Central Line-Associated Bloodstream Infections (CLABSI) in Non-Intensive Care Unit (non-ICU) Settings Toolkit

Assessment Reference Date
- Understanding the Importance of Reference Dates
- Special ARD (UTI, Pain, Weight, etc.)
- Selecting ARD
- Sample ARD
Naming, Timing, and Scheduling
- Admission (Initial) Assessment
- Annual Reassessment
- Significant Change in Status Reassessment
- Quarterly Assessment
- Significant Correction of a Completed Prior Full Assessment
- Significant Correction of a Completed Prior Quarterly Assessment
- Practicing Scheduling MDS 3.0
Tracking/Discharge MDS
- Entry
- Reentry
- Discharge Assessments (Return Not Anticipated or Return Anticipated)
- Planned
- Unplanned
- PPS Discharge Assessment
- Respite
- Death in Facility
Line by Line Coding Sections
- Section A: Identification Information
- Section B: Hearing, Speech, and Vision
- Section C: Cognitive Patterns
- Section D: Mood
- Section E: Behavior
- Section F: Preferences for Routine and Activities
- Section G: Functional Status
- Section GG: Functional Abilities and Goals
- Section H: Bladder and Bowel
- Section I: Active Diagnoses
- Section J: Health Conditions
- Section K: Swallowing/Nutritional Status
- Section L: Oral/Dental Status
- Section M: Skin Conditions
- Section N: Medications
- Section O: Special Treatments, Procedures, and Programs
- Section P: Restraints and Alarms
- Section Q: Participation in Assessment and Goal Setting
- Section S: State Optional Assessment
- Section V: Care Area Assessment Summary
- Section X: Correction Request
Care Area Assessment
- Delirium
- Cognitive Loss/Dementia
- Visual Function
- Communication
- ADL Functional/Rehabilitation Potential
- Urinary Incontinence and Indwelling Catheter
- Psychosocial Well-Being
- Mood State
- Behavioral Symptoms
- Activities
- Falls
- Nutritional Status
- Feeding Tube
- Dehydration/Fluid Maintenance
- Dental Care
- Pressure Ulcer
- Psychotropic Drug Use
- Physical Restraints
- Pain
- Return to Community Referral
Submitting MDS
Validating MDS/Attestation
Inactivation of Assessments
Modification of Assessments

MDS Essentials - Click for All Articles

CAA Documentation and Care Planning Process

Intro to Careplan in LTC
The Interdisciplinary Team Members Role in Care Plan
Baseline Care Plan
Baseline Care Plan Component Review
Comprehensive Care Plans
Admission Care Plan with Admission MDS
Significant Change Care Plan
Annual MDS Care Plan
Care Plan Completion Requirements for Comprehensive MDS
Care Plan Invitation
Care Plan Meeting
Care Plan Review
Updating Care Plan
Fall Prevention

Care Planning - Click for All Articles

Overview of ICD-10 for MDS 3.0
ICD-10 for MDS 3.0 Mapping
ICD-10 Mapping for PDPM Components
ICD-10 Clinical Category Mapping
ICD-10 Rehab Mapping
ICD-10 Categories
ICD-10 Resources | CMS
MCD Search (cms.gov)
PDPM
- CMS Patient Driven Payment Model Website
- Naming and Scheduling: PPS PDPM
- 5-day PPS Assessment
- Interim Payment Assessment (IPA)
- PPS Discharge Assessment
- Default Rate
- Default Prevention Guidelines
- Scheduling to Maximize Reimbursement
- Anti-Kickback Statute
- IPA Management
- Fact Sheet: PDPM
- PDPM Case Mix Components
- PDPM Components (OT, Nursing, SLP, PT, Non-Case Mix, NTA)
- ICD 10: Coding/Sequencing
- PDPM Clinical Categories
- FAQs: Patient-Driven Payment Model
- Naming and Scheduling: PPS RUG

ICD-10 and PDPM - Click for All Articles

Review of Medicaid CMI Management
Maximizing the ARD: Adjusting for Capturing Care Services

Medicaid Management - Click for All Articles

Medication Safety – High Alert and Hazardous Medication
Drug Classification & Categories
Gradual Dose Reduction

Medication Management

Reviewing Clinical Report
Skilled Care Documentation
End of Month and Triple Check
Clinical Checklist/Audit
Reviewing ADL Documentation
How to Review All Referral (Admission/Readmission) as IDT - Referral Review

Navigating Clinical Documentation - Click for All Articles

Medicare Basics
What is Skilled Care? / Criteria for Skilled Care Coverage
Skilled Nursing Facility 3-Day Rule Billing
Medicare SNF Coverage Guidelines Under PPS
Factors Impacting Medicare A
Presumption of Care
Clinical Eligibility Requirements - Medicare
Technical Eligibility Requirements - Medicare
Medicare 30-day Window
Medicare 60 Day Wellness Period
Medicare A / Hospice Dual Coverage
Medicare Certs
MCD Search (cms.gov)
TRICARE For Life
TRICARE Reimbursement Manual
Medicare Secondary Payer (MSP)
Deferred Covered Treatment
Understanding Medicare Part B: Frequency and Duration
Medicare Meeting
Managed Care Basics
Managed Medicare/Medicare Advantage
HMO Managed
Bed-Hold Policies
Denial and ABN Forms and Process
Denial Letters (Medicare A, Medicare Advantage, Medicare B)
Appeals Process
Detailed Explanation of Non-Coverage
Medicare Benefit Policy Manual
Medicare Program Integrity Manual
Medical Review Additional Development Request (ADR) Process

Medicare and Managed Care - Click for All Articles

Preparation of Survey Process (Annual Survey / Licensing Inspection / Complaint Investigation)
State Operations Manual
Understanding the Survey Process
Federal Regulatory Groups for Long Term Care Facilities
Mock Survey Resource
Nursing Home Search Page
Forms to Keep Updated
Completing Plan of Correction (POC)
- The Statement of Deficiencies and Plan of Correction (CMS-2567)
- Statement of Deficiencies and Plan Correction
LC Survey Pathways & Entrance Conference Form
LTCSP Initial Pool Care Areas
Quality Reporting Programs
- Quality Measures & Five Star Rating System for SNF
- CMS SNF QRP
- 5 Star Reporting
- CASPER
- QM
- Missed Assessment
- QRP
- QM Manual
- How to QAPI for Improvement of QM
- Nursing Home Compare
- RAC Audit

Survey Preparation and Quality Reporting - Click for All Articles

Daily Clinical Meeting
Huddles
Morning Meeting
Worksheet
48/72 Care Conference
Medicare Meeting
Risk Meeting
Care Plan Meeting (See under Care Planning)
Discharge Meeting
QAPI Meeting

Meetings and QAPI - Click for All Articles

Interpreting Weekly Summary Financial
Understanding How the MDS is Utilized in SNF Clinical Reimbursements

Financial Management - Click for All Articles

McGeer Criteria for Infection Surveillance Checklist
42 CFR § 483.80 - Infection Control
Antibiotic Stewardship for Nursing Homes
- Core Elements Checklist
- Nursing Home Resources

Infection Control - Click for All Articles

Activities Director: What They Do?
Social Services: What They Do?
Dietician: What They Do?
DON: What They Do?
Nursing Team: What They Do?
Department Heads: What They Do?

