Mds Hc Form – Fill Out and Use This PDF

SECTION AA. NAME AND IDENTIFICATION NUMBERS

1.

NAME OF

CLIENT

a. (Last/Family Name)

b. (First Name)

c. (Middle Initial)

2.

CASE

RECORD

NO.

3.

GOVERN-

a. Pension (Social Security) Number

MENT

PENSION

AND HEALTH

b.

Health

insurance

number

(or

other comparable insurance number)

INSURANCE

NUMBERS

SECTION BB. PERSONAL ITEMS (Complete at Intake Only)

1.

GENDER

1. Male

2. Female

2.

BIRTHDATE

Month

Day

Year

3.

RACE/

(Check all that apply)

ETHNICITY

RACE

Native Hawaiian or other Pacific

*

American Indian/Alaskan

Islander

d.

White

Native

a.

e.

Asian

b.

ETHNICITY:

Black or African American

c.

Hispanic or Latino

f.

4.

MARITAL

1. Never married

3. Widowed

5. Divorced

STATUS

2. Married

4. Separated

6. Other

5.LANGUAGE Primary Language

*		0. English	1. Spanish	2. French	3. Other
6.	EDUCATION	1. No schooling		5. Technical or trade school
	(Highest	2. 8th grade/less		6. Some college
	Level	3. 9-11 grades		7. Bachelor's degree
	Completed)	4. High school		8. Graduate degree

7.RESPONSI- (Code for responsibility/advanced directives)

BILITY/	0. No	1. Yes
ADVANCED
DIRECTIVES a. Client has a legal guardian

b. Client has advanced medical directives in place (for example, a do not hospitalize order)

SECTION CC. REFERRAL ITEMS (Complete at Intake Only)

1.DATE CASE

OPENED/

	REOPENED
			Month			Day			Year
2.	REASON	1. Post hospital care							4. Eligibility for home care
	FOR	2. Community chronic care							5. Day care
	REFERRAL	3. Home placement screen							6. Other
3.	GOALS OF	(Code for client/family understanding of goals of care)
	CARE	0. No			1. Yes
		a. Skilled nursing treatments							d. Client/family education
		b. Monitoring to avoid clinical							e. Family respite
		complications
		c. Rehabilitation							f. Palliative care

4.TIME SINCE Time since discharge from last in-patient setting (Code for most

LAST recent instance in LAST 180 DAYS)

HOSPITAL	0. No hospitalization within 180 days	3. Within 15 to 30 days
STAY	1. Within last week	4. More than 30 days ago
	2. Within 8 to 14 days
5. WHERE	1. Private home/apt. with no home care services
LIVED AT	2. Private home/apt. with home care services
TIME OF	3. Board and care/assisted living/group home
REFERRAL	4. Nursing home
	5. Other
6. WHO LIVED	1. Lived alone
WITH AT	2. Lived with spouse only
REFERRAL	3. Lived with spouse and other(s)
	4. Lived with child (not spouse)
	5. Lived with other(s) (not spouse or children)
	6. Lived in group setting with non-relative(s)

7.PRIOR NH Resided in a nursing home at anytime during 5 YEARS prior to case

PLACEMENT opening
0. No	1. Yes

8.RESIDENTIAL Moved to current residence within last two years

HISTORY

0. No

1. Yes

SECTION A. ASSESSMENT INFORMATION

1.ASSESSMENT Date of assessment

REFERENCE

DATE

Month

Day

Year

2.REASONS Type of assessment

FOR 1. Initial assessment

ASSESS- 2. Follow-up assessment

MENT 3. Routine assessment at fixed intervals

4.Review within 30-day period prior to discharge from the program

5.Review at return from hospital

6.Change in status

7.Other

SECTION B. COGNITIVE PATTERNS

1.MEMORY (Code for recall of what was learned or known)

RECALL	0. Memory OK	1. Memory problem
ABILITY	a. Short-term memory OK — seems/appears to recall after 5 minutes
	b. Procedural memory OK—Can perform all or almost all steps in a
	multitask sequence without cues for initiation

