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- I. Active Diagnoses
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- M. Skin Conditions
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MDS Item OCT 2024 - DRAFT
| MDS Item | Short Description |
| A0050 | Type of Record |
| A0100A | Facility National Provider Identifier (NPI) |
| A0100B | Facility CMS Certification Number (CCN) |
| A0100C | State provider number |
| A0200 | Type of provider |
| A0310A | Type of assessment: OBRA |
| A0310B | Type of assessment: PPS |
| A0310E | First assessment since most recent entry |
| A0310F | Entry/discharge reporting |
| A0310G | Planned/unplanned discharge |
| A0310G1 | Interrupted Stay |
| A0310H | SNF Part A PPS Discharge |
| A0410 | Unit Certification or Licensure Designation |
| A0500A | Resident first name |
| A0500B | Resident middle initial |
| A0500C | Resident last name |
| A0500D | Resident name suffix |
| A0600A | Social Security Number |
| A0600B | Medicare number |
| A0700 | Medicaid number |
| A0800 | Gender |
| A0900 | Birthdate |
| A1005A | Ethnicity: No, not of Hispanic, Latino/a, or Spanish origin |
| A1005B | Ethnicity: Yes, Mexican, Mexican American, Chicano/a |
| A1005C | Ethnicity: Yes, Puerto Rican |
| A1005D | Ethnicity: Yes, Cuban |
| A1005E | Ethnicity: Yes, another Hispanic, Latino, or Spanish origin |
| A1005X | Ethnicity: Resident unable to respond |
| A1005Y | Ethnicity: Resident declines to respond |
| A1010A | Race: White |
| A1010B | Race: Black or African American |
| A1010C | Race: American Indian or Alaska Native |
| A1010D | Race: Asian Indian |
| A1010E | Race: Chinese |
| A1010F | Race: Filipino |
| A1010G | Race: Japanese |
| A1010H | Race: Korean |
| A1010I | Race: Vietnamese |
| A1010J | Race: Other Asian |
| A1010K | Race: Native Hawaiian |
| A1010L | Race: Guamanian or Chamorro |
| A1010M | Race: Samoan |
| A1010N | Race: Other Pacific Islander |
| A1010X | Resident unable to respond |
| A1010Y | Resident declines to respond |
| A1010Z | None of the above |
| A1110A | Language: What is your preferred language? |
| A1110B | Language: Need or want an interpreter? |
| A1200 | Marital status |
| A1250A | Transportation (from NACHC©) : Yes, kept from med appts. |
| A1250B | Transportation (from NACHC©): Yes, kept from non-med appts. |
| A1250C | Transportation (from NACHC©): No |
| A1250X | Transportation (from NACHC©): Resident unable to respond |
| A1250Y | Transportation (from NACHC©): Resident declines to respond |
| A1300A | Medical record number |
| A1300B | Room number |
| A1300C | Name by which resident prefers to be addressed |
| A1300D | Lifetime occupation(s) |
| A1500 | Resident evaluated by PASRR |
| A1510A | Level II PASRR conditions: Serious Mental Illness |
| A1510B | Level II PASRR conditions: Intellectual Disability |
| A1510C | Level II PASRR conditions: Other related conditions |
| A1550A | ID/DD status: Down syndrome |
| A1550B | ID/DD status: Autism |
| A1550C | ID/DD status: Epilepsy |
| A1550D | ID/DD status: other organic ID/DD condition |
| A1550E | ID/DD status: ID/DD with no organic condition |
| A1550Z | ID/DD status: none of the above |
| A1600 | Entry date (date of admission/reentry in facility) |
| A1700 | Type of entry |
| A1805 | Entered From |
| A1900 | Admission date |
| A2000 | Discharge date |
| A2105 | Discharge Status |
| A2121 | Provision of Current Reconciled Medication List (To Provider) |
| A2122A | Route of Current Reconciled Medication List Transmission: EHR to provider |
| A2122B | Route of Current Reconciled Medication List Transmission: HIEO to provider |
| A2122C | Route of Current Reconciled Medication List Transmission: Verbal to provider |
| A2122D | Route of Current Reconciled Medication List Transmission: Paper-based to provider |
| A2122E | Route of Current Reconciled Medication List Transmission: Other Methods to provider |
| A2123 | Provision of Current Reconciled Medication List (To Resident) |
| A2124A | Route of Current Reconciled Medication List Transmission: EHR to res/fam/caregiver |
| A2124B | Route of Current Reconciled Medication List Transmission: HIEO to res/fam/caregiver |
| A2124C | Route of Current Reconciled Medication List Transmission: Verbal to res/fam/caregiver |
| A2124D | Route of Current Reconciled Medication List Transmission: Paper-based to res/fam/caregiver |
| A2124E | Route of Current Reconciled Medication List Transmission: Other Methods to res/fam/caregiver |
| A2200 | Previous assessment reference date for significant correction |
| A2300 | Assessment reference date |
| A2400A | Has resident had Medicare-covered stay |
| A2400B | Start date of most recent Medicare stay |
| A2400C | End date of most recent Medicare stay |
| Â | Â |
| B0100 | Comatose |
| B0200 | Hearing |
| B0300 | Hearing aid |
| B0600 | Speech clarity |
| B0700 | Makes self understood |
| B0800 | Ability to understand others |
| B1000 | Vision |
| B1200 | Corrective lenses |
| B1300 | Health Literacy |
| C0100 | BIMS: should resident interview be conducted |
| C0200 | BIMS res interview: repetition of three words |
| C0300A | BIMS res interview: able to report correct year |
| C0300B | BIMS res interview: able to report correct month |
| C0300C | BIMS res interview: able report correct day of week |
| C0400A | BIMS res interview: able to recall "sock" |
| C0400B | BIMS res interview: able to recall "blue" |
| C0400C | BIMS res interview: able to recall "bed" |
| C0500 | BIMS res interview: summary score |
| C0600 | Staff assessment mental status: conduct assessment |
| C0700 | Staff assessment mental status: short-term memory OK |
| C0800 | Staff assessment mental status: long-term memory OK |