IDT Roles - Click for All Articles

All-Point Click Care Videos - Click for All Articles

Nurse Practice Act Links- Click for All Links

MDS 3.0 Item Matrix Dashboard & Step-by-Step Guide

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
B0100	Comatose	Step-by-Step Guide	Click here for all articles
B0200	Hearing	Step-by-Step Guide	Click here for all articles
B0300	Hearing aid	Step-by-Step Guide	Click here for all articles
B0600	Speech clarity	Step-by-Step Guide	Click here for all articles
B0700	Makes self understood	Step-by-Step Guide	Click here for all articles
B0800	Ability to understand others	Step-by-Step Guide	Click here for all articles
B1000	Vision	Step-by-Step Guide	Click here for all articles
B1200	Corrective lenses	Step-by-Step Guide	Click here for all articles
B1300	Health Literacy	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
A0050	Type of Record	Step-by-Step Guide	Click here for all articles
A0100A	Facility National Provider Identifier (NPI)	Step-by-Step Guide	Click here for all articles
A0100B	Facility CMS Certification Number (CCN)	Step-by-Step Guide	Click here for all articles
A0100C	State provider number	Step-by-Step Guide	Click here for all articles
A0200	Type of provider	Step-by-Step Guide	Click here for all articles
A0310A	Type of assessment: OBRA	Step-by-Step Guide	Click here for all articles
A0310B	Type of assessment: PPS	Step-by-Step Guide	Click here for all articles
A0310E	First assessment since most recent entry	Step-by-Step Guide	Click here for all articles
A0310F	Entry/discharge reporting	Step-by-Step Guide	Click here for all articles
A0310G	Planned/unplanned discharge	Step-by-Step Guide	Click here for all articles
A0310G1	Interrupted Stay	Step-by-Step Guide	Click here for all articles
A0310H	SNF Part A PPS Discharge	Step-by-Step Guide	Click here for all articles
A0410	Unit Certification or Licensure Designation	Step-by-Step Guide	Click here for all articles
A0500A	Resident first name	Step-by-Step Guide	Click here for all articles
A0500B	Resident middle initial	Step-by-Step Guide	Click here for all articles
A0500C	Resident last name	Step-by-Step Guide	Click here for all articles
A0500D	Resident name suffix	Step-by-Step Guide	Click here for all articles
A0600A	Social Security Number	Step-by-Step Guide	Click here for all articles
A0600B	Medicare number	Step-by-Step Guide	Click here for all articles
A0700	Medicaid number	Step-by-Step Guide	Click here for all articles
A0800	Gender	Step-by-Step Guide	Click here for all articles
A0900	Birthdate	Step-by-Step Guide	Click here for all articles
A1005A	Ethnicity: No, not of Hispanic, Latino/a, or Spanish origin	Step-by-Step Guide	Click here for all articles
A1005B	Ethnicity: Yes, Mexican, Mexican American, Chicano/a	Step-by-Step Guide	Click here for all articles
A1005C	Ethnicity: Yes, Puerto Rican	Step-by-Step Guide	Click here for all articles
A1005D	Ethnicity: Yes, Cuban	Step-by-Step Guide	Click here for all articles
A1005E	Ethnicity: Yes, another Hispanic, Latino, or Spanish origin	Step-by-Step Guide	Click here for all articles
A1005X	Ethnicity: Resident unable to respond	Step-by-Step Guide	Click here for all articles
A1005Y	Ethnicity: Resident declines to respond	Step-by-Step Guide	Click here for all articles
A1010A	Race: White	Step-by-Step Guide	Click here for all articles
A1010B	Race: Black or African American	Step-by-Step Guide	Click here for all articles
A1010C	Race: American Indian or Alaska Native	Step-by-Step Guide	Click here for all articles
A1010D	Race: Asian Indian	Step-by-Step Guide	Click here for all articles
A1010E	Race: Chinese	Step-by-Step Guide	Click here for all articles
A1010F	Race: Filipino	Step-by-Step Guide	Click here for all articles
A1010G	Race: Japanese	Step-by-Step Guide	Click here for all articles
A1010H	Race: Korean	Step-by-Step Guide	Click here for all articles
A1010I	Race: Vietnamese	Step-by-Step Guide	Click here for all articles
A1010J	Race: Other Asian	Step-by-Step Guide	Click here for all articles
A1010K	Race: Native Hawaiian	Step-by-Step Guide	Click here for all articles
A1010L	Race: Guamanian or Chamorro	Step-by-Step Guide	Click here for all articles
A1010M	Race: Samoan	Step-by-Step Guide	Click here for all articles
A1010N	Race: Other Pacific Islander	Step-by-Step Guide	Click here for all articles
A1010X	Resident unable to respond	Step-by-Step Guide	Click here for all articles
A1010Y	Resident declines to respond	Step-by-Step Guide	Click here for all articles
A1010Z	None of the above	Step-by-Step Guide	Click here for all articles
A1110A	Language: What is your preferred language?	Step-by-Step Guide	Click here for all articles
A1110B	Language: Need or want an interpreter?	Step-by-Step Guide	Click here for all articles
A1200	Marital status	Step-by-Step Guide	Click here for all articles
A1250A	Transportation (from NACHC©) : Yes, kept from med appts.	Step-by-Step Guide	Click here for all articles
A1250B	Transportation (from NACHC©): Yes, kept from non-med appts.	Step-by-Step Guide	Click here for all articles
A1250C	Transportation (from NACHC©): No	Step-by-Step Guide	Click here for all articles
A1250X	Transportation (from NACHC©): Resident unable to respond	Step-by-Step Guide	Click here for all articles
A1250Y	Transportation (from NACHC©): Resident declines to respond	Step-by-Step Guide	Click here for all articles
A1300A	Medical record number	Step-by-Step Guide	Click here for all articles
A1300B	Room number	Step-by-Step Guide	Click here for all articles
A1300C	Name by which resident prefers to be addressed	Step-by-Step Guide	Click here for all articles
A1300D	Lifetime occupation(s)	Step-by-Step Guide	Click here for all articles
A1500	Resident evaluated by PASRR	Step-by-Step Guide	Click here for all articles
A1510A	Level II PASRR conditions: Serious Mental Illness	Step-by-Step Guide	Click here for all articles
A1510B	Level II PASRR conditions: Intellectual Disability	Step-by-Step Guide	Click here for all articles
A1510C	Level II PASRR conditions: Other related conditions	Step-by-Step Guide	Click here for all articles
A1550A	ID/DD status: Down syndrome	Step-by-Step Guide	Click here for all articles
A1550B	ID/DD status: Autism	Step-by-Step Guide	Click here for all articles
A1550C	ID/DD status: Epilepsy	Step-by-Step Guide	Click here for all articles
A1550D	ID/DD status: other organic ID/DD condition	Step-by-Step Guide	Click here for all articles
A1550E	ID/DD status: ID/DD with no organic condition	Step-by-Step Guide	Click here for all articles
A1550Z	ID/DD status: none of the above	Step-by-Step Guide	Click here for all articles
A1600	Entry date (date of admission/reentry in facility)	Step-by-Step Guide	Click here for all articles
A1700	Type of entry	Step-by-Step Guide	Click here for all articles
A1805	Entered From	Step-by-Step Guide	Click here for all articles
A1900	Admission date	Step-by-Step Guide	Click here for all articles
A2000	Discharge date	Step-by-Step Guide	Click here for all articles
A2105	Discharge Status	Step-by-Step Guide	Click here for all articles
A2121	Provision of Current Reconciled Medication List (To Provider)	Step-by-Step Guide	Click here for all articles
A2122A	Route of Current Reconciled Medication List Transmission: EHR to provider	Step-by-Step Guide	Click here for all articles
A2122B	Route of Current Reconciled Medication List Transmission: HIEO to provider	Step-by-Step Guide	Click here for all articles
A2122C	Route of Current Reconciled Medication List Transmission: Verbal to provider	Step-by-Step Guide	Click here for all articles
A2122D	Route of Current Reconciled Medication List Transmission: Paper-based to provider	Step-by-Step Guide	Click here for all articles
A2122E	Route of Current Reconciled Medication List Transmission: Other Methods to provider	Step-by-Step Guide	Click here for all articles
A2123	Provision of Current Reconciled Medication List (To Resident)	Step-by-Step Guide	Click here for all articles
A2124A	Route of Current Reconciled Medication List Transmission: EHR to res/fam/caregiver	Step-by-Step Guide	Click here for all articles
A2124B	Route of Current Reconciled Medication List Transmission: HIEO to res/fam/caregiver	Step-by-Step Guide	Click here for all articles
A2124C	Route of Current Reconciled Medication List Transmission: Verbal to res/fam/caregiver	Step-by-Step Guide	Click here for all articles
A2124D	Route of Current Reconciled Medication List Transmission: Paper-based to res/fam/caregiver	Step-by-Step Guide	Click here for all articles
A2124E	Route of Current Reconciled Medication List Transmission: Other Methods to res/fam/caregiver	Step-by-Step Guide	Click here for all articles
A2200	Previous assessment reference date for significant correction	Step-by-Step Guide	Click here for all articles
A2300	Assessment reference date	Step-by-Step Guide	Click here for all articles
A2400A	Has resident had Medicare-covered stay	Step-by-Step Guide	Click here for all articles
A2400B	Start date of most recent Medicare stay	Step-by-Step Guide	Click here for all articles
A2400C	End date of most recent Medicare stay	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
C0100	BIMS: should resident interview be conducted	Step-by-Step Guide	Click here for all articles
C0200	BIMS res interview: repetition of three words	Step-by-Step Guide	Click here for all articles
C0300A	BIMS res interview: able to report correct year	Step-by-Step Guide	Click here for all articles
C0300B	BIMS res interview: able to report correct month	Step-by-Step Guide	Click here for all articles
C0300C	BIMS res interview: able report correct day of week	Step-by-Step Guide	Click here for all articles
C0400A	BIMS res interview: able to recall "sock"	Step-by-Step Guide	Click here for all articles
C0400B	BIMS res interview: able to recall "blue"	Step-by-Step Guide	Click here for all articles
C0400C	BIMS res interview: able to recall "bed"	Step-by-Step Guide	Click here for all articles
C0500	BIMS res interview: summary score	Step-by-Step Guide	Click here for all articles
C0600	Staff assessment mental status: conduct assessment	Step-by-Step Guide	Click here for all articles
C0700	Staff assessment mental status: short-term memory OK	Step-by-Step Guide	Click here for all articles
C0800	Staff assessment mental status: long-term memory OK	Step-by-Step Guide	Click here for all articles
C0900A	Staff assessment mental status: recall current season	Step-by-Step Guide	Click here for all articles
C0900B	Staff assessment mental status: recall location of room	Step-by-Step Guide	Click here for all articles
C0900C	Staff assessment mental status: recall staff names/faces	Step-by-Step Guide	Click here for all articles
C0900D	Staff assessment mental status: recall in nursing home	Step-by-Step Guide	Click here for all articles
C0900Z	Staff assessment mental status: none of above recalled	Step-by-Step Guide	Click here for all articles
C1000	Cognitive skills for daily decision making	Step-by-Step Guide	Click here for all articles
C1310A	Acute Onset Mental Status Change	Step-by-Step Guide	Click here for all articles
C1310B	Signs of delirium: inattention	Step-by-Step Guide	Click here for all articles
C1310C	Signs of delirium: disorganized thinking	Step-by-Step Guide	Click here for all articles
C1310D	Signs of delirium: altered level of consciousness	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
D0100	PHQ: should resident mood interview be conducted	Step-by-Step Guide	Click here for all articles
D0150A1	PHQ res: little interest or pleasure - presence	Step-by-Step Guide	Click here for all articles
D0150A2	PHQ res: little interest or pleasure - frequency	Step-by-Step Guide	Click here for all articles
D0150B1	PHQ res: feeling down, depressed - presence	Step-by-Step Guide	Click here for all articles
D0150B2	PHQ res: feeling down, depressed - frequency	Step-by-Step Guide	Click here for all articles
D0150C1	PHQ res: trouble with sleep - presence	Step-by-Step Guide	Click here for all articles
D0150C2	PHQ res: trouble with sleep - frequency	Step-by-Step Guide	Click here for all articles
D0150D1	PHQ res: feeling tired/little energy - presence	Step-by-Step Guide	Click here for all articles
D0150D2	PHQ res: feeling tired/little energy - frequency	Step-by-Step Guide	Click here for all articles
D0150E1	PHQ res: poor appetite or overeating - presence	Step-by-Step Guide	Click here for all articles
D0150E2	PHQ res: poor appetite or overeating - frequency	Step-by-Step Guide	Click here for all articles
D0150F1	PHQ res: feeling bad about self - presence	Step-by-Step Guide	Click here for all articles
D0150F2	PHQ res: feeling bad about self - frequency	Step-by-Step Guide	Click here for all articles
D0150G1	PHQ res: trouble concentrating - presence	Step-by-Step Guide	Click here for all articles
D0150G2	PHQ res: trouble concentrating - frequency	Step-by-Step Guide	Click here for all articles
D0150H1	PHQ res: slow, fidgety, restless - presence	Step-by-Step Guide	Click here for all articles
D0150H2	PHQ res: slow, fidgety, restless - frequency	Step-by-Step Guide	Click here for all articles
D0150I1	PHQ res: thoughts better off dead - presence	Step-by-Step Guide	Click here for all articles
D0150I2	PHQ res: thoughts better off dead - frequency	Step-by-Step Guide	Click here for all articles
D0160	PHQ res: total mood severity score	Step-by-Step Guide	Click here for all articles
D0500A1	PHQ staff: little interest or pleasure - presence	Step-by-Step Guide	Click here for all articles
D0500A2	PHQ staff: little interest or pleasure - frequency	Step-by-Step Guide	Click here for all articles
D0500B1	PHQ staff: feeling down, depressed - presence	Step-by-Step Guide	Click here for all articles
D0500B2	PHQ staff: feeling down, depressed - frequency	Step-by-Step Guide	Click here for all articles
D0500C1	PHQ staff: trouble with sleep - presence	Step-by-Step Guide	Click here for all articles
D0500C2	PHQ staff: trouble with sleep - frequency	Step-by-Step Guide	Click here for all articles
D0500D1	PHQ staff: feeling tired/little energy - presence	Step-by-Step Guide	Click here for all articles
D0500D2	PHQ staff: feeling tired/little energy - frequency	Step-by-Step Guide	Click here for all articles
D0500E1	PHQ staff: poor appetite or overeating - presence	Step-by-Step Guide	Click here for all articles
D0500E2	PHQ staff: poor appetite or overeating - frequency	Step-by-Step Guide	Click here for all articles
D0500F1	PHQ staff: feeling bad about self - presence	Step-by-Step Guide	Click here for all articles
D0500F2	PHQ staff: feeling bad about self - frequency	Step-by-Step Guide	Click here for all articles
D0500G1	PHQ staff: trouble concentrating - presence	Step-by-Step Guide	Click here for all articles
D0500G2	PHQ staff: trouble concentrating -	Step-by-Step Guide	Click here for all articles
D0500H1	PHQ staff: slow, fidgety, restless - presence	Step-by-Step Guide	Click here for all articles
D0500H2	PHQ staff: slow, fidgety, restless - frequency	Step-by-Step Guide	Click here for all articles
D0500I1	PHQ staff: thoughts better off dead - presence	Step-by-Step Guide	Click here for all articles
D0500I2	PHQ staff: thoughts better off dead - frequency	Step-by-Step Guide	Click here for all articles
