Mds Hc Form PDF Details

Navigating the complexity of healthcare and support services requires accurate and detailed assessment forms to ensure that individuals receive the care and support they need. Among these essential tools in Massachusetts is the Minimum Data Set – Home Care (MDS-HC), introduced in a significant overhaul by the Executive Office of Health and Human Services, Division of Medical Assistance. As of February 2003, chronic disease and rehabilitation hospitals have been mandated to transition to this form and the accompanying Request for Services (RFS-1), moving away from the previous Long Term Care Assessment form. This shift aims to streamline the referral process for long-term care services, encompassing nursing-facility and adult-day-health services among others. The MDS-HC form must be completed meticulously by an assessment coordinator, a role designated to a registered nurse to guarantee the form’s accuracy and completeness, although certain sections can also be filled out by a licensed social worker. The assessment’s breadth covers various essential aspects of a patient’s care needs, from cognitive and communication patterns to social functioning and informal support services, underlining the importance of a comprehensive approach to patient care planning and implementation. The inclusion of meticulous documentation on the patient’s condition, coupled with ICD-9-CM codes for diagnoses, lays a robust foundation for determining clinical eligibility for MassHealth's long-term-care services. Furthermore, the directive for chronic disease and rehabilitation hospitals to adhere to the updated documentation requirements by February 1, 2003, emphasizes the state’s commitment to enhancing communication lines between providers and the Division, thereby facilitating a smoother and more efficient process in addressing the long-term care needs of Massachusetts’ residents.

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COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

DIVISION OF MEDICAL ASSISTANCE

600 Washington Street Boston, MA 02111 www.mass.gov/dma

MassHealth

Chronic Disease and

Rehabilitation Hospital Bulletin 83

January 2003

TO: Chronic Disease and Rehabilitation Hospitals Participating in MassHealth

FROM: Wendy E. Warring, Commissioner

RE:

Changes in Clinical Assessment Forms

 

 

 

 

Background

The Division determines clinical eligibility for MassHealth long-term-care

 

services based upon documentation submitted by the provider. The Long

 

Term Care Assessment form has been replaced by two new forms in

 

order to facilitate communication between providers and the Division.

 

 

 

New Forms

Attached to this bulletin are copies of the two new forms required for

 

approving referrals for long-term-care services, including, but not limited

 

to, nursing-facility and adult-day-health services.

 

Request for Services (RFS-1) (formerly called the MassHealth

 

Long Term Care Assessment form)

 

Minimum Data Set – Home Care (MDS-HC)

 

Chronic disease and rehabilitation hospitals must begin using these new

 

forms by February 1, 2003. Please discard all previous versions of the Long

 

Term Care Assessment form.

 

 

 

Who May Complete

The MDS-HC must be completed by an assessment coordinator. The

the MDS-HC

assessment coordinator must be a registered nurse who certifies the

 

accuracy and completeness of the MDS-HC.

 

The following sections of the MDS-HC may be completed by a licensed

 

social worker (LSW, LCSW, or LICSW).

 

AA – Name and Identification Numbers

 

BB – Personal Items

 

CC – Referral Items

 

B – Cognitive Patterns

 

C – Communication/Hearing Patterns

 

E – Mood and Behavior Patterns

 

F – Social Functioning

 

G – Informal Support Services

 

O – Environmental Assessment

 

 

 

 

CONTINUED ON BACK

MassHealth

Chronic Disease and

Rehabilitation Hospital Bulletin 83

January 2003

Page 2

Who May Complete

Each person who completes a portion of the MDS-HC must sign and

the MDS-HC

certify the sections he or she completes in Section R – Assessment

(cont.)

Information (Other Signatures, Title, Sections, Date).

 

 

Qualifications for

The registered nurse or social worker must be licensed by the

Completing the Forms

Massachusetts Board of Registration.

 

 

ICD-9-CM Codes

The MDS-HC assessment requires the use of the ICD-9-CM codes for

 

medical diagnoses.