| C0900A | Staff assessment mental status: recall current season |
| C0900B | Staff assessment mental status: recall location of room |
| C0900C | Staff assessment mental status: recall staff names/faces |
| C0900D | Staff assessment mental status: recall in nursing home |
| C0900Z | Staff assessment mental status: none of above recalled |
| C1000 | Cognitive skills for daily decision making |
| C1310A | Acute Onset Mental Status Change |
| C1310B | Signs of delirium: inattention |
| C1310C | Signs of delirium: disorganized thinking |
| C1310D | Signs of delirium: altered level of consciousness |
| D0100 | PHQ: should resident mood interview be conducted |
| D0150A1 | PHQ res: little interest or pleasure - presence |
| D0150A2 | PHQ res: little interest or pleasure - frequency |
| D0150B1 | PHQ res: feeling down, depressed - presence |
| D0150B2 | PHQ res: feeling down, depressed - frequency |
| D0150C1 | PHQ res: trouble with sleep - presence |
| D0150C2 | PHQ res: trouble with sleep - frequency |
| D0150D1 | PHQ res: feeling tired/little energy - presence |
| D0150D2 | PHQ res: feeling tired/little energy - frequency |
| D0150E1 | PHQ res: poor appetite or overeating - presence |
| D0150E2 | PHQ res: poor appetite or overeating - frequency |
| D0150F1 | PHQ res: feeling bad about self - presence |
| D0150F2 | PHQ res: feeling bad about self - frequency |
| D0150G1 | PHQ res: trouble concentrating - presence |
| D0150G2 | PHQ res: trouble concentrating - frequency |
| D0150H1 | PHQ res: slow, fidgety, restless - presence |
| D0150H2 | PHQ res: slow, fidgety, restless - frequency |
| D0150I1 | PHQ res: thoughts better off dead - presence |
| D0150I2 | PHQ res: thoughts better off dead - frequency |
| D0160 | PHQ res: total mood severity score |
| D0500A1 | PHQ staff: little interest or pleasure - presence |
| D0500A2 | PHQ staff: little interest or pleasure - frequency |
| D0500B1 | PHQ staff: feeling down, depressed - presence |
| D0500B2 | PHQ staff: feeling down, depressed - frequency |
| D0500C1 | PHQ staff: trouble with sleep - presence |
| D0500C2 | PHQ staff: trouble with sleep - frequency |
| D0500D1 | PHQ staff: feeling tired/little energy - presence |
| D0500D2 | PHQ staff: feeling tired/little energy - frequency |
| D0500E1 | PHQ staff: poor appetite or overeating - presence |
| D0500E2 | PHQ staff: poor appetite or overeating - frequency |
| D0500F1 | PHQ staff: feeling bad about self - presence |
| D0500F2 | PHQ staff: feeling bad about self - frequency |
| D0500G1 | PHQ staff: trouble concentrating - presence |
| D0500G2 | PHQ staff: trouble concentrating - frequency |
| D0500H1 | PHQ staff: slow, fidgety, restless - presence |
| D0500H2 | PHQ staff: slow, fidgety, restless - frequency |
| D0500I1 | PHQ staff: thoughts better off dead - presence |
| D0500I2 | PHQ staff: thoughts better off dead - frequency |
| D0500J1 | PHQ staff: short-tempered - presence |
| D0500J2 | PHQ staff: short-tempered - frequency |
| D0600 | PHQ staff: total mood severity score |
| D0700 | Social Isolation |
| E0100A | Psychosis: hallucinations |
| E0100B | Psychosis: delusions |
| E0100Z | Psychosis: none of the above |
| E0200A | Physical behavioral symptoms directed toward others |
| E0200B | Verbal behavioral symptoms directed toward others |
| E0200C | Other behavioral symptoms not directed toward others |
| E0300 | Overall presence of behavioral symptoms |
| E0500A | Behavioral symptoms put res at risk for illness/injury |
| E0500B | Behavioral symptoms interfere with resident care |
| E0500C | Behavioral symptoms interfere with social activities |
| E0600A | Behavioral symptoms put others at risk for injury |
| E0600B | Behavioral symptoms intrude on privacy of others |
| E0600C | Behavioral symptoms disrupt care or living environment |
| E0800 | Rejection of care: presence and frequency |
| E0900 | Wandering: presence and frequency |
| E1000A | Wandering: risk of getting to dangerous place |
| E1000B | Wandering: intrude on privacy of others |
| E1100 | Change in behavior or other symptoms |
| F0300 | Conduct res interview for daily/activity preferences |
| F0400A | Res interview: choose clothes to wear |
| F0400B | Res interview: take care of personal belongings |
| F0400C | Res interview: choose tub, bath, shower, sponge |
| F0400D | Res interview: have snacks between meals |
| F0400E | Res interview: choose own bedtime |
| F0400F | Res interview: discuss care with family/friend |
| F0400G | Res interview: use phone in private |
| F0400H | Res interview: lock things to keep them safe |
| F0500A | Res interview: have books, newspaper, mags to read |
| F0500B | Res interview: listen to music |
| F0500C | Res interview: be around animals/pets |
| F0500D | Res interview: keep up with news |
| F0500E | Res interview: do things with groups of people |
| F0500F | Res interview: do favorite activities |
| F0500G | Res interview: go outside when good weather |
| F0500H | Res interview: participate in religious practices |
| F0600 | Primary respondent: daily/activities prefs |
| F0700 | Conduct staff assessment for daily/activity prefs |
| F0800A | Staff assessment: choosing clothes to wear |
| F0800B | Staff assessment: caring for personal belongings |
| F0800C | Staff assessment: receiving tub bath |
| F0800D | Staff assessment: receiving shower |
| F0800E | Staff assessment: receiving bed bath |
| F0800F | Staff assessment: receiving sponge bath |
| F0800G | Staff assessment: snacks between meals |
| F0800H | Staff assessment: staying up past 8PM |
| F0800I | Staff assessment: discuss care with family/other |
| F0800J | Staff assessment: use phone in private |