D0500J1	PHQ staff: short-tempered - presence	Step-by-Step Guide	Click here for all articles
D0500J2	PHQ staff: short-tempered - frequency	Step-by-Step Guide	Click here for all articles
D0600	PHQ staff: total mood severity score	Step-by-Step Guide	Click here for all articles
D0700	Social Isolation	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
E0100A	Psychosis: hallucinations	Step-by-Step Guide	Click here for all articles
E0100B	Psychosis: delusions	Step-by-Step Guide	Click here for all articles
E0100Z	Psychosis: none of the above	Step-by-Step Guide	Click here for all articles
E0200A	Physical behavioral symptoms directed toward others	Step-by-Step Guide	Click here for all articles
E0200B	Verbal behavioral symptoms directed toward others	Step-by-Step Guide	Click here for all articles
E0200C	Other behavioral symptoms not directed toward others	Step-by-Step Guide	Click here for all articles
E0300	Overall presence of behavioral symptoms	Step-by-Step Guide	Click here for all articles
E0500A	Behavioral symptoms put res at risk for illness/injury	Step-by-Step Guide	Click here for all articles
E0500B	Behavioral symptoms interfere with resident care	Step-by-Step Guide	Click here for all articles
E0500C	Behavioral symptoms interfere with social activities	Step-by-Step Guide	Click here for all articles
E0600A	Behavioral symptoms put others at risk for injury	Step-by-Step Guide	Click here for all articles
E0600B	Behavioral symptoms intrude on privacy of others	Step-by-Step Guide	Click here for all articles
E0600C	Behavioral symptoms disrupt care or living environment	Step-by-Step Guide	Click here for all articles
E0800	Rejection of care: presence and frequency	Step-by-Step Guide	Click here for all articles
E0900	Wandering: presence and frequency	Step-by-Step Guide	Click here for all articles
E1000A	Wandering: risk of getting to dangerous place	Step-by-Step Guide	Click here for all articles
E1000B	Wandering: intrude on privacy of others	Step-by-Step Guide	Click here for all articles
E1100	Change in behavior or other symptoms	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
F0300	Conduct res interview for daily/activity preferences	Step-by-Step Guide	Click here for all articles
F0400A	Res interview: choose clothes to wear	Step-by-Step Guide	Click here for all articles
F0400B	Res interview: take care of personal belongings	Step-by-Step Guide	Click here for all articles
F0400C	Res interview: choose tub, bath, shower, sponge	Step-by-Step Guide	Click here for all articles
F0400D	Res interview: have snacks between meals	Step-by-Step Guide	Click here for all articles
F0400E	Res interview: choose own bedtime	Step-by-Step Guide	Click here for all articles
F0400F	Res interview: discuss care with family/friend	Step-by-Step Guide	Click here for all articles
F0400G	Res interview: use phone in private	Step-by-Step Guide	Click here for all articles
F0400H	Res interview: lock things to keep them safe	Step-by-Step Guide	Click here for all articles
F0500A	Res interview: have books, newspaper, mags to read	Step-by-Step Guide	Click here for all articles
F0500B	Res interview: listen to music	Step-by-Step Guide	Click here for all articles
F0500C	Res interview: be around animals/pets	Step-by-Step Guide	Click here for all articles
F0500D	Res interview: keep up with news	Step-by-Step Guide	Click here for all articles
F0500E	Res interview: do things with groups of people	Step-by-Step Guide	Click here for all articles
F0500F	Res interview: do favorite activities	Step-by-Step Guide	Click here for all articles
F0500G	Res interview: go outside when good weather	Step-by-Step Guide	Click here for all articles
F0500H	Res interview: participate in religious practices	Step-by-Step Guide	Click here for all articles
F0600	Primary respondent: daily/activities prefs	Step-by-Step Guide	Click here for all articles
F0700	Conduct staff assessment for daily/activity prefs	Step-by-Step Guide	Click here for all articles
F0800A	Staff assessment: choosing clothes to wear	Step-by-Step Guide	Click here for all articles
F0800B	Staff assessment: caring for personal belongings	Step-by-Step Guide	Click here for all articles
F0800C	Staff assessment: receiving tub bath	Step-by-Step Guide	Click here for all articles
F0800D	Staff assessment: receiving shower	Step-by-Step Guide	Click here for all articles
F0800E	Staff assessment: receiving bed bath	Step-by-Step Guide	Click here for all articles
F0800F	Staff assessment: receiving sponge bath	Step-by-Step Guide	Click here for all articles
F0800G	Staff assessment: snacks between meals	Step-by-Step Guide	Click here for all articles
F0800H	Staff assessment: staying up past 8PM	Step-by-Step Guide	Click here for all articles
F0800I	Staff assessment: discuss care with family/other	Step-by-Step Guide	Click here for all articles
F0800J	Staff assessment: use phone in private	Step-by-Step Guide	Click here for all articles
F0800K	Staff assessment: place to lock personal things	Step-by-Step Guide	Click here for all articles
F0800L	Staff assessment: reading books, newspapers, mags	Step-by-Step Guide	Click here for all articles
F0800M	Staff assessment: listening to music	Step-by-Step Guide	Click here for all articles
F0800N	Staff assessment: being around animals/pets	Step-by-Step Guide	Click here for all articles
F0800O	Staff assessment: keeping up with news	Step-by-Step Guide	Click here for all articles
F0800P	Staff assessment: doing things with groups	Step-by-Step Guide	Click here for all articles
F0800Q	Staff assessment: participating in favorite activities	Step-by-Step Guide	Click here for all articles
F0800R	Staff assessment: spend time away from nursing home	Step-by-Step Guide	Click here for all articles
F0800S	Staff assessment: spend time outdoors	Step-by-Step Guide	Click here for all articles
F0800T	Staff assessment: participating in religious activities	Step-by-Step Guide	Click here for all articles
F0800Z	Staff assessment: none of above activities	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
GG0100A	Self-Care: Prior Function	Step-by-Step Guide	Click here for all articles
GG0100B	Indoor Mobility (Ambulation): Prior Function	Step-by-Step Guide	Click here for all articles
GG0100C	Stairs: Prior Function	Step-by-Step Guide	Click here for all articles
GG0100D	Functional Cognition: Prior Function	Step-by-Step Guide	Click here for all articles
GG0110A	Manual wheelchair	Step-by-Step Guide	Click here for all articles
GG0110B	Motorized wheelchair and/or scooter	Step-by-Step Guide	Click here for all articles
GG0110C	Mechanical lift	Step-by-Step Guide	Click here for all articles
GG0110D	Walker	Step-by-Step Guide	Click here for all articles
GG0110E	Orthotics/Prosthetics	Step-by-Step Guide	Click here for all articles
GG0110Z	None of the above	Step-by-Step Guide	Click here for all articles
GG0115A	ROM limitation: upper extremity	Step-by-Step Guide	Click here for all articles
GG0115B	ROM limitation: lower extremity	Step-by-Step Guide	Click here for all articles
GG0120A	Mobility devices: cane/crutch	Step-by-Step Guide	Click here for all articles
GG0120B	Mobility devices: walker	Step-by-Step Guide	Click here for all articles
GG0120C	Mobility devices: wheelchair (manual or electric)	Step-by-Step Guide	Click here for all articles
GG0120D	Mobility devices: limb prosthesis	Step-by-Step Guide	Click here for all articles
GG0120Z	Mobility devices: none of the above	Step-by-Step Guide	Click here for all articles
GG0130A1	Eating (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0130A3	Eating (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0130A5	Eating (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0130B1	Oral Hygiene (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0130B3	Oral Hygiene (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0130B5	Oral Hygiene (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0130C1	Toileting Hygiene (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0130C3	Toileting Hygiene (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0130C5	Toileting Hygiene (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0130E1	Shower/bathe self (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0130E3	Shower/bathe self (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0130E5	Shower/bathe self (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0130F1	Upper body dressing (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0130F3	Upper body dressing (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0130F5	Upper body dressing (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0130G1	Lower body dressing (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0130G3	Lower body dressing (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0130G5	Lower body dressing (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0130H1	Putting on/taking off footwear (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0130H3	Putting on/taking off footwear (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0130H5	Putting on/taking off footwear(OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0130I1	Personal Hygiene (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0130I3	Personal Hygiene (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0130I5	Personal Hygiene (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0170A1	Roll left and right (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170A3	Roll left and right (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170A5	Roll left and right (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0170B1	Sit to lying (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170B3	Sit to lying (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170B5	Sit to lying (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0170C1	Lying to sitting on bed side (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170C3	Lying to sitting on bed side (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170C5	Lying to sitting on bed side (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0170D1	Sit to stand (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170D3	Sit to stand (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170D5	Sit to stand (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0170E1	Chair/bed-to-chair transfer (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170E3	Chair/bed-to-chair transfer (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170E5	Chair/bed-to-chair transfer (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0170F1	Toilet transfer (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170F3	Toilet transfer (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170F5	Toilet transfer (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0170FF1	Tub/Shower Transfer (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170FF3	Tub/Shower Transfer (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170FF5	Tub/Shower Transfer (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0170G1	Car Transfer (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170G3	Car Transfer (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170I1	Walk 10 feet (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170I3	Walk 10 feet (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170I5	Walk 10 feet (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0170J1	Walk 50 feet with two turns (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170J3	Walk 50 feet with two turns (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170J5	Walk 50 feet with two turns (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0170K1	Walk 150 feet (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170K3	Walk 150 feet (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170K5	Walk 150 feet (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0170L1	Walking 10 feet on uneven surfaces (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170L3	Walking 10 feet on uneven surfaces (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170M1	1 step (curb) (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170M3	1 step (curb) (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170N1	4 steps (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170N3	4 steps (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170O1	12 steps (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170O3	12 steps (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170P1	Picking up object (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170P3	Picking up object (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170Q1	Use of wheelchair/scooter (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170Q3	Use of wheelchair/scooter (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170Q5	Use of wheelchair/scooter (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0170R1	Wheel 50 feet with two turns (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170R3	Wheel 50 feet with two turns (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170R5	Wheel 50 feet with two turns (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0170RR1	Type wheelchair/scooter used (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170RR3	Type wheelchair/scooter used (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170RR5	Type wheelchair/scooter used (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0170S1	Wheel 150 feet (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170S3	Wheel 150 feet (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170S5	Wheel 150 feet (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles
GG0170SS1	Type wheelchair/scooter used (Admission Performance)	Step-by-Step Guide	Click here for all articles
GG0170SS3	Type wheelchair/scooter used (Discharge Performance)	Step-by-Step Guide	Click here for all articles
GG0170SS5	Type wheelchair/scooter used (OBRA/Interim Performance)	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
H0100A	Appliances: indwelling catheter	Step-by-Step Guide	Click here for all articles
H0100B	Appliances: external catheter	Step-by-Step Guide	Click here for all articles
H0100C	Appliances: ostomy	Step-by-Step Guide	Click here for all articles
H0100D	Appliances: intermittent catheterization	Step-by-Step Guide	Click here for all articles
H0100Z	Appliances: none of the above	Step-by-Step Guide	Click here for all articles
H0200A	Urinary toileting program: has been attempted	Step-by-Step Guide	Click here for all articles
H0200B	Urinary toileting program: response	Step-by-Step Guide	Click here for all articles
H0200C	Urinary toileting program: current program/trial	Step-by-Step Guide	Click here for all articles
H0300	Urinary continence	Step-by-Step Guide	Click here for all articles
H0400	Bowel continence	Step-by-Step Guide	Click here for all articles
H0500	Bowel toileting program being used	Step-by-Step Guide	Click here for all articles
H0600	Constipation	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
I0020	Indicate the resident’s primary medical condition category	Step-by-Step Guide	Click here for all articles
