Biopsychosocial Assessment

A0310 continued on next page.

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Resident Identifier Date

MINIMUM DATA SET (MDS) - Version 3.0. RESIDENT ASSESSMENT AND CARE SCREENING.

Nursing Home Comprehensive (NC) Item Set.

Section A. Identification Information. A0050. Type of Record.

1. Add new record Continue to A0100, Facility Provider Numbers. 2. Modify existing record Continue to A0100, Facility Provider Numbers. 3. Inactivate existing record Skip to X0150, Type of Provider.

Enter Code

A0100. Facility Provider Numbers.

A. National Provider Identifier (NPI):

B. CMS Certification Number (CCN):

C. State Provider Number:

A0200. Type of Provider. Type of provider.

1. Nursing home (SNF/NF). 2. Swing Bed.

Enter Code

A0310. Type of Assessment. A. Federal OBRA Reason for Assessment.

01. Admission assessment (required by day 14). 02. Quarterly review assessment. 03. Annual assessment. 04. Significant change in status assessment. 05. Significant correction to prior comprehensive assessment. 06. Significant correction to prior quarterly assessment. 99. None of the above.

Enter Code

B. PPS Assessment. PPS Scheduled Assessments for a Medicare Part A Stay. 01. 5-day scheduled assessment. 02. 14-day scheduled assessment. 03. 30-day scheduled assessment. 04. 60-day scheduled assessment. 05. 90-day scheduled assessment. PPS Unscheduled Assessments for a Medicare Part A Stay. 07. Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment). Not PPS Assessment. 99. None of the above.

Enter Code

C. PPS Other Medicare Required Assessment - OMRA. 0. No... 1. Start of therapy assessment. 2. End of therapy assessment. 3. Both Start and End of therapy assessment. 4. Change of therapy assessment.

Enter Code

D. Is this a Swing Bed clinical change assessment? Complete only if A0200 = 2. 0. No... 1. Yes.

Enter Code

E. Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry? 0. No... 1. Yes.

Enter Code

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Resident Identifier Date

Identification Information.Section A. A0310. Type of Assessment - Continued.

F. Entry/discharge reporting 01. Entry tracking record. 10. Discharge assessment-return not anticipated. 11. Discharge assessment-return anticipated. 12. Death in facility tracking record. 99. None of the above.

Enter Code

G. Type of discharge. - Complete only if A0310F = 10 or 11. 1. Planned... 2. Unplanned.

Enter Code

H. Is this a SNF PPS Part A Discharge (End of Stay) Assessment?. 0. No... 1. Yes.

Enter Code

A0410. Unit Certification or Licensure Designation.

1. Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State. 2. Unit is neither Medicare nor Medicaid certified but MDS data is required by the State. 3. Unit is Medicare and/or Medicaid certified.

Enter Code

A0500. Legal Name of Resident. A. First name: B. Middle initial:

C. Last name: D. Suffix:

A0600. Social Security and Medicare Numbers. A. Social Security Number:

_ _

B. Medicare number (or comparable railroad insurance number):

A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid recipient.

A0800. Gender.

1. Male. 2. Female.

Enter Code

A0900. Birth Date.

Month

_

Day

_

Year

A1000. Race/Ethnicity.

Check all that apply.

A. American Indian or Alaska Native.

B. Asian.

C. Black or African American.

D. Hispanic or Latino.

E. Native Hawaiian or Other Pacific Islander.

F. White.

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Resident Identifier Date

Identification Information.Section A. A1100. Language.

A. Does the resident need or want an interpreter to communicate with a doctor or health care staff? 0. No Skip to A1200, Marital Status. 1. Yes Specify in A1100B, Preferred language. 9. Unable to determine. Skip to A1200, Marital Status.

Enter Code

B. Preferred language:

A1200. Marital Status.

1. Never married. 2. Married. 3. Widowed. 4. Separated. 5. Divorced.

Enter Code

A1300. Optional Resident Items. A. Medical record number:

B. Room number:

C. Name by which resident prefers to be addressed:

D. Lifetime occupation(s) - put "/" between two occupations:

A1500. Preadmission Screening and Resident Review (PASRR). Complete only if A0310A = 01, 03, 04, or 05

Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability ("mental retardation" in federal regulation) or a related condition?

0. No Skip to A1550, Conditions Related to ID/DD Status. 1. Yes Continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.

Skip to A1550, Conditions Related to ID/DD Status.9. Not a Medicaid-certified unit

Enter Code

A1510. Level II Preadmission Screening and Resident Review (PASRR) Conditions. Complete only if A0310A = 01, 03, 04, or 05.

Check all that apply.

A. Serious mental illness.

B. Intellectual Disability ("mental retardation" in federal regulation).

C. Other related conditions.

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Resident Identifier Date

Identification Information.Section A. A1550. Conditions Related to ID/DD Status. If the resident is 22 years of age or older, complete only if A0310A = 01. If the resident is 21 years of age or younger, complete only if A0310A = 01, 03, 04, or 05.

Check all conditions that are related to ID/DD status that were manifested before age 22, and are likely to continue indefinitely.

ID/DD With Organic Condition.

A. Down syndrome.

B. Autism.

C. Epilepsy.

D. Other organic condition related to ID/DD.

ID/DD Without Organic Condition.

E. ID/DD with no organic condition.

No ID/DD.

Z. None of the above.

Most Recent Admission/Entry or Reentry into this Facility.

A1600. Entry Date.

Month

_

Day

_

Year

A1700. Type of Entry.

1. Admission. 2. Reentry.

Enter Code

A1800. Entered From. 01. Community (private home/apt., board/care, assisted living, group home). 02. Another nursing home or swing bed. 03. Acute hospital. 04. Psychiatric hospital. 05. Inpatient rehabilitation facility. 06. ID/DD facility. 07. Hospice. 09. Long Term Care Hospital (LTCH). 99. Other.

Enter Code

A1900. Admission Date (Date this episode of care in this facility began).

Month

_

Day

_

Year

A2000. Discharge Date. Complete only if A0310F = 10, 11, or 12

Month

_

Day

_

Year

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Resident Identifier Date

Identification Information.Section A. A2100. Discharge Status. Complete only if A0310F = 10, 11, or 12

01. Community (private home/apt., board/care, assisted living, group home). 02. Another nursing home or swing bed. 03. Acute hospital. 04. Psychiatric hospital. 05. Inpatient rehabilitation facility. 06. ID/DD facility. 07. Hospice. 08. Deceased. 09. Long Term Care Hospital (LTCH). 99. Other.

Enter Code

A2200. Previous Assessment Reference Date for Significant Correction. Complete only if A0310A = 05 or 06.

Month

_

Day

_

Year

A2300. Assessment Reference Date.

Observation end date:

Month

_

Day

_

Year

A2400. Medicare Stay. A. Has the resident had a Medicare-covered stay since the most recent entry?

0. No Skip to B0100, Comatose. 1. Yes Continue to A2400B, Start date of most recent Medicare stay.

Enter Code

B. Start date of most recent Medicare stay:

Month

_

Day

_

Year

C. End date of most recent Medicare stay - Enter dashes if stay is ongoing:

Month

_

Day

_

Year

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Resident Identifier Date

Look back period for all items is 7 days unless another time frame is indicated.

Section B. Hearing, Speech, and Vision. B0100. Comatose.

Persistent vegetative state/no discernible consciousness. 0. No Continue to B0200, Hearing. 1. Yes Skip to G0110, Activities of Daily Living (ADL) Assistance.

Enter Code

B0200. Hearing. Ability to hear (with hearing aid or hearing appliances if normally used).

0. Adequate - no difficulty in normal conversation, social interaction, listening to TV. 1. Minimal difficulty - difficulty in some environments (e.g., when person speaks softly or setting is noisy). 2. Moderate difficulty - speaker has to increase volume and speak distinctly. 3. Highly impaired - absence of useful hearing.

Enter Code

B0300. Hearing Aid. Hearing aid or other hearing appliance used in completing B0200, Hearing.

0. No... 1. Yes.

Enter Code

B0600. Speech Clarity.

Select best description of speech pattern. 0. Clear speech - distinct intelligible words. 1. Unclear speech - slurred or mumbled words. 2. No speech - absence of spoken words.

Enter Code

B0700. Makes Self Understood.

Ability to express ideas and wants, consider both verbal and non-verbal expression. 0. Understood. 1. Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time. 2. Sometimes understood - ability is limited to making concrete requests. 3. Rarely/never understood.

Enter Code

B0800. Ability To Understand Others.

Understanding verbal content, however able (with hearing aid or device if used). 0. Understands - clear comprehension. 1. Usually understands - misses some part/intent of message but comprehends most conversation. 2. Sometimes understands - responds adequately to simple, direct communication only. 3. Rarely/never understands.

Enter Code

B1000. Vision.

Ability to see in adequate light (with glasses or other visual appliances). 0. Adequate - sees fine detail, such as regular print in newspapers/books. 1. Impaired - sees large print, but not regular print in newspapers/books. 2. Moderately impaired - limited vision; not able to see newspaper headlines but can identify objects. 3. Highly impaired - object identification in question, but eyes appear to follow objects. 4. Severely impaired - no vision or sees only light, colors or shapes; eyes do not appear to follow objects.

Enter Code

B1200. Corrective Lenses.

Corrective lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision. 0. No... 1. Yes.

Enter Code

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Resident Identifier Date

Section C. Cognitive Patterns.

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted? Attempt to conduct interview with all residents.

0. No (resident is rarely/never understood) Skip to and complete C0700-C1000, Staff Assessment for Mental Status. 1. Yes Continue to C0200, Repetition of Three Words.

Enter Code

Brief Interview for Mental Status (BIMS). C0200. Repetition of Three Words.

Ask resident: “I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words.” Number of words repeated after first attempt.

0. None. 1. One. 2. Two. 3. Three.

After the resident's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece of furniture"). You may repeat the words up to two more times.

Enter Code

C0300. Temporal Orientation (orientation to year, month, and day). Ask resident: "Please tell me what year it is right now." A. Able to report correct year.

0. Missed by > 5 years or no answer. 1. Missed by 2-5 years. 2. Missed by 1 year. 3. Correct.

Enter Code

Ask resident: "What month are we in right now?" B. Able to report correct month.

0. Missed by > 1 month or no answer. 1. Missed by 6 days to 1 month. 2. Accurate within 5 days.

Enter Code

Ask resident: "What day of the week is today?" C. Able to report correct day of the week.

0. Incorrect or no answer. 1. Correct.

Enter Code

C0400. Recall. Ask resident: "Let's go back to an earlier question. What were those three words that I asked you to repeat?" If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word. A. Able to recall "sock".

0. No - could not recall. 1. Yes, after cueing ("something to wear"). 2. Yes, no cue required.

Enter Code

B. Able to recall "blue". 0. No - could not recall. 1. Yes, after cueing ("a color"). 2. Yes, no cue required.

Enter Code

C. Able to recall "bed". 0. No - could not recall. 1. Yes, after cueing ("a piece of furniture"). 2. Yes, no cue required.

Enter Code

C0500. BIMS Summary Score. Add scores for questions C0200-C0400 and fill in total score (00-15). Enter 99 if the resident was unable to complete the interview.

Enter Score

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Resident Identifier Date

Section C. Cognitive Patterns.

C0600. Should the Staff Assessment for Mental Status (C0700 - C1000) be Conducted?

0. No (resident was able to complete Brief Interview for Mental Status ) Skip to C1310, Signs and Symptoms of Delirium. 1. Yes (resident was unable to complete Brief Interview for Mental Status) Continue to C0700, Short-term Memory OK.

Enter Code

Staff Assessment for Mental Status.

Do not conduct if Brief Interview for Mental Status (C0200-C0500) was completed.

C0700. Short-term Memory OK.

Seems or appears to recall after 5 minutes. 0. Memory OK. 1. Memory problem.

Enter Code

C0800. Long-term Memory OK.

Seems or appears to recall long past. 0. Memory OK. 1. Memory problem.

Enter Code

C0900. Memory/Recall Ability.

Check all that the resident was normally able to recall.

A. Current season.

B. Location of own room.

C. Staff names and faces.

D. That he or she is in a nursing home/hospital swing bed.

Z. None of the above were recalled.

C1000. Cognitive Skills for Daily Decision Making.

Made decisions regarding tasks of daily life. 0. Independent - decisions consistent/reasonable. 1. Modified independence - some difficulty in new situations only. 2. Moderately impaired - decisions poor; cues/supervision required. 3. Severely impaired - never/rarely made decisions.

Enter Code

Delirium.

C1310. Signs and Symptoms of Delirium (from CAM©).

Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical record.

A. Acute Onset Mental Status Change.

Is there evidence of an acute change in mental status from the resident's baseline? 0. No... 1. Yes.

Enter Code

Coding: 0. Behavior not present . 1. Behavior continuously

present, does not fluctuate.

2. Behavior present, fluctuates (comes and goes, changes in severity).

Enter Codes in Boxes. B. Inattention - Did the resident have difficulty focusing attention, for example being easily distractible, or

having difficulty keeping track of what was being said?

C. Disorganized thinking - Was the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?

D. Altered level of consciousness - Did the resident have altered level of consciousness as indicated by any of the following criteria? ￭ vigilant - startled easily to any sound or touch. ￭ lethargic - repeatedly dozed off when being asked questions, but responded to voice or touch. ￭ stuporous - very difficult to arouse and keep aroused for the interview. ￭ comatose - could not be aroused.

Confusion Assessment Method. ©1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Used with permission.

Copyright © Pfizer Inc. All rights reserved. Reproduced with permission. MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 9 of 45

Resident Identifier Date

Section D. Mood.

D0100. Should Resident Mood Interview be Conducted? - Attempt to conduct interview with all residents.

0. No (resident is rarely/never understood) Skip to and complete D0500-D0600, Staff Assessment of Resident Mood (PHQ-9-OV).

1. Yes Continue to D0200, Resident Mood Interview (PHQ-9©).

Enter Code

D0200. Resident Mood Interview (PHQ-9©). Say to resident: "Over the last 2 weeks, have you been bothered by any of the following problems?" If symptom is present, enter 1 (yes) in column 1, Symptom Presence. If yes in column 1, then ask the resident: "About how often have you been bothered by this?" Read and show the resident a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.

1. Symptom Presence. 0. No (enter 0 in column 2). 1. Yes (enter 0-3 in column 2). 9. No response (leave column 2

blank).

2. Symptom Frequency. 0. Never or 1 day. 1. 2-6 days (several days). 2. 7-11 days (half or more of the days). 3. 12-14 days (nearly every day).

1. Symptom Presence.

2. Symptom

Frequency.

Enter Scores in Boxes

A. Little interest or pleasure in doing things.

B. Feeling down, depressed, or hopeless.

C. Trouble falling or staying asleep, or sleeping too much.

D. Feeling tired or having little energy.

E. Poor appetite or overeating.

F. Feeling bad about yourself - or that you are a failure or have let yourself or your family down.

G. Trouble concentrating on things, such as reading the newspaper or watching television.

H. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.