 

 

Trainings

The Division holds periodic trainings for providers. You will receive notice

 

of trainings when they are scheduled.

 

 

Supplies of the Forms

You may photocopy the forms as needed. To obtain supplies of the

 

forms, use the information below to mail or fax your request. Include your

 

provider number, address, telephone number, the exact title of the form,

 

and the desired quantity.

 

MassHealth Forms Distribution

 

P.O. Box 9101

 

Somerville, MA 02145

 

Fax: 703-917-4087

 

 

Questions

If you have any questions about this bulletin, please contact MassHealth

 

Provider Services at 617-628-4141 or 1-800-325-5231.

 

 

 

 

(With hearing appliance if used)

MINIMUM DATA SET - HOME CARE (MDS-HC

Unless otherwise noted, score for last 3 days

Examples of exceptions include IADLs/Continence/Services/Treatments where status scored over last 7 days

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

(A) (B)

SECTION E. MOOD AND BEHAVIOR PATTERNS

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.

 

 

 

 

 

 

 

 

 

 

MDS-HC Version 2.0 — July 21, 1999

MDS-HC - Pg 3

4.

PAIN

a. Frequency with which client complains or shows evidence of pain

 

 

0. No pain (score b-e as 0)

2. Daily - one period

 

 

1. Less than daily

 

3. Daily - multiple periods

 

 

 

 

 

 

(e.g., morning and evening)

 

 

 

b. Intensity of pain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0. No pain

2. Moderate

4. Times when pain is horrible

 

 

1. Mild

3. Severe

or excruciating

 

 

 

 

 

 

 

 

 

c. From client's point of view, pain intensity disrupts usual activities

 

 

0. No

1. Yes

 

 

 

 

 

 

d. Character of pain

 

 

 

 

 

 

 

0. No pain

1. Localized - single site

2. Multiple sites

 

 

 

e. From client's point of view, medications adequately control pain

 

 

0. Yes or no pain

1. Medications do not

2. Pain present,

 

 

 

adequately control pain

medication not

 

 

 

 

 

 

 

 

 

 

 

 

taken

 

 

 

 

 

 

 

 

 

5.FALLS Number of times fell in LAST 90 DAYS (or since last assessment if FREQUENCY less than 90 days) If none, code "0"; if more than 9, code "9"

6.

DANGER OF

(Code for danger of falling)

 

 

FALL

0. No

1. Yes

 

 

 

 

 

 

 

 

a. Unsteady gait

 

 

 

 

b. Client limits going outdoors due to fear of falling (e.g., stopped

 

 

 

 

 

 

using bus, goes out only with others)

 

 

 

 

 

7.

LIFE STYLE

(Code for drinking or smoking)

 

 

(Drinking/

0. No

1. Yes

 

 

Smoking)

 

 

 

a. In the LAST 90 DAYS (or since last assessment if less than 90 days),

 

 

 

 

 

 

client felt the need or was told by others to cut down on drinking, or

 

 

 

others were concerned with client's drinking

 

 

 

b. In the LAST 90 DAYS (or since last assessment if less than 90 days),

 

 

 

 

 

 

client had to have a drink first thing in the morning to steady nerves

 

 

 

(i.e., an "eye opener") or has been in trouble because of drinking

 

 

 

c. Smoked or chewed tobacco daily

 

8.HEALTH (Check all that apply)

STATUS

Client feels he/she has poor health (when asked)

a.

INDICATORS

Has conditions or diseases that make cognition, ADL, mood, or

 

 

 

 

behavior patterns unstable (fluctuations, precarious, or deteriorating)

b.

 

Experiencing a flare-up of a recurrent or chronic problem

c.

 

Treatments changed in LAST 30 DAYS (or since last assessment if

 

 

less than 30 days) because of a new acute episode or condition

d.

 

Prognosis of less than six months to live—e.g., physician has told

 

 

client or client's family that client has end-stage disease

e.

 

NONE OF ABOVE

f.

9.OTHER (Check all that apply)

STATUS

Fearful of a family member or caregiver

a.