I0020B	ICD Code 1 - 13	Step-by-Step Guide	Click here for all articles
I0100	Cancer (with or without metastasis)	Step-by-Step Guide	Click here for all articles
I0200	Anemia	Step-by-Step Guide	Click here for all articles
I0300	Atrial fibrillation and other dysrhythmias	Step-by-Step Guide	Click here for all articles
I0400	Coronary artery disease (CAD)	Step-by-Step Guide	Click here for all articles
I0500	Deep venous thrombosis (DVT), PE, or PTE	Step-by-Step Guide	Click here for all articles
I0600	Heart failure	Step-by-Step Guide	Click here for all articles
I0700	Hypertension	Step-by-Step Guide	Click here for all articles
I0800	Orthostatic hypotension	Step-by-Step Guide	Click here for all articles
I0900	Peripheral vascular disease (PVD) or PAD	Step-by-Step Guide	Click here for all articles
I1100	Cirrhosis	Step-by-Step Guide	Click here for all articles
I1200	Gastroesophageal reflux disease (GERD) or ulcer	Step-by-Step Guide	Click here for all articles
I1300	Ulcerative colitis, Crohn's, inflammatory bowel disease	Step-by-Step Guide	Click here for all articles
I1400	Benign prostatic hyperplasia (BPH)	Step-by-Step Guide	Click here for all articles
I1500	Renal insufficiency, renal failure, ESRD	Step-by-Step Guide	Click here for all articles
I1550	Neurogenic bladder	Step-by-Step Guide	Click here for all articles
I1650	Obstructive uropathy	Step-by-Step Guide	Click here for all articles
I1700	Multidrug-resistant organism (MDRO)	Step-by-Step Guide	Click here for all articles
I2000	Pneumonia	Step-by-Step Guide	Click here for all articles
I2100	Septicemia	Step-by-Step Guide	Click here for all articles
I2200	Tuberculosis	Step-by-Step Guide	Click here for all articles
I2300	Urinary tract infection (UTI) (LAST 30 DAYS)	Step-by-Step Guide	Click here for all articles
I2400	Viral hepatitis (includes type A, B, C, D, and E)	Step-by-Step Guide	Click here for all articles
I2500	Wound infection (other than foot)	Step-by-Step Guide	Click here for all articles
I2900	Diabetes mellitus (DM)	Step-by-Step Guide	Click here for all articles
I3100	Hyponatremia	Step-by-Step Guide	Click here for all articles
I3200	Hyperkalemia	Step-by-Step Guide	Click here for all articles
I3300	Hyperlipidemia (e.g., hypercholesterolemia)	Step-by-Step Guide	Click here for all articles
I3400	Thyroid disorder	Step-by-Step Guide	Click here for all articles
I3700	Arthritis	Step-by-Step Guide	Click here for all articles
I3800	Osteoporosis	Step-by-Step Guide	Click here for all articles
I3900	Hip fracture	Step-by-Step Guide	Click here for all articles
I4000	Other fracture	Step-by-Step Guide	Click here for all articles
I4200	Alzheimer's disease	Step-by-Step Guide	Click here for all articles
I4300	Aphasia	Step-by-Step Guide	Click here for all articles
I4400	Cerebral palsy	Step-by-Step Guide	Click here for all articles
I4500	Cerebrovascular accident (CVA), TIA, or stroke	Step-by-Step Guide	Click here for all articles
I4800	Non-Alzheimer's Dementia	Step-by-Step Guide	Click here for all articles
I4900	Hemiplegia or hemiparesis	Step-by-Step Guide	Click here for all articles
I5000	Paraplegia	Step-by-Step Guide	Click here for all articles
I5100	Quadriplegia	Step-by-Step Guide	Click here for all articles
I5200	Multiple sclerosis	Step-by-Step Guide	Click here for all articles
I5250	Huntington's disease	Step-by-Step Guide	Click here for all articles
I5300	Parkinson's disease	Step-by-Step Guide	Click here for all articles
I5350	Tourette's syndrome	Step-by-Step Guide	Click here for all articles
I5400	Seizure disorder or epilepsy	Step-by-Step Guide	Click here for all articles
I5500	Traumatic brain injury (TBI)	Step-by-Step Guide	Click here for all articles
I5600	Malnutrition (protein, calorie), risk of malnutrition	Step-by-Step Guide	Click here for all articles
I5700	Anxiety disorder	Step-by-Step Guide	Click here for all articles
I5800	Depression (other than bipolar)	Step-by-Step Guide	Click here for all articles
I5900	Bipolar Disorder	Step-by-Step Guide	Click here for all articles
I5950	Psychotic disorder (other than schizophrenia)	Step-by-Step Guide	Click here for all articles
I6000	Schizophrenia	Step-by-Step Guide	Click here for all articles
I6100	Post-traumatic stress disorder (PTSD)	Step-by-Step Guide	Click here for all articles
I6200	Asthma, COPD, or chronic lung disease	Step-by-Step Guide	Click here for all articles
I6300	Respiratory failure	Step-by-Step Guide	Click here for all articles
I6500	Cataracts, glaucoma, or macular degeneration	Step-by-Step Guide	Click here for all articles
I7900	None of above active diagnoses within last 7 days	Step-by-Step Guide	Click here for all articles
I8000A	Additional active ICD diagnosis 1	Step-by-Step Guide	Click here for all articles
I8000B	Additional active ICD diagnosis 2	Step-by-Step Guide	Click here for all articles
I8000C	Additional active ICD diagnosis 3	Step-by-Step Guide	Click here for all articles
I8000D	Additional active ICD diagnosis 4	Step-by-Step Guide	Click here for all articles
I8000E	Additional active ICD diagnosis 5	Step-by-Step Guide	Click here for all articles
I8000F	Additional active ICD diagnosis 6	Step-by-Step Guide	Click here for all articles
I8000G	Additional active ICD diagnosis 7	Step-by-Step Guide	Click here for all articles
I8000I	Additional active ICD diagnosis 9	Step-by-Step Guide	Click here for all articles
I8000J	Additional active ICD diagnosis 10	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
J0100A	Pain: received scheduled pain med regimen	Step-by-Step Guide	Click here for all articles
J0100B	Pain: received PRN pain medications	Step-by-Step Guide	Click here for all articles
J0100C	Pain: received non-medication intervention	Step-by-Step Guide	Click here for all articles
J0200	Should pain assessment interview be conducted	Step-by-Step Guide	Click here for all articles
J0300	Res pain interview: presence	Step-by-Step Guide	Click here for all articles
J0410	Res pain interview: frequency	Step-by-Step Guide	Click here for all articles
J0510	Pain Effect on Sleep	Step-by-Step Guide	Click here for all articles
J0520	Pain Interference with Therapy Activities	Step-by-Step Guide	Click here for all articles
J0530	Pain Interference with Day-to-Day Activities	Step-by-Step Guide	Click here for all articles
J0600A	Res pain interview: intensity rating scale	Step-by-Step Guide	Click here for all articles
J0600B	Res pain interview: verbal descriptor scale	Step-by-Step Guide	Click here for all articles
J0700	Should staff assessment for pain be conducted	Step-by-Step Guide	Click here for all articles
J0800A	Staff pain assessment: non-verbal sounds	Step-by-Step Guide	Click here for all articles
J0800B	Staff pain assessment: vocal complaints of pain	Step-by-Step Guide	Click here for all articles
J0800C	Staff pain assessment: facial expressions	Step-by-Step Guide	Click here for all articles
J0800D	Staff pain assessment: protective movements/postures	Step-by-Step Guide	Click here for all articles
J0800Z	Staff pain assessment: none of these signs observed	Step-by-Step Guide	Click here for all articles
J0850	Staff pain assessment: frequency of pain	Step-by-Step Guide	Click here for all articles
J1100A	Short breath/trouble breathing: with	Step-by-Step Guide	Click here for all articles
J1100B	Short breath/trouble breathing: sitting at rest	Step-by-Step Guide	Click here for all articles
J1100C	Short breath/trouble breathing: lying flat	Step-by-Step Guide	Click here for all articles
J1100Z	Short breath/trouble breathing: none of above	Step-by-Step Guide	Click here for all articles
J1300	Current tobacco use	Step-by-Step Guide	Click here for all articles
J1400	Prognosis: life expectancy of less than 6 months	Step-by-Step Guide	Click here for all articles
J1550A	Problem conditions: fever	Step-by-Step Guide	Click here for all articles
J1550B	Problem conditions: vomiting	Step-by-Step Guide	Click here for all articles
J1550C	Problem conditions: dehydrated	Step-by-Step Guide	Click here for all articles
J1550D	Problem conditions: internal bleeding	Step-by-Step Guide	Click here for all articles
J1550Z	Problem conditions: none of the above	Step-by-Step Guide	Click here for all articles
J1700A	Fall history: fall during month before admission	Step-by-Step Guide	Click here for all articles
J1700B	Fall history: fall 2-6 months before admission	Step-by-Step Guide	Click here for all articles
J1700C	Fall history: fracture from fall 6 month pre admit	Step-by-Step Guide	Click here for all articles
J1800	Falls since admit/prior assessment: any falls	Step-by-Step Guide	Click here for all articles
J1900A	Falls since admit/prior assessment: no injury	Step-by-Step Guide	Click here for all articles
J1900B	Falls since admit/prior assessment: injury (not major)	Step-by-Step Guide	Click here for all articles
J1900C	Falls since admit/prior assessment: major injury	Step-by-Step Guide	Click here for all articles
J2000	Prior Surgery	Step-by-Step Guide	Click here for all articles
J2100	Recent Surgery Requiring Active SNF Care	Step-by-Step Guide	Click here for all articles
J2300	Knee Replacement - partial or total	Step-by-Step Guide	Click here for all articles
J2310	Hip Replacement - partial or total	Step-by-Step Guide	Click here for all articles
J2320	Ankle Replacement - partial or total	Step-by-Step Guide	Click here for all articles
J2330	Shoulder Replacement - partial or total	Step-by-Step Guide	Click here for all articles
J2400	Spinal surgery - spinal cord or major spinal nerves	Step-by-Step Guide	Click here for all articles
J2410	Spinal surgery - fusion of spinal bones	Step-by-Step Guide	Click here for all articles
J2420	Spinal surgery - lamina, discs, or facets	Step-by-Step Guide	Click here for all articles
J2499	Spinal surgery - other	Step-by-Step Guide	Click here for all articles
J2500	Ortho surgery - repair fractures of shoulder or arm	Step-by-Step Guide	Click here for all articles
J2510	Ortho surgery - repair fractures of pelvis, hip, leg, knee, or ankle	Step-by-Step Guide	Click here for all articles
J2520	Ortho surgery - repair but not replace joints	Step-by-Step Guide	Click here for all articles
J2530	Ortho surgery - repair other bones	Step-by-Step Guide	Click here for all articles
J2599	Ortho surgery - other	Step-by-Step Guide	Click here for all articles
J2600	Neuro surgery - brain, surrounding tissue or blood vessels	Step-by-Step Guide	Click here for all articles
J2610	Neuro surgery - peripheral and autonomic nervous system - open and percutaneous	Step-by-Step Guide	Click here for all articles
J2620	Neuro surgery - insertion or removal of spinal and brain neurostimulators, electrodes, catheters, and CSF drainage devices	Step-by-Step Guide	Click here for all articles
J2699	Neuro surgery - Other	Step-by-Step Guide	Click here for all articles
J2700	Cardiopulmonary surgery - heart or major blood vessels - open and percutaneous procedures	Step-by-Step Guide	Click here for all articles
J2710	Cardiopulmonary surgery - respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords – open and endoscopic	Step-by-Step Guide	Click here for all articles
J2799	Cardiopulmonary surgery - Other	Step-by-Step Guide	Click here for all articles
J2800	Genitourinary surgery - genital systems	Step-by-Step Guide	Click here for all articles
J2810	Genitourinary surgery - the kidneys, ureter, adrenals, and bladder—open, laparoscopic	Step-by-Step Guide	Click here for all articles
J2899	Other major genitourinary surgery	Step-by-Step Guide	Click here for all articles
J2900	Major surgery - tendons, ligament, or muscles	Step-by-Step Guide	Click here for all articles
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	Step-by-Step Guide	Click here for all articles
J2920	Major surgery - endocrine organs (such as thyroid, parathyroid), neck, lymph nodes, and thymus—open	Step-by-Step Guide	Click here for all articles
J2930	Major surgery - the breast	Step-by-Step Guide	Click here for all articles
J2940	Major surgery - repair of deep ulcers, internal brachytherapy, bone marrow, or stem cell harvest or transplant	Step-by-Step Guide	Click here for all articles
J5000	Major surgery - Other surgery not listed above	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
K0100A	Swallow disorder: loss liquids/solids from mouth	Step-by-Step Guide	Click here for all articles
K0100B	Swallow disorder: holds food in mouth/cheeks	Step-by-Step Guide	Click here for all articles
K0100C	Swallow disorder: cough/choke with meals/meds	Step-by-Step Guide	Click here for all articles
K0100D	Swallow disorder: difficulty or pain swallowing	Step-by-Step Guide	Click here for all articles
K0100Z	Swallow disorder: none of the above	Step-by-Step Guide	Click here for all articles
K0200A	Height (in inches)	Step-by-Step Guide	Click here for all articles
K0200B	Weight (in pounds)	Step-by-Step Guide	Click here for all articles
K0300	Weight loss	Step-by-Step Guide	Click here for all articles
K0310	Weight gain	Step-by-Step Guide	Click here for all articles
K0520A1	Nutritional approaches: Parenteral/IV Feeding - Adm	Step-by-Step Guide	Click here for all articles
K0520A2	Nutritional approaches: Parenteral/IV Feeding - Not a Res	Step-by-Step Guide	Click here for all articles
K0520A3	Nutritional approaches: Parenteral/IV Feeding - While a Res	Step-by-Step Guide	Click here for all articles
K0520A4	Nutritional approaches: Parenteral/IV Feeding - At Discharge	Step-by-Step Guide	Click here for all articles
K0520B1	Nutritional approaches: Feeding Tube - Adm	Step-by-Step Guide	Click here for all articles
K0520B2	Nutritional approaches: Feeding Tube - Not a Res	Step-by-Step Guide	Click here for all articles
K0520B3	Nutritional approaches: Feeding Tube - While a Res	Step-by-Step Guide	Click here for all articles
K0520B4	Nutritional approaches: Feeding Tube - At Discharge	Step-by-Step Guide	Click here for all articles
K0520C1	Nutritional approaches: Mechanically Altered Diet - Adm	Step-by-Step Guide	Click here for all articles
K0520C3	Nutritional approaches: Mechanically Altered Diet - While a Res	Step-by-Step Guide	Click here for all articles
K0520C4	Nutritional approaches: Mechanically Altered Diet - At Discharge	Step-by-Step Guide	Click here for all articles
K0520D1	Nutritional approaches: Therapeutic Diet - Adm	Step-by-Step Guide	Click here for all articles
K0520D3	Nutritional approaches: Therapeutic Diet - While a Res	Step-by-Step Guide	Click here for all articles
K0520D4	Nutritional approaches: Therapeutic Diet - At Discharge	Step-by-Step Guide	Click here for all articles
K0520Z1	Nutritional approaches: None of the above - Adm	Step-by-Step Guide	Click here for all articles
K0520Z2	Nutritional approaches: None of the above - Not a Res	Step-by-Step Guide	Click here for all articles
K0520Z3	Nutritional approaches: None of the above - While a Res	Step-by-Step Guide	Click here for all articles
K0520Z4	Nutritional approaches: None of the above - At Discharge	Step-by-Step Guide	Click here for all articles
K0710A2	Prop calories parenteral/tube feed: while a resident	Step-by-Step Guide	Click here for all articles
K0710A3	Prop calories parenteral/tube feed: 7 days	Step-by-Step Guide	Click here for all articles