| F0800K | Staff assessment: place to lock personal things |
| F0800L | Staff assessment: reading books, newspapers, mags |
| F0800M | Staff assessment: listening to music |
| F0800N | Staff assessment: being around animals/pets |
| F0800O | Staff assessment: keeping up with news |
| F0800P | Staff assessment: doing things with groups |
| F0800Q | Staff assessment: participating in favorite activities |
| F0800R | Staff assessment: spend time away from nursing home |
| F0800S | Staff assessment: spend time outdoors |
| F0800T | Staff assessment: participating in religious activities |
| F0800Z | Staff assessment: none of above activities |
| GG0100A | Self-Care: Prior Function |
| GG0100B | Indoor Mobility (Ambulation): Prior Function |
| GG0100C | Stairs: Prior Function |
| GG0100D | Functional Cognition: Prior Function |
| GG0110A | Manual wheelchair |
| GG0110B | Motorized wheelchair and/or scooter |
| GG0110C | Mechanical lift |
| GG0110D | Walker |
| GG0110E | Orthotics/Prosthetics |
| GG0110Z | None of the above |
| GG0115A | ROM limitation: upper extremity |
| GG0115B | ROM limitation: lower extremity |
| GG0120A | Mobility devices: cane/crutch |
| GG0120B | Mobility devices: walker |
| GG0120C | Mobility devices: wheelchair (manual or electric) |
| GG0120D | Mobility devices: limb prosthesis |
| GG0120Z | Mobility devices: none of the above |
| GG0130A1 | Eating (Admission Performance) |
| GG0130A3 | Eating (Discharge Performance) |
| GG0130A5 | Eating (OBRA/Interim Performance) |
| GG0130B1 | Oral Hygiene (Admission Performance) |
| GG0130B3 | Oral Hygiene (Discharge Performance) |
| GG0130B5 | Oral Hygiene (OBRA/Interim Performance) |
| GG0130C1 | Toileting Hygiene (Admission Performance) |
| GG0130C3 | Toileting Hygiene (Discharge Performance) |
| GG0130C5 | Toileting Hygiene (OBRA/Interim Performance) |
| GG0130E1 | Shower/bathe self (Admission Performance) |
| GG0130E3 | Shower/bathe self (Discharge Performance) |
| GG0130E5 | Shower/bathe self (OBRA/Interim Performance) |
| GG0130F1 | Upper body dressing (Admission Performance) |
| GG0130F3 | Upper body dressing (Discharge Performance) |
| GG0130F5 | Upper body dressing (OBRA/Interim Performance) |
| GG0130G1 | Lower body dressing (Admission Performance) |
| GG0130G3 | Lower body dressing (Discharge Performance) |
| GG0130G5 | Lower body dressing (OBRA/Interim Performance) |
| GG0130H1 | Putting on/taking off footwear (Admission Performance) |
| GG0130H3 | Putting on/taking off footwear (Discharge Performance) |
| GG0130H5 | Putting on/taking off footwear(OBRA/Interim Performance) |
| GG0130I1 | Personal Hygiene (Admission Performance) |
| GG0130I3 | Personal Hygiene (Discharge Performance) |
| GG0130I5 | Personal Hygiene (OBRA/Interim Performance) |
| GG0170A1 | Roll left and right (Admission Performance) |
| GG0170A3 | Roll left and right (Discharge Performance) |
| GG0170A5 | Roll left and right (OBRA/Interim Performance) |
| GG0170B1 | Sit to lying (Admission Performance) |
| GG0170B3 | Sit to lying (Discharge Performance) |
| GG0170B5 | Sit to lying (OBRA/Interim Performance) |
| GG0170C1 | Lying to sitting on bed side (Admission Performance) |
| GG0170C3 | Lying to sitting on bed side (Discharge Performance) |
| GG0170C5 | Lying to sitting on bed side (OBRA/Interim Performance) |
| GG0170D1 | Sit to stand (Admission Performance) |
| GG0170D3 | Sit to stand (Discharge Performance) |
| GG0170D5 | Sit to stand (OBRA/Interim Performance) |
| GG0170E1 | Chair/bed-to-chair transfer (Admission Performance) |
| GG0170E3 | Chair/bed-to-chair transfer (Discharge Performance) |
| GG0170E5 | Chair/bed-to-chair transfer (OBRA/Interim Performance) |
| GG0170F1 | Toilet transfer (Admission Performance) |
| GG0170F3 | Toilet transfer (Discharge Performance) |
| GG0170F5 | Toilet transfer (OBRA/Interim Performance) |
| GG0170FF1 | Tub/Shower Transfer (Admission Performance) |
| GG0170FF3 | Tub/Shower Transfer (Discharge Performance) |
| GG0170FF5 | Tub/Shower Transfer (OBRA/Interim Performance) |
| GG0170G1 | Car Transfer (Admission Performance) |
| GG0170G3 | Car Transfer (Discharge Performance) |
| GG0170I1 | Walk 10 feet (Admission Performance) |
| GG0170I3 | Walk 10 feet (Discharge Performance) |
| GG0170I5 | Walk 10 feet (OBRA/Interim Performance) |
| GG0170J1 | Walk 50 feet with two turns (Admission Performance) |
| GG0170J3 | Walk 50 feet with two turns (Discharge Performance) |
| GG0170J5 | Walk 50 feet with two turns (OBRA/Interim Performance) |
| GG0170K1 | Walk 150 feet (Admission Performance) |
| GG0170K3 | Walk 150 feet (Discharge Performance) |
| GG0170K5 | Walk 150 feet (OBRA/Interim Performance) |
| GG0170L1 | Walking 10 feet on uneven surfaces (Admission Performance) |
| GG0170L3 | Walking 10 feet on uneven surfaces (Discharge Performance) |
| GG0170M1 | 1 step (curb) (Admission Performance) |
| GG0170M3 | 1 step (curb) (Discharge Performance) |
| GG0170N1 | 4 steps (Admission Performance) |
| GG0170N3 | 4 steps (Discharge Performance) |
| GG0170O1 | 12 steps (Admission Performance) |
| GG0170O3 | 12 steps (Discharge Performance) |
| GG0170P1 | Picking up object (Admission Performance) |
| GG0170P3 | Picking up object (Discharge Performance) |
| GG0170Q1 | Use of wheelchair/scooter (Admission Performance) |
| GG0170Q3 | Use of wheelchair/scooter (Discharge Performance) |
| GG0170Q5 | Use of wheelchair/scooter (OBRA/Interim Performance) |
| GG0170R1 | Wheel 50 feet with two turns (Admission Performance) |
| GG0170R3 | Wheel 50 feet with two turns (Discharge Performance) |
| GG0170R5 | Wheel 50 feet with two turns (OBRA/Interim Performance) |
| GG0170RR1 | Type wheelchair/scooter used (Admission Performance) |