INDICATORS

Unusually poor hygiene

b.

 

 

 

 

Unexplained injuries, broken bones, or burns

c.

 

 

 

Neglected, abused, or mistreated

d.

 

 

 

Physically restrained (e.g., limbs restrained, used bed rails,

 

 

constrained to chair when sitting)

e.

 

NONE OF ABOVE

f.

SECTION L. NUTRITION/HYDRATION STATUS

1.

WEIGHT

(Code for weight items)

1. Yes

 

 

 

 

0. No

 

 

 

 

a. Unintended weight loss of 5% or more in the LAST 30 DAYS [or 10%

 

 

 

 

or more in the LAST 180 DAYS]

 

 

 

 

 

 

 

 

 

b. Severe malnutrion (cachexia)

 

 

 

 

c. Morbid obesity

 

 

 

 

 

 

 

2.

CONSUMP-

(Code for consumption)

 

 

0. No

1. Yes

 

 

TION

 

 

 

 

 

 

 

 

a. In at least 2 of the last 3 days, ate one or fewer meals a day

 

 

 

 

 

 

 

 

 

b. In last 3 days, noticeable decrease in the amount of food client

 

 

 

usually eats or fluids usually consumes

c. Insufficient fluid—did not consume all/almost all fluids during last

3 days

d.Enteral tube feeding

3.SWALLOWING 0. NORMAL—Safe and efficient swallowing of all diet consistencies

1.REQUIRES DIET MODIFICATION TO SWALLOW SOLID FOODS (mechanical diet or able to ingest specific foods only)

2.REQUIRES MODIFICATION TO SWALLOW SOLID FOODS AND LIQUIDS (puree, thickened liquids)

3.COMBINED ORAL AND TUBE FEEDING

4.NO ORAL INTAKE (NPO)

SECTION M. DENTAL STATUS (ORAL HEALTH)

1.

ORAL

(Check all that apply)

 

 

STATUS

Problem chewing (e.g., poor mastication, immobile jaw, surgical resec-

 

 

 

 

 

 

 

 

tion, decreased sensation/motor control, pain while eating)

a.

 

 

 

 

 

Mouth is "dry" when eating a meal

b.

 

 

Problem brushing teeth or dentures

c.

 

 

NONE OF ABOVE

d.

SECTION N. SKIN CONDITION

1.

SKIN

Any troubling skin conditions or changes in skin condition (e.g., burns,

 

 

PROBLEMS

bruises, rashes, itchiness, body lice, scabies)

 

 

 

0. No

1. Yes

 

 

2.

ULCERS

Presence of an ulcer anywhere on the body. Ulcers include any area of

 

 

(Pressure/

persistent skin redness (Stage 1); partial loss of skin layers (Stage 2);

 

 

deep craters in the skin (Stage 3); breaks in skin exposing muscle or

 

 

Stasis)

 

 

bone (Stage 4).[Code 0 if no ulcer,otherwise record the highest ulcer

 

 

 

 

 

 

stage (Stage 1-4).]

 

 

 

 

 

 

 

 

 

 

 

 

a. Pressure ulcer—any lesion caused by pressure, shear forces,

 

 

 

resulting in damage of underlying tissues

 

 

 

b. Stasis ulcer—open lesion caused by poor circulation in the lower

 

 

 

 

 

 

extremities

 

 

 

 

3.

OTHERSKIN

(Check all that apply)

 

 

 

 

 

PROBLEMS

Burns (second or third

 

 

Surgical wound

 

 

 

 

 

 

REQUIRING

 

 

d.

 

degree)

 

 

 

TREATMENT

 

 

 

 

 

 

a.

Corns, calluses, structural prob-

 

 

 

 

 

 

 

 

Open lesions other than

 

 

 

 

 

 

 

lems, infections, fungi

e.

 

 

ulcers, rashes, cuts (e.g.,

 

 

 

 

 

 

 

 

 

 

 

 

cancer)

 

b.