K0710B2	Avg fluid intake per day IV/ tube: while a resident	Step-by-Step Guide	Click here for all articles
K0710B3	Avg fluid intake per day IV/tube: 7 days	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
L0200A	Dental: broken or loosely fitting denture	Step-by-Step Guide	Click here for all articles
L0200B	Dental: no natural teeth or tooth	Step-by-Step Guide	Click here for all articles
L0200C	Dental: abnormal mouth tissue	Step-by-Step Guide	Click here for all articles
L0200D	Dental: cavity or broken natural teeth	Step-by-Step Guide	Click here for all articles
L0200E	Dental: inflamed/bleeding gums or loose teeth	Step-by-Step Guide	Click here for all articles
L0200F	Dental: pain, discomfort, difficulty chewing	Step-by-Step Guide	Click here for all articles
L0200G	Dental: unable to examine	Step-by-Step Guide	Click here for all articles
L0200Z	Dental: none of the above	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
M0100A	Risk determination: has ulcer, scar, or dressing	Step-by-Step Guide	Click here for all articles
M0100B	Risk determination: formal assessment	Step-by-Step Guide	Click here for all articles
M0100C	Risk determination: clinical assessment	Step-by-Step Guide	Click here for all articles
M0100Z	Risk determination: none of the above	Step-by-Step Guide	Click here for all articles
M0150	Is resident at risk of developing pressure ulcer	Step-by-Step Guide	Click here for all articles
M0210	Resident has Stage 1 or higher pressure ulcers	Step-by-Step Guide	Click here for all articles
M0300A1	Stage 1 pressure ulcers: number present	Step-by-Step Guide	Click here for all articles
M0300B1	Stage 2 pressure ulcers: number present	Step-by-Step Guide	Click here for all articles
M0300B2	Stage 2 pressure ulcers: number at admit/reentry	Step-by-Step Guide	Click here for all articles
M0300C1	Stage 3 pressure ulcers: number present	Step-by-Step Guide	Click here for all articles
M0300C2	Stage 3 pressure ulcers: number at admit/reentry	Step-by-Step Guide	Click here for all articles
M0300D1	Stage 4 pressure ulcers: number present	Step-by-Step Guide	Click here for all articles
M0300D2	Stage 4 pressure ulcers: number at admit/reentry	Step-by-Step Guide	Click here for all articles
M0300E1	Unstaged due to dressing: number present	Step-by-Step Guide	Click here for all articles
M0300E2	Unstaged due to dressing: number at admit/reentry	Step-by-Step Guide	Click here for all articles
M0300F1	Unstaged slough/eschar: number present	Step-by-Step Guide	Click here for all articles
M0300F2	Unstaged slough/eschar: number at admit/reentry	Step-by-Step Guide	Click here for all articles
M0300G1	Unstageable - deep tissue: number present	Step-by-Step Guide	Click here for all articles
M0300G2	Unstageable - deep tissue: number at admit/reentry	Step-by-Step Guide	Click here for all articles
M1030	Number of venous and arterial ulcers	Step-by-Step Guide	Click here for all articles
M1040A	Other skin problems: infection of the foot	Step-by-Step Guide	Click here for all articles
M1040B	Other skin problems: diabetic foot ulcer(s)	Step-by-Step Guide	Click here for all articles
M1040C	Other skin problems: other open lesion(s) on the foot	Step-by-Step Guide	Click here for all articles
M1040D	Other skin problems: lesions not ulcers, rashes, cuts	Step-by-Step Guide	Click here for all articles
M1040E	Other skin problems: surgical wound(s)	Step-by-Step Guide	Click here for all articles
M1040F	Other skin problems: burns (second or third degree)	Step-by-Step Guide	Click here for all articles
M1040G	Skin tear(s)	Step-by-Step Guide	Click here for all articles
M1040H	Moisture Associated Skin Damage (MASD)	Step-by-Step Guide	Click here for all articles
M1040Z	Other skin problems: none of the above	Step-by-Step Guide	Click here for all articles
M1200A	Skin/ulcer treatments: pressure reducing device for chair	Step-by-Step Guide	Click here for all articles
M1200B	Skin/ulcer treatments: pressure reducing device for bed	Step-by-Step Guide	Click here for all articles
M1200C	Skin/ulcer treatments: turning/repositioning	Step-by-Step Guide	Click here for all articles
M1200D	Skin/ulcer treatments: nutrition/hydration	Step-by-Step Guide	Click here for all articles
M1200E	Skin/ulcer treatments: pressure ulcer/injury care	Step-by-Step Guide	Click here for all articles
M1200F	Skin/ulcer treatments: surgical wound care	Step-by-Step Guide	Click here for all articles
M1200G	Skin/ulcer treatments: application of dressings	Step-by-Step Guide	Click here for all articles
M1200H	Skin/ulcer treatments: apply ointments/medications	Step-by-Step Guide	Click here for all articles
M1200I	Skin/ulcer treatments: apply dressings to feet	Step-by-Step Guide	Click here for all articles
M1200Z	Skin/ulcer treatments: none of the above	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
N0300	Number of days injectable medications received	Step-by-Step Guide	Click here for all articles
N0350A	Insulin: insulin injections	Step-by-Step Guide	Click here for all articles
N0350B	Insulin: orders for insulin	Step-by-Step Guide	Click here for all articles
N0415A1	High-Risk Drug Classes: Antipsychotic: Has received	Step-by-Step Guide	Click here for all articles
N0415A2	High-Risk Drug Classes: Antipsychotic: Indication noted	Step-by-Step Guide	Click here for all articles
N0415B1	High-Risk Drug Classes: Antianxiety: Has received	Step-by-Step Guide	Click here for all articles
N0415B2	High-Risk Drug Classes: Antianxiety: Indication noted	Step-by-Step Guide	Click here for all articles
N0415C1	High-Risk Drug Classes: Antidepressant: Has received	Step-by-Step Guide	Click here for all articles
N0415C2	High-Risk Drug Classes: Antidepressant: Indication noted	Step-by-Step Guide	Click here for all articles
N0415D1	High-Risk Drug Classes: Hypnotic: Has received	Step-by-Step Guide	Click here for all articles
N0415D2	High-Risk Drug Classes: Hypnotic: Indication noted	Step-by-Step Guide	Click here for all articles
N0415E1	High-Risk Drug Classes: Anticoagulant: Has received	Step-by-Step Guide	Click here for all articles
N0415E2	High-Risk Drug Classes: Anticoagulant: Indication noted	Step-by-Step Guide	Click here for all articles
N0415F1	High-Risk Drug Classes: Antibiotic: Has received	Step-by-Step Guide	Click here for all articles
N0415F2	High-Risk Drug Classes: Antibiotic: Indication noted	Step-by-Step Guide	Click here for all articles
N0415G1	High-Risk Drug Classes: Diuretic: Has received	Step-by-Step Guide	Click here for all articles
N0415G2	High-Risk Drug Classes: Diuretic: Indication noted	Step-by-Step Guide	Click here for all articles
N0415H1	High-Risk Drug Classes: Opioid: Has received	Step-by-Step Guide	Click here for all articles
N0415H2	High-Risk Drug Classes: Opioid: Indication noted	Step-by-Step Guide	Click here for all articles
N0415I1	High-Risk Drug Classes: Antiplatelet: Has received	Step-by-Step Guide	Click here for all articles
N0415I2	High-Risk Drug Classes: Antiplatelet: Indication noted	Step-by-Step Guide	Click here for all articles
N0415J1	High-Risk Drug Classes: Hypoglycemic: Has received	Step-by-Step Guide	Click here for all articles
N0415J2	High-Risk Drug Classes: Hypoglycemic: Indication noted	Step-by-Step Guide	Click here for all articles
N0415K1	High-Risk Drug Classes: Anti-convulsants: Has received	Step-by-Step Guide	Click here for all articles
N0415K2	High-Risk Drug Classes: Anti-convulsants: Indication noted	Step-by-Step Guide	Click here for all articles
N0415Z1	High-Risk Drug Classes: None of Above: Has Received	Step-by-Step Guide	Click here for all articles
N0450A	Resident received antipsychotic medications	Step-by-Step Guide	Click here for all articles
N0450B	GDR attempted	Step-by-Step Guide	Click here for all articles
N0450C	Date of last attempted GDR	Step-by-Step Guide	Click here for all articles
N0450D	Physician documented GDR	Step-by-Step Guide	Click here for all articles
N0450E	Date physician documented GDR	Step-by-Step Guide	Click here for all articles
N2001	Drug Regimen Review	Step-by-Step Guide	Click here for all articles
N2003	Medication Follow-up	Step-by-Step Guide	Click here for all articles
N2005	Medication Intervention	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
O0110A1a	Treatment: Chemotherapy - On Adm	Step-by-Step Guide	Click here for all articles
O0110A1b	Treatment: Chemotherapy - While a Res	Step-by-Step Guide	Click here for all articles
O0110A1c	Treatment: Chemotherapy - At Discharge	Step-by-Step Guide	Click here for all articles
O0110A2a	Treatment: Chemotherapy - IV - On Adm	Step-by-Step Guide	Click here for all articles
O0110A2c	Treatment: Chemotherapy - IV - At Discharge	Step-by-Step Guide	Click here for all articles
O0110A3a	Treatment: Chemotherapy - Oral - On Adm	Step-by-Step Guide	Click here for all articles
O0110A3c	Treatment: Chemotherapy - Oral - At Discharge.	Step-by-Step Guide	Click here for all articles
O0110A10a	Treatment: Chemotherapy - Other - On Adm	Step-by-Step Guide	Click here for all articles
O0110A10c	Treatment: Chemotherapy - Other - At Discharge	Step-by-Step Guide	Click here for all articles
O0110B1a	Treatment: Radiation - On Adm	Step-by-Step Guide	Click here for all articles
O0110B1b	Treatment: Radiation - While a Resident	Step-by-Step Guide	Click here for all articles
O0110B1c	Treatment: Radiation - At Discharge	Step-by-Step Guide	Click here for all articles
O0110C1a	Treatment: Oxygen Therapy - On Adm	Step-by-Step Guide	Click here for all articles
O0110C1b	Treatment: Oxygen Therapy - While a Res	Step-by-Step Guide	Click here for all articles
O0110C1c	Treatment: Oxygen Therapy - At Discharge	Step-by-Step Guide	Click here for all articles
O0110C2a	Treatment: Oxygen Therapy - Continuous - On Adm	Step-by-Step Guide	Click here for all articles
O0110C2c	Treatment: Oxygen Therapy - Continuous - At Discharge	Step-by-Step Guide	Click here for all articles
O0110C3a	Treatment: Oxygen Therapy - Intermittent - On Adm	Step-by-Step Guide	Click here for all articles
O0110C3c	Treatment: Oxygen Therapy - Intermittent - At Discharge	Step-by-Step Guide	Click here for all articles
O0110C4a	Treatment: Oxygen Therapy - High- concentration - On Adm	Step-by-Step Guide	Click here for all articles
O0110C4c	Treatment: Oxygen Therapy - High- concentration - At Discharge	Step-by-Step Guide	Click here for all articles
O0110D1a	Treatment: Suctioning - On Adm	Step-by-Step Guide	Click here for all articles
O0110D1b	Treatment: Suctioning - While a Res	Step-by-Step Guide	Click here for all articles
O0110D1c	Treatment: Suctioning - At Discharge	Step-by-Step Guide	Click here for all articles
O0110D2a	Treatment: Suctioning - Scheduled - Adm	Step-by-Step Guide	Click here for all articles
O0110D2c	Treatment: Suctioning - Scheduled - At Discharge	Step-by-Step Guide	Click here for all articles
O0110D3a	Treatment: Suctioning - As Needed - Adm	Step-by-Step Guide	Click here for all articles
O0110D3c	Treatment: Suctioning - As Needed - At Discharge	Step-by-Step Guide	Click here for all articles
O0110E1a	Treatment: Tracheostomy care - Adm	Step-by-Step Guide	Click here for all articles
O0110E1b	Treatment: Tracheostomy care - While a Resident	Step-by-Step Guide	Click here for all articles
O0110E1c	Treatment: Tracheostomy care - At Discharge	Step-by-Step Guide	Click here for all articles
O0110F1a	Treatment: Invasive Mechanical Ventilator - Adm	Step-by-Step Guide	Click here for all articles
O0110F1b	Treatment: Invasive Mechanical Ventilator - While a Res	Step-by-Step Guide	Click here for all articles
O0110F1c	Treatment: Invasive Mechanical Ventilator - At Discharge	Step-by-Step Guide	Click here for all articles
O0110G1a	Treatment: Non-Invasive Mechanic Ventilator - On Adm	Step-by-Step Guide	Click here for all articles
O0110G1b	Treatment: Non-Invasive Mechanic Ventilator - While a Res	Step-by-Step Guide	Click here for all articles
O0110G1c	Treatment: Non-Invasive Mechanic Ventilator - At Discharge	Step-by-Step Guide	Click here for all articles
O0110G2a	Treatment: Non-Invasive Mechanic Ventilator - BiPAP - On Adm	Step-by-Step Guide	Click here for all articles
O0110G2c	Treatment: Non-Invasive Mechanic Ventilator - BiPAP - At Discharge	Step-by-Step Guide	Click here for all articles
O0110G3a	Treatment: Non-Invasive Mechanic Ventilator - CPAP - On Adm	Step-by-Step Guide	Click here for all articles
O0110G3c	Treatment: Non-Invasive Mechanic Ventilator - CPAP - At Discharge	Step-by-Step Guide	Click here for all articles
O0110H1a	Treatment: IV Medications - On Adm	Step-by-Step Guide	Click here for all articles
O0110H1b	Treatment: IV Medications - While a Res	Step-by-Step Guide	Click here for all articles
O0110H1c	Treatment: IV Medications - At Discharge	Step-by-Step Guide	Click here for all articles
O0110H2a	Treatment: IV Medications - Vasoactive Med - On Adm	Step-by-Step Guide	Click here for all articles
O0110H2c	Treatment: IV Medications - Vasoactive Med - At Discharge	Step-by-Step Guide	Click here for all articles
O0110H3a	Treatment: IV Medications - Antibiotics - On Adm	Step-by-Step Guide	Click here for all articles
O0110H3c	Treatment: IV Medications - Antibiotics - At Discharge	Step-by-Step Guide	Click here for all articles
O0110H4a	Treatment: IV Medications - Anticoagulant - On Adm	Step-by-Step Guide	Click here for all articles
O0110H4c	Treatment: IV Medications - Anticoagulant - At Discharge	Step-by-Step Guide	Click here for all articles
O0110H10a	Treatment: IV Medications - Other - On Adm	Step-by-Step Guide	Click here for all articles
O0110H10c	Treatment: IV Medications - Other - At Discharge	Step-by-Step Guide	Click here for all articles
O0110I1a	Treatment: Transfusions - On Adm	Step-by-Step Guide	Click here for all articles
O0110I1b	Treatment: Transfusions - While a Res	Step-by-Step Guide	Click here for all articles
O0110I1c	Treatment: Transfusions - At Discharge	Step-by-Step Guide	Click here for all articles
O0110J1a	Treatment: Dialysis - On Adm	Step-by-Step Guide	Click here for all articles
O0110J1b	Treatment: Dialysis - while a Resident	Step-by-Step Guide	Click here for all articles
O0110J1c	Treatment: Dialysis - At Discharge	Step-by-Step Guide	Click here for all articles
O0110J2a	Treatment: Dialysis - Hemodialysis - On Adm	Step-by-Step Guide	Click here for all articles
O0110J2c	Treatment: Dialysis - Hemodialysis - At Discharge	Step-by-Step Guide	Click here for all articles
O0110J3a	Treatment: Dialysis - Peritoneal - On Adm	Step-by-Step Guide	Click here for all articles
O0110J3c	Treatment: Dialysis - Peritoneal - At Discharge	Step-by-Step Guide	Click here for all articles
O0110K1b	Treatment: Hospice - While a Res	Step-by-Step Guide	Click here for all articles
O0110M1b	Treatment: isolate/quarantine - While a Res	Step-by-Step Guide	Click here for all articles
O0110O1a	Treatment: IV Access - On Adm	Step-by-Step Guide	Click here for all articles
O0110O1b	Treatment: IV Access - While a Res	Step-by-Step Guide	Click here for all articles
O0110O1c	Treatment: IV Access - At Discharge	Step-by-Step Guide	Click here for all articles
O0110O2a	Treatment: IV Access - Peripheral - On Adm	Step-by-Step Guide	Click here for all articles
O0110O2c	Treatment: IV Access - Peripheral - At Discharge	Step-by-Step Guide	Click here for all articles