| GG0170RR3 | Type wheelchair/scooter used (Discharge Performance) |
| GG0170RR5 | Type wheelchair/scooter used (OBRA/Interim Performance) |
| GG0170S1 | Wheel 150 feet (Admission Performance) |
| GG0170S3 | Wheel 150 feet (Discharge Performance) |
| GG0170S5 | Wheel 150 feet (OBRA/Interim Performance) |
| GG0170SS1 | Type wheelchair/scooter used (Admission Performance) |
| GG0170SS3 | Type wheelchair/scooter used (Discharge Performance) |
| GG0170SS5 | Type wheelchair/scooter used (OBRA/Interim Performance) |
| H0100A | Appliances: indwelling catheter |
| H0100B | Appliances: external catheter |
| H0100C | Appliances: ostomy |
| H0100D | Appliances: intermittent catheterization |
| H0100Z | Appliances: none of the above |
| H0200A | Urinary toileting program: has been attempted |
| H0200B | Urinary toileting program: response |
| H0200C | Urinary toileting program: current program/trial |
| H0300 | Urinary continence |
| H0400 | Bowel continence |
| H0500 | Bowel toileting program being used |
| H0600 | Constipation |
| I0020 | Indicate the resident’s primary medical condition category |
| I0020B | ICD Code 1 - 13 |
| I0100 | Cancer (with or without metastasis) |
| I0200 | Anemia |
| I0300 | Atrial fibrillation and other dysrhythmias |
| I0400 | Coronary artery disease (CAD) |
| I0500 | Deep venous thrombosis (DVT), PE, or PTE |
| I0600 | Heart failure |
| I0700 | Hypertension |
| I0800 | Orthostatic hypotension |
| I0900 | Peripheral vascular disease (PVD) or PAD |
| I1100 | Cirrhosis |
| I1200 | Gastroesophageal reflux disease (GERD) or ulcer |
| I1300 | Ulcerative colitis, Crohn's, inflammatory bowel disease |
| I1400 | Benign prostatic hyperplasia (BPH) |
| I1500 | Renal insufficiency, renal failure, ESRD |
| I1550 | Neurogenic bladder |
| I1650 | Obstructive uropathy |
| I1700 | Multidrug-resistant organism (MDRO) |
| I2000 | Pneumonia |
| I2100 | Septicemia |
| I2200 | Tuberculosis |
| I2300 | Urinary tract infection (UTI) (LAST 30 DAYS) |
| I2400 | Viral hepatitis (includes type A, B, C, D, and E) |
| I2500 | Wound infection (other than foot) |
| I2900 | Diabetes mellitus (DM) |
| I3100 | Hyponatremia |
| I3200 | Hyperkalemia |
| I3300 | Hyperlipidemia (e.g., hypercholesterolemia) |
| I3400 | Thyroid disorder |
| I3700 | Arthritis |
| I3800 | Osteoporosis |
| I3900 | Hip fracture |
| I4000 | Other fracture |
| I4200 | Alzheimer's disease |
| I4300 | Aphasia |
| I4400 | Cerebral palsy |
| I4500 | Cerebrovascular accident (CVA), TIA, or stroke |
| I4800 | Non-Alzheimer's Dementia |
| I4900 | Hemiplegia or hemiparesis |
| I5000 | Paraplegia |
| I5100 | Quadriplegia |
| I5200 | Multiple sclerosis |
| I5250 | Huntington's disease |
| I5300 | Parkinson's disease |
| I5350 | Tourette's syndrome |
| I5400 | Seizure disorder or epilepsy |
| I5500 | Traumatic brain injury (TBI) |
| I5600 | Malnutrition (protein, calorie), risk of malnutrition |
| I5700 | Anxiety disorder |
| I5800 | Depression (other than bipolar) |
| I5900 | Bipolar Disorder |
| I5950 | Psychotic disorder (other than schizophrenia) |
| I6000 | Schizophrenia |
| I6100 | Post-traumatic stress disorder (PTSD) |
| I6200 | Asthma, COPD, or chronic lung disease |
| I6300 | Respiratory failure |
| I6500 | Cataracts, glaucoma, or macular degeneration |
| I7900 | None of above active diagnoses within last 7 days |
| I8000A | Additional active ICD diagnosis 1 |
| I8000B | Additional active ICD diagnosis 2 |
| I8000C | Additional active ICD diagnosis 3 |
| I8000D | Additional active ICD diagnosis 4 |
| I8000E | Additional active ICD diagnosis 5 |
| I8000F | Additional active ICD diagnosis 6 |
| I8000G | Additional active ICD diagnosis 7 |
| I8000H | Additional active ICD diagnosis 8 |
| I8000I | Additional active ICD diagnosis 9 |
| I8000J | Additional active ICD diagnosis 10 |
| J0100A | Pain: received scheduled pain med regimen |
| J0100B | Pain: received PRN pain medications |
| J0100C | Pain: received non-medication intervention |
| J0200 | Should pain assessment interview be conducted |
| J0300 | Res pain interview: presence |
| J0410 | Res pain interview: frequency |
| J0510 | Pain Effect on Sleep |
| J0520 | Pain Interference with Therapy Activities |
| J0530 | Pain Interference with Day-to-Day Activities |
| J0600A | Res pain interview: intensity rating scale |
| J0600B | Res pain interview: verbal descriptor scale |
| J0700 | Should staff assessment for pain be conducted |
| J0800A | Staff pain assessment: non-verbal sounds |
| J0800B | Staff pain assessment: vocal complaints of pain |
| J0800C | Staff pain assessment: facial expressions |
| J0800D | Staff pain assessment: protective movements/postures |
| J0800Z | Staff pain assessment: none of these signs observed |
| J0850 | Staff pain assessment: frequency of pain |
| J1100A | Short breath/trouble breathing: with exertion |
| J1100B | Short breath/trouble breathing: sitting at rest |
| J1100C | Short breath/trouble breathing: lying flat |
| J1100Z | Short breath/trouble breathing: none of above |
| J1300 | Current tobacco use |
| J1400 | Prognosis: life expectancy of less than 6 months |
| J1550A | Problem conditions: fever |
| J1550B | Problem conditions: vomiting |
| J1550C | Problem conditions: dehydrated |
| J1550D | Problem conditions: internal bleeding |
| J1550Z | Problem conditions: none of the above |
| J1700A | Fall history: fall during month before admission |
| J1700B | Fall history: fall 2-6 months before admission |
| J1700C | Fall history: fracture from fall 6 month pre admit |
| J1800 | Falls since admit/prior assessment: any falls |
| J1900A | Falls since admit/prior assessment: no injury |
| J1900B | Falls since admit/prior assessment: injury (not major) |
