardation- Did the resident have an unusually decreased level of activity such as sluggishness, staring into space, staying in one position, moving very slowly?

C1600. Acute Onset Mental Status Change.

Enter Code

Is there evidence of an acute change in mental status from the resident's baseline?

0.No...

1.Yes.

Copyright © 1990 Annals of Internal Medicine. All rights reserved. Adapted with permission.

 

MDS 3.0 Item Listing-Version 1.00.2 10/01/2010

Page 7 of 38

Resident

 

Identifier

 

Date

 

 

 

 

 

Section D.

Mood.

D0100. Should Resident Mood Interview be Conducted? - Attempt to conduct interview with all residents.

Enter Code

0.No (resident is rarely/never understood) Skip to and complete D0500-D0600, Staff Assessment of Resident Mood (PHQ-9-OV).

1.Yes Continue to D0200, Resident Mood Interview (PHQ-9©).

D0200. Resident Mood Interview (PHQ-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.

1.

2.

 

0.

No (enter 0 in column 2).

0.

Never or 1 day.

 

Symptom

Symptom

 

1.

Yes (enter 0-3 in column 2).

1.

2-6 days (several days).

 

Presence.

Frequency.

 

9.

No response (leave column 2

2.

7-11 days (half or more of the days).

 

 

blank).

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.

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.

D0300. 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 items).

D0350. Safety Notification - Complete only if D0200I1 = 1 indicating possibility of resident self harm.

Enter Code

Was responsible staff or provider informed that there is a potential for resident self harm?

0.No...

1.Yes.

Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.

 

MDS 3.0 Item Listing-Version 1.00.2 10/01/2010

Page 8 of 38

Resident

 

Identifier

 

Date

 

 

 

 

 

Section D.

Mood.

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

Do not conduct if Resident Mood Interview (D0200-D0300) 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.

1.

2.

 

0.

No (enter 0 in column 2).

0.

Never or 1 day.

 

Symptom

Symptom

 

1.

Yes (enter 0-3 in column 2).

1.

2-6 days (several days).

 

Presence.

Frequency.

 

 

 

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 s/he feels bad about self, is a failure, or has 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 s/he has 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.

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.

D0650. Safety Notification - Complete only if D0500I1 = 1 indicating possibility of resident self harm.

Enter Code

Was responsible staff or provider informed that there is a potential for resident self harm?

0.No...

1.Yes.

* Copyright © Pfizer Inc. All rights reserved.

 

MDS 3.0 Item Listing-Version 1.00.2 10/01/2010

Page 9 of 38

Resident

 

Identifier

 

Date

 

 

 

 

 

Section E.

Behavior.

E0100. 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 & Frequency.

Note presence of symptoms and their frequency.

Enter Codes in Boxes.

Coding:

 

 

 

 

A.

Physical behavioral symptoms directed toward others (e.g., hitting,

 

 

 

 

 

 

 

kicking, pushing, scratching, grabbing, abusing others sexually).

0.

Behavior not exhibited.

 

 

 

 

 

 

 

 

 

1.

Behavior of this type occurred 1 to 3 days.

 

 

 

B.

Verbal behavioral symptoms directed toward others (e.g., threatening

 

 

 

 

others, screaming at others, cursing at others).

2.

Behavior of this type occurred 4 to 6 days,

 

 

 

 

 

 

 

 

 

 

but less than daily.

 

 

 

C.

Other behavioral symptoms not directed toward others (e.g., physical

 

 

 

 

3.

Behavior of this type occurred daily.

 

 

 

 

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).

 

 

 

 

 

 

 

 

E0300. Overall Presence of Behavioral Symptoms.

Enter Code

Were any behavioral symptoms in questions E0200 coded 1, 2, or 3?

0.No Skip to E0800, Rejection of Care.

1.Yes Considering all of E0200, Behavioral Symptoms, answer E0500 and E0600 below.

E0500. Impact on Resident.

Enter Code

Enter Code

Enter Code

Did any of the identified symptom(s):

A.Put the resident at significant risk for physical illness or injury?

0.No...

1.Yes.

B.Significantly interfere with the resident's care?

0.No...

1.Yes.

C.Significantly interfere with the resident's participation in activities or social interactions?

0.No...

1.Yes.

E0600. Impact on Others.

Enter Code

Enter Code

Enter Code

Did any of the identified symptom(s):

A.Put others at significant risk for physical injury?

0.No...

1.Yes.

B.Significantly intrude on the privacy or activity of others?

0.No...

1.Yes.

C.Significantly disrupt care or living environment?

0.No...

1.Yes.

E0800. Rejection of Care - Presence & 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/or 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.

MDS 3.0 Item Listing-Version 1.00.2 10/01/2010

Page 10 of 38

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