Fri Nov 02 09:11:33 EDT 2012 QIES Workbench. Record Layout Report

Transcription

1 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 1 of 24 11/27/212 Fri Nov 2 9:11:33 EDT 212 QIES Workbench Record Layout Report For Job: MDS 3. NH All Elements 4/1/212 ( ) Report Name: MDS 3. NH All Elements 4/1/212 Data Type Offset Length DP Field Name CHAR 1 2 State NUM 3 1 Facility/Provider Internal ID NUM 13 1 Resident Internal ID NUM Assessment ID CHAR 38 4 Item Subset (ISC) DATE 42 8 Target Date DATE 5 8 Submission Date NUM Submission ID CHAR 8 1 Submission Required (SUB_REQ) CHAR 81 1 Birth Date Submit NUM 82 2 Correction CHAR 84 1 Correction Status CHAR 85 1 Data Submission Specification Version CHAR 95 2 Facility Document Identifier CHAR Item Set Version NUM Original Assessment ID DATE Processed Timestamp NUM Resident Age NUM Resident Match Criteria ID CHAR Software Product Name CHAR Software Product Version CHAR Software Vendor ID CHAR CBSA Urban/Rural CHAR Recalculated Z1A CHAR Recalculated Z1B CHAR Recalculated Z1C CHAR CMI Set for Recalculated Z1A CHAR CMI Value for Recalculated Z1A CHAR Recalculated Z15A CHAR 28 1 Recalculated Z15B CHAR 29 3 CMI Set for Recalculated Z15A CHAR CMI Value for Recalculated Z15A

2 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 2 of 24 11/27/212 CHAR 3 1 Recalculated Z2A CHAR 31 1 Recalculated Z2B CHAR 32 3 CMI Set for Recalculated Z2A CHAR CMI Value for Recalculated Z2A CHAR 33 1 Recalculated Z25A CHAR 34 1 Recalculated Z25B CHAR 35 3 CMI Set for Recalculated Z25A CHAR CMI Value for Recalculated Z25A CHAR 36 1 Medicare RUG III Index Maximized Group CHAR 37 1 Medicare RUG III Index Maximized Version CHAR 38 3 Medicare RUG III Index Maximized CMI Set CHAR Medicare RUG III Index Maximized CMI Value CHAR 39 1 Medicare RUG III Hierarchical Group CHAR 4 1 Medicare RUG III Hierarchical Version CHAR 41 1 Medicare RUG IV Hierarchical Group CHAR 42 1 Medicare RUG IV Hierarchical Version CHAR 43 1 A5 Type of Record CHAR A1A Facility National Provider Identifier (NPI) CHAR A1B Facility CMS Certification (CCN) CHAR A1C State Provider CHAR A2 Type of Provider CHAR A31A Federal OBRA Reason for Assessment CHAR A31B PPS Assessment CHAR A31C PPS Other Medicare Required Assessment (OMRA) CHAR A31D Swing Bed Clinical Change CHAR A31E First Assessment Since Most Recent Admission CHAR A31F Entry/Discharge CHAR A31G Planned Discharge CHAR A41 Submission Required CHAR A5A Resident First Name CHAR A5B Resident Middle Initial CHAR A5C Resident Last Name CHAR A5D Resident Name Suffix CHAR A6A Social Security CHAR A6B Resident Medicare/Railroad Insurance CHAR A7 Resident Medicaid

3 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 3 of 24 11/27/212 CHAR 55 1 A8 Gender DATE A9 Birth Date CHAR A1A Race/Ethnicity: American Indian or Alaskan Native CHAR 56 1 A1B Race/Ethnicity: Asian CHAR A1C Race/Ethnicity: African American CHAR A1D Race/Ethnicity: Hispanic CHAR A1E Race/Ethnicity: Native Hawaiian/Pacific Islander CHAR A1F Race/Ethnicity: White CHAR A11A Resident Need Interpreter CHAR A11B Preferred Language CHAR A12 Marital Status CHAR A13A Medical Record CHAR A13B Room CHAR A13C Preferred Name CHAR A13D Lifetime Occupation(s) Text CHAR 65 1 A15 Preadmission Screening and Resident Review (PASRR) CHAR A151A Serious Mental Illness CHAR A151B Intellectual Disability CHAR A151C Other Related Conditions CHAR A155A ID/DD Status: Down Syndrome CHAR A155B ID/DD Status: Autism CHAR A155C ID/DD Status: Epilepsy CHAR A155D ID/DD Status: Other Organic ID/DD Condition CHAR A155E ID/DD Status: ID/DD With No Organic Condition CHAR A155Z ID/DD Status: None of the Above DATE 66 8 A16 Entry Date CHAR A17 Type of Entry CHAR A18 Entered From CHAR A2 Discharge Date CHAR A21 Discharge Status CHAR A22 Previous Assessment Reference Date For Significant Correction DATE A23 Assessment Reference Date CHAR A24A Has Resident Had a Medicare Stay Since Most Recent Admission