| J1900C | Falls since admit/prior assessment: major injury |
| J2000 | Prior Surgery |
| J2100 | Recent Surgery Requiring Active SNF Care |
| J2300 | Knee Replacement - partial or total |
| J2310 | Hip Replacement - partial or total |
| J2320 | Ankle Replacement - partial or total |
| J2330 | Shoulder Replacement - partial or total |
| J2400 | Spinal surgery - spinal cord or major spinal nerves |
| J2410 | Spinal surgery - fusion of spinal bones |
| J2420 | Spinal surgery - lamina, discs, or facets |
| J2499 | Spinal surgery - other |
| J2500 | Ortho surgery - repair fractures of shoulder or arm |
| J2510 | Ortho surgery - repair fractures of pelvis, hip, leg, knee, or ankle |
| J2520 | Ortho surgery - repair but not replace joints |
| J2530 | Ortho surgery - repair other bones |
| J2599 | Ortho surgery - other |
| J2600 | Neuro surgery - brain, surrounding tissue or blood vessels |
| J2610 | Neuro surgery - peripheral and autonomic nervous system - open and percutaneous |
| J2620 | Neuro surgery - insertion or removal of spinal and brain neurostimulators, electrodes, catheters, and CSF drainage devices |
| J2699 | Neuro surgery - Other |
| J2700 | Cardiopulmonary surgery - heart or major blood vessels - open and percutaneous procedures |
| J2710 | Cardiopulmonary surgery - respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords – open and endoscopic |
| J2799 | Cardiopulmonary surgery - Other |
| J2800 | Genitourinary surgery - genital systems |
| J2810 | Genitourinary surgery - the kidneys, ureter, adrenals, and bladder—open, laparoscopic |
| J2899 | Other major genitourinary surgery |
| J2900 | Major surgery - tendons, ligament, or muscles |
| J2910 | Major surgery - the GI tract and abdominal contents from the esophagus to the anus, the biliary tree, gall bladder, liver, pancreas, spleen—open or laparoscopic |
| J2920 | Major surgery - endocrine organs (such as thyroid, parathyroid), neck, lymph nodes, and thymus—open |
| J2930 | Major surgery - the breast |
| J2940 | Major surgery - repair of deep ulcers, internal brachytherapy, bone marrow, or stem cell harvest or transplant |
| J5000 | Major surgery - Other surgery not listed above |
| K0100A | Swallow disorder: loss liquids/solids from mouth |
| K0100B | Swallow disorder: holds food in mouth/cheeks |
| K0100C | Swallow disorder: cough/choke with meals/meds |
| K0100D | Swallow disorder: difficulty or pain swallowing |
| K0100Z | Swallow disorder: none of the above |
| K0200A | Height (in inches) |
| K0200B | Weight (in pounds) |
| K0300 | Weight loss |
| K0310 | Weight gain |
| K0520A1 | Nutritional approaches: Parenteral/IV Feeding - Adm |
| K0520A2 | Nutritional approaches: Parenteral/IV Feeding - Not a Res |
| K0520A3 | Nutritional approaches: Parenteral/IV Feeding - While a Res |
| K0520A4 | Nutritional approaches: Parenteral/IV Feeding - At Discharge |
| K0520B1 | Nutritional approaches: Feeding Tube - Adm |
| K0520B2 | Nutritional approaches: Feeding Tube - Not a Res |
| K0520B3 | Nutritional approaches: Feeding Tube - While a Res |
| K0520B4 | Nutritional approaches: Feeding Tube - At Discharge |
| K0520C1 | Nutritional approaches: Mechanically Altered Diet - Adm |
| K0520C3 | Nutritional approaches: Mechanically Altered Diet - While a Res |
| K0520C4 | Nutritional approaches: Mechanically Altered Diet - At Discharge |
| K0520D1 | Nutritional approaches: Therapeutic Diet - Adm |
| K0520D3 | Nutritional approaches: Therapeutic Diet - While a Res |
| K0520D4 | Nutritional approaches: Therapeutic Diet - At Discharge |
| K0520Z1 | Nutritional approaches: None of the above - Adm |
| K0520Z2 | Nutritional approaches: None of the above - Not a Res |
| K0520Z3 | Nutritional approaches: None of the above - While a Res |
| K0520Z4 | Nutritional approaches: None of the above - At Discharge |
| K0710A2 | Prop calories parenteral/tube feed: while a resident |
| K0710A3 | Prop calories parenteral/tube feed: 7 days |
| K0710B2 | Avg fluid intake per day IV/ tube: while a resident |
| K0710B3 | Avg fluid intake per day IV/tube: 7 days |
| L0200A | Dental: broken or loosely fitting denture |
| L0200B | Dental: no natural teeth or tooth fragment(s) |
| L0200C | Dental: abnormal mouth tissue |
| L0200D | Dental: cavity or broken natural teeth |
| L0200E | Dental: inflamed/bleeding gums or loose teeth |
| L0200F | Dental: pain, discomfort, difficulty chewing |
| L0200G | Dental: unable to examine |
| L0200Z | Dental: none of the above |
| M0100A | Risk determination: has ulcer, scar, or dressing |
| M0100B | Risk determination: formal assessment |
| M0100C | Risk determination: clinical assessment |
| M0100Z | Risk determination: none of the above |
| M0150 | Is resident at risk of developing pressure ulcer |
| M0210 | Resident has Stage 1 or higher pressure ulcers |
| M0300A1 | Stage 1 pressure ulcers: number present |
| M0300B1 | Stage 2 pressure ulcers: number present |
| M0300B2 | Stage 2 pressure ulcers: number at admit/reentry |
| M0300C1 | Stage 3 pressure ulcers: number present |
| M0300C2 | Stage 3 pressure ulcers: number at admit/reentry |
| M0300D1 | Stage 4 pressure ulcers: number present |
| M0300D2 | Stage 4 pressure ulcers: number at admit/reentry |
| M0300E1 | Unstaged due to dressing: number present |
| M0300E2 | Unstaged due to dressing: number at admit/reentry |
| M0300F1 | Unstaged slough/eschar: number present |
| M0300F2 | Unstaged slough/eschar: number at admit/reentry |
| M0300G1 | Unstageable - deep tissue: number present |
| M0300G2 | Unstageable - deep tissue: number at admit/reentry |
| M1030 | Number of venous and arterial ulcers |
| M1040A | Other skin problems: infection of the foot |
| M1040B | Other skin problems: diabetic foot ulcer(s) |