NONE OF ABOVE

f.

 

 

 

 

 

 

Skin tears or cuts

 

c.

 

 

 

 

 

 

 

 

4.

HISTORY OF

Client previously had (at any time) or has an ulcer anywhere on the

 

 

RESOLVED

body

 

 

 

 

 

 

 

 

 

 

 

PRESSURE

0. No

1. Yes

 

 

 

ULCERS

 

 

 

 

 

 

 

 

5.

WOUND/

(Check for formal care in LAST 7 DAYS)

 

 

ULCER

Antibiotics, systemic or topical

 

a.

 

CARE

 

 

 

 

 

 

 

 

Dressings

 

 

 

b.

 

 

 

 

 

 

 

 

Surgical wound care

 

 

 

c.

 

 

 

 

 

 

 

 

Other wound/ulcer care (e.g., pressure relieving device, nutrition, turn-

 

 

 

ing, debridement)

 

 

 

d.

 

 

 

 

 

 

 

 

NONE OF ABOVE

 

 

 

e.

SECTION O. ENVIRONMENTAL ASSESSMENT

1.

HOME

Lighting in evening (including inadequate or no lighting in living room,

 

 

ENVIRON-

sleeping room, kitchen, toilet, corridors)

a.

 

MENT

Flooring and carpeting (e.g., holes in floor, electric wires where client

 

 

[Check any

 

 

walks, scatter rugs)

 

 

 

of following

 

b.

 

 

 

 

that make

Bathroom and toiletroom (e.g., non-operating toilet, leaking pipes, no

 

 

home

 

 

rails though needed, slippery bathtub, outside toilet)

c.

 

environment

 

hazardous or

Kitchen (e.g., dangerous stove, inoperative refrigerator, infestation by

 

 

uninhabit-

rats or bugs)

 

d.

 

able (if none

 

 

apply, check

Heating and cooling (e.g., too hot in summer, too cold in winter, wood

 

 

NONE OF

 

 

stove in a home with an asthmatic)

e.

 

ABOVE; if

 

 

 

 

 

 

 

 

temporarily

Personal safety (e.g., fear of violence, safety problem in going to

 

 

in institution,

mailbox or visiting neighbors, heavy traffic in street)

f.

 

base

 

 

 

Access to home (e.g., difficulty entering/leaving home)

 

 

assessment

g.

 

on home

Access to rooms in house (e.g., unable to climb stairs)

h.

 

visit)]

 

 

NONE OF ABOVE

 

i.

2.

LIVING

a. As compared to 90 DAYS AGO (or since last assessment), client

 

 

ARRANGE-

now lives with other persons—e.g., moved in with another person,

 

 

other moved in with client

 

 

MENT

 

 

0. No

1. Yes

 

 

 

 

 

 

b. Client or primary caregiver feels that client would be better off in

 

 

 

 

 

 

another living environment

 

 

 

0. No 1. Client only

2. Caregiver only 3. Client and caregiver

 

 

 

 

 

 

 

 

 

SECTION P. SERVICE UTILIZATION (IN LAST 7 DAYS)

1.

FORMAL

Extent of care or care management in LAST 7 DAYS (or since last

 

 

 

CARE

assessment if less than 7 days) involving

(A)

 

(B)

(C)

 

 

 

 

 

(Minutes

 

# of

 

 

 

 

 

 

 

Days

Hours

Mins

 

rounded to

a. Home health aides

 

 

 

 

 

 

 

 

 

 

 

 

 

even 10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

minutes)

b. Visiting nurses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Homemaking services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Meals

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

e. Volunteer services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

f. Physical therapy

 

 

 

 

 

 

 

 

g. Occupational therapy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

h. Speech therapy

 

 

 

 

 

 

 

 

i. Day care or day hospital

 

 

 

 

 

 

 

 

j. Social worker in home

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MDS-HC Version 2.0 — July 21, 1999

MDS-HC - Pg 4

2. SPECIAL

Special treatments, therapies, and programs received or scheduled during the

TREAT-

LAST 7 DAYS (or since last assessment if less than 7 days) and adherence to

MENTS,

the required schedule. Includes services received in the home or on an

THERAPIES,

outpatient basis.