4 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 4 of 24 11/27/212 CHAR A24B Start Date of Most Recent Medicare Stay CHAR 76 8 A24C End Date of Most Recent Medicare Stay CHAR B1 Comatose CHAR B2 Hearing CHAR B3 Hearing Aide CHAR B6 Speech Clarity CHAR B7 Makes Self Understood CHAR B8 Ability to Understand Others CHAR 72 1 B1 Vision CHAR B12 Corrective Lenses CHAR C1 Brief Interview for Mental Status Be Conducted CHAR C2 BIMS: of Words Repeated After First Attempt CHAR C3A BIMS: Temporal Orientation - Able to Report Correct Year CHAR C3B BIMS: Temporal Orientation - Able to Report Correct Month CHAR C3C BIMS: Temporal Orientation - Able to Report Correct Day of Week CHAR C4A BIMS: Recall - Able to Recall Sock CHAR C4B BIMS: Recall - Able to Recall Blue CHAR C4C BIMS: Recall - Able to Recall Bed CHAR 73 2 C5 Brief Interview for Mental Status (BIMS) Score CHAR C6 Staff to Conduct Brief Interview for Mental Status CHAR C7 Staff Assessment of Mental Status - Short Term Memory CHAR C8 Staff Assessment of Mental Status - Long Term Memory CHAR C9A Staff Assessment of Mental Status - Recalls Current Season CHAR C9B Staff Assessment of Mental Status - Recalls Location of Room CHAR C9C Staff Assessment of Mental Status - Recalls Staff Name CHAR C9D Staff Assessment of Mental Status - Recalls Nursing Home CHAR C9Z Staff Assessment of Mental Status - Recalls None of Above

5 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 5 of 24 11/27/212 CHAR 74 1 C1 Cognitive Skills for Decision Making CHAR C13A Signs and Symptoms of Delirium - Inattention CHAR C13B Signs and Symptoms of Delirium - Disorganized Thinking CHAR C13C Signs and Symptoms of Delirium - Altered Level of Consciousness CHAR C13D Signs and Symptoms of Delirium - Psychomotor Retardation CHAR C16 Acute Onset Mental Status Change CHAR D1 Resident Mood Interview Be Conducted CHAR D2A1 Resident Mood Interview - Interest Loss CHAR D2A2 Resident Mood Interview - Interest Loss Frequency CHAR D2B1 Resident Mood Interview - Feel Down CHAR 75 1 D2B2 Resident Mood Interview - Feel Down Frequency CHAR D2C1 Resident Mood Interview - Trouble Sleep CHAR D2C2 Resident Mood Interview - Trouble Sleep Frequency CHAR D2D1 Resident Mood Interview - Little Energy CHAR D2D2 Resident Mood Interview - Little Energy Frequency CHAR D2E1 Resident Mood Interview - Poor Appetite CHAR D2E2 Resident Mood Interview - Poor Appetite Frequency CHAR D2F1 Resident Mood Interview - Self Depreciation CHAR D2F2 Resident Mood Interview - Self Depreciation Frequency CHAR D2G1 Resident Mood Interview - Lack of Concentration CHAR 76 1 D2G2 Resident Mood Interview - Lack of Concentration Frequency CHAR D2H1 Resident Mood Interview - Movement Different CHAR D2H2 Resident Mood Interview - Movement Different Frequency CHAR D2I1 Resident Mood Interview - Negative Statement CHAR D2I2 Resident Mood Interview - Negative Statement

6 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 6 of 24 11/27/212 CHAR CHAR CHAR CHAR CHAR 77 1 CHAR CHAR CHAR CHAR CHAR CHAR CHAR CHAR CHAR CHAR 78 1 CHAR CHAR CHAR CHAR CHAR CHAR Frequency D3 Resident Mood Interview - Total Severity Mood Score D35 Resident Mood Interview - Negative Statements Notify Staff D5A1 Staff Assessment of Resident Mood - Interest Loss D5A2 Staff Assessment of Resident Mood - Interest Loss Frequency D5B1 Staff Assessment of Resident Mood - Feel Down D5B2 Staff Assessment of Resident Mood - Feel Down Frequency D5C1 Staff Assessment of Resident Mood - Trouble Sleep D5C2 Staff Assessment of Resident Mood - Trouble Sleep Frequency D5D1 Staff Assessment of Resident Mood - Little Energy D5D2 Staff Assessment of Resident Mood - Little Energy Frequency D5E1 Staff Assessment of Resident Mood - Poor Appetite D5E2 Staff Assessment of Resident Mood - Poor Appetite Frequency D5F1 Staff Assessment of Resident Mood - Self Depreciation D5F2 Staff Assessment of Resident Mood - Self Depreciation Frequency D5G1 Staff Assessment of Resident Mood - Concentration D5G2 Staff Assessment of Resident Mood - Concentration Frequency D5H1 Staff Assessment of Resident Mood - Movement Different D5H2 Staff Assessment of Resident Mood - Movement Different Frequency D5I1 Staff Assessment of Resident Mood - Negative Statement D5I2 Staff Assessment of Resident Mood - Negative Statement Frequency D5J1 Staff Assessment of Resident Mood - Short Temper