I. Thoughts that you would be better off dead, or of hurting yourself in some way.

Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 27. Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more items).

Enter Score

D0300. Total Severity Score.

D0350. Safety Notification - Complete only if D0200I1 = 1 indicating possibility of resident self harm.

Was responsible staff or provider informed that there is a potential for resident self harm? 0. No... 1. Yes.

Enter Code

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Resident Identifier Date

Section D. Mood. D0500. Staff Assessment of Resident Mood (PHQ-9-OV*). Do not conduct if Resident Mood Interview (D0200-D0300) was completed. Over the last 2 weeks, did the resident have any of the following problems or behaviors?

If symptom is present, enter 1 (yes) in column 1, Symptom Presence. Then move to column 2, Symptom Frequency, and indicate symptom frequency.

1. Symptom Presence. 0. No (enter 0 in column 2). 1. Yes (enter 0-3 in column 2).

2. Symptom Frequency. 0. Never or 1 day. 1. 2-6 days (several days). 2. 7-11 days (half or more of the days). 3. 12-14 days (nearly every day).

1. Symptom Presence.

2. Symptom

Frequency.

Enter Scores in Boxes

A. Little interest or pleasure in doing things.

B. Feeling or appearing down, depressed, or hopeless.

C. Trouble falling or staying asleep, or sleeping too much.

D. Feeling tired or having little energy.

E. Poor appetite or overeating.

F. Indicating that s/he feels bad about self, is a failure, or has let self or family down.

G. Trouble concentrating on things, such as reading the newspaper or watching television.

H. Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety or restless that s/he has been moving around a lot more than usual.

I. States that life isn't worth living, wishes for death, or attempts to harm self.

J. Being short-tempered, easily annoyed.

Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 30. Enter Score

D0600. Total Severity Score.

D0650. Safety Notification - Complete only if D0500I1 = 1 indicating possibility of resident self harm.

Was responsible staff or provider informed that there is a potential for resident self harm? 0. No... 1. Yes.

Enter Code

* Copyright © Pfizer Inc. All rights reserved.

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Resident Identifier Date

Section E. Behavior. E0100. Potential Indicators of Psychosis.

Check all that apply A. Hallucinations (perceptual experiences in the absence of real external sensory stimuli).

B. Delusions (misconceptions or beliefs that are firmly held, contrary to reality).

Z. None of the above.

Behavioral Symptoms.

E0200. Behavioral Symptom - Presence & Frequency.

Note presence of symptoms and their frequency.

Coding: 0. Behavior not exhibited. 1. Behavior of this type occurred 1 to 3 days. 2. Behavior of this type occurred 4 to 6 days,

but less than daily. 3. Behavior of this type occurred daily.

Enter Codes in Boxes. A. Physical behavioral symptoms directed toward others (e.g., hitting,

kicking, pushing, scratching, grabbing, abusing others sexually).

B. Verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others).

C. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds).

E0300. Overall Presence of Behavioral Symptoms.

Were any behavioral symptoms in questions E0200 coded 1, 2, or 3? 0. No Skip to E0800, Rejection of Care. 1. Yes Considering all of E0200, Behavioral Symptoms, answer E0500 and E0600 below.

Enter Code

E0500. Impact on Resident.

Did any of the identified symptom(s): A. Put the resident at significant risk for physical illness or injury?

0. No... 1. Yes.

Enter Code

B. Significantly interfere with the resident's care? 0. No... 1. Yes.

Enter Code

C. Significantly interfere with the resident's participation in activities or social interactions? 0. No... 1. Yes.

Enter Code

E0600. Impact on Others.

Did any of the identified symptom(s): A. Put others at significant risk for physical injury?

0. No... 1. Yes.

Enter Code

B. Significantly intrude on the privacy or activity of others? 0. No... 1. Yes.

Enter Code

C. Significantly disrupt care or living environment? 0. No... 1. Yes.

Enter Code

E0800. Rejection of Care - Presence & Frequency.

Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? Do not include behaviors that have already been addressed (e.g., by discussion or care planning with the resident or family), and determined to be consistent with resident values, preferences, or goals.

0. Behavior not exhibited. 1. Behavior of this type occurred 1 to 3 days. 2. Behavior of this type occurred 4 to 6 days, but less than daily. 3. Behavior of this type occurred daily.

Enter Code

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Resident Identifier Date

Section E. Behavior. E0900. Wandering - Presence & Frequency.

Has the resident wandered? 0. Behavior not exhibited Skip to E1100, Change in Behavioral or Other Symptoms. 1. Behavior of this type occurred 1 to 3 days. 2. Behavior of this type occurred 4 to 6 days, but less than daily. 3. Behavior of this type occurred daily.

Enter Code

E1000. Wandering - Impact.

A. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility)? 0. No... 1. Yes.

Enter Code

B. Does the wandering significantly intrude on the privacy or activities of others? 0. No... 1. Yes.

Enter Code

E1100. Change in Behavior or Other Symptoms. Consider all of the symptoms assessed in items E0100 through E1000.

How does resident's current behavior status, care rejection, or wandering compare to prior assessment (OBRA or Scheduled PPS)? 0. Same. 1. Improved. 2. Worse. 3. N/A because no prior MDS assessment.

Enter Code

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Resident Identifier Date

Section F. Preferences for Customary Routine and Activities.

F0300. Should Interview for Daily and Activity Preferences be Conducted? - Attempt to interview all residents able to communicate. If resident is unable to complete, attempt to complete interview with family member or significant other.

0. No (resident is rarely/never understood and family/significant other not available) Skip to and complete F0800, Staff Assessment of Daily and Activity Preferences.

1. Yes Continue to F0400, Interview for Daily Preferences.

Enter Code

F0400. Interview for Daily Preferences. Show resident the response options and say: "While you are in this facility..."

Enter Codes in Boxes.

Coding: 1. Very important. 2. Somewhat important. 3. Not very important. 4. Not important at all. 5. Important, but can't do or no

choice. 9. No response or non-responsive.

A. how important is it to you to choose what clothes to wear?

B. how important is it to you to take care of your personal belongings or things?

C. how important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?

D. how important is it to you to have snacks available between meals?

E. how important is it to you to choose your own bedtime?

F. how important is it to you to have your family or a close friend involved in discussions about your care?

G. how important is it to you to be able to use the phone in private?

H. how important is it to you to have a place to lock your things to keep them safe?

F0500. Interview for Activity Preferences. Show resident the response options and say: "While you are in this facility..."

Enter Codes in Boxes

Coding: 1. Very important. 2. Somewhat important. 3. Not very important. 4. Not important at all. 5. Important, but can't do or no

choice. 9. No response or non-responsive.

A. how important is it to you to have books, newspapers, and magazines to read?

B. how important is it to you to listen to music you like?

C. how important is it to you to be around animals such as pets?

D. how important is it to you to keep up with the news?

E. how important is it to you to do things with groups of people?

F. how important is it to you to do your favorite activities?

G. how important is it to you to go outside to get fresh air when the weather is good?

H. how important is it to you to participate in religious services or practices?

F0600. Daily and Activity Preferences Primary Respondent.

Indicate primary respondent for Daily and Activity Preferences (F0400 and F0500). 1. Resident. 2. Family or significant other (close friend or other representative). 9. Interview could not be completed by resident or family/significant other ("No response" to 3 or more items").

Enter Code

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Resident Identifier Date

Section F. Preferences for Customary Routine and Activities.

F0700. Should the Staff Assessment of Daily and Activity Preferences be Conducted?

0. No (because Interview for Daily and Activity Preferences (F0400 and F0500) was completed by resident or family/significant other) Skip to and complete G0110, Activities of Daily Living (ADL) Assistance.

1. Yes (because 3 or more items in Interview for Daily and Activity Preferences (F0400 and F0500) were not completed by resident or family/significant other) Continue to F0800, Staff Assessment of Daily and Activity Preferences.

Enter Code

F0800. Staff Assessment of Daily and Activity Preferences.

Do not conduct if Interview for Daily and Activity Preferences (F0400-F0500) was completed.

Resident Prefers: Check all that apply.

A. Choosing clothes to wear.

B. Caring for personal belongings.

C. Receiving tub bath.

D. Receiving shower.

E. Receiving bed bath.

F. Receiving sponge bath.

G. Snacks between meals.

H. Staying up past 8:00 p.m.

I. Family or significant other involvement in care discussions.

J. Use of phone in private.

K. Place to lock personal belongings.

L. Reading books, newspapers, or magazines.

M. Listening to music.

N. Being around animals such as pets.

O. Keeping up with the news.

P. Doing things with groups of people.

Q. Participating in favorite activities.

R. Spending time away from the nursing home.

S. Spending time outdoors.

T. Participating in religious activities or practices.

Z. None of the above.

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Resident Identifier Date

Section G. Functional Status. G0110. Activities of Daily Living (ADL) Assistance. Refer to the ADL flow chart in the RAI manual to facilitate accurate coding.

1. ADL Self-Performance. Code for resident's performance over all shifts - not including setup. If the ADL activity occurred 3 or more times at various levels of assistance, code the most dependent - except for total dependence, which requires full staff performance every time.

Coding: Activity Occurred 3 or More Times.

0. Independent - no help or staff oversight at any time. 1. Supervision - oversight, encouragement or cueing. 2. Limited assistance - resident highly involved in activity; staff provide guided maneuvering

of limbs or other non-weight-bearing assistance. 3. Extensive assistance - resident involved in activity, staff provide weight-bearing support. 4. Total dependence - full staff performance every time during entire 7-day period.

Activity Occurred 2 or Fewer Times. 7. Activity occurred only once or twice - activity did occur but only once or twice. 8. Activity did not occur - activity did not occur or family and/or non-facility staff provided

care 100% of the time for that activity over the entire 7-day period.

2. ADL Support Provided. Code for most support provided over all shifts; code regardless of resident's self- performance classification.

Coding: 0. No setup or physical help from staff. 1. Setup help only. 2. One person physical assist. 3. Two+ persons physical assist. 8. ADL activity itself did not occur or family

and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period..

1. Self-Performance.

2. Support.

Enter Codes in Boxes

A. Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture.

B. Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet).

C. Walk in room - how resident walks between locations in his/her room.

D. Walk in corridor - how resident walks in corridor on unit.

E. Locomotion on unit - how resident moves between locations in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair.

F. Locomotion off unit - how resident moves to and returns from off-unit locations (e.g., areas set aside for dining, activities or treatments). If facility has only one floor, how resident moves to and from distant areas on the floor. If in wheelchair, self-sufficiency once in chair.

G. Dressing - how resident puts on, fastens and takes off all items of clothing, including donning/removing a prosthesis or TED hose. Dressing includes putting on and changing pajamas and housedresses.

H. Eating - how resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. Includes intake of nourishment by other means (e.g., tube feeding, total parenteral nutrition, IV fluids administered for nutrition or hydration).

I. Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag or ostomy bag.

J. Personal hygiene - how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers).

Instructions for Rule of 3 ￭ When an activity occurs three times at any one given level, code that level. ￭ When an activity occurs three times at multiple levels, code the most dependent, exceptions are total dependence (4), activity must require full assist

every time, and activity did not occur (8), activity must not have occurred at all. Example, three times extensive assistance (3) and three times limited assistance (2), code extensive assistance (3).

￭ When an activity occurs at various levels, but not three times at any given level, apply the following: ￮ When there is a combination of full staff performance, and extensive assistance, code extensive assistance. ￮ When there is a combination of full staff performance, weight bearing assistance and/or non-weight bearing assistance code limited assistance (2).

If none of the above are met, code supervision.

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 16 of 45

Resident Identifier Date

Section G. Functional Status. G0120. Bathing. How resident takes full-body bath/shower, sponge bath, and transfers in/out of tub/shower (excludes washing of back and hair). Code for most dependent in self-performance and support.

A. Self-performance. 0. Independent - no help provided. 1. Supervision - oversight help only. 2. Physical help limited to transfer only. 3. Physical help in part of bathing activity. 4. Total dependence. 8. Activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire

7-day period

Enter Code

B. Support provided. (Bathing support codes are as defined in item G0110 column 2, ADL Support Provided, above).

Enter Code

G0300. Balance During Transitions and Walking.

After observing the resident, code the following walking and transition items for most dependent.

Coding: 0. Steady at all times. 1. Not steady, but able to stabilize without staff

assistance. 2. Not steady, only able to stabilize with staff

assistance. 8. Activity did not occur.

Enter Codes in Boxes.

A. Moving from seated to standing position.

B. Walking (with assistive device if used).

C. Turning around and facing the opposite direction while walking.

D. Moving on and off toilet.

E. Surface-to-surface transfer (transfer between bed and chair or wheelchair).

G0400. Functional Limitation in Range of Motion.

Code for limitation that interfered with daily functions or placed resident at risk of injury.

Coding: 0. No impairment. 1. Impairment on one side. 2. Impairment on both sides.

Enter Codes in Boxes.

A. Upper extremity (shoulder, elbow, wrist, hand).

B. Lower extremity (hip, knee, ankle, foot).

G0600. Mobility Devices.

Check all that were normally used.

A. Cane/crutch.

B. Walker.

C. Wheelchair (manual or electric).

D. Limb prosthesis.

Z. None of the above were used.

G0900. Functional Rehabilitation Potential. Complete only if A0310A = 01.

Enter Code A. Resident believes he or she is capable of increased independence in at least some ADLs. 0. No... 1. Yes. 9. Unable to determine.

Enter Code B. Direct care staff believe resident is capable of increased independence in at least some ADLs. 0. No... 1. Yes.

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 17 of 45

Resident Identifier Date

Section GG. Functional Abilities and Goals - Admission (Start of SNF PPS Stay). GG0130. Self-Care (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B). Complete only if A0310B = 01. Code the resident's usual performance at the start of the SNF PPS stay for each activity using the 6-point scale. If activity was not attempted at the start of the SNF PPS stay, code the reason. Code the patient's end of SNF PPS stay goal(s) using the 6-point scale. Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices.

06. Independent - Resident completes the activity by him/herself with no assistance from a helper. 05. Setup or clean-up assistance - Helper SETS UP or CLEANS UP; resident completes activity. Helper

assists only prior to or following the activity. 04. Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING

assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.

03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort..

02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort..

01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.

If activity was not attempted, code reason:

07. Resident refused. 09. Not applicable. 88. Not attempted due to medical

condition or safety concerns.

1. Admission

Performance.

2. Discharge

Goal. Enter Codes in Boxes

A. Eating: The ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on a table/tray. Includes modified food consistency.

B. Oral hygiene: The ability to use suitable items to clean teeth. [Dentures (if applicable): The ability to remove and replace dentures from and to the mouth, and manage equipment for soaking and rinsing them.]