 

PROGRAMS

[Blank]. Not applicable

2. Scheduled, partial adherence

 

1.Scheduled, full adherence as prescribed 3. Scheduled, not received [If no treatments provided, check NONE OF ABOVE P2aa]

 

RESPIRATORYTREATMENTS

 

o. Occupational therapy

 

 

 

 

p. Physical therapy

 

 

a. Oxygen

 

 

 

b. Respirator for assistive

 

PROGRAMS

 

 

 

 

 

 

breathing

 

q. Day center

 

 

 

 

 

 

 

c. All other respiratory treat-

 

r.

Day hospital

 

 

 

ments

 

s. Hospice care

 

 

 

 

 

 

OTHERTREATMENTS

 

 

 

 

t. Physician or clinic visit

 

 

 

 

d. Alcohol/drug treatment

 

 

 

 

 

 

 

u. Respite care

 

 

 

 

 

program

 

 

 

e. Blood transfusion(s)

 

SPECIAL PROCEDURES DONE

 

 

 

IN HOME

 

 

 

 

 

 

 

f.

Chemotherapy

 

 

 

 

v. Daily nurse monitoring (e.g.,

 

 

 

 

g. Dialysis

 

 

 

 

 

 

 

 

EKG, urinary output)

 

 

h. IV infusion - central

 

w. Nurse monitoring less than

 

 

 

 

 

 

 

 

 

 

i .

IV infusion - peripheral

 

 

daily

 

 

j .

Medication by injection

 

x. Medical alert bracelet or elec-

 

 

 

 

 

k. Ostomy care

 

 

tronic security alert

 

 

 

 

 

 

 

y.

Skin treatment

 

 

l .

Radiation

 

 

 

 

 

 

 

 

 

 

 

m. Tracheostomy care

 

z .

Special diet

 

 

 

 

 

 

 

 

 

 

THERAPIES

 

aa. NONE OF ABOVE

aa.

 

 

 

 

 

 

 

n. Exercise therapy

 

 

 

 

 

 

 

 

 

 

 

3.MANAGE- Management codes:

MENT OF

0. Not used

 

EQUIPMENT

1. Managed on own

 

(In Last 3

2. Managed on own if laid out or with verbal reminders

Days)

3. Partially performed by others

 

 

4. Fully performed by others

 

 

 

 

 

 

a. Oxygen

 

c. Catheter

 

b. IV

 

d. Ostomy

 

 

4.VISITS IN Enter 0 if none, if more than 9, code "9" LAST90

DAYS

a. Number of times ADMITTED TO HOSPITAL with an overnight stay

OR

 

SINCELAST

b. Number of times VISITED EMERGENCY ROOM without an overnight

ASSESSMENT

stay

c. EMERGENT CARE—including unscheduled nursing, physician, or therapeutic visits to office or home

5.TREATMENT Any treatment goals that have been met in the LAST 90 DAYS (or since

GOALS last assessment if less than 90 days)

0. No

1. Yes

6.OVERALL Overall self sufficiency has changed significantly as compared to

CHANGE IN status of 90 DAYS AGO (or since last assessment if less than 90 days)

CARE NEEDS 0. No change 1. Improved—receives

2. Deteriorated—

fewer supports

receives more support

7.TRADE OFFS Because of limited funds, during the last month, client made trade-offs among purchasing any of the following: prescribed medications, suffi- cient home heat, necessary physician care, adequate food, home care

0. No

1. Yes

SECTION Q. MEDICATIONS

1.NUMBER OF Record the number of different medicines (prescriptions and over the

MEDICA-

counter), including eye drops, taken regularly or on an occasional basis

in the LAST 7 DAYS (or since last assessment)[If none, code "0", if

TIONS

more than 9, code "9"]

 