2.	COGNITIVE	a. How well client made decisions about organizing the day (e.g., when
	SKILLS FOR	to get up or have meals, which clothes to wear or activities to do)
	DAILY	0.	INDEPENDENT—Decisions consistent/reasonable/safe
	DECISION-
	MAKING	1.	MODIFIED INDEPENDENCE—Some difficulty in new situations
			only
		2.	MINIMALLY IMPAIRED—In specific situations, decisions become
			poor or unsafe and cues/supervision necessary at those times
		3.	MODERATELY IMPAIRED—Decisions consistently poor or un-
			safe, cues/supervision required at all times
		4.	SEVERELY IMPAIRED—Never/rarely made decisions
		b. Worsening of decision making as compared to status of 90 DAYS
		AGO (or since last assessment if less than 90 days)
		0. No		1. Yes

3.INDICATORS a. Sudden or new onset/change in mental function over LAST 7 DAYS

OF DELIRIUM (including ability to pay attention, awareness of surroundings, being
coherent, unpredictable variation over course of day)
0. No	1. Yes
b. In the LAST 90 DAYS (or since last assessment if less than 90
days), client has become agitated or disoriented such that his or
her safety is endangered or client requires protection by others
0. No	1. Yes

SECTION C. COMMUNICATION/HEARING PATTERNS

1. HEARING

0.HEARS ADEQUATELY—Normal talk, TV, phone, doorbell

1.MINIMAL DIFFICULTY—When not in quiet setting

2.HEARS IN SPECIAL SITUATIONS ONLY—Speaker has to adjust tonal quality and speak distinctly

3.HIGHLY IMPAIRED —Absence of useful hearing

2.MAKING (Expressing information content—however able)

SELF	0. UNDERSTOOD—Expresses ideas without difficulty
UNDERSTOOD
	1. USUALLY UNDERSTOOD—Difficulty finding words or finishing thoughts
(Expression)	BUT if given time, little or no prompting required
	2. OFTEN UNDERSTOOD—Difficulty finding words or finishing thoughts,
	prompting usuallly required
	3. SOMETIMES UNDERSTOOD—Ability is limited to making concrete
	requests
	4. RARELY/NEVERUNDERSTOOD

3.ABILITY TO (Understands verbal information—however able)

	UNDER-	0. UNDERSTANDS—Clear comprehension
	STAND
		1. USUALLY UNDERSTANDS—Misses some part/intent of message,
	OTHERS
		BUT comprehends most conversation with little or no prompting
	(Comprehen-	2. OFTEN UNDERSTANDS—Misses some part/intent of message;with
	sion)	prompting can often comprehend conversation
		3. SOMETIMES UNDERSTANDS—Responds adequately to simple, di-
		rect communication
		4. RARELY/NEVERUNDERSTANDS

4.	COMMUNICA-	Worsening in communication (making self understood or understand-
	TION	ing others) as compared to status of 90 DAYS AGO (or since last
	DECLINE	assessment if less than 90 days)
		0. No	1. Yes

SECTION D. VISION PATTERNS

1.VISION (Ability to see in adequate light and with glasses if used)

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 newspa- per headlines, but can identify objects

3.HIGHLY IMPAIRED—Object identification in question, but eyes ap- pear to follow objects

4.SEVERELY IMPAIRED—No vision or sees only light, colors, or shapes; eyes do not appear to follow objects

2.VISUAL Saw halos or rings around lights, curtains over eyes, or flashes of LIMITATION/ lights

	DIFFICUL-	0. No	1. Yes
	TIES
3.	VISION	Worsening of vision as compared to status of 90 DAYS AGO (or since
	DECLINE	last assessment if less than 90 days)
		0. No	1. Yes
	MDS-HC Version 2.0 — July 21, 1999			MDS-HC - Pg 1

1. INDICATORS OF

DEPRES-

SION,

ANXIETY,

(Code for observed indicators irrespective of the assumed cause)

0.Indicator not exhibited in last 3 days

1.Exhibited 1-2 of last 3 days

2.Exhibited on each of last 3 days

1. TWO KEY				(A)	(B)
INFORMAL				PrIm	Secn
HELPERS	If needed, willingness (with ability) to increase help:
Primary (A)	0. More than 2 hours 1. 1-2 hours per day	2. No