7 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 7 of 24 11/27/212 CHAR D5J2 Staff Assessment of Resident Mood - Short Temper Frequency CHAR D6 Staff Assessment Total Severity Mood Score CHAR 79 1 D65 Staff Assessment of Resident Mood - Negative Statement Notify CHAR E1A Behavior: Hallucinations CHAR E1B Behavior: Delusion CHAR E1Z Behavior: No Psychosis CHAR E2A Behavior: Physical Behavioral CHAR E2B Behavior: Verbal Behavioral CHAR E2C Behavior: Other Behavioral CHAR E3 Overall Presence of Behavioral Symptoms CHAR E5A Behavior Impact on Resident: Risk to Injure Self CHAR E5B Behavior Impact on Resident: Interferes With Care CHAR 8 1 E5C Behavior Impact on Resident: Interferes With Participation CHAR 81 1 E6A Behavior Impact on Others: Risk to Injure Others CHAR 82 1 E6B Behavior Impact on Others: Intrude On Privacy of Others CHAR 83 1 E6C Behavior Impact on Others: Disrupt Care or Living Environment CHAR 84 1 E8 Rejection of Care: Presence and Frequency CHAR 85 1 E9 Wandering: Presence and Frequency CHAR 86 1 E1A Wander Risk Impact CHAR 87 1 E1B Wandering Intrudes on Privacy of Others CHAR 88 1 E11 Change in Behavior or Other Symptoms CHAR 89 1 CHAR 81 1 CHAR CHAR CHAR CHAR F3 Should Daily and Activity Preference Interview Be Conducted F4A Interview for Daily Preferences: Chooses Clothes F4B Interview for Daily Preferences: Care Personal Items F4C Interview for Daily Preferences: Bathing Option F4D Interview for Daily Preferences: Snack Between Meals F4E Interview for Daily Preferences: Choose Bed Time

8 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 8 of 24 11/27/212 CHAR F4F Interview for Daily Preferences: Family Involvement CHAR F4G Interview for Daily Preferences: Private Phone Time CHAR F4H Interview for Daily Preferences: Lock Item CHAR F5A Interview for Activity Preferences: Reading Materials Available CHAR F5B Interview for Activity Preferences: Music CHAR 82 1 F5C Interview for Activity Preferences: Animal Presence CHAR F5D Interview for Activity Preferences: News CHAR F5E Interview for Activity Preferences: Group Activity CHAR F5F Interview for Activity Preferences: Favorite Activity CHAR F5G Interview for Activity Preferences: Time Outdoors CHAR F5H Interview for Activity Preferences: Religion CHAR F6 Daily and Activity Preferences Primary Respondent CHAR F7 Conduct Staff Assessment of Daily and Activity Preferences CHAR F8A Staff Assessment: Chooses Clothes CHAR F8B Staff Assessment: Care Personal Item CHAR 83 1 F8C Staff Assessment: Tub Bath CHAR F8D Staff Assessment: Shower CHAR F8E Staff Assessment: Bed Bath CHAR F8F Staff Assessment: Sponge Bath CHAR F8G Staff Assessment: Snacks Between CHAR F8H Staff Assessment: Bed Time CHAR F8I Staff Assessment: Family Involvement CHAR F8J Staff Assessment: Private Phone CHAR F8K Staff Assessment: Lock Item CHAR F8L Staff Assessment: Reading Materials Available CHAR 84 1 F8M Staff Assessment: Music CHAR F8N Staff Assessment: Animal Presence CHAR F8O Staff Assessment: News CHAR F8P Staff Assessment: Group Activity

9 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 9 of 24 11/27/212 CHAR F8Q Staff Assessment: Favorite Activity CHAR F8R Staff Assessment: Time Away Nursing Home CHAR F8S Staff Assessment: Time Outdoors CHAR F8T Staff Assessment: Participating in Religious Activities CHAR F8Z Staff Assessment: None of Above Activity CHAR G11A1 ADL Assistance: Bed Mobility Self Performance CHAR 85 1 G11A2 ADL Assistance: Bed Mobility Support Provided CHAR G11B1 ADL Assistance: Transfer Self Performance CHAR G11B2 ADL Assistance: Transfer Self Support Provided CHAR G11C1 ADL Assistance: Walk In Room Self Performance CHAR G11C2 ADL Assistance: Walk In Room Support Provided CHAR G11D1 ADL Assistance: Walk In Corridor Self Performance CHAR G11D2 ADL Assistance: Walk In Corridor Self Support Provided CHAR G11E1 ADL Assistance: Locomotion On Self Performance CHAR G11E2 ADL Assistance: Locomotion On Support Provided CHAR G11F1 ADL Assistance: Locomotion Off Self Performance CHAR 86 1 G11F2 ADL Assistance: Locomotion Off Support Provided CHAR G11G1 ADL Assistance: Dress Self Performance CHAR G11G2 ADL Assistance: Dress Support Provided CHAR G11H1 ADL Assistance: Eating Self Performance CHAR G11H2 ADL Assistance: Eating Support Provided CHAR G11I1 ADL Assistance: Toileting Self Performance G11I2 ADL Assistance: Toileting Support Provided