2.RECEIPT OF Psychotropic medications taken in the LAST 7 DAYS (or since last PSYCHO- assesssment) [Note—Review client's medications with the list that

TROPIC applies to the following categories]

0. No

1. Yes

MEDICATION

 

 

 

a. Antipsychotic/neuroleptic

 

c. Antidepressant

 

b. Anxiolytic

 

d. Hypnotic

 

 

 

 

 

 

 

 

 

3.MEDICAL Physician reviewed client's medications as a whole in LAST 180 DAYS OVERSIGHT (or since last assessment)

0.Discussed with at least one physician (or no medication taken)

1.No single physician reviewed all medications

4.COMPLI- Compliant all or most of time with medications prescribed by physician

ANCE/ (both during and between therapy visits) in LAST 7 DAYS

ADHERENCE

 

WITH

0. Always compliant

MEDICA-

1. Compliant 80% of time or more

TIONS

2. Compliant less than 80% of time, including failure to purchase

 

prescribed medications

3.NO MEDICATIONS PRESCRIBED

=When box blank, must enter number or letter a. = When letter in box, check if condition applies

MDS-HC Version 2.0 — July 21, 1999

©Copyright interRAI, 1994,1996, 1997, 1999

5.LIST OF ALL List prescribed and nonprescribed medications taken in LAST 7 DAYS (or since MEDICATIONS last assessment)

a.Name and Dose—Record the name of the medication and dose ordered.

b.Form: Code the route of Administration using the following list:

1.

By mouth (PO)

5. Subcutaneous (SQ)

9. Enteral tube

2.

Sub lingual (SL)

6. Rectal (R)

10. Other

3.

Intramuscular (IM)

7.

Topical

 

 

4.

Intravenous (IV)

8. Inhalation

 

 

c. Number taken—Record the amount of medication administered each time

 

the medication is given

 

 

 

 

 

d. Freq: Code the number of times per day, week, or month the medication is

 

administered using the following list:

 

 

 

PRN. As necessary

 

5D.

Five times daily

 

QH.

 

Every hour

 

QOD. Every other day

 

Q2H.

Every two hours

 

QW.

Once each wk

 

 

Q3H.

Every three hours

 

2W.

Two times every week

 

Q4H.

Every four hours

 

3W.

Three times every week

 

Q6H.

Every six hours

 

4W.

Four times each week

 

Q8H.

Every eight hours

 

5W.

Five times each week

 

QD.

 

Once daily

 

6W.

Six times each week

 

BID.

 

Two times daily

 

1M.

Once every month

 

 

 

(includes every 12 hrs)

2M.

Twice every month

 

TID.

 

Three times daily

 

C.

Continuous

 

 

QID.

 

Four times daily

 

O.

Other

 

 

 

 

 

 

 

 

 

a. Name and Dose

 

 

 

 

b. Form

c. Number d. Freq.

 

 

 

 

 

 

 

Taken

a._________________________________________________________________________

b._________________________________________________________________________

c._________________________________________________________________________

d._________________________________________________________________________

e._________________________________________________________________________

f._________________________________________________________________________

g._________________________________________________________________________

h._________________________________________________________________________

i._________________________________________________________________________

j._________________________________________________________________________

k._________________________________________________________________________

SECTION R. ASSESSMENT INFORMATION

1.SIGNATURES OF PERSONS COMPLETINGTHE ASSESSMENT:

a.Signature of Assessment Coordinator

b.Title of Assessment Coordinator

c.Date Assessment Coordinator signed as complete

Month

Day

Year

 

 

 

 

 

 

 

d. Other Signatures

Title

Sections

Date

 

 

 

 

 

 

e.

 

 

Date

 

 

 

 

 

 

f.

 

 

Date

 

 

 

 

 

 

g.

 

 

Date

 

 

 

 

 

 

h.

 

 

Date

 

 

 

 

 

 

i .

 

 

Date

 

* Country specific

 

MDS-HC Version 2.0 — July 21, 1999

MDS-HC - Pg 5

Request for Services

Type of clinical eligibility determination all requested services.