SAD MOOD

a. A FEELING OF SADNESS OR BEING DEPRESSED, that life is not worth living, that nothing matters, that he or she is of no use to anyone or would rather be dead

b.PERSISTENTANGER WITH SELF OR OTHERS— e.g., easily annoyed, anger at care received

c.EXPRESSIONS OF WHAT APPEARTO BE UNREAL- ISTIC FEARS—e.g., fear of being abandoned, left alone, being with others

d.REPETITIVEHEALTHCOM- PLAINTS—e.g., persistently seeks medical attention, obsessive concern with body functions

e.REPETITIVEANXIOUSCOM- PLAINTS,CONCERNS—e.g., persistently seeks attention/ reassurance regarding sched- ules, meals, laundry, clothing, relationship issues

f.SAD,PAINED,WORRIED FA- CIAL EXPRESSIONS — e.g.,

furrowed brows

g.RECURRENTCRYING,TEAR- FULNESS

h.WITHDRAWALFROMACTIVI- TIES OF INTEREST—e.g., no interest in long standing ac- tivities or being with family/ friends

i . REDUCED SOCIAL INTER-

ACTION

	and	j . — Advice or emotional support
	Secondary (B)
		k. — IADL care
	(cont)
		l. — ADL care
2.	CAREGIVER	(Check all that apply)
	STATUS	A caregiver is unable to continue in caring activities—e.g., decline in
		the health of the caregiver makes it difficult to continue			a.
		Primary caregiver is not satisfied with support received from family			b.
		and friends (e.g., other children of client)
					c.
		Primary caregiver expresses feelings of distress, anger or depression
		NONE OF ABOVE			d.
3.	EXTENT OF	For instrumental and personal activities of daily living received over the
	INFORMAL	LAST 7 DAYS, indicate extent of help from family, friends, and
		neighbors		HOURS
	HELP
	(HOURS	a. Sum of time across five weekdays
	OF CARE,
	ROUNDED)	b. Sum of time across two weekend days

2.MOOD Mood indicators have become worse as compared to status of 90

DECLINE days ago (or since last assessment if less than 90 days)
0. No	1. Yes

3.BEHAVIORAL Instances when client exhibited behavioral symptoms. If EXHIBITED, ease of SYMPTOMS altering the symptom when it occurred.

0.Did not occur in last 3 days

1.Occurred, easily altered

2.Occurred, not easily altered

a.WANDERING—Moved with no rational purpose, seemingly oblivious to needs or safety

b.VERBALLY ABUSIVE BEHAVIORAL SYMPTOMS—Threatened, screamed at, cursed at others

c.PHYSICALLY ABUSIVE BEHAVIORAL SYMPTOMS—Hit, shoved, scratched, sexually abused others

d.SOCIALLY INAPPROPRIATE/DISRUPTIVE BEHAVIORAL SYMP- TOMS—Disruptive sounds, noisiness, screaming, self-abusive acts, sexual behavior or disrobing in public, smears/throws food/feces, rummaging, repetitive behavior, rises early and causes disruption

e.RESISTS CARE—Resisted taking medications/injections, ADL as- sistance, eating, or changes in position

4.CHANGES IN Behavioral symptoms have become worse or are less well tolerated BEHAVIOR by family as compared to 90 DAYS AGO (or since last assessment if

SYMPTOMS less than 90 days)
0. No, or no change in behavioral symptoms	1. Yes

SECTION F. SOCIAL FUNCTIONING

1.INVOLVE- a. At ease interacting with others (e.g., likes to spend time with others)

MENT	0. At ease	1. Not at ease
	b. Openly expresses conflict or anger with family/friends
	0. No	1. Yes

2.CHANGE IN As compared to 90 DAYS AGO (or since last assessment if less than

SOCIAL 90 days ago), decline in the client's level of participation in social,

ACTIVITIES religious, occupational or other preferred activities. IF THERE WAS A
DECLINE, client distressed by this fact
0. No decline
1. Decline, not distressed
2. Decline, distressed
3. ISOLATION a. Length of time client is alone during the day (morning and afternoon)
0. Never or hardly ever
1. About one hour
2. Long periods of time—e.g., all morning
3. All of the time
b. Client says or indicates that he/she feels lonely
0. No	1. Yes