O0110O3a	Treatment: IV Access - Midline - On Adm	Step-by-Step Guide	Click here for all articles
O0110O3c	Treatment: IV Access - Midline - At Discharge	Step-by-Step Guide	Click here for all articles
O0110O4a	Treatment: IV Access - Central - On Adm	Step-by-Step Guide	Click here for all articles
O0110O4c	Treatment: IV Access - Central - At Discharge	Step-by-Step Guide	Click here for all articles
O0110Z1a	Treatment: None of the above - On Adm	Step-by-Step Guide	Click here for all articles
O0110Z1b	Treatment: None of the above - While a Res	Step-by-Step Guide	Click here for all articles
O0110Z1c	Treatment: None of the above - At Discharge	Step-by-Step Guide	Click here for all articles
O0250A	Was influenza vaccine received	Step-by-Step Guide	Click here for all articles
O0250B	Date influenza vaccine received	Step-by-Step Guide	Click here for all articles
O0250C	If influenza vaccine not received, state reason	Step-by-Step Guide	Click here for all articles
O0300A	Is pneumococcal vaccination up to date	Step-by-Step Guide	Click here for all articles
O0300B	If pneumococcal vaccination not received, state reason	Step-by-Step Guide	Click here for all articles
O0350	Resident’s COVID-19 vaccination is up to date	Step-by-Step Guide	Click here for all articles
O0400A1	Speech-language/audiology: individual minutes	Step-by-Step Guide	Click here for all articles
O0400A2	Speech-language/audiology: concurrent minutes	Step-by-Step Guide	Click here for all articles
O0400A3	Speech-language/audiology: group minutes	Step-by-Step Guide	Click here for all articles
O0400A3A	Speech-language/audiology: co-treatment minutes	Step-by-Step Guide	Click here for all articles
O0400A4	Speech-language/audiology: number of days	Step-by-Step Guide	Click here for all articles
O0400A5	Speech-language/audiology: start date	Step-by-Step Guide	Click here for all articles
O0400A6	Speech-language/audiology: end date	Step-by-Step Guide	Click here for all articles
O0400B1	Occupational therapy: individual minutes	Step-by-Step Guide	Click here for all articles
O0400B2	Occupational therapy: concurrent minutes	Step-by-Step Guide	Click here for all articles
O0400B3	Occupational therapy: group minutes	Step-by-Step Guide	Click here for all articles
O0400B3A	Occupational therapy: co-treatment	Step-by-Step Guide	Click here for all articles
O0400B4	Occupational therapy: number of days	Step-by-Step Guide	Click here for all articles
O0400B5	Occupational therapy: start date	Step-by-Step Guide	Click here for all articles
O0400B6	Occupational therapy: end date	Step-by-Step Guide	Click here for all articles
O0400C1	Physical therapy: individual minutes	Step-by-Step Guide	Click here for all articles
O0400C2	Physical therapy: concurrent minutes	Step-by-Step Guide	Click here for all articles
O0400C3	Physical therapy: group minutes	Step-by-Step Guide	Click here for all articles
O0400C3A	Physical therapy: co-treatment minutes	Step-by-Step Guide	Click here for all articles
O0400C4	Physical therapy: number of days	Step-by-Step Guide	Click here for all articles
O0400C5	Physical therapy: start date	Step-by-Step Guide	Click here for all articles
O0400C6	Physical therapy: end date	Step-by-Step Guide	Click here for all articles
O0400D1	Respiratory therapy: number of minutes	Step-by-Step Guide	Click here for all articles
O0400D2	Respiratory therapy: number of days	Step-by-Step Guide	Click here for all articles
O0400E1	Psychological therapy: number of minutes	Step-by-Step Guide	Click here for all articles
O0400E2	Psychological therapy: number of days	Step-by-Step Guide	Click here for all articles
O0400F1	Recreational therapy: number of minutes	Step-by-Step Guide	Click here for all articles
O0400F2	Recreational therapy: number of days	Step-by-Step Guide	Click here for all articles
O0420	Distinct calendar days of therapy (7 look back)	Step-by-Step Guide	Click here for all articles
O0425A1	SLP and Audiology Services: Individual Minutes	Step-by-Step Guide	Click here for all articles
O0425A2	SLP and Audiology Services: Concurrent Minutes	Step-by-Step Guide	Click here for all articles
O0425A3	SLP and Audiology Services: Group Minutes	Step-by-Step Guide	Click here for all articles
O0425A4	SLP and Audiology Services: Co-treatment Minutes	Step-by-Step Guide	Click here for all articles
O0425A5	SLP and Audiology Services: Days	Step-by-Step Guide	Click here for all articles
O0425B1	Occupational Therapy: Individual Minutes	Step-by-Step Guide	Click here for all articles
O0425B2	Occupational Therapy: Concurrent Minutes	Step-by-Step Guide	Click here for all articles
O0425B3	Occupational Therapy: Group Minutes	Step-by-Step Guide	Click here for all articles
O0425B4	Occupational Therapy: Co-treatment Minutes	Step-by-Step Guide	Click here for all articles
O0425B5	Occupational Therapy: Days	Step-by-Step Guide	Click here for all articles
O0425C1	Physical Therapy: Individual Minutes	Step-by-Step Guide	Click here for all articles
O0425C2	Physical Therapy: Concurrent Minutes	Step-by-Step Guide	Click here for all articles
O0425C3	Physical Therapy: Group Minutes	Step-by-Step Guide	Click here for all articles
O0425C4	Physical Therapy: Co-treatment Minutes	Step-by-Step Guide	Click here for all articles
O0425C5	Physical Therapy: Days	Step-by-Step Guide	Click here for all articles
O0430	Distinct Calendar Days of Part A Therapy	Step-by-Step Guide	Click here for all articles
O0500A	Range of motion (passive): number of days	Step-by-Step Guide	Click here for all articles
O0500B	Range of motion (active): number of days	Step-by-Step Guide	Click here for all articles
O0500C	Splint or brace assistance: number of days	Step-by-Step Guide	Click here for all articles
O0500D	Bed mobility training: number of days	Step-by-Step Guide	Click here for all articles
O0500E	Transfer training: number of days	Step-by-Step Guide	Click here for all articles
O0500F	Walking training: number of days	Step-by-Step Guide	Click here for all articles
O0500G	Dressing and/or grooming training: number of days	Step-by-Step Guide	Click here for all articles
O0500H	Eating and/or swallowing training: number of days	Step-by-Step Guide	Click here for all articles
O0500I	Amputation/prosthesis training: number of days	Step-by-Step Guide	Click here for all articles
O0500J	Communication training: number of days	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
P0200A	Bed alarm	Step-by-Step Guide	Click here for all articles
P0200B	Chair alarm	Step-by-Step Guide	Click here for all articles
P0200C	Floor mat alarm	Step-by-Step Guide	Click here for all articles
P0200D	Motion sensor alarm	Step-by-Step Guide	Click here for all articles
P0200E	Wander/elopement alarm	Step-by-Step Guide	Click here for all articles
P0200F	Other alarm	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
Q0110A	Asmt and Goal Participation: Resident	Step-by-Step Guide	Click here for all articles
Q0110B	Asmt and Goal Participation: Family	Step-by-Step Guide	Click here for all articles
Q0110C	Asmt and Goal Participation: Significant other	Step-by-Step Guide	Click here for all articles
Q0110D	Asmt and Goal Participation: Legal guardian	Step-by-Step Guide	Click here for all articles
Q0110E	Asmt and Goal Participation: Other legally authorized representative	Step-by-Step Guide	Click here for all articles
Q0110Z	Asmt and Goal Participation: None of the above.	Step-by-Step Guide	Click here for all articles
Q0310A	Resident's overall goal for discharge	Step-by-Step Guide	Click here for all articles
Q0310B	Information source for Q0310A	Step-by-Step Guide	Click here for all articles
Q0400A	Active discharge plan for return to community	Step-by-Step Guide	Click here for all articles
Q0490	Resident's preference to avoid being asked	Step-by-Step Guide	Click here for all articles
Q0500B	Do you want to talk about returning to community	Step-by-Step Guide	Click here for all articles
Q0500C	Information source for Q500B	Step-by-Step Guide	Click here for all articles
Q0550A	Reasking resident preference	Step-by-Step Guide	Click here for all articles
Q0550C	Information source for Q0550A	Step-by-Step Guide	Click here for all articles
Q0610A	Referral been made to local contact agency	Step-by-Step Guide	Click here for all articles
Q0620	Reason Referral to Local Contact Agency Not Made	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
V0100A	Prior OBRA reason for assessment	Step-by-Step Guide	Click here for all articles
V0100B	Prior PPS reason for assessment	Step-by-Step Guide	Click here for all articles
V0100C	Prior assessment reference date	Step-by-Step Guide	Click here for all articles
V0100D	Prior assessment BIMS summary score	Step-by-Step Guide	Click here for all articles
V0100E	Prior assessment PHQ res: total mood severity score	Step-by-Step Guide	Click here for all articles
V0100F	Prior assessment PHQ staff: total mood score	Step-by-Step Guide	Click here for all articles
V0200A01A	CAA-Delirium: triggered	Step-by-Step Guide	Click here for all articles
V0200A01B	CAA-Delirium: plan	Step-by-Step Guide	Click here for all articles
V0200A02A	CAA-Cognitive loss/dementia: triggered	Step-by-Step Guide	Click here for all articles
V0200A02B	CAA-Cognitive loss/dementia: plan	Step-by-Step Guide	Click here for all articles
V0200A03A	CAA-Visual function: triggered	Step-by-Step Guide	Click here for all articles
V0200A03B	CAA-Visual function: plan	Step-by-Step Guide	Click here for all articles
V0200A04A	CAA-Communication: triggered	Step-by-Step Guide	Click here for all articles
V0200A04B	CAA-Communication: plan	Step-by-Step Guide	Click here for all articles
V0200A05A	CAA-ADL functional/rehab potential: triggered	Step-by-Step Guide	Click here for all articles
V0200A05B	CAA-ADL functional/rehab potential: plan	Step-by-Step Guide	Click here for all articles
V0200A06A	CAA-Urinary incontinence/indwelling catheter: triggered	Step-by-Step Guide	Click here for all articles
V0200A06B	CAA-Urinary incontinence/indwelling catheter: plan	Step-by-Step Guide	Click here for all articles
V0200A07A	CAA-Psychosocial well-being: triggered	Step-by-Step Guide	Click here for all articles
V0200A07B	CAA-Psychosocial well-being: plan	Step-by-Step Guide	Click here for all articles
V0200A08A	CAA-Mood state: triggered	Step-by-Step Guide	Click here for all articles
V0200A08B	CAA-Mood state: plan	Step-by-Step Guide	Click here for all articles
V0200A09A	CAA-Behavioral symptoms: triggered	Step-by-Step Guide	Click here for all articles
V0200A09B	CAA-Behavioral symptoms: plan	Step-by-Step Guide	Click here for all articles
V0200A10A	CAA-Activities: triggered	Step-by-Step Guide	Click here for all articles
V0200A10B	CAA-Activities: plan	Step-by-Step Guide	Click here for all articles
V0200A11A	CAA-Falls: triggered	Step-by-Step Guide	Click here for all articles
V0200A11B	CAA-Falls: plan	Step-by-Step Guide	Click here for all articles
V0200A12A	CAA-Nutritional status: triggered	Step-by-Step Guide	Click here for all articles
V0200A12B	CAA-Nutritional status: plan	Step-by-Step Guide	Click here for all articles
V0200A13A	CAA-Feeding tubes: triggered	Step-by-Step Guide	Click here for all articles
V0200A13B	CAA-Feeding tubes: plan	Step-by-Step Guide	Click here for all articles
V0200A14A	CAA-Dehydration/fluid maintenance: triggered	Step-by-Step Guide	Click here for all articles
V0200A14B	CAA-Dehydration/fluid maintenance: plan	Step-by-Step Guide	Click here for all articles
V0200A15A	CAA-Dental care: triggered	Step-by-Step Guide	Click here for all articles
V0200A15B	CAA-Dental care: plan	Step-by-Step Guide	Click here for all articles
V0200A16A	CAA-Pressure ulcer: triggered	Step-by-Step Guide	Click here for all articles
V0200A16B	CAA-Pressure ulcer: plan	Step-by-Step Guide	Click here for all articles
V0200A17A	CAA-Psychotropic drug use: triggered	Step-by-Step Guide	Click here for all articles
V0200A17B	CAA-Psychotropic drug use: plan	Step-by-Step Guide	Click here for all articles
V0200A18A	CAA-Physical restraints: triggered	Step-by-Step Guide	Click here for all articles
V0200A18B	CAA-Physical restraints: plan	Step-by-Step Guide	Click here for all articles
V0200A19A	CAA-Pain: triggered	Step-by-Step Guide	Click here for all articles
V0200A19B	CAA-Pain: plan	Step-by-Step Guide	Click here for all articles
V0200A20A	CAA-Return to community referral: triggered	Step-by-Step Guide	Click here for all articles
V0200A20B	CAA-Return to community referral: plan	Step-by-Step Guide	Click here for all articles
V0200B1	CAA-Assessment process RN signature	Step-by-Step Guide	Click here for all articles
V0200B2	CAA-Assessment process signature date	Step-by-Step Guide	Click here for all articles
V0200C1	CAA-Care planning signature	Step-by-Step Guide	Click here for all articles
V0200C2	CAA-Care planning signature date	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
X0150	Correction: type of provider	Step-by-Step Guide	Click here for all articles
X0200A	Correction: resident first name	Step-by-Step Guide	Click here for all articles
X0200C	Correction: resident last name	Step-by-Step Guide	Click here for all articles
X0300	Correction: resident gender	Step-by-Step Guide	Click here for all articles
X0400	Correction: resident birth date	Step-by-Step Guide	Click here for all articles
X0500	Correction: resident social security number	Step-by-Step Guide	Click here for all articles
X0600A	Correction: OBRA reason for assessment	Step-by-Step Guide	Click here for all articles
X0600B	Correction: PPS reason for assessment	Step-by-Step Guide	Click here for all articles
X0600F	Correction: entry/discharge reporting	Step-by-Step Guide	Click here for all articles
X0600H	Correction: SNF Part A PPS Discharge	Step-by-Step Guide	Click here for all articles
X0700A	Correction: assessment reference date	Step-by-Step Guide	Click here for all articles
X0700B	Correction: discharge date	Step-by-Step Guide	Click here for all articles
X0700C	Correction: entry date	Step-by-Step Guide	Click here for all articles
X0800	Correction: correction number	Step-by-Step Guide	Click here for all articles
X0900A	Correction: modification reasons - transcription error	Step-by-Step Guide	Click here for all articles
X0900B	Correction: modification reasons - data entry error	Step-by-Step Guide	Click here for all articles
X0900C	Correction: modification reasons - software error	Step-by-Step Guide	Click here for all articles
X0900D	Correction: modification reasons - item coding error	Step-by-Step Guide	Click here for all articles
X0900Z	Correction: modification reasons - other error	Step-by-Step Guide	Click here for all articles
X1050A	Correction: inactivation reasons - event did not occur	Step-by-Step Guide	Click here for all articles
X1050Z	Correction: inactivation reasons - other reason	Step-by-Step Guide	Click here for all articles
X1100A	Correction: attestor first name	Step-by-Step Guide	Click here for all articles
X1100B	Correction: attestor last name	Step-by-Step Guide	Click here for all articles
X1100C	Correction: attestor title	Step-by-Step Guide	Click here for all articles
X1100D	Correction: attestor signature	Step-by-Step Guide	Click here for all articles
X1100E	Correction: attestation date	Step-by-Step Guide	Click here for all articles