| M1040C | Other skin problems: other open lesion(s) on the foot |
| M1040D | Other skin problems: lesions not ulcers, rashes, cuts |
| M1040E | Other skin problems: surgical wound(s) |
| M1040F | Other skin problems: burns (second or third degree) |
| M1040G | Skin tear(s) |
| M1040H | Moisture Associated Skin Damage (MASD) |
| M1040Z | Other skin problems: none of the above |
| M1200A | Skin/ulcer treatments: pressure reducing device for chair |
| M1200B | Skin/ulcer treatments: pressure reducing device for bed |
| M1200C | Skin/ulcer treatments: turning/repositioning |
| M1200D | Skin/ulcer treatments: nutrition/hydration |
| M1200E | Skin/ulcer treatments: pressure ulcer/injury care |
| M1200F | Skin/ulcer treatments: surgical wound care |
| M1200G | Skin/ulcer treatments: application of dressings |
| M1200H | Skin/ulcer treatments: apply ointments/medications |
| M1200I | Skin/ulcer treatments: apply dressings to feet |
| M1200Z | Skin/ulcer treatments: none of the above |
| N0300 | Number of days injectable medications received |
| N0350A | Insulin: insulin injections |
| N0350B | Insulin: orders for insulin |
| N0415A1 | High-Risk Drug Classes: Antipsychotic: Has received |
| N0415A2 | High-Risk Drug Classes: Antipsychotic: Indication noted |
| N0415B1 | High-Risk Drug Classes: Antianxiety: Has received |
| N0415B2 | High-Risk Drug Classes: Antianxiety: Indication noted |
| N0415C1 | High-Risk Drug Classes: Antidepressant: Has received |
| N0415C2 | High-Risk Drug Classes: Antidepressant: Indication noted |
| N0415D1 | High-Risk Drug Classes: Hypnotic: Has received |
| N0415D2 | High-Risk Drug Classes: Hypnotic: Indication noted |
| N0415E1 | High-Risk Drug Classes: Anticoagulant: Has received |
| N0415E2 | High-Risk Drug Classes: Anticoagulant: Indication noted |
| N0415F1 | High-Risk Drug Classes: Antibiotic: Has received |
| N0415F2 | High-Risk Drug Classes: Antibiotic: Indication noted |
| N0415G1 | High-Risk Drug Classes: Diuretic: Has received |
| N0415G2 | High-Risk Drug Classes: Diuretic: Indication noted |
| N0415H1 | High-Risk Drug Classes: Opioid: Has received |
| N0415H2 | High-Risk Drug Classes: Opioid: Indication noted |
| N0415I1 | High-Risk Drug Classes: Antiplatelet: Has received |
| N0415I2 | High-Risk Drug Classes: Antiplatelet: Indication noted |
| N0415J1 | High-Risk Drug Classes: Hypoglycemic: Has received |
| N0415J2 | High-Risk Drug Classes: Hypoglycemic: Indication noted |
| N0415K1 | High-Risk Drug Classes: Anti-convulsants: Has received |
| N0415K2 | High-Risk Drug Classes: Anti-convulsants: Indication noted |
| N0415Z1 | High-Risk Drug Classes: None of Above: Has Received |
| N0450A | Resident received antipsychotic medications |
| N0450B | GDR attempted |
| N0450C | Date of last attempted GDR |
| N0450D | Physician documented GDR |
| N0450E | Date physician documented GDR |
| N2001 | Drug Regimen Review |
| N2003 | Medication Follow-up |
| N2005 | Medication Intervention |
| O0110A1a | Treatment: Chemotherapy - On Adm |
| O0110A1b | Treatment: Chemotherapy - While a Res |
| O0110A1c | Treatment: Chemotherapy - At Discharge |
| O0110A2a | Treatment: Chemotherapy - IV - On Adm |
| O0110A2c | Treatment: Chemotherapy - IV - At Discharge |
| O0110A3a | Treatment: Chemotherapy - Oral - On Adm |
| O0110A3c | Treatment: Chemotherapy - Oral - At Discharge. |
| O0110A10a | Treatment: Chemotherapy - Other - On Adm |
| O0110A10c | Treatment: Chemotherapy - Other - At Discharge |
| O0110B1a | Treatment: Radiation - On Adm |
| O0110B1b | Treatment: Radiation - While a Resident |
| O0110B1c | Treatment: Radiation - At Discharge |
| O0110C1a | Treatment: Oxygen Therapy - On Adm |
| O0110C1b | Treatment: Oxygen Therapy - While a Res |
| O0110C1c | Treatment: Oxygen Therapy - At Discharge |
| O0110C2a | Treatment: Oxygen Therapy - Continuous - On Adm |
| O0110C2c | Treatment: Oxygen Therapy - Continuous - At Discharge |
| O0110C3a | Treatment: Oxygen Therapy - Intermittent - On Adm |
| O0110C3c | Treatment: Oxygen Therapy - Intermittent - At Discharge |
| O0110C4a | Treatment: Oxygen Therapy - High- concentration - On Adm |
| O0110C4c | Treatment: Oxygen Therapy - High- concentration - At Discharge |
| O0110D1a | Treatment: Suctioning - On Adm |
| O0110D1b | Treatment: Suctioning - While a Res |
| O0110D1c | Treatment: Suctioning - At Discharge |
| O0110D2a | Treatment: Suctioning - Scheduled - Adm |
| O0110D2c | Treatment: Suctioning - Scheduled - At Discharge |
| O0110D3a | Treatment: Suctioning - As Needed - Adm |
| O0110D3c | Treatment: Suctioning - As Needed - At Discharge |
| O0110E1a | Treatment: Tracheostomy care - Adm |
| O0110E1b | Treatment: Tracheostomy care - While a Resident |
| O0110E1c | Treatment: Tracheostomy care - At Discharge |
| O0110F1a | Treatment: Invasive Mechanical Ventilator - Adm |
| O0110F1b | Treatment: Invasive Mechanical Ventilator - While a Res |
| O0110F1c | Treatment: Invasive Mechanical Ventilator - At Discharge |
| O0110G1a | Treatment: Non-Invasive Mechanic Ventilator - On Adm |
| O0110G1b | Treatment: Non-Invasive Mechanic Ventilator - While a Res |
| O0110G1c | Treatment: Non-Invasive Mechanic Ventilator - At Discharge |
| O0110G2a | Treatment: Non-Invasive Mechanic Ventilator - BiPAP - On Adm |
| O0110G2c | Treatment: Non-Invasive Mechanic Ventilator - BiPAP - At Discharge |
| O0110G3a | Treatment: Non-Invasive Mechanic Ventilator - CPAP - On Adm |
| O0110G3c | Treatment: Non-Invasive Mechanic Ventilator - CPAP - At Discharge |
| O0110H1a | Treatment: IV Medications - On Adm |
| O0110H1b | Treatment: IV Medications - While a Res |
| O0110H1c | Treatment: IV Medications - At Discharge |