SECTION G. INFORMAL SUPPORT SERVICES

SECTION H. PHYSICAL FUNCTIONING:

•IADL PERFORMANCE IN 7 DAYS

•ADL PERFORMANCE IN 3 DAYS

1.IADL SELF PERFORMANCE—Code for functioning in routine activities around the home or in the community during the LAST 7 DAYS,

(A)IADL SELF PERFORMANCE CODE (Code for client's performance during LAST 7 DAYS)

0.INDEPENDENT—did on own

1.SOME HELP—help some of the time

2.FULL HELP—performed with help all of the time

3.BY OTHERS—performed by others

8.ACTIVITY DID NOT OCCUR

(B)IADL DIFFICULTY CODE How difficult it is (or would it be) for client to do

activity on ownPerformance

0.NO DIFFICULTY

1.SOME DIFFICULTY—e.g., needs some help, is very slow, or fatiguesDifficulty

2.GREAT DIFFICULTY—e.g., little or no involvement in the activity is possible

a.MEAL PREPARATION—How meals are prepared (e.g., planning meals, cooking, assembling ingredients, setting out food and utensils)

b.ORDINARY HOUSEWORK—How ordinary work around the house is performed (e.g., doing dishes, dusting, making bed, tidying up, laundry)

c.MANAGING FINANCE—How bills are paid, checkbook is balanced, household expenses are balanced

d.MANAGING MEDICATIONS—How medications are managed (e.g., remembering to take medicines, opening bottles, taking correct drug dosages, giving injections, applying ointments)

e.PHONE USE—How telephone calls are made or received (with assistive devices such as large numbers on telephone, amplification as needed)

f.SHOPPING—How shopping is performed for food and household items (e.g., selecting items, managing money)

g.TRANSPORTATION—How client travels by vehicle (e.g., gets to places beyond walk- ing distance)

2.ADL SELF-PERFORMANCE—The following address the client's physical functioning in routine personal activities of daily life, for example, dressing, eating, etc. during the LAST 3 DAYS, considering all episodes of these activities. For clients who performed an activity indepen- dently, be sure to determine and record whether others encouraged the activity or were present to supervise or oversee the activity [Note—For bathing, code for most dependent single episode in LAST 7 DAYS]

0.INDEPENDENT—No help, setup, or oversight —OR— Help, setup, oversight provided only 1 or 2 times (with any task or subtask)

1.SETUP HELP ONLY—Article or device provided within reach of client 3 or more times

2.SUPERVISION—Oversight, encouragement or cueing provided 3 or more times during last 3 days —OR— Supervision (1 or more times) plus physical assistance provided only 1 or

1.

TWO KEY

INFORMAL HELPERS

Primary (A)

and

Secondary

(B)

NAME OF PRIMARY AND SECONDARY HELPERS

a. (Last/Family Name)		b. (First)
c. (Last/Family Name)		d. (First)
			(A)	(B)
			PrIm	Secn
e. Lives with client
0. Yes	1. No	2. No such helper [skip other items in
		the appropriate column]

f.Relationship to client

0. Child or child-in-law 2. Other Relative

1. Spouse	3. Friend/neighbor
Areas of help:	0. Yes	1. No

g. — Advice or emotional support h. — IADL care

i. — ADL care

2 times (for a total of 3 or more episodes of help or supervision)

3.LIMITED ASSISTANCE—Client highly involved in activity;received physical help in guided maneuvering of limbs or other non-weight bearing assistance 3 or more times —OR— Combination of non-weight bearing help with more help provided only 1 or 2 times during period (for a total of 3 or more episodes of physical help)

4.EXTENSIVE ASSISTANCE—Client performed part of activity on own (50% or more of subtasks), but help of following type(s) were provided 3 or more times:

—Weight-bearing support —OR—

—Full performance by another during part (but not all) of last 3 days

5.MAXIMAL ASSISTANCE—Client involved and completed less than 50% of subtasks on own (includes 2+ person assist), received weight bearing help or full performance of certain subtasks 3 or more times