10 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 1 of 24 11/27/212 CHAR CHAR G11J1 ADL Assistance: Personal Hygiene Self Performance CHAR G11J2 ADL Assistance: Personal Hygiene Support Provided CHAR G12A ADL Assistance: Bathing Self Performance CHAR 87 1 G12B ADL Assistance: Bathing Support Provided CHAR G3A Balance During Seated to Standing Position CHAR G3B Balance During Walking CHAR G3C Balance When Turning Around CHAR G3D Balance Moving On and Off Toilet CHAR G3E Balance With Surface to Surface Transfer CHAR G4A Functional Limitation in ROM: Upper Extremity Motion CHAR G4B Functional Limitation in ROM: Lower Extremity Motion CHAR G6A Mobility Devices: Cane CHAR G6B Mobility Devices: Walker CHAR 88 1 G6C Mobility Devices: Wheelchair CHAR G6D Mobility Devices: Limb Prosthesis CHAR G6Z Mobility Devices: None of Above CHAR G9A Functional Rehabilitation Potential: Resident Increased Independence CHAR G9B Functional Rehabilitation Potential: Staff Increased Independence CHAR H1A Bladder and Bowel Appliances: Indwelling Catheter CHAR H1B Bladder and Bowel Appliances: External Catheter CHAR H1C Bladder and Bowel Appliances: Ostomy CHAR H1D Bladder and Bowel Appliances: Intermittent Catheter CHAR H1Z Bladder and Bowel Appliances: No Urinary Appliance CHAR 89 1 H2A Urinary Toileting Program: Trial Toileting Program CHAR H2B Urinary Toileting Program: Response To Toileting Program H2C Urinary Toileting Program: Current Toileting

11 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 11 of 24 11/27/212 CHAR Program CHAR H3 Urinary Continence CHAR H4 Bowel Continence CHAR H5 Bowel Toileting Program CHAR H6 Constipation CHAR I1 Active Diagnoses: Cancer CHAR I2 Active Diagnoses: Anemia CHAR I3 Active Diagnoses: Dysrhythmia CHAR 9 1 I4 Active Diagnoses: Coronary Artery Disease (CAD) CHAR 91 1 I5 Active Diagnoses: Deep Vein Thrombosis (DVT) CHAR 92 1 I6 Active Diagnoses: Heart Failure (CHF) CHAR 93 1 I7 Active Diagnoses: Hypertension CHAR 94 1 I8 Active Diagnoses: Hypotension CHAR 95 1 I9 Active Diagnoses: Peripheral Vascular Disease (PVD) CHAR 96 1 I11 Active Diagnoses: Cirrhosis CHAR 97 1 I12 Active Diagnoses: Gastroesophageal Reflux Disease (GERD) CHAR 98 1 I13 Active Diagnoses: Ulcerative Colitis CHAR 99 1 I14 Active Diagnoses: Benign Prostatic Hyperplasia (BPH) CHAR 91 1 I15 Active Diagnoses: End Stage Renal Disease (ESRD) CHAR I155 Active Diagnoses: Neurogenic Bladder CHAR I165 Active Diagnoses: Obstructive Uropathy CHAR I17 Active Diagnoses: Multi-drug Resistant Drug Organism (MDRO) CHAR I2 Active Diagnoses: Pneumonia CHAR I21 Active Diagnoses: Septicemia CHAR I22 Active Diagnoses: Tuberculosis CHAR I23 Active Diagnoses: Urinary Tract Infection (UTI) CHAR I24 Active Diagnoses: Viral Hepatitis CHAR I25 Wound Infection CHAR 92 1 I29 Active Diagnoses: Diabetes Mellitus (DM) CHAR I31 Active Diagnoses: Hyponatremia CHAR I32 Active Diagnoses: Hyperkalemia CHAR I33 Active Diagnoses: Hyperlipidemia

12 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 12 of 24 11/27/212 CHAR I34 Active Diagnoses: Thyroid CHAR I37 Active Diagnoses: Arthritis CHAR I38 Active Diagnoses: Osteoporosis CHAR I39 Active Diagnoses: Hip Fracture CHAR I4 Active Diagnoses: Other Fracture CHAR I42 Active Diagnoses: Alzheimers Disease CHAR 93 1 I43 Active Diagnoses: Aphasia CHAR I44 Active Diagnoses: Cerebral Palsy CHAR I45 Active Diagnoses: Stroke (CVA or TIA or Stroke) CHAR I48 Active Diagnoses: Dementia CHAR I49 Active Diagnoses: Hemiplegia CHAR I5 Active Diagnoses: Paraplegia CHAR I51 Active Diagnoses: Quadriplegia CHAR I52 Active Diagnoses: Multiple Sclerosis CHAR I525 Active Diagnoses: Huntingtons CHAR I53 Active Diagnoses: Parkinsons CHAR 94 1 I535 Tourettes CHAR I54 Active Diagnoses: Seizure CHAR I55 Active Diagnoses: Traumatic Brain Injury (TBI) CHAR I56 Active Diagnoses: Malnutrition CHAR I57 Active Diagnoses: Anxiety Disorder CHAR I58 Active Diagnoses: Depression CHAR I59 Active Diagnoses: Manic Depression CHAR I595 Active Diagnoses: Psychotic CHAR I6 Active Diagnoses: Schizophrenia CHAR I61 Active Diagnoses: Post-traumatic Stress Disorder (PTSD) CHAR 95 1 I62 Active Diagnoses: Asthma, COPD, Chronic Lung Disease CHAR I63 Active Diagnoses: Respiratory Failure CHAR I65 Active Diagnoses: Cataracts, Glaucoma or Macular Degeneration CHAR I79 Active Diagnoses: No Active Disease CHAR I8A Additional Active Diagnoses: ICD 1 CHAR I8B Additional Active Diagnoses: ICD 2 CHAR 97 8 I8C Additional Active Diagnoses: ICD 3 CHAR I8D Additional Active Diagnoses: ICD 4