C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan, or urinal. If managing an ostomy, include wiping the opening but not managing equipment..

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 18 of 45

Resident Identifier Date

Section GG. Functional Abilities and Goals - Admission (Start of SNF PPS Stay). GG0170. Mobility (Assessment period is days 1 through 3 of the SNF PPS Stay starting with A2400B). Complete only if A0310B = 01. Code the resident's usual performance at the start of the SNF PPS stay for each activity using the 6-point scale. If activity was not attempted at the start of the SNF PPS stay, code the reason. Code the patient's end of SNF PPS stay goal(s) using the 6-point scale. Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices.

06. Independent - Resident completes the activity by him/herself with no assistance from a helper. 05. Setup or clean-up assistance - Helper SETS UP or CLEANS UP; resident completes activity. Helper

assists only prior to or following the activity. 04. Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING

assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.

03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort..

02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort..

01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.

If activity was not attempted, code reason:

07. Resident refused. 09. Not applicable. 88. Not attempted due to medical

condition or safety concerns.

1. Admission

Performance.

2. Discharge

Goal. Enter Codes in Boxes

B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.

C. Lying to sitting on side of bed: The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support.

D. Sit to stand: The ability to safely come to a standing position from sitting in a chair or on the side of the bed..

E. Chair/bed-to-chair transfer: The ability to safely transfer to and from a bed to a chair (or wheelchair).

F. Toilet transfer: The ability to safely get on and off a toilet or commode.

H1. Does the resident walk? 0. No, and walking goal is not clinically indicated. Skip to GG0170Q1, Does the resident use a

wheelchair/scooter? 1. No, and walking goal is clinically indicated Code the resident's discharge goal(s) for items GG0170J

and GG0170K. 2. Yes Continue to GG0170J, Walk 50 feet with two turns.

J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.

K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.

Q1. Does the resident use a wheelchair/scooter? 0. No Skip to GG0130, Self Care. 1. Yes. Continue to GG0170R, Wheel 50 feet with two turns.

R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, can wheel at least 50 feet and make two turns..

RR1. Indicate the type of wheelchair/scooter used. 1. Manual. 2. Motorized.

S. Wheel 150 feet: Once seated in wheelchair/scooter, can wheel at least 150 feet in a corridor or similar space.

SS1. Indicate the type of wheelchair/scooter used. 1. Manual. 2. Motorized.

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 19 of 45

Resident Identifier Date

Section GG. Functional Abilities and Goals - Discharge (End of SNF PPS Stay). GG0130. Self-Care (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C). Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03. Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted at the end of the SNF PPS stay, code the reason. Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices.

06. Independent - Resident completes the activity by him/herself with no assistance from a helper. 05. Setup or clean-up assistance - Helper SETS UP or CLEANS UP; resident completes activity. Helper

assists only prior to or following the activity. 04. Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING

assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.

03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort..

02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort..

01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.

If activity was not attempted, code reason:

07. Resident refused. 09. Not applicable. 88. Not attempted due to medical

condition or safety concerns.

3. Discharge

Performance.

A. Eating: The ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on a table/ tray. Includes modified food consistency.

Enter Code

B. Oral hygiene: The ability to use suitable items to clean teeth. [Dentures (if applicable): The ability to remove and replace dentures from and to the mouth, and manage equipment for soaking and rinsing them.]

Enter Code

C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after using the toilet, commode, bedpan, or urinal. If managing an ostomy, include wiping the opening but not managing equipment..

Enter Code

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Resident Identifier Date

Section GG. Functional Abilities and Goals - Discharge (End of SNF PPS Stay). GG0170. Mobility (Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C). Complete only if A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2 and A2100 is not = 03. Code the resident's usual performance at the end of the SNF PPS stay for each activity using the 6-point scale. If an activity was not attempted at the end of the SNF PPS stay, code the reason. Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices.

06. Independent - Resident completes the activity by him/herself with no assistance from a helper. 05. Setup or clean-up assistance - Helper SETS UP or CLEANS UP; resident completes activity. Helper

assists only prior to or following the activity. 04. Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING

assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.

03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort..

02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort..

01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.

If activity was not attempted, code reason:

07. Resident refused. 09. Not applicable. 88. Not attempted due to medical

condition or safety concerns.

3. Discharge

Performance. Enter Codes in Boxes

B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.

C. Lying to sitting on side of bed: The ability to safely move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support.

D. Sit to stand: The ability to safely come to a standing position from sitting in a chair or on the side of the bed..

E. Chair/bed-to-chair transfer: The ability to safely transfer to and from a bed to a chair (or wheelchair).

F. Toilet transfer: The ability to safely get on and off a toilet or commode.

H3. Does the resident walk? 0. No Skip to GG0170Q3, Does the resident use a wheelchair/scooter? 2. Yes Continue to GG0170J, Walk 50 feet with two turns

J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.

K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.

Q3. Does the resident use a wheelchair/scooter? 0. No Skip to H0100, Appliances 1. Yes. Continue to GG0170R, Wheel 50 feet with two turns

R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, can wheel at least 50 feet and make two turns..

RR3. Indicate the type of wheelchair/scooter used. 1. Manual. 2. Motorized.

S. Wheel 150 feet: Once seated in wheelchair/scooter, can wheel at least 150 feet in a corridor or similar space.

SS3. Indicate the type of wheelchair/scooter used. 1. Manual. 2. Motorized.

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 21 of 45

Resident Identifier Date

Section H. Bladder and Bowel. H0100. Appliances.

Check all that apply.

A. Indwelling catheter (including suprapubic catheter and nephrostomy tube).

B. External catheter.

C. Ostomy (including urostomy, ileostomy, and colostomy).

D. Intermittent catheterization.

Z. None of the above.

H0200. Urinary Toileting Program.

A. Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility? 0. No Skip to H0300, Urinary Continence. 1. Yes Continue to H0200B, Response. 9. Unable to determine Skip to H0200C, Current toileting program or trial.

Enter Code

B. Response - What was the resident's response to the trial program? 0. No improvement. 1. Decreased wetness. 2. Completely dry (continent). 9. Unable to determine or trial in progress.

Enter Code

C. Current toileting program or trial - Is a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) currently being used to manage the resident's urinary continence? 0. No... 1. Yes.

Enter Code

H0300. Urinary Continence.

Urinary continence - Select the one category that best describes the resident. 0. Always continent. 1. Occasionally incontinent (less than 7 episodes of incontinence). 2. Frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). 3. Always incontinent (no episodes of continent voiding). 9. Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days.

Enter Code

H0400. Bowel Continence.

Bowel continence - Select the one category that best describes the resident. 0. Always continent. 1. Occasionally incontinent (one episode of bowel incontinence). 2. Frequently incontinent (2 or more episodes of bowel incontinence, but at least one continent bowel movement). 3. Always incontinent (no episodes of continent bowel movements). 9. Not rated, resident had an ostomy or did not have a bowel movement for the entire 7 days.

Enter Code

H0500. Bowel Toileting Program.

Is a toileting program currently being used to manage the resident's bowel continence? 0. No... 1. Yes.

Enter Code

H0600. Bowel Patterns.

Constipation present? 0. No... 1. Yes.

Enter Code

Neurological Diagnoses continued on next page.

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 22 of 45

Resident Identifier Date

Section I. Active Diagnoses. Active Diagnoses in the last 7 days - Check all that apply. Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.

Cancer. I0100. Cancer (with or without metastasis). Heart/Circulation. I0200. Anemia (e.g., aplastic, iron deficiency, pernicious, and sickle cell).

I0300. Atrial Fibrillation or Other Dysrhythmias (e.g., bradycardias and tachycardias).

I0400. Coronary Artery Disease (CAD) (e.g., angina, myocardial infarction, and atherosclerotic heart disease (ASHD)).

I0500. Deep Venous Thrombosis (DVT), Pulmonary Embolus (PE), or Pulmonary Thrombo-Embolism (PTE).

I0600. Heart Failure (e.g., congestive heart failure (CHF) and pulmonary edema).

I0700. Hypertension.

I0800. Orthostatic Hypotension.

I0900. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD). Gastrointestinal. I1100. Cirrhosis.

I1200. Gastroesophageal Reflux Disease (GERD) or Ulcer (e.g., esophageal, gastric, and peptic ulcers).

I1300. Ulcerative Colitis, Crohn's Disease, or Inflammatory Bowel Disease. Genitourinary. I1400. Benign Prostatic Hyperplasia (BPH).

I1500. Renal Insufficiency, Renal Failure, or End-Stage Renal Disease (ESRD).

I1550. Neurogenic Bladder.

I1650. Obstructive Uropathy. Infections. I1700. Multidrug-Resistant Organism (MDRO).

I2000. Pneumonia.

I2100. Septicemia.

I2200. Tuberculosis.

I2300. Urinary Tract Infection (UTI) (LAST 30 DAYS).

I2400. Viral Hepatitis (e.g., Hepatitis A, B, C, D, and E).

I2500. Wound Infection (other than foot). Metabolic. I2900. Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy).

I3100. Hyponatremia.

I3200. Hyperkalemia.

I3300. Hyperlipidemia (e.g., hypercholesterolemia).

I3400. Thyroid Disorder (e.g., hypothyroidism, hyperthyroidism, and Hashimoto's thyroiditis). Musculoskeletal. I3700. Arthritis (e.g., degenerative joint disease (DJD), osteoarthritis, and rheumatoid arthritis (RA)).

I3800. Osteoporosis.

I3900. Hip Fracture - any hip fracture that has a relationship to current status, treatments, monitoring (e.g., sub-capital fractures, and fractures of the trochanter and femoral neck).

I4000. Other Fracture. Neurological. I4200. Alzheimer's Disease.

I4300. Aphasia.

I4400. Cerebral Palsy.

I4500. Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke.

I4800. Non-Alzheimer's Dementia (e.g. Lewy body dementia, vascular or multi-infarct dementia; mixed dementia; frontotemporal dementia such as Pick's disease; and dementia related to stroke, Parkinson's or Creutzfeldt-Jakob diseases).

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 23 of 45

Resident Identifier Date

Section I. Active Diagnoses. Active Diagnoses in the last 7 days - Check all that apply. Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.

Neurological - Continued. I4900. Hemiplegia or Hemiparesis.

I5000. Paraplegia.

I5100. Quadriplegia.

I5200. Multiple Sclerosis (MS).

I5250. Huntington's Disease.

I5300. Parkinson's Disease.

I5350. Tourette's Syndrome.

I5400. Seizure Disorder or Epilepsy.

I5500. Traumatic Brain Injury (TBI). Nutritional. I5600. Malnutrition (protein or calorie) or at risk for malnutrition. Psychiatric/Mood Disorder. I5700. Anxiety Disorder.

I5800. Depression (other than bipolar).

I5900. Manic Depression (bipolar disease).

I5950. Psychotic Disorder (other than schizophrenia).

I6000. Schizophrenia (e.g., schizoaffective and schizophreniform disorders).

I6100. Post Traumatic Stress Disorder (PTSD). Pulmonary. I6200. Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease (e.g., chronic bronchitis and restrictive lung

diseases such as asbestosis). I6300. Respiratory Failure Vision. I6500. Cataracts, Glaucoma, or Macular Degeneration. None of Above. I7900. None of the above active diagnoses within the last 7 days. Other. I8000. Additional active diagnoses. Enter diagnosis on line and ICD code in boxes. Include the decimal for the code in the appropriate box.

A.

B.

C.

D.

E.

F.

G.

H.

I.

J.

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 24 of 45

Resident Identifier Date

Section J. Health Conditions. J0100. Pain Management - Complete for all residents, regardless of current pain level. At any time in the last 5 days, has the resident:

A. Received scheduled pain medication regimen? 0. No... 1. Yes.

Enter Code

B. Received PRN pain medications OR was offered and declined? 0. No... 1. Yes.

Enter Code

C. Received non-medication intervention for pain? 0. No... 1. Yes.

Enter Code

J0200. Should Pain Assessment Interview be Conducted? Attempt to conduct interview with all residents. If resident is comatose, skip to J1100, Shortness of Breath (dyspnea).

0. No (resident is rarely/never understood) Skip to and complete J0800, Indicators of Pain or Possible Pain. 1. Yes Continue to J0300, Pain Presence.

Enter Code

Pain Assessment Interview. J0300. Pain Presence.

Ask resident: "Have you had pain or hurting at any time in the last 5 days?" 0. No Skip to J1100, Shortness of Breath. 1. Yes Continue to J0400, Pain Frequency. 9. Unable to answer Skip to J0800, Indicators of Pain or Possible Pain.

Enter Code

J0400. Pain Frequency. Ask resident: "How much of the time have you experienced pain or hurting over the last 5 days?"

1. Almost constantly. 2. Frequently. 3. Occasionally. 4. Rarely. 9. Unable to answer.

Enter Code

J0500. Pain Effect on Function. A. Ask resident: "Over the past 5 days, has pain made it hard for you to sleep at night?"

0. No... 1. Yes. 9. Unable to answer.

Enter Code

B. Ask resident: "Over the past 5 days, have you limited your day-to-day activities because of pain?" 0. No... 1. Yes. 9. Unable to answer.

Enter Code

J0600. Pain Intensity - Administer ONLY ONE of the following pain intensity questions (A or B). A. Numeric Rating Scale (00-10).

Ask resident: "Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine." (Show resident 00 -10 pain scale) Enter two-digit response. Enter 99 if unable to answer.

Enter Rating

B. Verbal Descriptor Scale. Ask resident: "Please rate the intensity of your worst pain over the last 5 days." (Show resident verbal scale) 1. Mild. 2. Moderate. 3. Severe. 4. Very severe, horrible. 9. Unable to answer.

Enter Code

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 25 of 45

Resident Identifier Date

Section J. Health Conditions.

J0700. Should the Staff Assessment for Pain be Conducted?

0. No (J0400 = 1 thru 4) Skip to J1100, Shortness of Breath (dyspnea). 1. Yes (J0400 = 9) Continue to J0800, Indicators of Pain or Possible Pain.

Enter Code

Staff Assessment for Pain.

J0800. Indicators of Pain or Possible Pain in the last 5 days.

Check all that apply.

A. Non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning).

B. Vocal complaints of pain (e.g., that hurts, ouch, stop).

C. Facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw).

D. Protective body movements or postures (e.g., bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement).

Z. None of these signs observed or documented If checked, skip to J1100, Shortness of Breath (dyspnea).

J0850. Frequency of Indicator of Pain or Possible Pain in the last 5 days.

Frequency with which resident complains or shows evidence of pain or possible pain. 1. Indicators of pain or possible pain observed 1 to 2 days. 2. Indicators of pain or possible pain observed 3 to 4 days. 3. Indicators of pain or possible pain observed daily.

Enter Code

Other Health Conditions.