6.TOTAL DEPENDENCE—Full performance of activity by another

8. ACTIVITY DID NOT OCCUR (regardless of ability)

MDS-HC Version 2.0 — July 21, 1999

MDS-HC - Pg 2

2. ADLSELF-PERFORMANCE(cont)

a. MOBILITY IN BED—Including moving to and from lying position, turning side to side, and

positioning body while in bed.

b. TRANSFER—Including moving to and between surfaces—to/from bed, chair, wheelchair,

standing position. [Note—Excludes to/from bath/toilet]

c. LOCOMOTION IN HOME—[Note—If in wheelchair, self-sufficiency once in chair]

d. LOCOMOTION OUTSIDE OF HOME—[Note—If in wheelchair, self-sufficiency once in

chair]

e. DRESSING UPPER BODY—How client dresses and undresses (street clothes,under-

wear) above the waist, includes prostheses, orthotics, fasteners, pullovers, etc.

f. DRESSING LOWER BODY—How client dresses and undresses (street clothes, under-

wear) from the waist down, includes prostheses, orthotics, belts, pants, skirts, shoes,

and fasteners

3.BOWEL CONTI- NENCE

In LAST 7 DAYS, control of bowel movement (with appliance or bowel continence program if employed)

0.CONTINENT—Complete control; DOES NOT USE ostomy device

1.CONTINENT WITH OSTOMY—Complete control with use of ostomy device that does not leak stool

2.USUALLY CONTINENT—Bowel incontinent episodes less than weekly

3.OCCASIONALLY INCONTINENT—Bowel incontinent episode once a week

4.FREQUENTLY INCONTINENT—Bowel incontinent episodes 2-3 times a week

5.INCONTINENT—Bowel incontinent all (or almost all) of the time

8.DID NOT OCCUR—No bowel movement during entire 7 day assessment period

g. EATING—Including taking in food by any method, including tube feedings.

h. TOILET USE—Including using the toilet room or commode, bedpan, urinal, transferring

on/off toilet, cleaning self after toilet use or incontinent episode, changing pad, managing

any special devices required (ostomy or catheter), and adjusting clothes.

i . PERSONAL HYGIENE—Including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (EXCLUDE baths and showers)

j . BATHING—How client takes full-body bath/shower or sponge bath (EXCLUDE washing of back and hair). Includes how each part of body is bathed: arms, upper and lower legs, chest, abdomen, perineal area. Code for most dependent episode in LAST 7 DAYS

3.ADLDECLINE ADL status has become worse (i.e., now more impaired in self perfor- mance) as compared to status 90 days ago (or since last assessment

		if less than 90 days)
		0. No	1. Yes
4.	PRIMARY	0. No assistive device	3. Scooter (e.g., Amigo)
	MODES OF	1. Cane	4. Wheelchair
	LOCOMO-	2. Walker/crutch	8. ACTIVITY DID NOT OCCUR
	TION	a. Indoors
		b. Outdoors
5.	STAIR	In the last 3 days, how client went up and down stairs (e.g., single or
	CLIMBING	multiple steps, using handrail as needed)
		0. Up and down stairs without help
		1. Up and down stairs with help
		2. Not go up and down stairs
6.	STAMINA	a. In a typical week, during the LAST 30 DAYS (or since last assess-
		ment), code the number of days client usually went out of the house
		or building in which client lives (no matter how short a time period )
		0. Every day	2. 1 day a week
		1. 2-6 days a week	3. No days
		b. Hours of physical activities in the last 3 days (e.g., walking, cleaning
		house, exercise)
		0. Two or more hours	1. Less than two hours
	7.FUNCTIONAL	Client believes he/she capable of increased functional independence
	POTENTIAL	(ADL, IADL, mobility)			a.
		Caregivers believe client is capable of increased functional indepen-
		dence (ADL, IADL, mobility)			b.
		Good prospects of recovery from current disease or conditions, im-
		proved health status expected			c.
		NONE OF ABOVE			d.