13 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 13 of 24 11/27/212 CHAR I8E Additional Active Diagnoses: ICD 5 CHAR I8F Additional Active Diagnoses: ICD 6 CHAR 12 8 I8G Additional Active Diagnoses: ICD 7 CHAR 11 8 I8H Additional Active Diagnoses: ICD 8 CHAR I8I Additional Active Diagnoses: ICD 9 CHAR I8J Additional Active Diagnoses: ICD 1 CHAR J1A Pain management: Scheduled Pain Medication CHAR J1B Pain management: PRN Pain Medication CHAR J1C Pain management: Other Pain Intervention CHAR J2 Should Pain Assessment be Conducted CHAR J3 Pain Assessment Interview: Pain Presence CHAR J4 Pain Assessment Interview: Pain Frequency CHAR 14 1 J5A Pain Assessment Interview: Pain Effect Sleep CHAR J5B Pain Assessment Interview: Pain Effect Activity CHAR J6A Pain Intensity Numeric Rating Scale CHAR J6B Pain Intensity Verbal Descriptor Scale CHAR J7 Staff Conduct Pain Assessment CHAR J8A Staff Assessment for Pain: Nonverbal Sound CHAR J8B Staff Assessment for Pain: Vocal Complaint CHAR J8C Staff Assessment for Pain: Facial Expression CHAR J8D Staff Assessment for Pain: Protective Movement CHAR 15 1 J8Z Staff Assessment for Pain: None of Above Signs of Pain CHAR J85 Staff Frequency of Indicator of Pain or Possible Pain Frequency CHAR J11A Shortness of Breath With Exertion CHAR J11B Shortness of Breath When Sitting CHAR J11C Shortness of Breath When Lying Flat CHAR J11Z None of Above Shortness of Breath CHAR J13 Tobacco Use CHAR J14 Life Prognosis Less Than Six Months CHAR J155A Problem Conditions: Fever CHAR J155B Problem Conditions: Vomiting

14 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 14 of 24 11/27/212 CHAR 16 1 J155C Problem Conditions: Dehydration CHAR J155D Problem Conditions: Internal Bleeding CHAR J155Z Problem Conditions: None of Above CHAR J17A Fall History on Admission: Fall 3 Day CHAR J17B Fall History on Admission: Fall Day CHAR J17C Fall History on Admission: Fall Six Month CHAR J18 Falls Since Admission or Prior Assessment CHAR J19A of Falls Since Admission or Prior Assessment With No Injury CHAR J19B of Falls Since Admission or Prior Assessment With Injury Except Major CHAR J19C of Falls Since Admission or Prior Assessment With Major Injury CHAR 17 1 K1A Swallowing Disorder: Loss Mouth Eating CHAR K1B Swallowing Disorder: Hold Food Mouth CHAR K1C Swallowing Disorder: Choke Drinking Meal CHAR K1D Swallowing Disorder: Complaint Swallowing CHAR K1Z Swallowing Disorder: None of Above CHAR K2A Height CHAR K2B Weight CHAR 18 1 K3 Weight Loss CHAR K31 Weight Gain CHAR K5A Nutritional Approaches: Parenteral/IV Feeding CHAR K5B Nutritional Approaches: Feeding Tube CHAR K5C Nutritional Approaches: Mechanically Altered Diet CHAR K5D Nutritional Approaches: Therapeutic Diet CHAR K5Z Nutritional Approaches: None of Above CHAR K51A1 Nutritional Approaches: Prior Parenteral/IV Feeding CHAR K51A2 Nutritional Approaches: Post Parenteral/IV Feeding CHAR K51B1 Nutritional Approaches: Prior Feeding Tube CHAR 19 1 K51B2 Nutritional Approaches: Post Feeding Tube K51C1 Nutritional Approaches: Prior Mechanically

15 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 15 of 24 11/27/212 CHAR Altered Diet CHAR K51C2 Nutritional Approaches: Post Mechanically Altered Diet CHAR K51D1 Nutritional Approaches: Prior Therapeutic Diet CHAR K51D2 Nutritional Approaches: Post Therapeutic Diet CHAR K51Z1 Nutritional Approaches: Prior None of Above CHAR K51Z2 Nutritional Approaches: Post None of Above CHAR K7A Percent Caloric Intake Through Parenteral/Tube Feeding CHAR K7B Average Fluid Intake by IV Or Tube Feeding CHAR L2A Dental Status: Broken Denture CHAR 11 1 L2B Dental Status: No Teeth CHAR L2C Dental Status: Abnormal Mouth Tissue CHAR L2D Dental Status: Cavity CHAR L2E Dental Status: Inflamed Gum CHAR L2F Dental Status: Mouth or Facial Pain CHAR L2G Dental Status: Unable to Examine CHAR L2Z Dental Status: None of Above CHAR M1A Determination of Pressure Ulcer Risk: Ulcer Visible CHAR M1B Determination of Pressure Ulcer Risk: Formal Assessment/Instrument CHAR M1C Determination of Pressure Ulcer Risk: Clinical Assessment CHAR M1Z Determination of Pressure Ulcer Risk: None of Above CHAR M15 Pressure Ulcer Risk CHAR M21 One or More Stage 1 or Higher Unhealed Pressure Ulcer CHAR M3A Stage 1 Pressure Ulcer CHAR M3B1 Stage 2 Pressure Ulcer CHAR M3B2 Stage 2 Pressure Ulcer Present on Admission CHAR M3B3 Date of Oldest Stage 2 Pressure Ulcer CHAR M3C1 Stage 3 Pressure Ulcer CHAR M3C2 Stage 3 Pressure Ulcer Present on Admission