| O0110H2a | Treatment: IV Medications - Vasoactive Med - On Adm |
| O0110H2c | Treatment: IV Medications - Vasoactive Med - At Discharge |
| O0110H3a | Treatment: IV Medications - Antibiotics - On Adm |
| O0110H3c | Treatment: IV Medications - Antibiotics - At Discharge |
| O0110H4a | Treatment: IV Medications - Anticoagulant - On Adm |
| O0110H4c | Treatment: IV Medications - Anticoagulant - At Discharge |
| O0110H10a | Treatment: IV Medications - Other - On Adm |
| O0110H10c | Treatment: IV Medications - Other - At Discharge |
| O0110I1a | Treatment: Transfusions - On Adm |
| O0110I1b | Treatment: Transfusions - While a Res |
| O0110I1c | Treatment: Transfusions - At Discharge |
| O0110J1a | Treatment: Dialysis - On Adm |
| O0110J1b | Treatment: Dialysis - while a Resident |
| O0110J1c | Treatment: Dialysis - At Discharge |
| O0110J2a | Treatment: Dialysis - Hemodialysis - On Adm |
| O0110J2c | Treatment: Dialysis - Hemodialysis - At Discharge |
| O0110J3a | Treatment: Dialysis - Peritoneal - On Adm |
| O0110J3c | Treatment: Dialysis - Peritoneal - At Discharge |
| O0110K1b | Treatment: Hospice - While a Res |
| O0110M1b | Treatment: isolate/quarantine - While a Res |
| O0110O1a | Treatment: IV Access - On Adm |
| O0110O1b | Treatment: IV Access - While a Res |
| O0110O1c | Treatment: IV Access - At Discharge |
| O0110O2a | Treatment: IV Access - Peripheral - On Adm |
| O0110O2c | Treatment: IV Access - Peripheral - At Discharge |
| O0110O3a | Treatment: IV Access - Midline - On Adm |
| O0110O3c | Treatment: IV Access - Midline - At Discharge |
| O0110O4a | Treatment: IV Access - Central - On Adm |
| O0110O4c | Treatment: IV Access - Central - At Discharge |
| O0110Z1a | Treatment: None of the above - On Adm |
| O0110Z1b | Treatment: None of the above - While a Res |
| O0110Z1c | Treatment: None of the above - At Discharge |
| O0250A | Was influenza vaccine received |
| O0250B | Date influenza vaccine received |
| O0250C | If influenza vaccine not received, state reason |
| O0300A | Is pneumococcal vaccination up to date |
| O0300B | If pneumococcal vaccination not received, state reason |
| O0350 | Resident’s COVID-19 vaccination is up to date |
| O0400A1 | Speech-language/audiology: individual minutes |
| O0400A2 | Speech-language/audiology: concurrent minutes |
| O0400A3 | Speech-language/audiology: group minutes |
| O0400A3A | Speech-language/audiology: co-treatment minutes |
| O0400A4 | Speech-language/audiology: number of days |
| O0400A5 | Speech-language/audiology: start date |
| O0400A6 | Speech-language/audiology: end date |
| O0400B1 | Occupational therapy: individual minutes |
| O0400B2 | Occupational therapy: concurrent minutes |
| O0400B3 | Occupational therapy: group minutes |
| O0400B3A | Occupational therapy: co-treatment minutes |
| O0400B4 | Occupational therapy: number of days |
| O0400B5 | Occupational therapy: start date |
| O0400B6 | Occupational therapy: end date |
| O0400C1 | Physical therapy: individual minutes |
| O0400C2 | Physical therapy: concurrent minutes |
| O0400C3 | Physical therapy: group minutes |
| O0400C3A | Physical therapy: co-treatment minutes |
| O0400C4 | Physical therapy: number of days |
| O0400C5 | Physical therapy: start date |
| O0400C6 | Physical therapy: end date |
| O0400D1 | Respiratory therapy: number of minutes |
| O0400D2 | Respiratory therapy: number of days |
| O0400E1 | Psychological therapy: number of minutes |
| O0400E2 | Psychological therapy: number of days |
| O0400F1 | Recreational therapy: number of minutes |
| O0400F2 | Recreational therapy: number of days |
| O0420 | Distinct calendar days of therapy (7 look back) |
| O0425A1 | SLP and Audiology Services: Individual Minutes |
| O0425A2 | SLP and Audiology Services: Concurrent Minutes |
| O0425A3 | SLP and Audiology Services: Group Minutes |
| O0425A4 | SLP and Audiology Services: Co-treatment Minutes |
| O0425A5 | SLP and Audiology Services: Days |
| O0425B1 | Occupational Therapy: Individual Minutes |
| O0425B2 | Occupational Therapy: Concurrent Minutes |
| O0425B3 | Occupational Therapy: Group Minutes |
| O0425B4 | Occupational Therapy: Co-treatment Minutes |
| O0425B5 | Occupational Therapy: Days |
| O0425C1 | Physical Therapy: Individual Minutes |
| O0425C2 | Physical Therapy: Concurrent Minutes |
| O0425C3 | Physical Therapy: Group Minutes |
| O0425C4 | Physical Therapy: Co-treatment Minutes |
| O0425C5 | Physical Therapy: Days |
| O0430 | Distinct Calendar Days of Part A Therapy |
| O0500A | Range of motion (passive): number of days |
| O0500B | Range of motion (active): number of days |
| O0500C | Splint or brace assistance: number of days |
| O0500D | Bed mobility training: number of days |
| O0500E | Transfer training: number of days |
| O0500F | Walking training: number of days |
| O0500G | Dressing and/or grooming training: number of days |
| O0500H | Eating and/or swallowing training: number of days |
| O0500I | Amputation/prosthesis training: number of days |
| O0500J | Communication training: number of days |
| P0100A | Restraints used in bed: bed rail |
| P0100B | Restraints used in bed: trunk restraint |
| P0100C | Restraints used in bed: limb restraint |
| P0100D | Restraints used in bed: other |
| P0100E | Restraints in chair/out of bed: trunk restraint |
| P0100F | Restraints in chair/out of bed: limb restraint |
| P0100G | Restraints in chair/out of bed: chair stops rising |
| P0100H | Restraints in chair/out of bed: other |
| P0200A | Bed alarm |
| P0200B | Chair alarm |
| P0200C | Floor mat alarm |
| P0200D | Motion sensor alarm |
| P0200E | Wander/elopement alarm |
| P0200F | Other alarm |
| Q0110A | Asmt and Goal Participation: Resident |