SECTION I. CONTINENCE IN LAST 7 DAYS

1. BLADDER	a. In LAST 7 DAYS control of urinary bladder function (with appliances
CONTI-	such as catheters or incontinence program employed) [Note—if
NENCE	dribbles, volume insufficient to soak through underpants]

0.CONTINENT —Complete control; DOES NOT USE any type of catheter or other urinary collection device

1.CONTINENTWITH CATHETER—Complete control with use of any type of catheter or urinary collection device that does not leak urine

2.USUALLY CONTINENT—Incontinent episodes once a week or less

3.OCCASIONALLY INCONTINENT—Incontinent episodes 2 or more times a week but not daily

4.FREQUENTLY INCONTINENT—Tends to be incontinent daily, but some control present

5.INCONTINENT—Inadequate control, multiple daily episodes

8. DID NOT OCCUR —No urine output from bladder

b.Worsening of bladder incontinence as compared to status 90 DAYS AGO (or since last assessment if less than 90 days)

0. No1. Yes

2.	BLADDER	(Check all that apply in LAST 7 DAYS)
	DEVICES	Use of pads or briefs to protect against wetness	a.
		Use of an indwelling urinary catheter	b.
		NONE OF ABOVE	c.

SECTION J. DISEASE DIAGNOSES

Disease/infection that doctor has indicated is present and affects client's status, requires treat- ment, or symptom management. Also include if disease is monitored by a home care professional or is the reason for a hospitalization in LAST 90 DAYS (or since last assessment if less than 90 days)

[blank]. Not present

1.Present—not subject to focused treatment or monitoring by home care professional

2.Present—monitored or treated by home care professional

[If no disease in list, check J1ac, None of Above]

1.

DISEASES

HEART/CIRCULATION

p. Osteoporosis

a. Cerebrovascular accident

SENSES

(stroke)

q. Cataract

b. Congestive heart failure

r. Glaucoma

c. Coronary artery disease

PSYCHIATRIC/MOOD

d. Hypertension

s. Any psychiatric diagnosis

e. Irregularly irregular pulse

INFECTIONS

f. Peripheral vascular disease

t. HIV infection

NEUROLOGICAL

u. Pneumonia

g. Alzheimer's

v. Tuberculosis

h. Dementia other than

w. Urinary tract infection (in

Alzheimer's disease

LAST 30 DAYS)

i . Head trauma

OTHER DISEASES

j . Hemiplegia/hemiparesis

x. Cancer—(in past 5 years)

k. Multiple sclerosis

not including skin cancer

l . Parkinsonism

y. Diabetes

MUSCULO-SKELETAL

z . Emphysema/COPD/asthma

m.Arthritis

aa. Renal Failure

n. Hip fracture

ab.Thyroid disease (hyper or

o. Other fractures (e.g., wrist,

hypo)

vertebral)

ac. NONE OF ABOVE

ac.

2.

OTHER

a.

•

CURRENT

OR MORE

b.

•

DETAILED

DIAGNOSES

c.

•

AND ICD-9

CODES

d.

•

SECTION K. HEALTH CONDITIONS AND PREVENTIVE HEALTH

MEASURES

1.

PREVENTIVE

(Check all that apply—in PAST 2YEARS)

HEALTH

Blood pressure measured

a.

(PAST TWO

Received influenza vaccination

b.

YEARS)

Test for blood in stool or screening endoscopy

c.

IF FEMALE: Received breast examination or mammography

d.

NONE OF ABOVE

e.

PROBLEM

(Check all that were present on at least 2 of the last 3 days)

CONDITIONS

Diarrhea

Loss of appetite

PRESENT ON

a.

d.

2 OR MORE

Difficulty urinating or urinating

Vomiting

DAYS

3 or more times at night

b.

e.

Fever

c.

NONE OF ABOVE

f.

3.

PROBLEM

(Check all present at any point during last 3 days)

CONDITIONS

PHYSICAL HEALTH

Shortness of breath

e.

Chest pain/pressure at rest or

MENTAL HEALTH

on exertion

a.

Delusions

f.

No bowel movement in 3 days

b.

Hallucinations

g.

Dizziness or lightheadedness

c.

NONE OF ABOVE

h.

Edema

d.