16 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 16 of 24 11/27/212 CHAR M3D1 Stage 4 Pressure Ulcer CHAR M3D2 Stage 4 Pressure Ulcer Present on Admission CHAR M3E1 Unstageable Pressure Ulcer Due To Dressing CHAR M3E2 Unstageable Pressure Ulcer Due To Dressing on Admission CHAR M3F1 Unstageable Pressure Ulcer With Slough or Eschar CHAR M3F2 Unstageable Pressure Ulcer With Slough or Eschar on Admission CHAR M3G1 Unstageable Pressure Ulcer With Deep Tissue Injury CHAR M3G2 Unstageable Pressure Ulcer With Deep Tissue Injury on Admission CHAR M61A Unhealed Stage 3-4 Pressure Ulcer Length CHAR M61B Unhealed Stage 3-4 Pressure Ulcer Width CHAR M61C Unhealed Stage 3-4 Pressure Ulcer Depth CHAR M7 Most Severe Pressure Ulcer Tissue Type CHAR M8A Worsening Stage 2 Pressure Ulcer Since Prior Assessment CHAR M8B Worsening Stage 3 Pressure Ulcer Since Prior Assessment CHAR M8C Worsening Stage 4 Pressure Ulcer Since Prior Assessment CHAR M9A Healed Pressure Ulcer Present on Prior Assessment CHAR M9B Healed Stage 2 Pressure Ulcer CHAR M9C Healed Stage 3 Pressure Ulcer CHAR M9D Healed Stage 4 Pressure Ulcer CHAR M13 Venous and Arterial Ulcer CHAR M14A Other Foot Skin Problems: Foot Infection CHAR M14B Other Foot Skin Problems: Diabetic Foot Ulcer CHAR M14C Other Foot Skin Problems: Other Open Lesion on Foot CHAR M14D Other Skin Problems: Open Lesions Other

17 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 17 of 24 11/27/212 Than Ulcers, Rashes, Cuts CHAR M14E Other Skin Problems: Surgical Wound(s) CHAR M14F Other Skin Problems: Burn(s) CHAR M14G Other Skin Problems: Skin Tear(s) CHAR M14H Other Skin Problems: Moisture Associated Skin Damage CHAR M14Z Other Skin Problems: None of Above CHAR M12A Skin and Ulcer Treatments: Pressure Reducing Device in Chair CHAR M12B Skin and Ulcer Treatments: Pressure Reducing Device in Bed CHAR M12C Skin and Ulcer Treatments: Turning/Repositioning Program CHAR M12D Skin and Ulcer Treatments: Nutrition/Hydration CHAR M12E Skin and Ulcer Treatments: Ulcer Care CHAR M12F Skin and Ulcer Treatments: Surgical Wound Care CHAR M12G Skin and Ulcer Treatments: Application Nonsurgical Dressing CHAR M12H Skin and Ulcer Treatments: Application Ointments/Medications CHAR M12I Skin and Ulcer Treatments: Application Dressings to Foot CHAR M12Z Skin and Ulcer Treatments: None of Above CHAR N3 of Days Injections of Any Type CHAR N35A of Days Insulin Injections CHAR N35B of Days Insulin Orders Changed CHAR N4A Medications Received: Antipsychotic CHAR N4B Medications Received: Antianxiety CHAR N4C Medications Received: Antidepressant CHAR N4D Medications Received: Hypnotic CHAR N4E Medications Received: Anticoagulant CHAR N4F Medications Received: Antibiotic CHAR N4G Medications Received: Diuretic CHAR N4Z Medications Received: None of Above CHAR CHAR N41A Medications Received: Antipsychotic Days N41B Medications Received: Antianxiety Days