J1100. Shortness of Breath (dyspnea).

Check all that apply.

A. Shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring).

B. Shortness of breath or trouble breathing when sitting at rest.

C. Shortness of breath or trouble breathing when lying flat.

Z. None of the above.

J1300. Current Tobacco Use.

Tobacco use. 0. No... 1. Yes.

Enter Code

J1400. Prognosis.

Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? (Requires physician documentation).

0. No... 1. Yes.

Enter Code

J1550. Problem Conditions.

Check all that apply.

A. Fever.

B. Vomiting.

C. Dehydrated.

D. Internal bleeding.

Z. None of the above.

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Resident Identifier Date

Section J. Health Conditions. J1700. Fall History on Admission/Entry or Reentry. Complete only if A0310A = 01 or A0310E = 1

A. Did the resident have a fall any time in the last month prior to admission/entry or reentry? 0. No... 1. Yes. 9. Unable to determine.

Enter Code

B. Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry? 0. No... 1. Yes. 9. Unable to determine.

Enter Code

C. Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry? 0. No... 1. Yes. 9. Unable to determine.

Enter Code

J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent.

Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent? 0. No Skip to K0100, Swallowing Disorder. 1. Yes Continue to J1900, Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS).

Enter Code

J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent.

Coding: 0. None 1. One 2. Two or more

Enter Codes in Boxes

A. No injury - no evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the resident; no change in the resident's behavior is noted after the fall.

B. Injury (except major) - skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the resident to complain of pain.

C. Major injury - bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma.

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 27 of 45

Resident Identifier Date

Section K. Swallowing/Nutritional Status. K0100. Swallowing Disorder. Signs and symptoms of possible swallowing disorder.

Check all that apply. A. Loss of liquids/solids from mouth when eating or drinking.

B. Holding food in mouth/cheeks or residual food in mouth after meals.

C. Coughing or choking during meals or when swallowing medications.

D. Complaints of difficulty or pain with swallowing.

Z. None of the above.

K0200. Height and Weight - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up.

A. Height (in inches). Record most recent height measure since the most recent admission/entry or reentry. inches

B. Weight (in pounds). Base weight on most recent measure in last 30 days; measure weight consistently, according to standard facility practice (e.g., in a.m. after voiding, before meal, with shoes off, etc.).

pounds

K0300. Weight Loss.

Loss of 5% or more in the last month or loss of 10% or more in last 6 months. 0. No or unknown. 1. Yes, on physician-prescribed weight-loss regimen. 2. Yes, not on physician-prescribed weight-loss regimen.

Enter Code

K0310. Weight Gain.

Gain of 5% or more in the last month or gain of 10% or more in last 6 months. 0. No or unknown. 1. Yes, on physician-prescribed weight-gain regimen. 2. Yes, not on physician-prescribed weight-gain regimen.

Enter Code

K0510. Nutritional Approaches. Check all of the following nutritional approaches that were performed during the last 7 days. 1. While NOT a Resident.

Performed while NOT a resident of this facility and within the last 7 days. Only check column 1 if resident entered (admission or reentry) IN THE LAST 7 DAYS. If resident last entered 7 or more days ago, leave column 1 blank.

2. While a Resident. Performed while a resident of this facility and within the last 7 days.

1. While NOT a

Resident.

2. While a

Resident.

Check all that apply

A. Parenteral/IV feeding.

B. Feeding tube - nasogastric or abdominal (PEG).

C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food, thickened liquids).

D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol).

Z. None of the above.

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 28 of 45

Resident Identifier Date

Section K. Swallowing/Nutritional Status. K0710. Percent Intake by Artificial Route - Complete K0710 only if Column 1 and/or Column 2 are checked for K0510A and/or K0510B. 1. While NOT a Resident.

Performed while NOT a resident of this facility and within the last 7 days. Only enter a code in column 1 if resident entered (admission or reentry) IN THE LAST 7 DAYS. If resident last entered 7 or more days ago, leave column 1 blank.

2. While a Resident. Performed while a resident of this facility and within the last 7 days.

3. During Entire 7 Days. Performed during the entire last 7 days.

1. While NOT a

Resident.

2. While a

Resident.

3. During Entire

7 Days.

Enter Codes A. Proportion of total calories the resident received through parenteral or tube feeding.

1. 25% or less. 2. 26-50%. 3. 51% or more.

B. Average fluid intake per day by IV or tube feeding. 1. 500 cc/day or less. 2. 501 cc/day or more.

L0200. Dental

Check all that apply. A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose).

B. No natural teeth or tooth fragment(s) (edentulous).

C. Abnormal mouth tissue (ulcers, masses, oral lesions, including under denture or partial if one is worn).

D. Obvious or likely cavity or broken natural teeth.

E. Inflamed or bleeding gums or loose natural teeth.

F. Mouth or facial pain, discomfort or difficulty with chewing.

G. Unable to examine.

Z. None of the above were present.

Section L. Oral/Dental Status.

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 29 of 45

Resident Identifier Date

Section M. Skin Conditions.

Report based on highest stage of existing ulcer(s) at its worst; do not "reverse" stage.

M0100. Determination of Pressure Ulcer Risk.

Check all that apply.

A. Resident has a stage 1 or greater, a scar over bony prominence, or a non-removable dressing/device.

B. Formal assessment instrument/tool (e.g., Braden, Norton, or other).

C. Clinical assessment.

Z. None of the above.

M0150. Risk of Pressure Ulcers.

Is this resident at risk of developing pressure ulcers? 0. No... 1. Yes.

Enter Code

M0210. Unhealed Pressure Ulcer(s).

Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? 0. No Skip to M0900, Healed Pressure Ulcers. 1. Yes Continue to M0300, Current Number of Unhealed Pressure Ulcers at Each Stage.

Enter Code

M0300. Current Number of Unhealed Pressure Ulcers at Each Stage. A. Number of Stage 1 pressure ulcers.

Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.

Enter Number

B. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.

1. Number of Stage 2 pressure ulcers.- If 0 Skip to M0300C, Stage 3.

Enter Number

2. Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry.

Enter Number

3. Date of oldest Stage 2 pressure ulcer - Enter dashes if date is unknown:

Month

_

Day

_

Year

C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

1. Number of Stage 3 pressure ulcers - If 0 Skip to M0300D, Stage 4.

Enter Number

2. Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry.

Enter Number

D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.

1. Number of Stage 4 pressure ulcers - If 0 Skip to M0300E, Unstageable: Non-removable dressing.

Enter Number

2. Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry.

Enter Number

M0300 continued on next page.

Page 30 of 45

Resident Identifier Date

Section M. Skin Conditions. M0300. Current Number of Unhealed Pressure Ulcers at Each Stage - Continued.

E. Unstageable - Non-removable dressing: Known but not stageable due to non-removable dressing/device.

1. Number of unstageable pressure ulcers due to non-removable dressing/device - If 0 Skip to M0300F, Unstageable: Slough and/or eschar.

Enter Number

2. Number of these unstageable pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry.

Enter Number

F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar.

1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar - If 0 Skip to M0300G, Unstageable: Deep tissue.

Enter Number

2. Number of these unstageable pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry.

Enter Number

G. Unstageable - Deep tissue: Suspected deep tissue injury in evolution.

1. Number of unstageable pressure ulcers with suspected deep tissue injury in evolution - If 0 Skip to M0610, Dimension of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar.

Enter Number

2. Number of these unstageable pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the time of admission/entry or reentry.

Enter Number

M0610. Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar. Complete only if M0300C1, M0300D1 or M0300F1 is greater than 0. If the resident has one or more unhealed Stage 3 or 4 pressure ulcers or an unstageable pressure ulcer due to slough or eschar, identify the pressure ulcer with the largest surface area (length x width) and record in centimeters:

. cm A. Pressure ulcer length: Longest length from head to toe.

. cm B. Pressure ulcer width: Widest width of the same pressure ulcer, side-to-side perpendicular (90-degree angle) to length.

. cm C. Pressure ulcer depth: Depth of the same pressure ulcer from the visible surface to the deepest area (if depth is unknown,

enter a dash in each box).

M0700. Most Severe Tissue Type for Any Pressure Ulcer.

Select the best description of the most severe type of tissue present in any pressure ulcer bed. 1. Epithelial tissue - new skin growing in superficial ulcer. It can be light pink and shiny, even in persons with darkly pigmented skin. 2. Granulation tissue - pink or red tissue with shiny, moist, granular appearance. 3. Slough - yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. 4. Eschar - black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding

skin. 9. None of the Above.

Enter Code

M0800. Worsening in Pressure Ulcer Status Since Prior Assessment (OBRA or Scheduled PPS) or Last Admission/Entry or Reentry. Complete only if A0310E = 0. Indicate the number of current pressure ulcers that were not present or were at a lesser stage on prior assessment (OBRA or scheduled PPS) or last entry. If no current pressure ulcer at a given stage, enter 0.

A. Stage 2. Enter Number

B. Stage 3. Enter Number

Enter Number

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT

C. Stage 4.

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 31 of 45

Resident Identifier Date

Section M. Skin Conditions. M0900. Healed Pressure Ulcers. Complete only if A0310E = 0.

A. Were pressure ulcers present on the prior assessment (OBRA or scheduled PPS)? 0. No Skip to M1030, Number of Venous and Arterial Ulcers. 1. Yes Continue to M0900B, Stage 2.

Enter Code

Indicate the number of pressure ulcers that were noted on the prior assessment (OBRA or scheduled PPS) that have completely closed (resurfaced with epithelium). If no healed pressure ulcer at a given stage since the prior assessment (OBRA or scheduled PPS), enter 0.

B. Stage 2. Enter Number

C. Stage 3. Enter Number

D. Stage 4. Enter Number

M1030. Number of Venous and Arterial Ulcers.

Enter the total number of venous and arterial ulcers present. Enter Number

M1040. Other Ulcers, Wounds and Skin Problems.

Check all that apply. Foot Problems.

A. Infection of the foot (e.g., cellulitis, purulent drainage).

B. Diabetic foot ulcer(s).

C. Other open lesion(s) on the foot.

Other Problems.

D. Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion).

E. Surgical wound(s).

F. Burn(s) (second or third degree).

G. Skin tear(s).

H. Moisture Associated Skin Damage (MASD) (e.g., incontinence-associated dermatitis [IAD], perspiration, drainage).

None of the Above.

Z. None of the above were present.

M1200. Skin and Ulcer Treatments.

Check all that apply.

A. Pressure reducing device for chair.

B. Pressure reducing device for bed.

C. Turning/repositioning program.

D. Nutrition or hydration intervention to manage skin problems.

E. Pressure ulcer care.

F. Surgical wound care.

G. Application of nonsurgical dressings (with or without topical medications) other than to feet.

H. Applications of ointments/medications other than to feet.

I. Application of dressings to feet (with or without topical medications).

Z. None of the above were provided.

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 32 of 45

Resident Identifier Date

Section N. Medications. N0300. Injections.

Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days. If 0 Skip to N0410, Medications Received.

Enter Days

N0350. Insulin.

A. Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days.

Enter Days

B. Orders for insulin - Record the number of days the physician (or authorized assistant or practitioner) changed the resident's insulin orders during the last 7 days or since admission/entry or reentry if less than 7 days.

Enter Days

N0410. Medications Received.

Indicate the number of DAYS the resident received the following medications during the last 7 days or since admission/entry or reentry if less than 7 days. Enter "0" if medication was not received by the resident during the last 7 days..

A. Antipsychotic. Enter Days

B. Antianxiety. Enter Days

C. Antidepressant. Enter Days

D. Hypnotic. Enter Days

E. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin). Enter Days

F. Antibiotic. Enter Days

G. Diuretic. Enter Days

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 33 of 45

Resident Identifier Date

Section O. Special Treatments, Procedures, and Programs. O0100. Special Treatments, Procedures, and Programs. Check all of the following treatments, procedures, and programs that were performed during the last 14 days. 1. While NOT a Resident.

Performed while NOT a resident of this facility and within the last 14 days. Only check column 1 if resident entered (admission or reentry) IN THE LAST 14 DAYS. If resident last entered 14 or more days ago, leave column 1 blank.

2. While a Resident. Performed while a resident of this facility and within the last 14 days.

1. While NOT a

Resident.

2. While a

Resident.

Check all that apply Cancer Treatments.

A. Chemotherapy.

B. Radiation.

Respiratory Treatments.

C. Oxygen therapy.

D. Suctioning.

E. Tracheostomy care.

F. Ventilator or respirator.

G. BiPAP/CPAP.

None of the Above.

H. IV medications.

I. Transfusions.

J. Dialysis.

K. Hospice care.

L. Respite care.

M. Isolation or quarantine for active infectious disease (does not include standard body/fluid precautions).

Other.

Z. None of the above.

O0250. Influenza Vaccine - Refer to current version of RAI manual for current influenza vaccination season and reporting period. A. Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season?

0. No Skip to O0250C, If influenza vaccine not received, state reason. 1. Yes Continue to O0250B, Date influenza vaccine received.

Enter Code

B. Date influenza vaccine received Complete date and skip to O0300A, Is the resident's Pneumococcal vaccination up to date?

Month

_

Day

_

Year

C. If influenza vaccine not received, state reason: 1. Resident not in this facility during this year's influenza vaccination season. 2. Received outside of this facility. 3. Not eligible - medical contraindication. 4. Offered and declined. 5. Not offered. 6. Inability to obtain influenza vaccine due to a declared shortage. 9. None of the above.

Enter Code

O0300. Pneumococcal Vaccine. A. Is the resident's Pneumococcal vaccination up to date?

0. No Continue to O0300B, If Pneumococcal vaccine not received, state reason. 1. Yes Skip to O0400, Therapies.

Enter Code

B. If Pneumococcal vaccine not received, state reason: 1. Not eligible - medical contraindication. 2. Offered and declined. 3. Not offered.

Enter Code

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Resident Identifier Date

Section O. Special Treatments, Procedures, and Programs. O0400. Therapies.

A. Speech-Language Pathology and Audiology Services.

Enter Number of Minutes 1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the last 7 days.

Enter Number of Minutes 2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the last 7 days.

Enter Number of Minutes 3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days.

If the sum of individual, concurrent, and group minutes is zero, skip to O0400A5, Therapy start date

Enter Number of Minutes 3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment sessions in the last 7 days.

Enter Number of Days 4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.

5. Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started.

Month

_

Day

_

Year

6. Therapy end date - record the date the most recent therapy regimen (since the most recent entry) ended - enter dashes if therapy is ongoing.

Month

_

Day

_

Year

B. Occupational Therapy.

Enter Number of Minutes 1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the last 7 days.

Enter Number of Minutes 2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the last 7 days.

Enter Number of Minutes 3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days.

If the sum of individual, concurrent, and group minutes is zero, skip to O0400B5, Therapy start date

Enter Number of Minutes 3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment sessions in the last 7 days.