MDS Item	Short Description	Step-by-Step Guide for the Item Set	All Articles for the Item Set
Z0100A	Medicare Part A: HIPPS code	Step-by-Step Guide	Click here for all articles
Z0100B	Medicare Part A: Version code	Step-by-Step Guide	Click here for all articles
Z0200A	State Medicaid Billing: Case Mix group	Step-by-Step Guide	Click here for all articles
Z0200B	State Medicaid Billing: Version code	Step-by-Step Guide	Click here for all articles
Z0250A	Alt State Medicaid Billing: Case Mix group	Step-by-Step Guide	Click here for all articles
Z0250B	Alt State Medicaid Billing: Version Code	Step-by-Step Guide	Click here for all articles
Z0300A	Insurance Billing: Billing Code	Step-by-Step Guide	Click here for all articles
Z0300B	Insurance Billing: Billing Version	Step-by-Step Guide	Click here for all articles
Z0400A	Attestation signature, title, sections, date	Step-by-Step Guide	Click here for all articles
Z0400B	Attestation signature, title, sections, date	Step-by-Step Guide	Click here for all articles
Z0400C	Attestation signature, title, sections, date	Step-by-Step Guide	Click here for all articles
Z0400D	Attestation signature, title, sections, date	Step-by-Step Guide	Click here for all articles
Z0400E	Attestation signature, title, sections, date	Step-by-Step Guide	Click here for all articles
Z0400F	Attestation signature, title, sections, date	Step-by-Step Guide	Click here for all articles
Z0400G	Attestation signature, title, sections, date	Step-by-Step Guide	Click here for all articles
Z0400H	Attestation signature, title, sections, date	Step-by-Step Guide	Click here for all articles
Z0400I	Attestation signature, title, sections, date	Step-by-Step Guide	Click here for all articles
Z0400J	Attestation signature, title, sections, date	Step-by-Step Guide	Click here for all articles
Z0400K	Attestation signature, title, sections, date	Step-by-Step Guide	Click here for all articles
Z0400L	Attestation signature, title, sections, date	Step-by-Step Guide	Click here for all articles
Z0500A	Signature of RN assessment coordinator	Step-by-Step Guide	Click here for all articles
Z0500B	Date RN signed assessment as complete	Step-by-Step Guide	Click here for all articles