18 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 18 of 24 11/27/212 CHAR N41C Medications Received: Antidepressant Days CHAR N41D Medications Received: Hypnotic Days CHAR N41E Medications Received: Anticoagulant Days CHAR N41F Medications Received: Antibiotic Days CHAR N41G Medications Received: Diuretic Days CHAR CHAR CHAR CHAR CHAR CHAR CHAR CHAR CHAR 12 1 CHAR CHAR CHAR CHAR CHAR CHAR CHAR CHAR CHAR O1A1 Special Treatments/Programs: Chemotherapy Pre-admit O1A2 Special Treatments/Programs: Chemotherapy Post-admit O1B1 Special Treatments/Programs: Radiation Preadmit O1B2 Special Treatments/Programs: Radiation Postadmit O1C1 Special Treatments/Programs: Oxygen Preadmit O1C2 Special Treatments/Programs: Oxygen Postadmit O1D1 Special Treatments/Programs: Suctioning Preadmit O1D2 Special Treatments/Programs: Suctioning Post-admit O1E1 Special Treatments/Programs: Tracheostomy Pre-admit O1E2 Special Treatments/Programs: Tracheostomy Post-admit O1F1 Special Treatments/Programs: Ventilator Preadmit O1F2 Special Treatments/Programs: Ventilator Postadmit O1G1 Special Treatments/Programs: Continuous Positive Airway Pressure Pre-admit O1G2 Special Treatments/Programs: Continuous Positive Airway Pressure Post-admit O1H1 Special Treatments/Programs: Intravenous Medication Pre-admit O1H2 Special Treatments/Programs: Intravenous Medication Post-admit O1I1 Special Treatments/Programs: Transfusion Preadmit O1I2 Special Treatments/Programs: Transfusion Post-admit

19 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 19 of 24 11/27/212 CHAR O1J1 Special Treatments/Programs: Dialysis Preadmit CHAR O1J2 Special Treatments/Programs: Dialysis Postadmit CHAR O1K1 Special Treatments/Programs: Hospice Preadmit CHAR O1K2 Special Treatments/Programs: Hospice Postadmit CHAR O1L2 Special Treatments/Programs: Respite Postadmit CHAR O1M1 Special Treatments/Programs: Isolation Preadmit CHAR O1M2 Special Treatments/Programs: Isolation Postadmit CHAR O1Z1 Special Treatments/Programs: None of Above Pre-admit Treatment Prior CHAR O1Z2 Special Treatments/Programs: None of Above Treatment Post-admit CHAR O25A Influenza Received CHAR O25B Influenza Received Date CHAR O25C Reason Influenza Not Received CHAR O3A Pneumococcal Vaccination CHAR O3B Reason Pneumococcal Vaccination Not Received CHAR O4A1 Speech Therapy/Audiology Individual Minutes CHAR O4A2 Speech Therapy/Audiology Concurrent Minutes CHAR O4A3 Speech Therapy/Audiology Group Minutes CHAR O4A4 of Days Speech Therapy/Audiology Administered CHAR O4A5 Speech Therapy/Audiology Start Date CHAR O4A6 Speech Therapy/Audiology End Date CHAR O4B1 Occupational Therapy Individual Minutes CHAR O4B2 Occupational Therapy Concurrent Minutes CHAR O4B3 Occupational Therapy Group Minutes CHAR O4B4 of Days Occupational Therapy Administered CHAR O4B5 Occupational Therapy Start Date

20 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 2 of 24 11/27/212 CHAR O4B6 Occupational Therapy End Date CHAR O4C1 Physical Therapy Individual Minutes CHAR O4C2 Physical Therapy Concurrent Minutes CHAR O4C3 Physical Therapy Group Minutes CHAR O4C4 of Days Physical Therapy Administered CHAR O4C5 Physical Therapy Start Date CHAR O4C6 Physical Therapy End Date CHAR O4D1 Respiratory Therapy Minutes CHAR O4D2 of Days Respiratory Therapy Administered CHAR O4E1 Psychological Therapy Minutes CHAR O4E2 of Days Psychological Therapy Administered CHAR O4F1 Recreational Therapy Minutes CHAR O4F2 of Days Recreational Therapy Administered CHAR O45A Has Therapy Resumed CHAR O45B Date Therapy Resumed CHAR O5A Restorative Nursing: Passive Range of Motion CHAR O5B Restorative Nursing: Active Range of Motion CHAR O5C Restorative Nursing: Splint/Brace Assistance CHAR O5D Restorative Nursing: Bed Mobility Training CHAR O5E Restorative Nursing: Transfer Training CHAR O5F Restorative Nursing: Walking Training CHAR O5G Restorative Nursing: Dressing/Grooming Training CHAR O5H Restorative Nursing: Eating/Swallowing Training CHAR O5I Restorative Nursing: Amputation/Prosthesis Care Training CHAR O5J Restorative Nursing: Communication Training CHAR O6 Physician Examination Day CHAR O7 Physician Order Day CHAR P1A Physical Restraints in Bed: Bed Rail P1B Physical Restraints in Bed: Trunk Restraint Bed

21 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 21 of 24 11/27/212 CHAR CHAR P1C Physical Restraints in Bed: Limb Restraint Bed CHAR P1D Physical Restraints in Bed: Other Restraint Bed CHAR P1E Physical Restraints in Chair: Trunk Restraint Chair CHAR P1F Physical Restraints in Chair: Limb Restraint Chair CHAR P1G Physical Restraints in Chair: Chair Prevent Rise CHAR P1H Physical Restraints in Chair: Other Restraint Chair CHAR Q1A Resident Participation in Assessment CHAR Q1B Family Participation in Assessment CHAR Q1C Guardian Participation in Assessment CHAR Q3A Resident Overall Goal CHAR Q3B Overall Goal Source CHAR Q4A Discharge Plan CHAR Q4B Discharge Determination CHAR Q49 Residents Preference Answering Q5B CHAR Q5A Has Resident Been Asked About Return To Community CHAR Q5B Staff Asked Resident or Family About Return To Community CHAR Q55A Preference In Answering Q55B CHAR Q55B Source Answering Q55A CHAR Q6 Local Contact Agency Referral CHAR V1A Prior Assessment Federal OBRA Reason for Assessment CHAR V1B Prior Assessment PPS Reason for Assessment CHAR V1C Prior Assessment Reference Date CHAR V1D Prior Assessment Brief Interview for Mental Status (BIMS) Summary Score CHAR V1E Prior Assessment Resident Mood Interview (PHQ-9) Total Severity Score CHAR V1F Prior Assessment Staff Assessment of Resident Mood (PHQ-9) Total Severity Score CHAR V2A1A Delirium Care Area Trigger CHAR V2A1B Delirium Addressed in Care Plan