Enter Number of Days 4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.

5. Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started.

Month

_

Day

_

Year

6. Therapy end date - record the date the most recent therapy regimen (since the most recent entry) ended - enter dashes if therapy is ongoing.

Month

_

Day

_

Year

O0400 continued on next page

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 35 of 45

Resident Identifier Date

Section O. Special Treatments, Procedures, and Programs. O0400. Therapies - Continued.

C. Physical Therapy.

Enter Number of Minutes 1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the last 7 days.

Enter Number of Minutes 2. Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the last 7 days.

Enter Number of Minutes 3. Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days.

If the sum of individual, concurrent, and group minutes is zero, skip to O0400C5, Therapy start date

Enter Number of Minutes 3A. Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment sessions in the last 7 days.

Enter Number of Days 4. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.

5. Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started.

Month

_

Day

_

Year

6. Therapy end date - record the date the most recent therapy regimen (since the most recent entry) ended - enter dashes if therapy is ongoing.

Month

_

Day

_

Year

D. Respiratory Therapy.

1. Total minutes - record the total number of minutes this therapy was administered to the resident in the last 7 days.

If zero, skip to O0400E, Psychological Therapy.

Enter Number of Minutes

2. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days. Enter Number of Days

E. Psychological Therapy (by any licensed mental health professional).

1. Total minutes - record the total number of minutes this therapy was administered to the resident in the last 7 days.

If zero, skip to O0400F, Recreational Therapy.

Enter Number of Minutes

2. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days. Enter Number of Days

F. Recreational Therapy (includes recreational and music therapy).

1. Total minutes - record the total number of minutes this therapy was administered to the resident in the last 7 days.

If zero, skip to O0420, Distinct Calendar Days of Therapy.

Enter Number of Minutes

2. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days. Enter Number of Days

O0420. Distinct Calendar Days of Therapy.

Record the number of calendar days that the resident received Speech-Language Pathology and Audiology Services, Occupational Therapy, or Physical Therapy for at least 15 minutes in the past 7 days.

Enter Number of Days

O0450. Resumption of Therapy - Complete only if A0310C = 2 or 3 and A0310F = 99. A. Has a previous rehabilitation therapy regimen (speech, occupational, and/or physical therapy) ended, as reported on this End of

Therapy OMRA, and has this regimen now resumed at exactly the same level for each discipline? 0. No Skip to O0500, Restorative Nursing Programs. 1. Yes

Enter Code

B. Date on which therapy regimen resumed:

Month

_

Day

_

Year

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 36 of 45

Resident Identifier Date

Section O. Special Treatments, Procedures, and Programs. O0500. Restorative Nursing Programs. Record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days (enter 0 if none or less than 15 minutes daily).

Number of Days. Technique.

A. Range of motion (passive).

B. Range of motion (active).

C. Splint or brace assistance.

Number of Days. Training and Skill Practice In:

D. Bed mobility.

E. Transfer.

F. Walking.

G. Dressing and/or grooming.

H. Eating and/or swallowing.

I. Amputation/prostheses care.

J. Communication.

O0700. Physician Orders.

Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) change the resident's orders? Enter Days

O0600. Physician Examinations.

Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) examine the resident? Enter Days

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 37 of 45

Resident Identifier Date

Section P. Restraints. P0100. Physical Restraints. Physical restraints are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.

Coding: 0. Not used. 1. Used less than daily. 2. Used daily.

Enter Codes in Boxes. Used in Bed.

A. Bed rail.

B. Trunk restraint.

C. Limb restraint.

D. Other.

Used in Chair or Out of Bed.

E. Trunk restraint.

F. Limb restraint.

G. Chair prevents rising.

H. Other.

Section Q. Participation in Assessment and Goal Setting. Q0100. Participation in Assessment.

A. Resident participated in assessment. 0. No... 1. Yes.

Enter Code

B. Family or significant other participated in assessment. 0. No... 1. Yes. 9. Resident has no family or significant other.

Enter Code

C. Guardian or legally authorized representative participated in assessment. 0. No... 1. Yes. 9. Resident has no guardian or legally authorized representative.

Enter Code

Q0300. Resident's Overall Expectation. Complete only if A0310E = 1.

A. Select one for resident's overall goal established during assessment process. 1. Expects to be discharged to the community. 2. Expects to remain in this facility. 3. Expects to be discharged to another facility/institution. 9. Unknown or uncertain.

Enter Code

B. Indicate information source for Q0300A. 1. Resident. 2. If not resident, then family or significant other. 3. If not resident, family, or significant other, then guardian or legally authorized representative. 9. Unknown or uncertain.

Enter Code

Q0400. Discharge Plan.

A. Is active discharge planning already occurring for the resident to return to the community? 0. No... 1. Yes Skip to Q0600, Referral.

Enter Code

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 38 of 45

Resident Identifier Date

Section Q. Participation in Assessment and Goal Setting. Q0490. Resident's Preference to Avoid Being Asked Question Q0500B. Complete only if A0310A = 02, 06, or 99.

Enter Code Does the resident's clinical record document a request that this question be asked only on comprehensive assessments? 0. No... 1. Yes Skip to Q0600, Referral.

Q0500. Return to Community. B. Ask the resident (or family or significant other or guardian or legally authorized representative if resident is unable to understand or

respond): "Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community?" 0. No... 1. Yes. 9. Unknown or uncertain.

Enter Code

Q0550. Resident's Preference to Avoid Being Asked Question Q0500B Again.

A. Does the resident (or family or significant other or guardian or legally authorized representative if resident is unable to understand or respond) want to be asked about returning to the community on all assessments? (Rather than only on comprehensive assessments.) 0. No - then document in resident's clinical record and ask again only on the next comprehensive assessment... 1. Yes. 8. Information not available.

Enter Code

B. Indicate information source for Q0550A. 1. Resident... 2. If not resident, then family or significant other. 3. If not resident, family or significant other, then guardian or legally authorized representative. 9. None of the above.

Enter Code

Has a referral been made to the Local Contact Agency? (Document reasons in resident's clinical record). 0. No - referral not needed. 1. No - referral is or may be needed (For more information see Appendix C, Care Area Assessment Resources #20). 2. Yes - referral made.

Q0600. Referral.

Enter Code

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Resident Identifier Date

Section V. Care Area Assessment (CAA) Summary. V0100. Items From the Most Recent Prior OBRA or Scheduled PPS Assessment. Complete only if A0310E = 0 and if the following is true for the prior assessment: A0310A = 01- 06 or A0310B = 01- 05

A. Prior Assessment Federal OBRA Reason for Assessment (A0310A value from prior assessment). 01. Admission assessment (required by day 14). 02. Quarterly review assessment. 03. Annual assessment. 04. Significant change in status assessment. 05. Significant correction to prior comprehensive assessment. 06. Significant correction to prior quarterly assessment. 99. None of the above.

Enter Code

B. Prior Assessment PPS Reason for Assessment (A0310B value from prior assessment). 01. 5-day scheduled assessment. 02. 14-day scheduled assessment. 03. 30-day scheduled assessment. 04. 60-day scheduled assessment. 05. 90-day scheduled assessment. 07. Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment). 99. None of the above.

Enter Code

C. Prior Assessment Reference Date (A2300 value from prior assessment).

Month

_

Day

_

Year

D. Prior Assessment Brief Interview for Mental Status (BIMS) Summary Score (C0500 value from prior assessment). Enter Score

E. Prior Assessment Resident Mood Interview (PHQ-9©) Total Severity Score (D0300 value from prior assessment). Enter Score

F. Prior Assessment Staff Assessment of Resident Mood (PHQ-9-OV) Total Severity Score (D0600 value from prior assessment). Enter Score

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 40 of 45

Resident Identifier Date

Section V. Care Area Assessment (CAA) Summary. V0200. CAAs and Care Planning.

1. Check column A if Care Area is triggered. 2. For each triggered Care Area, indicate whether a new care plan, care plan revision, or continuation of current care plan is necessary to address

the problem(s) identified in your assessment of the care area. The Care Planning Decision column must be completed within 7 days of completing the RAI (MDS and CAA(s)). Check column B if the triggered care area is addressed in the care plan.

3. Indicate in the Location and Date of CAA Documentation column where information related to the CAA can be found. CAA documentation should include information on the complicating factors, risks, and any referrals for this resident for this care area.

A. CAA Results.

Care Area.

A. Care Area Triggered.

B. Care Planning

Decision. Location and Date of CAA documentation.

Check all that apply

01. Delirium.

02. Cognitive Loss/Dementia.

03. Visual Function.

04. Communication.

05. ADL Functional/Rehabilitation Potential.

06. Urinary Incontinence and Indwelling Catheter.

07. Psychosocial Well-Being.

08. Mood State.

09. Behavioral Symptoms.

10. Activities.

11. Falls.

12. Nutritional Status.

13. Feeding Tube.

14. Dehydration/Fluid Maintenance.

15. Dental Care.

16. Pressure Ulcer.

17. Psychotropic Drug Use.

18. Physical Restraints.

19. Pain.

20. Return to Community Referral.

B. Signature of RN Coordinator for CAA Process and Date Signed.

1. Signature. 2. Date.

Month

_

Day

_

Year

C. Signature of Person Completing Care Plan Decision and Date Signed.

1. Signature. 2. Date.

Month

_

Day

_

Year

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 41 of 45

Resident Identifier Date

Section X. Correction Request. Complete Section X only if A0050 = 2 or 3. Identification of Record to be Modified/Inactivated - The following items identify the existing assessment record that is in error. In this section, reproduce the information EXACTLY as it appeared on the existing erroneous record, even if the information is incorrect. This information is necessary to locate the existing record in the National MDS Database.

X0150. Type of Provider (A0200 on existing record to be modified/inactivated). Type of provider.

1. Nursing home (SNF/NF). 2. Swing Bed.

Enter Code

X0200. Name of Resident (A0500 on existing record to be modified/inactivated). A. First name:

C. Last name:

X0300. Gender (A0800 on existing record to be modified/inactivated).

1. Male 2. Female

Enter Code

X0400. Birth Date (A0900 on existing record to be modified/inactivated).

Month

_

Day

_

Year

X0500. Social Security Number (A0600A on existing record to be modified/inactivated).

_ _

X0600. Type of Assessment (A0310 on existing record to be modified/inactivated).

A. Federal OBRA Reason for Assessment. 01. Admission assessment (required by day 14). 02. Quarterly review assessment. 03. Annual assessment. 04. Significant change in status assessment. 05. Significant correction to prior comprehensive assessment. 06. Significant correction to prior quarterly assessment. 99. None of the above.

Enter Code

B. PPS Assessment. PPS Scheduled Assessments for a Medicare Part A Stay. 01. 5-day scheduled assessment. 02. 14-day scheduled assessment. 03. 30-day scheduled assessment. 04. 60-day scheduled assessment. 05. 90-day scheduled assessment. PPS Unscheduled Assessments for a Medicare Part A Stay. 07. Unscheduled assessment used for PPS (OMRA, significant or clinical change, or significant correction assessment). Not PPS Assessment. 99. None of the above.

Enter Code

C. PPS Other Medicare Required Assessment - OMRA 0. No... 1. Start of therapy assessment. 2. End of therapy assessment. 3. Both Start and End of therapy assessment. 4. Change of therapy assessment.

Enter Code

X0600 continued on next page.

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 42 of 45

Resident Identifier Date

Section X. Correction Request. X0600. Type of Assessment.- Continued.

D. Is this a Swing Bed clinical change assessment? Complete only if X0150 = 2. 0. No... 1. Yes.

Enter Code

F. Entry/discharge reporting 01. Entry tracking record. 10. Discharge assessment-return not anticipated. 11. Discharge assessment-return anticipated. 12. Death in facility tracking record. 99. None of the above.

Enter Code

H. Is this a SNF PPS Part A Discharge (End of Stay) Assessment?. 0. No... 1. Yes.

Enter Code

X0700. Date on existing record to be modified/inactivated - Complete one only. A. Assessment Reference Date (A2300 on existing record to be modified/inactivated) - Complete only if X0600F = 99.

Month

_

Day

_

Year B. Discharge Date (A2000 on existing record to be modified/inactivated) - Complete only if X0600F = 10, 11, or 12.

Month

_

Day

_

Year C. Entry Date (A1600 on existing record to be modified/inactivated) - Complete only if X0600F = 01.

Month

_

Day

_

Year

Correction Attestation Section.- Complete this section to explain and attest to the modification/inactivation request.

X0800. Correction Number.

Enter the number of correction requests to modify/inactivate the existing record, including the present one. Enter Number

X0900. Reasons for Modification.- Complete only if Type of Record is to modify a record in error (A0050 = 2).

Check all that apply. A. Transcription error.

B. Data entry error.

C. Software product error.

D. Item coding error.

E. End of Therapy - Resumption (EOT-R) date.

Z. Other error requiring modification. If "Other" checked, please specify:

X1050. Reasons for Inactivation.- Complete only if Type of Record is to inactivate a record in error (A0050 = 3).

Check all that apply. A. Event did not occur.

Z. Other error requiring inactivation. If "Other" checked, please specify:

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 43 of 45

Resident Identifier Date

Section X. Correction Request. X1100. RN Assessment Coordinator Attestation of Completion.

A. Attesting individual's first name:

B. Attesting individual's last name:

C. Attesting individual's title:

D. Signature.

E. Attestation date.

Month

_

Day

_

Year

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 44 of 45

Resident Identifier Date

Section Z. Assessment Administration. Z0100. Medicare Part A Billing.

A. Medicare Part A HIPPS code (RUG group followed by assessment type indicator):

B. RUG version code:

C. Is this a Medicare Short Stay assessment? 0. No... 1. Yes

Enter Code

Z0150. Medicare Part A Non-Therapy Billing.

A. Medicare Part A non-therapy HIPPS code (RUG group followed by assessment type indicator):

B. RUG version code:

Z0200. State Medicaid Billing (if required by the state).

A. RUG Case Mix group:

B. RUG version code:

Z0250. Alternate State Medicaid Billing (if required by the state).

A. RUG Case Mix group:

B. RUG version code:

Z0300. Insurance Billing.

A. RUG billing code:

B. RUG billing version:

MDS 3.0 Nursing Home Comprehensive (NC) Corrected Version 1.14.0 DRAFT Page 45 of 45

Resident Identifier Date

Section Z. Assessment Administration. Z0400. Signature of Persons Completing the Assessment or Entry/Death Reporting.

I certify that the accompanying information accurately reflects resident assessment information for this resident and that I collected or coordinated collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable Medicare and Medicaid requirements. I understand that this information is used as a basis for ensuring that residents receive appropriate and quality care, and as a basis for payment from federal funds. I further understand that payment of such federal funds and continued participation in the government-funded health care programs is conditioned on the accuracy and truthfulness of this information, and that I may be personally subject to or may subject my organization to substantial criminal, civil, and/or administrative penalties for submitting false information. I also certify that I am authorized to submit this information by this facility on its behalf.