| Q0110B | Asmt and Goal Participation: Family |
| Q0110C | Asmt and Goal Participation: Significant other |
| Q0110D | Asmt and Goal Participation: Legal guardian |
| Q0110E | Asmt and Goal Participation: Other legally authorized representative |
| Q0110Z | Asmt and Goal Participation: None of the above. |
| Q0310A | Resident's overall goal for discharge |
| Q0310B | Information source for Q0310A |
| Q0400A | Active discharge plan for return to community |
| Q0490 | Resident's preference to avoid being asked |
| Q0500B | Do you want to talk about returning to community |
| Q0500C | Information source for Q500B |
| Q0550A | Reasking resident preference |
| Q0550C | Information source for Q0550A |
| Q0610A | Referral been made to local contact agency |
| Q0620 | Reason Referral to Local Contact Agency Not Made |
| V0100A | Prior OBRA reason for assessment |
| V0100B | Prior PPS reason for assessment |
| V0100C | Prior assessment reference date |
| V0100D | Prior assessment BIMS summary score |
| V0100E | Prior assessment PHQ res: total mood severity score |
| V0100F | Prior assessment PHQ staff: total mood score |
| V0200A01A | CAA-Delirium: triggered |
| V0200A01B | CAA-Delirium: plan |
| V0200A02A | CAA-Cognitive loss/dementia: triggered |
| V0200A02B | CAA-Cognitive loss/dementia: plan |
| V0200A03A | CAA-Visual function: triggered |
| V0200A03B | CAA-Visual function: plan |
| V0200A04A | CAA-Communication: triggered |
| V0200A04B | CAA-Communication: plan |
| V0200A05A | CAA-ADL functional/rehab potential: triggered |
| V0200A05B | CAA-ADL functional/rehab potential: plan |
| V0200A06A | CAA-Urinary incontinence/indwelling catheter: triggered |
| V0200A06B | CAA-Urinary incontinence/indwelling catheter: plan |
| V0200A07A | CAA-Psychosocial well-being: triggered |
| V0200A07B | CAA-Psychosocial well-being: plan |
| V0200A08A | CAA-Mood state: triggered |
| V0200A08B | CAA-Mood state: plan |
| V0200A09A | CAA-Behavioral symptoms: triggered |
| V0200A09B | CAA-Behavioral symptoms: plan |
| V0200A10A | CAA-Activities: triggered |
| V0200A10B | CAA-Activities: plan |
| V0200A11A | CAA-Falls: triggered |
| V0200A11B | CAA-Falls: plan |
| V0200A12A | CAA-Nutritional status: triggered |
| V0200A12B | CAA-Nutritional status: plan |
| V0200A13A | CAA-Feeding tubes: triggered |
| V0200A13B | CAA-Feeding tubes: plan |
| V0200A14A | CAA-Dehydration/fluid maintenance: triggered |
| V0200A14B | CAA-Dehydration/fluid maintenance: plan |
| V0200A15A | CAA-Dental care: triggered |
| V0200A15B | CAA-Dental care: plan |
| V0200A16A | CAA-Pressure ulcer: triggered |
| V0200A16B | CAA-Pressure ulcer: plan |
| V0200A17A | CAA-Psychotropic drug use: triggered |
| V0200A17B | CAA-Psychotropic drug use: plan |
| V0200A18A | CAA-Physical restraints: triggered |
| V0200A18B | CAA-Physical restraints: plan |
| V0200A19A | CAA-Pain: triggered |
| V0200A19B | CAA-Pain: plan |
| V0200A20A | CAA-Return to community referral: triggered |
| V0200A20B | CAA-Return to community referral: plan |
| V0200B1 | CAA-Assessment process RN signature |
| V0200B2 | CAA-Assessment process signature date |
| V0200C1 | CAA-Care planning signature |
| V0200C2 | CAA-Care planning signature date |
| X0150 | Correction: type of provider |
| X0200A | Correction: resident first name |
| X0200C | Correction: resident last name |
| X0300 | Correction: resident gender |
| X0400 | Correction: resident birth date |
| X0500 | Correction: resident social security number |
| X0600A | Correction: OBRA reason for assessment |
| X0600B | Correction: PPS reason for assessment |
| X0600F | Correction: entry/discharge reporting |
| X0600H | Correction: SNF Part A PPS Discharge |
| X0700A | Correction: assessment reference date |
| X0700B | Correction: discharge date |
| X0700C | Correction: entry date |
| X0800 | Correction: correction number |
| X0900A | Correction: modification reasons - transcription error |
| X0900B | Correction: modification reasons - data entry error |
| X0900C | Correction: modification reasons - software error |
| X0900D | Correction: modification reasons - item coding error |
| X0900Z | Correction: modification reasons - other error |
| X1050A | Correction: inactivation reasons - event did not occur |
| X1050Z | Correction: inactivation reasons - other reason |
| X1100A | Correction: attestor first name |
| X1100B | Correction: attestor last name |
| X1100C | Correction: attestor title |
| X1100D | Correction: attestor signature |
| X1100E | Correction: attestation date |
| Z0100A | Medicare Part A: HIPPS code |
| Z0100B | Medicare Part A: Version code |
| Z0200A | State Medicaid Billing: Case Mix group |
| Z0200B | State Medicaid Billing: Version code |
| Z0250A | Alt State Medicaid Billing: Case Mix group |
| Z0250B | Alt State Medicaid Billing: Version Code |
| Z0300A | Insurance Billing: Billing Code |
| Z0300B | Insurance Billing: Billing Version |
| Z0400A | Attestation signature, title, sections, date |
| Z0400B | Attestation signature, title, sections, date |
| Z0400C | Attestation signature, title, sections, date |
| Z0400D | Attestation signature, title, sections, date |
| Z0400E | Attestation signature, title, sections, date |
| Z0400F | Attestation signature, title, sections, date |
| Z0400G | Attestation signature, title, sections, date |
| Z0400H | Attestation signature, title, sections, date |
| Z0400I | Attestation signature, title, sections, date |
| Z0400J | Attestation signature, title, sections, date |
| Z0400K | Attestation signature, title, sections, date |
| Z0400L | Attestation signature, title, sections, date |
| Z0500A | Signature of RN assessment coordinator |
| Z0500B | Date RN signed assessment as complete |