MDS 3.0 Section Guide & Navigation Dashboard- Click section titles for all articles.

MDS 3.0 Section Navigation

Section	Title	Intent
A	Identification Information	Obtain key information to uniquely identify each resident, nursing home, type of record, and reasons for assessment.
B	Hearing, Speech, and Vision	Document the resident's ability to hear, understand, and communicate with others, and whether the resident experiences visual, hearing, or speech limitations.
C	Cognitive Patterns	Determine the resident’s attention, orientation, and ability to register and recall information.
D	Mood	Identify signs and symptoms of mood distress.
E	Behavior	Identify behavioral symptoms that may cause distress or are potentially harmful to the resident, or may be distressing or disruptive to facility residents, staff, or the environment.
F	Preferences for Customary Routine and Activities	Obtain information regarding the resident’s preferences for his or her daily routine and activities.
GG	Functional Abilities and Goals	Assess the need for assistance with self-care and mobility activities.
GG	Functional Abilities and Goals - Discharge (End of SNF PPS Stay)	Assess the resident’s functional abilities at the time of discharge, focusing on self-care and mobility activities. This documents the resident's final performance after their skilled nursing facility stay.
H	Bladder and Bowel	Gather information on the use of bowel and bladder appliances, the use of and response to urinary toileting programs, and bowel training programs.
I	Active Diagnoses	Code diseases related to the resident's current functional, cognitive, mood, or behavior status, medical treatments, nursing monitoring, or risk of death.
J	Health Conditions	Document health conditions that impact the resident's functional status and quality of life.
K	Swallowing/Nutritional Status	Assess conditions that could affect the resident’s ability to maintain adequate nutrition and hydration.
L	Oral/Dental Status	Record any oral or dental problems present.
M	Skin Conditions	Document the presence, appearance, and change of pressure ulcers, as well as other skin conditions or lesions.
N	Medications	Record the number of days the resident received injections, insulin, and select medications.
O	Special Treatments, Procedures, and Programs	Identify any special treatments, procedures, and programs that the resident received during specified time periods.
P	Restraints and Alarms	Record the frequency that the resident was restrained by any of the listed devices during the day or night; document whether any listed alarms were used.
Q	Participation in Assessment and Goal Setting	Record the participation of the resident, family, or significant others in the assessment and understanding of the resident's goals.
V	Care Area Assessment (CAA) Summary	Document triggered care areas, and whether or not a care plan was developed for each triggered area; record the location of care area assessment documentation.
X	Correction Request	Request to modify or inactivate a record already present in the QIES ASAP database.
Z	Assessment Administration	Provide billing information and signatures of assessors completing the assessment.