Signature Title Sections Date Section Completed A.

B.

C.

D.

E.

F.

G.

H.

I.

J.

K.

L.

Z0500. Signature of RN Assessment Coordinator Verifying Assessment Completion.

A. Signature: B. Date RN Assessment Coordinator signed assessment as complete:

Month

_

Day

_

Year

Legal Notice Regarding MDS 3.0 - Copyright 2011 United States of America and InterRAI. This work may be freely used and distributed solely within the United States. Portions of the MDS 3.0 are under separate copyright protections; Pfizer Inc. holds the copyright for the PHQ-9 and the Annals of Internal Medicine holds the copyright for the CAM. Both Pfizer Inc. and the Annals of Internal Medicine have granted permission to freely use these instruments in association with the MDS 3.0.

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1. E0200CField[0]:
2. E0300[0]:
1. E0300Field[0]:
1. E0300Field[0]:
3. E0500[0]:
1. E0500A[0]:
1. E0500AField[0]:
1. E0500AField[0]:
2. E0500B[0]:
1. E0500BField[0]:
1. E0500BField[0]:
3. E0500C[0]:
1. E0500CField[0]:
1. E0500CField[0]:
4. E0600[0]:
1. E0600A[0]:
1. E0600AField[0]:
1. E0600AField[0]:
2. E0600B[0]:
1. E0600BField[0]:
1. E0600BField[0]:
3. E0600C[0]:
1. E0600CField[0]:
1. E0600CField[0]:
3. E0800[0]:
1. E0800Field[0]:
1. E0800Field[0]:
13. Page12-SectionE[0]:
1. E0900[0]:
1. E0900Field[0]:
1. E0900Field[0]:
2. E1000[0]:
1. E1000AField[0]:
1. E1000AField[0]:
2. E1000BField[0]:
1. E1000BField[0]:
3. E1100[0]:
1. E1100Field[0]:
1. E1100Field[0]:
14. Page13-SectionF[0]:
1. F0300[0]:
1. F0300Field[0]:
1. F0300Field[0]:
2. DailyPreferencesInterview[0]:
1. F0400[0]:
1. F0400AField[0]:
1. F0400AField[0]:
2. F0400BField[0]:
1. F0400BField[0]:
3. F0400CField[0]:
1. F0400CField[0]:
4. F0400DField[0]:
1. F0400DField[0]:
5. F0400EField[0]:
1. F0400EField[0]:
6. F0400FField[0]:
1. F0400FField[0]:
7. F0400GField[0]:
1. F0400GField[0]:
8. F0400HField[0]:
1. F0400HField[0]:
2. F0500[0]:
1. F0500AField[0]:
1. F0500AField[0]:
2. F0500BField[0]:
1. F0500BField[0]:
3. F0500CField[0]:
1. F0500CField[0]:
4. F0500DField[0]:
1. F0500DField[0]:
5. F0500EField[0]:
1. F0500EField[0]:
6. F0500FField[0]:
1. F0500FField[0]:
7. F0500GField[0]:
1. F0500GField[0]:
8. F0500HField[0]:
1. F0500HField[0]:
3. F0600[0]:
1. F0600Field[0]:
1. F0600Field[0]:
15. Page14-SectionF[0]:
1. F0700[0]:
1. F0700Field[0]:
1. F0700Field[0]:
2. StaffAssessment[0]:
1. F0800[0]:
1. F0800AField[0]:
1. F0800AField[0]:
2. F0800BField[0]:
1. F0800BField[0]:
3. F0800CField[0]:
1. F0800CField[0]:
4. F0800DField[0]:
1. F0800DField[0]:
5. F0800EField[0]:
1. F0800EField[0]:
6. F0800FField[0]:
1. F0800FField[0]:
7. F0800GField[0]:
1. F0800GField[0]:
8. F0800HField[0]:
1. F0800HField[0]:
9. F0800IField[0]:
1. F0800IField[0]:
10. F0800JField[0]:
1. F0800JField[0]:
11. F0800KField[0]:
1. F0800KField[0]:
12. F0800LField[0]:
1. F0800LField[0]:
13. F0800MField[0]:
1. F0800MField[0]:
14. F0800NField[0]:
1. F0800NField[0]:
15. F0800OField[0]:
1. F0800OField[0]:
16. F0800PField[0]:
1. F0800PField[0]:
17. F0800QField[0]:
1. F0800QField[0]:
18. F0800RField[0]:
1. F0800RField[0]:
19. F0800SField[0]:
1. F0800SField[0]:
20. F0800TField[0]:
1. F0800TField[0]:
21. F0800ZField[0]:
1. F0800ZField[0]:
16. Page15-SectionG[0]:
1. G0110[0]:
1. G0110A1Field[0]:
1. G0110A1Field[0]:
2. G0110A2Field[0]:
1. G0110A2Field[0]:
3. G0110B1Field[0]:
1. G0110B1Field[0]:
4. G0110B2Field[0]:
1. G0110B2Field[0]:
5. G0110C1Field[0]:
1. G0110C1Field[0]:
6. G0110C2Field[0]:
1. G0110C2Field[0]:
7. G0110D1Field[0]:
1. G0110D1Field[0]:
8. G0110D2Field[0]:
1. G0110D2Field[0]:
9. G0110E1Field[0]:
1. G0110E1Field[0]:
10. G0110E2Field[0]:
1. G0110E2Field[0]:
11. G0110F1Field[0]:
1. G0110F1Field[0]:
12. G0110F2Field[0]:
1. G0110F2Field[0]:
13. G0110G1Field[0]:
1. G0110G1Field[0]:
14. G0110G2Field[0]:
1. G0110G2Field[0]:
15. G0110H1Field[0]:
1. G0110H1Field[0]:
16. G0110H2Field[0]:
1. G0110H2Field[0]:
17. G0110I1Field[0]:
1. G0110I1Field[0]:
18. G0110I2Field[0]:
1. G0110I2Field[0]:
19. G0110J1Field[0]:
1. G0110J1Field[0]:
20. G0110J2Field[0]:
1. G0110J2Field[0]:
17. Page16-SectionG[0]:
1. G0120[0]:
1. G0120AField[0]:
1. G0120AField[0]:
2. G0120BField[0]:
1. G0120BField[0]:
2. G0300[0]:
1. G0300AField[0]:
1. G0300AField[0]:
2. G0300BField[0]:
1. G0300BField[0]:
3. G0300CField[0]:
1. G0300CField[0]:
4. G0300DField[0]:
1. G0300DField[0]:
5. G0300EField[0]:
1. G0300EField[0]:
3. G0400[0]:
1. G0400AField[0]:
1. G0400AField[0]:
2. G0400BField[0]:
1. G0400BField[0]:
4. G0600[0]:
1. G0600AField[0]:
1. G0600AField[0]:
2. G0600BField[0]:
1. G0600BField[0]:
3. G0600CField[0]:
1. G0600CField[0]:
4. G0600DField[0]:
1. G0600DField[0]:
5. G0600ZField[0]:
1. G0600ZField[0]:
5. G0900[0]:
1. G0900AField[0]:
1. G0900AField[0]:
2. G0900BField[0]:
1. G0900BField[0]:
18. Page17-SectionGGSOS[0]:
1. GG0130[0]:
1. GG0130A[0]:
1. GG0130A1Field[0]:
1. GG0130A1Field[0]:
2. GG0130A2Field[0]:
1. GG0130A2Field[0]:
2. GG0130B[0]:
1. GG0130B1Field[0]:
1. GG0130B1Field[0]:
2. GG0130B2Field[0]:
1. GG0130B2Field[0]:
3. GG0130C[0]:
1. GG0130C1Field[0]:
1. GG0130C1Field[0]:
2. GG0130C2Field[0]:
1. GG0130C2Field[0]:
19. Page18-SectionGGSOS[0]:
1. GG0170[0]:
1. GG0170B[0]:
1. GG0170B1Field[0]:
1. GG0170B1Field[0]:
2. GG0170B2Field[0]:
1. GG0170B2Field[0]:
2. GG0170C[0]:
1. GG0170C1Field[0]:
1. GG0170C1Field[0]:
2. GG0170C2Field[0]:
1. GG0170C2Field[0]:
3. GG0170D[0]:
1. GG0170D1Field[0]:
1. GG0170D1Field[0]:
2. GG0170D2Field[0]:
1. GG0170D2Field[0]:
4. GG0170E[0]:
1. GG0170E1Field[0]:
1. GG0170E1Field[0]:
2. GG0170E2Field[0]:
1. GG0170E2Field[0]:
5. GG0170F[0]:
1. GG0170F1Field[0]:
1. GG0170F1Field[0]:
2. GG0170F2Field[0]:
1. GG0170F2Field[0]:
6. GG0170H[0]:
1. GG0170HField[0]:
1. GG0170H1Field[0]:
7. GG0170J[0]:
1. GG0170J1Field[0]:
1. GG0170J1Field[0]:
2. GG0170J2Field[0]:
1. GG0170J2Field[0]:
8. GG0170K[0]:
1. GG0170K1Field[0]:
1. GG0170K1Field[0]:
2. GG0170K2Field[0]:
1. GG0170K2Field[0]:
9. GG0170Q[0]:
1. GG0170QField[0]:
1. GG0170Q1Field[0]:
10. GG0170R[0]:
1. GG0170R1Field[0]:
1. GG0170R1Field[0]:
2. GG0170R2Field[0]:
1. GG0170R2Field[0]:
11. GG0170RR1[0]:
1. GG0170RR1Field[0]:
1. GG0170RR1Field[0]:
12. GG0170S[0]:
1. GG0170S1Field[0]:
1. GG0170S1Field[0]:
2. GG0170S2Field[0]:
1. GG0170S2Field[0]:
13. GG0170SS1[0]:
1. GG0170SS1Field[0]:
1. GG0170SS1Field[0]:
20. Page19-SectionGGEOS[0]:
1. GG0130[0]:
1. GG0130A[0]:
1. GG0130A3Field[0]:
1. GG0130A3Field[0]:
2. GG0130B[0]:
1. GG0130B3Field[0]:
1. GG0130B3Field[0]:
3. GG0130C[0]:
1. GG0130C3Field[0]:
1. GG0130C3Field[0]:
21. Page20-SectionGGEOS[0]:
1. GG0170[0]:
1. GG0170B[0]:
1. GG0170B3Field[0]:
1. GG0170B3Field[0]:
2. GG0170C[0]:
1. GG0170C3Field[0]:
1. GG0170C3Field[0]:
3. GG0170D[0]:
1. GG0170D3Field[0]:
1. GG0170D3Field[0]:
4. GG0170E[0]:
1. GG0170E3Field[0]:
1. GG0170E3Field[0]:
5. GG0170F[0]:
1. GG0170F3Field[0]:
1. GG0170F3Field[0]:
6. GG0170H[0]:
1. GG0170HField[0]:
1. GG0170H3Field[0]:
7. GG0170J[0]:
1. GG0170J3Field[0]:
1. GG0170J3Field[0]:
8. GG0170K[0]:
1. GG0170K3Field[0]:
1. GG0170K3Field[0]:
9. GG0170Q[0]:
1. GG0170QField[0]:
1. GG0170Q3Field[0]:
10. GG0170R[0]:
1. GG0170R3Field[0]:
1. GG0170R3Field[0]:
11. GG0170RR[0]:
1. GG0170RRField[0]:
1. GG0170RR3Field[0]:
12. GG0170S[0]:
1. GG0170S3Field[0]:
1. GG0170S3Field[0]:
13. GG0170SS[0]:
1. GG0170SSField[0]:
1. GG0170SS3Field[0]:
22. Page22-SectionH[0]:
1. H0100[0]:
1. H0100AField[0]:
1. H0100AField[0]:
2. H0100BField[0]:
1. H0100BField[0]:
3. H0100CField[0]:
1. H0100CField[0]:
4. H0100DField[0]:
1. H0100DField[0]:
5. H0100ZField[0]:
1. H0100ZField[0]:
2. H0200[0]:
1. H0200AField[0]:
1. H0200AField[0]:
2. H0200BField[0]:
1. H0200BField[0]:
3. H0200CField[0]:
1. H0200CField[0]:
3. H0300[0]:
1. H0300Field[0]:
1. H0300Field[0]:
4. H0400[0]:
1. H0400Field[0]:
1. H0400Field[0]:
5. H0500[0]:
1. H0500Field[0]:
1. H0500Field[0]:
6. H0600[0]:
1. H0600Field[0]:
1. H0600Field[0]:
23. Page23-SectionI[0]:
1. Diagnoses[0]:
1. Cancer[0]:
1. I0100Field[0]:
1. I0100Field[0]:
2. HeartCirculation[0]:
1. I0200Field[0]:
1. I0200Field[0]:
2. I0300Field[0]:
1. I0300Field[0]:
3. I0400Field[0]:
1. I0400Field[0]:
4. I0500Field[0]:
1. I0500Field[0]:
5. I0600Field[0]:
1. I0600Field[0]:
6. I0700Field[0]:
1. I0700Field[0]:
7. I0800Field[0]:
1. I0800Field[0]:
8. I0900[0]:
1. I0900Field[0]:
1. I0900Field[0]:
3. Gastrointestinal[0]:
1. I1100Field[0]:
1. I1100Field[0]:
2. I1200Field[0]:
1. I1200Field[0]:
3. I1300Field[0]:
1. I1300Field[0]:
4. Genitourinary[0]:
1. I1400Field[0]:
1. I1400Field[0]:
2. I1500Field[0]:
1. I1500Field[0]:
3. I1550Field[0]:
1. I1550Field[0]:
4. I1650Field[0]:
1. I1650Field[0]:
5. Infections[0]:
1. I1700Field[0]:
1. I1700Field[0]:
2. I2000Field[0]:
1. I2000Field[0]:
3. I2100Field[0]:
1. I2100Field[0]:
4. I2200Field[0]:
1. I2200Field[0]:
5. I2300Field[0]:
1. I2300Field[0]:
6. I2400Field[0]:
1. I2400Field[0]:
7. I2500Field[0]:
1. I2500Field[0]:
6. Metabolic[0]:
1. I2900Field[0]:
1. I2900Field[0]:
2. I3100Field[0]:
1. I3100Field[0]:
3. I3200Field[0]:
1. I3200Field[0]:
4. I3300Field[0]:
1. I3300Field[0]:
5. I3400Field[0]:
1. I3400Field[0]:
7. Musculoskeletal[0]:
1. I3700Field[0]:
1. I3700Field[0]:
2. I3800Field[0]:
1. I3800Field[0]:
3. I3900Field[0]:
1. I3900Field[0]:
4. I4000Field[0]:
1. I4000Field[0]:
8. Neurological1[0]:
1. I4200Field[0]:
1. I4200Field[0]:
2. I4300Field[0]:
1. I4300Field[0]:
3. I4400Field[0]:
1. I4400Field[0]:
4. I4500Field[0]:
1. I4500Field[0]:
5. I4800Field[0]:
1. I4800Field[0]:
24. Page24-SectionI[0]:
1. Diagnoses2[0]:
1. Neurological2[0]:
1. I4900Field[0]:
1. I4900Field[0]:
2. I5000Field[0]:
1. I5000Field[0]:
3. I5100Field[0]:
1. I5100Field[0]:
4. I5200Field[0]:
1. I5200Field[0]:
5. I5250Field[0]:
1. I5250Field[0]:
6. I5300Field[0]:
1. I5300Field[0]:
7. I5350[0]:
1. I5350Field[0]:
1. I5350Field[0]:
8. I5400Field[0]:
1. I5400Field[0]:
9. I5500Field[0]:
1. I5500Field[0]:
2. Nutritional[0]:
1. I5600Field[0]:
1. I5600Field[0]:
3. PsychiatricMoodDisorder[0]:
1. I5700Field[0]:
1. I5700Field[0]:
2. I5800Field[0]:
1. I5800Field[0]:
3. I5900Field[0]:
1. I5900Field[0]:
4. I5950Field[0]:
1. I5950Field[0]:
5. I6000Field[0]:
1. I6000Field[0]:
6. I6100Field[0]:
1. I6100Field[0]:
4. Pulmonary[0]:
1. I6200Field[0]:
1. I6200Field[0]:
2. I6300Field[0]:
1. I6300Field[0]:
5. Vision[0]:
1. I6500Field[0]:
1. I6500Field[0]:
6. NoneOfAbove[0]:
1. I7900Field[0]:
1. I7900Field[0]:
7. Other[0]:
1. I8000A[0]:
1. DiagnosisA[0]:
2. I8000AICD[0]:
2. I8000B[0]:
1. DiagnosisB[0]:
2. I8000BICD[0]:
3. I8000C[0]:
1. DiagnosisC[0]:
2. I8000CICD[0]:
4. I8000D[0]:
1. DiagnosisD[0]:
2. I8000DICD[0]:
5. I8000E[0]:
1. DiagnosisE[0]:
2. I8000EICD[0]:
6. I8000F[0]:
1. DiagnosisF[0]:
2. I8000FICD[0]:
7. I8000G[0]:
1. DiagnosisG[0]:
2. I8000GICD[0]:
8. I8000H[0]:
1. DiagnosisH[0]:
2. I8000HICD[0]:
9. I8000I[0]:
1. DiagnosisI[0]:
2. I8000IICD[0]:
10. I8000J[0]:
1. DiagnosisJ[0]:
2. I8000JICD[0]:
25. Page25-SectionJ[0]:
1. J0100[0]:
1. J0100A[0]:
1. J0100AField[0]:
1. J0100AField[0]:
2. J0100B[0]:
1. J0100BField[0]:
1. J0100BField[0]:
3. J0100C[0]:
1. J0100CField[0]:
1. J0100CField[0]:
2. J0200[0]:
1. J0200Field[0]:
1. J0200Field[0]:
3. PainAssessmentInterview[0]:
1. J0300[0]:
1. J0300Field[0]:
1. J0300Field[0]:
2. J0400[0]:
1. J0400Field[0]:
1. J0400Field[0]:
3. J0500[0]:
1. J0500AField[0]:
1. J0500AField[0]:
2. J0500BField[0]:
1. J0500BField[0]:
4. J0600[0]:
1. J0600AField[0]:
1. J0600AField[0]:
2. J0600BField[0]:
1. J0600BField[0]:
26. Page26-SectionJ[0]:
1. J0700[0]:
1. J0700Field[0]:
1. J0700Field[0]:
2. StaffAssessmentPain[0]:
1. J0800[0]:
1. J0800AField[0]:
1. J0800AField[0]:
2. J0800BField[0]:
1. J0800BField[0]:
3. J0800CField[0]:
1. J0800CField[0]:
4. J0800DField[0]:
1. J0800DField[0]:
5. J0800ZField[0]:
1. J0800ZField[0]:
2. J0850[0]:
1. J0850Field[0]:
1. J0850Field[0]:
3. OtheHealthConditions[0]:
1. J1100[0]:
1. J1100AField[0]:
1. J1100AField[0]:
2. J1100BField[0]:
1. J1100BField[0]:
3. J1100CField[0]:
1. J1100CField[0]:
4. J1100ZField[0]:
1. J1100ZField[0]:
2. J1300[0]:
1. J1300Field[0]:
1. J1300Field[0]:
3. J1400[0]:
1. J1400Field[0]:
1. #area[0]:
1. J1400Field[0]:
4. J1550[0]:
1. J1550AField[0]:
1. J1550AField[0]:
2. J1550BField[0]:
1. J1550BField[0]:
3. J1550CField[0]:
1. J1550CField[0]:
4. J1550DField[0]:
1. J1550DField[0]:
5. J1550ZField[0]:
1. J1550ZField[0]:
27. Page27-SectionJ[0]:
1. J1700[0]:
1. J1700A[0]:
1. J1700AField[0]:
1. J1700AField[0]:
2. J1700B[0]:
1. J1700BField[0]:
1. J1700BField[0]:
3. J1700c[0]:
1. J1700CField[0]:
1. J1700CField[0]:
2. J1800[0]:
1. J1800Field[0]:
1. J1800Field[0]:
3. J1900[0]:
1. J1900AField[0]:
1. J1900AField[0]:
2. J1900BField[0]:
1. J1900BField[0]:
3. J1900CField[0]:
1. J1900CField[0]:
28. Page28-SectionK[0]:
1. K0100[0]:
1. K0100AField[0]:
1. K0100AField[0]:
2. K0100BField[0]:
1. K0100BField[0]:
3. K0100CField[0]:
1. K0100CField[0]:
4. K0100DField[0]:
1. K0100DField[0]:
5. K0100ZField[0]:
1. K0100ZField[0]:
2. K0200[0]:
1. K0200AField[0]:
1. K0200AField[0]:
2. K0200BField[0]:
1. K0200BField[0]:
3. K0300[0]:
1. K0300Field[0]:
1. K0300Field[0]:
4. K0310[0]:
1. K0310Field[0]:
1. K0310Field[0]:
5. K0510[0]:
1. K0510A1Field[0]:
1. K0510A1Field[0]:
2. K0510A2Field[0]:
1. K0510A2Field[0]:
3. K0510B1Field[0]:
1. K0510B1Field[0]:
4. K0510B2Field[0]:
1. K0510B2Field[0]:
5. K0510C1Field[0]:
1. K0510C1Field[0]:
6. K0510CA2Field[0]:
1. K0510C2Field[0]:
7. K0510DA1Field[0]:
1. K0510D1Field[0]:
8. K0510D2Field[0]:
1. K0510D2Field[0]:
9. K0510Z1Field[0]:
1. K0510Z1Field[0]:
10. K0510Z2Field[0]:
1. K0510Z2Field[0]:
29. Page29-SectionK-L[0]:
1. K0710[0]:
1. K0710A[0]:
1. K0710A1Field[0]:
1. K0710A1Field[0]:
2. K0710A2Field[0]:
1. K0710A2Field[0]:
3. K0710A3Field[0]:
1. K0710A3Field[0]:
2. K0710B[0]:
1. K0710B1Field[0]:
1. K0710B1Field[0]:
2. K0710B2Field[0]:
1. K0710B2Field[0]:
3. K0710B3Field[0]:
1. K0710B3Field[0]:
2. L0200[0]:
1. L0200AField[0]:
1. L0200AField[0]:
2. L0200BField[0]:
1. L0200BField[0]:
3. L0200CField[0]:
1. L0200CField[0]:
4. L0200DField[0]:
1. L0200DField[0]:
5. L0200EField[0]:
1. L0200EField[0]:
6. L0200FField[0]:
1. L0200FField[0]:
7. L0200GField[0]:
1. L0200GField[0]:
8. L0200ZField[0]:
1. L0200ZField[0]:
30. Page30-SectionM[0]:
1. M0100[0]:
1. M0100AField[0]:
1. M0100AField[0]:
2. M0100BField[0]:
1. M0100BField[0]:
3. M0100CField[0]:
1. M0100CField[0]:
4. M0100ZField[0]:
1. M0100ZField[0]:
2. M0150[0]:
1. M0150Field[0]:
1. M0150Field[0]:
3. M0210[0]:
1. M0210Field[0]:
1. M0210Field[0]:
4. M0300[0]:
1. M0300A[0]:
1. M0300AField[0]:
1. M0300AField[0]:
2. M0300B[0]:
1. M0300B1[0]:
1. M0300B1Field[0]:
1. M0300B1Field[0]:
2. M0300B2[0]:
1. M0300B2Field[0]:
1. M0300B2Field[0]:
3. M0300B3[0]:
1. Date[0]:
1. M0300B3Month[0]:
2. M0300B3Day[0]:
3. M0300B3Year[0]:
3. M0300C[0]:
1. M0300C1[0]:
1. M0300C1Field[0]:
1. M0300C1Field[0]:
2. M0300C2[0]:
1. M0300C2Field[0]:
1. M0300C2Field[0]:
4. M0300D[0]:
1. M0300D1[0]:
1. M0300D1Field[0]:
1. M0300D1Field[0]:
2. M0300D2[0]:
1. M0300D2Field[0]:
1. M0300D2Field[0]:
31. Page31-SectionM[0]:
1. M0300Continued[0]:
1. M0300E1[0]:
1. M0300E1Field[0]:
1. M0300E1Field[0]:
2. M0300E2[0]:
1. M0300E2Field[0]:
1. M0300E2Field[0]:
3. M0300F1[0]:
1. M0300F1Field[0]:
1. M0300F1Field[0]:
4. M0300F2[0]:
1. M0300F2Field[0]:
1. M0300F2Field[0]:
5. M0300G1[0]:
1. M0300G1Field[0]:
1. M0300G1Field[0]:
6. M0300G2[0]:
1. M0300G2Field[0]:
1. M0300G2Field[0]:
2. M0610[0]:
1. M0610AField[0]:
1. M0610AField1[0]:
2. M0610AField2[0]:
2. M0610BField[0]:
1. M0610BField1[0]:
2. M0610BField2[0]:
3. M0610CField[0]:
1. M0610CField1[0]:
2. M0610CField2[0]:
3. M0700[0]:
1. M0700Field[0]:
1. M0700Field[0]:
4. M0800[0]:
1. M0800AField[0]:
1. M0800AField[0]:
2. M0800BField[0]:
1. M0800BField[0]:
3. M0800CField[0]:
1. M0800CField[0]:
32. Page32-SectionM[0]:
1. M0900[0]:
1. M09090A[0]:
1. M0900AField[0]:
1. M0900AField[0]:
2. M0900B[0]:
1. M0900BField[0]:
1. M0900BField[0]:
3. M0900C[0]:
1. M0900CField[0]:
1. M0900CField[0]:
4. M0900D[0]:
1. M0900DField[0]:
1. M0900DField[0]:
2. M1030[0]:
1. M1030Field[0]:
1. #area[0]:
1. M1030Field[0]:
3. M1040[0]:
1. M1040AField[0]:
1. M1040AField[0]:
2. M1040BField[0]:
1. M1040BField[0]:
3. M1040CField[0]:
1. M1040CField[0]:
4. M1040DField[0]:
1. M1040DField[0]:
5. M1040EField[0]:
1. M1040EField[0]:
6. M1040FField[0]:
1. M1040FField[0]:
7. M1040GField[0]:
1. M1040GField[0]:
8. M1040HField[0]:
1. M1040HField[0]:
9. M1040ZField[0]:
1. M1040ZField[0]:
4. M1200[0]:
1. M1200AField[0]:
1. M1200AField[0]:
2. M1200BField[0]:
1. M1200BField[0]:
3. M1200CField[0]:
1. M1200CField[0]:
4. M1200DField[0]:
1. M1200DField[0]:
5. M1200EField[0]:
1. M1200EField[0]:
6. M1200FField[0]:
1. M1200FField[0]:
7. M1200GField[0]:
1. M1200GField[0]:
8. M1200HField[0]:
1. M1200HField[0]:
9. M1200IField[0]:
1. M1200IField[0]:
10. M1200ZField[0]:
1. M1200ZField[0]:
33. Page33-SectionN[0]:
1. N0300[0]:
1. N0300Field[0]:
1. N0300Field[0]:
2. N0350[0]:
1. N0350A[0]:
1. N0350AField[0]:
1. N0350AField[0]:
2. N0350B[0]:
1. N0350BField[0]:
1. N0350BField[0]:
3. N0410[0]:
1. N0410AField[0]:
1. N0410AField[0]:
2. N0410BField[0]:
1. N0410BField[0]:
3. N0410CField[0]:
1. N0410CField[0]:
4. N0410DField[0]:
1. N0410DField[0]:
5. N0410EField[0]:
1. N0410EField[0]:
6. N0410FField[0]:
1. N0410FField[0]:
7. N0410GField[0]:
1. N0410GField[0]:
34. Page34-SectionO[0]:
1. O0100[0]:
1. O0100A1Field[0]:
1. O0100A1Field[0]:
2. O0100A2Field[0]:
1. O0100A2Field[0]:
3. O0100B1Field[0]:
1. O0100B1Field[0]:
4. O0100B2Field[0]:
1. O0100B2Field[0]:
5. O0100C1Field[0]:
1. O0100C1Field[0]:
6. O0100C2Field[0]:
1. O0100C2Field[0]:
7. O0100DA1Field[0]:
1. O0100D1Field[0]:
8. O0100D2Field[0]:
1. O0100D2Field[0]:
9. O0100E1Field[0]:
1. O0100E1Field[0]:
10. O0100E2Field[0]:
1. O0100E2Field[0]:
11. O0100F1Field[0]:
1. O0100F1Field[0]:
12. O0100F2Field[0]:
1. O0100F2Field[0]:
13. O0100G1Field[0]:
1. O0100G1Field[0]:
14. O0100G2Field[0]:
1. O0100G2Field[0]:
15. O0100H1Field[0]:
1. O0100H1Field[0]:
16. O0100H2Field[0]:
1. O0100H2Field[0]:
17. O0100I1Field[0]:
1. O0100I1Field[0]:
18. O0100I2Field[0]:
1. O0100I2Field[0]:
19. O0100J1Field[0]:
1. O0100J1Field[0]:
20. O0100J2Field[0]:
1. O0100J2Field[0]:
21. O0100K1Field[0]:
1. O0100K1Field[0]:
22. O0100K2Field[0]:
1. O0100K2Field[0]:
23. O0100L2Field[0]:
1. O0100L2Field[0]:
24. O0100M1Field[0]:
1. O0100M1Field[0]:
25. O0100M2Field[0]:
1. O0100M2Field[0]:
26. O0100Z1Field[0]:
1. O0100Z1Field[0]:
27. O0100Z2Field[0]:
1. O0100Z2Field[0]:
2. O0250[0]:
1. O0250AField[0]:
1. O0250AField[0]:
2. O0250B[0]:
1. Date[0]:
1. O0250BMonth[0]:
2. O0250BDay[0]:
3. O0250BYear[0]:
3. O0250CField[0]:
1. O0250CField[0]:
3. O0300[0]:
1. O0300AField[0]:
1. O0300AField[0]:
2. O0300BField[0]:
1. O0300BField[0]:
35. Page35-SectionO[0]:
1. O0400[0]:
1. O0400A[0]:
1. O0400A1[0]:
1. O0400A1Field[0]:
1. O0400A1Field[0]:
2. O0400A2[0]:
1. O0400A2Field[0]:
1. O0400A2Field[0]:
3. O0400A3[0]:
1. O0400A3Field[0]:
1. O0400A3Field[0]:
4. O0400A3A[0]:
1. O0400A3AField[0]:
1. O0400A3AField[0]:
5. O0400A4[0]:
1. O0400A4Field[0]:
1. O0400A4Field[0]:
6. O0400A5[0]:
1. O0400A5Field[0]:
1. #subform[0]:
1. O0400A5Month[0]:
2. O0400A5Day[0]:
3. O0400A5Year[0]:
7. O0400A6[0]:
1. O0400A6Field[0]:
1. Date[0]:
1. O0400A6Month[0]:
2. O0400A6Day[0]:
3. O0400A6Year[0]:
2. O0400B[0]:
1. O0400B1[0]:
1. O0400B1Field[0]:
1. O0400B1Field[0]:
2. O0400B2[0]:
1. O0400B2Field[0]:
1. O0400B2Field[0]:
3. O0400B3[0]:
1. O0400B3Field[0]:
1. O0400B3Field[0]:
4. O0400B3A[0]:
1. O0400B3AField[0]:
1. O0400B3AField[0]:
5. O0400B4[0]:
1. O0400B4Field[0]:
1. O0400B4Field[0]:
6. O0400B5[0]:
1. O0400B5Field[0]:
1. Date[0]:
1. O0400B5Month[0]:
2. O0400B5Day[0]:
3. O0400B5Year[0]:
7. O0400B6[0]:
1. O0400B6Field[0]:
1. Date[0]:
1. O0400B6Month[0]:
2. O0400B6Day[0]:
3. O0400B6Year[0]:
36. Page36-SectionO[0]:
1. O0400Continued[0]:
1. O0400C[0]:
1. O0400C1[0]:
1. O0400C1Field[0]:
1. O0400C1Field[0]:
2. O0400C2[0]:
1. O0400C2Field[0]:
1. O0400C2Field[0]:
3. O0400C3[0]:
1. O0400C3Field[0]:
1. O0400C3Field[0]:
4. O0400C3A[0]:
1. O0400C3AField[0]:
1. O0400C3AField[0]:
5. O0400C4[0]:
1. O0400C4Field[0]:
1. O0400C4Field[0]:
6. O0400C5[0]:
1. O0400C5Field[0]:
1. Date[0]:
1. O0400C5Month[0]:
2. O0400C5Day[0]:
3. O0400C5Year[0]:
7. O0400C6[0]:
1. O0400C6Field[0]:
1. Date[0]:
1. O0400C6Month[0]:
2. O0400C6Day[0]:
3. O0400C6Year[0]:
2. O0400D[0]:
1. O0400D1Field[0]:
1. O0400D1Field[0]:
2. O0400D2Field[0]:
1. O0400D2Field[0]:
3. O0400E[0]:
1. O0400E1Field[0]:
1. O0400E1Field[0]:
2. O0400E2Field[0]:
1. O0400E2Field[0]:
4. O0400F[0]:
1. O0400F1Field[0]:
1. O0400F1Field[0]:
2. O0400F2Field[0]:
1. O0400F2Field[0]:
2. O0420[0]:
1. O0420Field[0]:
1. O0420Field[0]:
3. O0450[0]:
1. O0450AField[0]:
1. O0450AField[0]:
2. O0450BBody[0]:
1. Date[0]:
1. O0450BMonth[0]:
2. O0450BDay[0]:
3. O0450BYear[0]:
37. Page37-SectionO[0]:
1. O0500[0]:
1. O0500AField[0]:
1. O0500AField[0]:
2. O0500BField[0]:
1. O0500BField[0]:
3. O0500CField[0]:
1. O0500CField[0]:
4. O0500DField[0]:
1. O0500DField[0]:
5. O0500EField[0]:
1. O0500EField[0]:
6. O0500FField[0]:
1. O0500FField[0]:
7. O0500GField[0]:
1. O0500GField[0]:
8. O0500HField[0]:
1. O0500HField[0]:
9. O0500IField[0]:
1. O0500IField[0]:
10. O0500JField[0]:
1. O0500JField[0]:
2. O0700[0]:
1. O0700Field[0]:
1. O0700Field[0]:
3. O0600[0]:
1. O0600Field[0]:
1. O0600Field[0]:
38. Page38-SectionP-Q[0]:
1. P0100[0]:
1. P0100AField[0]:
1. P0100AField[0]:
2. P0100BField[0]:
1. P0100BField[0]:
3. P0100CField[0]:
1. P0100CField[0]:
4. P0100DField[0]:
1. P0100DField[0]:
5. P0100EField[0]:
1. P0100EField[0]:
6. P0100FField[0]:
1. P0100FField[0]:
7. P0100GField[0]:
1. P0100GField[0]:
8. P0100HField[0]:
1. P0100HField[0]:
2. Q0100[0]:
1. Q0100A[0]:
1. Q0100AField[0]:
1. Q0100AField[0]:
2. Q0100B[0]:
1. Q0100BField[0]:
1. Q0100BField[0]:
3. Q0100C[0]:
1. Q0100CField[0]:
1. Q0100CField[0]:
3. Q0300[0]:
1. Q0300A[0]:
1. Q0300AField[0]:
1. Q0300AField[0]:
2. Q0300B[0]:
1. Q0300BField[0]:
1. Q0300BField[0]:
4. Q0400[0]:
1. Q0400A[0]:
1. Q0400AField[0]:
1. Q0400AField[0]:
39. Page39-SectionQ[0]:
1. Q0490[0]:
1. Q0490[0]:
1. Q0490AField[0]:
1. Q0490Field[0]:
2. Q0500[0]:
1. Q0500B[0]:
1. Q0500BField[0]:
1. Q0500BField[0]:
3. Q0550[0]:
1. Q0550A[0]:
1. Q0550AField[0]:
1. Q0550AField[0]:
2. Q0550B[0]:
1. Q0550BField[0]:
1. Q0550BField[0]:
4. Q0600[0]:
1. Q0600Field[0]:
1. Q0600Field[0]:
40. Page40-SectionV[0]:
1. V0100[0]:
1. V0100A[0]:
1. V0100AField[0]:
1. V0100AField[0]:
2. V0100B[0]:
1. V0100BField[0]:
1. V0100BField[0]:
3. V0100C[0]:
1. Date[0]:
1. V0100CMonth[0]:
2. V0100CDay[0]:
3. V0100CYear[0]:
4. V0100D[0]:
1. V0100DField[0]:
1. V0100DField[0]:
5. V0100E[0]:
1. V0100EField[0]:
1. V0100EField[0]:
6. V0100F[0]:
1. V0100FField[0]:
1. V0100FField[0]:
41. Page41-SectionV[0]:
1. V0200[0]:
1. V0200A[0]:
1. V0200A01AField[0]:
1. V0200A01AField[0]:
2. V0200A01BField[0]:
1. V0200A01BField[0]:
3. V0200A01Location[0]:
1. V0200A01Location[0]:
4. V0200A02AField[0]:
1. V0200A02AField[0]:
5. V0200A02BField[0]:
1. V0200A02BField[0]:
6. V0200A02Location[0]:
1. V0200A02Location[0]:
7. V0200A03AField[0]:
1. V0200A03AField[0]:
8. V0200A03BField[0]:
1. V0200A03BField[0]:
9. V0200A03Location[0]:
1. V0200A03Location[0]:
10. V0200A04AField[0]:
1. V0200A04AField[0]:
11. V0200A04BField[0]:
1. V0200A04BField[0]:
12. V0200A04Location[0]:
1. V0200A04Location[0]:
13. V0200A05AField[0]:
1. V0200A05AField[0]:
14. V0200A05BField[0]:
1. V0200A05BField[0]:
15. V0200A05Location[0]:
1. V0200A05Location[0]:
16. V0200A06AField[0]:
1. V0200A06AField[0]:
17. V0200A06BField[0]:
1. V0200A06BField[0]:
18. V0200A06Location[0]:
1. V0200A06Location[0]:
19. V0200A07AField[0]:
1. V0200A07AField[0]:
20. V0200A07BField[0]:
1. V0200A07BField[0]:
21. V0200A07Location[0]:
1. V0200A07Location[0]:
22. V0200A08AField[0]:
1. V0200A08AField[0]:
23. V0200A08BField[0]:
1. V0200A08BField[0]:
24. V0200A08Location[0]:
1. V0200A08Location[0]:
25. V0200A09AField[0]:
1. V0200A09AField[0]:
26. V0200A09BField[0]:
1. V0200A09BField[0]:
27. V0200A09Location[0]:
1. V0200A09Location[0]:
28. V0200A10AField[0]:
1. V0200A10AField[0]:
29. V0200A10BField[0]:
1. V0200A10BField[0]:
30. V0200A10Location[0]:
1. V0200A10Location[0]:
31. V0200A11AField[0]:
1. V0200A11AField[0]:
32. V0200A11BField[0]:
1. V0200A11BField[0]:
33. V0200A11Location[0]:
1. V0200A11Location[0]:
34. V0200A12AField[0]:
1. V0200A12AField[0]:
35. V0200A12BField[0]:
1. V0200A12BField[0]:
36. V0200A12Location[0]:
1. V0200A12Location[0]:
37. V0200A13AField[0]:
1. V0200A13AField[0]:
38. V0200A13BField[0]:
1. V0200A13BField[0]:
39. V0200A13Location[0]:
1. V0200A13Location[0]:
40. V0200A14AField[0]:
1. V0200A14AField[0]:
41. V0200A14BField[0]:
1. V0200A14BField[0]:
42. V0200A14Location[0]:
1. V0200A14Location[0]:
43. V0200A15AField[0]:
1. V0200A15AField[0]:
44. V0200A15BField[0]:
1. V0200A15BField[0]:
45. V0200A15Location[0]:
1. V0200A15Location[0]:
46. V0200A16AField[0]:
1. V0200A16AField[0]:
47. V0200A16BField[0]:
1. V0200A16BField[0]:
48. V0200A16Location[0]:
1. V0200A16Location[0]:
49. V0200A17AField[0]:
1. V0200A17AField[0]:
50. V0200A17BField[0]:
1. V0200A17BField[0]:
51. V0200A17Location[0]:
1. V0200A17Location[0]:
52. V0200A18AField[0]:
1. V0200A18AField[0]:
53. V0200A18BField[0]:
1. V0200A18BField[0]:
54. V0200A18Location[0]:
1. V0200A18Location[0]:
55. V0200A19AField[0]:
1. V0200A19AField[0]:
56. V0200A19BField[0]:
1. V0200A19BField[0]:
57. V0200A19Location[0]:
1. V0200A19Location[0]:
58. V0200A20AField[0]:
1. V0200A20AField[0]:
59. V0200A20BField[0]:
1. V0200A20BField[0]:
60. V0200A20Location[0]:
1. V0200A20Location[0]:
2. V0200B[0]:
1. Date[0]:
1. V0200B2Month[0]:
2. V0200B2Day[0]:
3. V0200B2Year[0]:
3. V0200C[0]:
1. Date[0]:
1. V0200C2Month[0]:
2. V0200C2Day[0]:
3. V0200C2Year[0]:
42. Page42-SectionX[0]:
1. X0150[0]:
1. X0150Field[0]:
1. X0150Field[0]:
2. X0200[0]:
1. X0200Body[0]:
1. X0200AField[0]:
2. X0200CField[0]:
3. X0300[0]:
1. X0300Field[0]:
1. X0300Field[0]:
4. X0400[0]:
1. X0400Body[0]:
1. Date[0]:
1. X0400Month[0]:
2. X0400Day[0]:
3. X0400Year[0]:
5. X0500[0]:
1. X0500Body[0]:
1. X0500Field1[0]:
2. X0500Field2[0]:
3. X0500Field3[0]:
6. X0600[0]:
1. X0600A[0]:
1. X0600AField[0]:
1. X0600AField[0]:
2. X0600B[0]:
1. X0600BField[0]:
1. X0600BField[0]:
3. X0600C[0]:
1. X0600CField[0]:
1. X0600CField[0]:
43. Page43-SectionX[0]:
1. X0600Continued[0]:
1. X0600D[0]:
1. X0600DField[0]:
1. X0600DField[0]:
2. X0600F[0]:
1. X0600FField[0]:
1. X0600FField[0]:
3. X0600H[0]:
1. X0600HField[0]:
1. X0600HField[0]:
2. X0700[0]:
1. X0700A[0]:
1. Date[0]:
1. X0700AMonth[0]:
2. X0700ADay[0]:
3. X0700AYear[0]:
2. X0700B[0]:
1. Date[0]:
1. X0700BMonth[0]:
2. X0700BDay[0]:
3. X0700BYear[0]:
3. X0700C[0]:
1. Date[0]:
1. X0700CMonth[0]:
2. X0700CDay[0]:
3. X0700CYear[0]:
3. X0800[0]:
1. X0800Field[0]:
1. X0800Field[0]:
4. X0900[0]:
1. X0900AField[0]:
1. X0900AField[0]:
2. X0900BField[0]:
1. X0900BField[0]:
3. X0900CField[0]:
1. X0900CField[0]:
4. X0900DField[0]:
1. X0900DField[0]:
5. X0900EField[0]:
1. X0900EField[0]:
6. X0900ZField[0]:
1. X0900ZField[0]:
7. X0900ZBody[0]:
1. X0900ZSpecify[0]:
5. X1050[0]:
1. X1050AField[0]:
1. X1050AField[0]:
2. X1050ZField[0]:
1. X1050ZField[0]:
3. X1050ZBody[0]:
1. X1050ZSpecify[0]:
44. Page44-SectionX[0]:
1. X1100[0]:
1. X1100A[0]:
1. X1100AField[0]:
2. X1100B[0]:
1. X1100BField[0]:
3. X1100C[0]:
4. X1100E[0]:
1. Date[0]:
1. X1100EMonth[0]:
2. X1100EDay[0]:
3. X1100EYear[0]:
45. Page45-SectionZ[0]:
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