Service(s) requested

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pre-admission nursing facility (NF)

Home and community

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

based services (HCBS) waiver

 

 

Adult day health (ADH)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Adult foster care (AFC)

 

 

 

 

Program for All-inclusive Care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

for the Elderly (PACE)

 

 

Group adult foster care (GAFC)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

Date

Nursing facility use only

Conversion

Continued stay

Short term review

Transfer NF to NF

Retrospective

Member information

Member/applicant

Last name

First name

Telephone

Address

City

Zip

Check one

 

 

 

 

 

 

 

 

MassHealth

 

 

MassHealth

 

 

GAFC/

 

 

 

 

 

 

 

member

 

 

application pending

 

 

Assisted living residence

 

 

 

 

 

 

 

 

 

 

 

 

 

MassHealth ID number

 

Date application iled

 

 

Date SSI-G application iled

Next of kin/Responsible party

 

 

 

 

 

 

 

Last name

 

First name

Telephone

Address

City

Zip

Physician

Last name

 

First name

Telephone

Address

City

Zip

Screening for mental illness, mental retardation, and developmental disability

Does the member/applicant have any of the following diagnoses/conditions? Check all that apply.

 

Mental illness

 

Specify:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mental retardation without related condition

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Developmental disability with related condition that occurred prior to age 22.

Check all that apply.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Autism

 

 

 

 

 

 

 

 

Deafness/severe hearing impairment

 

Multiple sclerosis

 

 

 

 

Severe learning disability

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Blindness/severe visual impairment

Epilepsy/seizure disorder

 

 

 

 

 

 

 

 

Muscular dystrophy

 

 

 

Spina biida

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cerebral palsy

 

Head/brain injury

 

 

 

Orthopedic impairment

 

 

Spinal cord injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Major mental illness

 

 

 

 

 

 

 

 

Cystic ibrosis

 

 

 

Speech/language impairment

 

 

 

 

 

RFS-1 (Rev. 10/02)

OVER

Name of member/applicant

Community services recommended

Check all that apply.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Skilled nursing

 

 

 

 

 

 

HCBS waiver

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rest home

Homemaker

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical therapy

Elderly housing

 

 

 

 

 

 

Personal emergency response system

 

 

 

 

 

 

 

 

 

 

 

Meals

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Occupational therapy

 

 

 

 

Adult foster care

 

 

 

Adult day health

 

 

 

Transportation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Speech therapy

 

 

 

 

 

 

Group adult foster care

 

 

PACE

 

 

 

Chore service

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mental health services

Home health aide

Grocery shopping/delivery

 

 

Assisted living

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social worker services

 

 

 

Congregate housing

 

 

 

 

 

 

Personal care/homemaker

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional information

1. Is the home or apartment available for the member or applicant?

 

 

 

 

yes

 

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

yes

 

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Is there a caregiver to assist the member in the community?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

yes

 

no

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Has the member or applicant experienced unexplained weight gain in the last 30 days?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

yes

 

no

4.

Does the member or applicant receive personal care/homemaker services?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes:

days per week

 

 

hours per week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

no

5.

Has the member or applicant experienced a signiicant change in condition in the last 30 days?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes:

 

 

 

 

improvement

 

 

 

 

 

deterioration

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Indicate the changes below.

For nursing facility requests only

1.Does the nursing facility member/applicant express an interest to remain in or return to the community?

2.Is the nursing facility stay expected to be short-term (up to 90 days)?

3.Is the nursing facility stay expected to be long-term (more than 90 days)?

Referral source Name of registered nurse completing this form

Signature

 

 

Print name

 

 

 

 

 

 

 

 

yes

no

yes

no

yes

no

Title

Name of organization

Telephone

Address

City

Zip

For community providers:

For nursing facility providers:

Attach the MDS-HC and Physician’s Summary form according to provider’s regulations/guidelines.

Attach the most recent comprehensive MDS, current quarterly MDS, and current physician orders.