22 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 22 of 24 11/27/212 CHAR V2A2A Dementia Care Area Trigger CHAR V2A2B Dementia Addressed in Care Plan CHAR V2A3A Visual Function Care Area Trigger CHAR 14 1 V2A3B Visual Function Addressed in Care Plan CHAR V2A4A Communication Care Area Trigger CHAR V2A4B Communication Addressed in Care Plan CHAR V2A5A ADL Care Area Trigger CHAR V2A5B ADL Addressed in Care Plan CHAR V2A6A Urinary Care Area Trigger CHAR V2A6B Urinary Addressed in Care Plan CHAR V2A7A Psychosocial Care Area Trigger CHAR V2A7B Psychosocial Addressed in Care Plan CHAR V2A8A Mood Care Area Trigger CHAR V2A8B Mood Addressed in Care Plan CHAR V2A9A Behavioral Care Area Trigger CHAR V2A9B Behavioral Addressed in Care Plan CHAR V2A1A Activity Care Area Trigger CHAR V2A1B Activity Addressed in Care Plan CHAR V2A11A Fall Care Area Trigger CHAR V2A11B Fall Addressed in Care Plan CHAR V2A12A Nutritional Care Area Trigger CHAR V2A12B Nutritional Addressed in Care Plan CHAR V2A13A Feeding Tube Care Area Trigger CHAR V2A13B Feeding Tube Addressed in Care Plan CHAR V2A14A Dehydration Care Area Trigger CHAR V2A14B Dehydration Addressed in Care Plan CHAR V2A15A Dental Care Area Trigger CHAR V2A15B Dental Addressed in Care Plan CHAR V2A16A Pressure Ulcer Care Area Trigger CHAR V2A16B Pressure Ulcer Addressed in Care Plan CHAR V2A17A Psychotropic Drug Care Area Trigger CHAR V2A17B Psychotropic Drug Addressed in Care Plan CHAR V2A18A Restraint Care Area Trigger CHAR V2A18B Restraint Addressed in Care Plan

23 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 23 of 24 11/27/212 CHAR V2A19A Pain Care Area Trigger CHAR V2A19B Pain Addressed in Care Plan CHAR V2A2A Return to Community Care Area Trigger CHAR V2A2B Return to Community Addressed in Care Plan CHAR V2B2 Care Area Assessment Completion Date CHAR V2C2 Care Plan Completion Date CHAR X15 Correction Provider Type CHAR X2A Correction Resident First Name CHAR X2C Correction Resident Last Name CHAR X3 Correction Gender CHAR X4 Correction Birth Date CHAR X5 Correction Social Security CHAR 15 2 X6A Correction Federal OBRA Reason for Assessment CHAR X6B Correction PPS Reason for Assessment CHAR X6C PPS Other Medicare Required Assessment (OMRA) CHAR X6D Correction Swing Bed Clinical Change CHAR X6F Correction Entry/Discharge CHAR X7A Correction Assessment Reference Date CHAR X7B Correction Discharge Date CHAR X7C Correction Entry Date CHAR X8 Correction CHAR CHAR CHAR CHAR CHAR CHAR CHAR CHAR X9A Reason for Modification: Transcription Error X9B Reason for Modification: Data Entry Error X9C Reason for Modification: Software Product Error X9D Reason for Modification: Item Coding Error X9E Modification Reason - Add Resume Therapy Date X9Z Reason for Modification: Other Error Requiring Modification X15A Reason for Inactivation: Event Did Not Occur X15Z Reason for Inactivation: Other Error Requiring Inactivation

24 file:///c:/users/hpmresdacsw1/appdata/local/temp/qwu_j78975_p1_mds_3 NH_... Page 24 of 24 11/27/212 CHAR X11A Attesting Individuals First Name CHAR X11B Attesting Individuals Last Name CHAR X11E Attestation Date CHAR Z1A Medicare Part A HIPPS Text CHAR Z1B Medicare Part A RUG Version Text CHAR Z1C Medicare Part A Short Stay Assessment CHAR Z15A Medicare Part A Non-therapy HIPPS Text CHAR Z15B Medicare Non-therapy Part A RUG Version Text CHAR Z2A State Medicaid RUG Case Mix Group Text CHAR Z2B State Medicaid RUG Version Text CHAR Z25A Alternate State Medicaid RUG Case Mix Group Text CHAR Z25B Alternate State Medicaid RUG Version Text DATE Z5B Date RN Assessment Coordinator Signed Assessment as Complete