Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment Information. MDS Conversion/Validation Utilities

12/01/2011

Patient Adam Everyman, Jr
Date of birth September 24, 1932 Sex Male
Contact info address not available
Telecom information not available
Patient IDs 444-33-3333 2.16.840.1.113883.4.1
9999999999 2.16.840.1.113883.4.290
1234567 2.16.840.1.113883.4.6.9999999999
Document Id 7c2ff8c0-bf15-11dd-ad8b-0800200c9a66
Document Created: March 1, 2008, 16:30
Author Nancy Nightingale, RN

Table of Contents


Section A - Identification Information

Section Author: Clarence Barton, NA
 
  • A0100A (Facility National Provider Identifier (NPI)): 9999999999.
  • A0100B (Facility CMS Certification Number (CCN)): .
  • A0100C (State facility provider number): .
  • A0200 (Type of provider): 1 (Nursing home (SNF/NF)).
  • A0300A (Type of assessment: OBRA): 1 (Admission assessment (required by day 14)).
  • A0300B (Type of assessment: PPS): 1 (5-day scheduled assessment).
  • A0300C (Type of assessment: OMRA): 0 (No).
  • A0300D (Type of assessment: state required): 0 (No).
  • A0300E (First assessment since most recent entry): 1 (Yes).
  • A0400 (Submission requirement): 1 (Federal required submission).
  • A0500A (Resident first name): Adam.
  • A0500B (Resident middle initial): A.
  • A0500C (Resident last name): Everyman.
  • A0500D (Resident name suffix): Jr.
  • A0600A (Social Security Number): 444-33-3333.
  • A0600B (Resident Medicare/railroad insurance number): .
  • A0700 (Resident Medicaid number): 9999999999.
  • A0800 (Gender): male.
  • A0900 (Birthdate): September 24, 1932 .
  • A1000A (Ethnicity: American Indian or Alaska Native): unknown.
  • A1000B (Ethnicity: Asian): unknown.
  • A1000C (Ethnicity: Black or African American): false.
  • A1000D (Ethnicity: Hispanic or Latino): unknown.
  • A1000E (Ethnicity: Native Hawaiian/Pacific Islander): unknown.
  • A1000F (Ethnicity: White): true.
  • A1000Z (Ethnicity: unable to determine/unknown): false.
  • A1100A (Does the resident need or want an interpreter): 0 (No).
  • A1100B (Preferred language): .
  • A1200 (Marital status): widowed.
  • A1300A (Medical record number): 1234567 2.16.840.1.113883.4.6.9999999999.
  • A1300B (Room number): Room 222.
  • A1300C (Name by which resident prefers to be addressed): Addy.
  • A1300D (Lifetime occupation(s)): Truck Driver/Veteran.
  • A1500 (Resident evaluated by PASRR): 1 (Yes).
  • A1550A (MR/DD status: Down's syndrome): falsetrue.
  • A1550B (MR/DD status: Autism): false.
  • A1550C (MR/DD status: Epilepsy): false.
  • A1550D (MR/DD status: other organic MR/DD condition): false.
  • A1550E (MR/DD status: MR/DD with no organic condition): false.
  • A1550Z (MR/DD status: none of the above): false.
  • A1600 (Entry date (date of admission/reentry in facility)): .
  • A1700 (Type of entry): 1 (Admission).
  • A1800 (Entered from): 3 (Acute hospital).
  • A2000 (Discharge date): .
  • A2100 (Discharge status): .
  • A2400B (Start date of most recent Medicare stay): November 25, 2007 .
  • A2400C (End date of most recent Medicare stay): November 28, 2007 .

Section B - Hearing, Speech and Vision

  • B0100 (Comatose): 0 (No).
  • B0200 (Hearing): 0 (Adequate - no difficulty in normal conversation, social interaction, listening to TV).
  • B0300 (Hearing aid): 0 (No).
  • B0600 (Speech clarity): 0 (Clear speech - distinct intelligible words).
  • B0700 (Makes self understood): 1 (Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time).
  • B0800 (Ability to understand others): 1 (Usually understands - misses some part/intent of message but comprehends most conversation).
  • B1000 (Vision): 0 (Adequate - sees fine detail, including regular print in newspapers/books).
  • B1200 (Corrective lenses): 0 (No).

Section C - Cognitive Pattern

  • C0100 (BIMS: should resident interview be conducted): 1 (Yes).
  • C0200 (BIMS res interview: repetition of three words): 2 (Two).
  • C0300A (BIMS res interview: able to report correct year): 2 (Missed by 1 year).
  • C0300B (BIMS res interview: able to report correct month): 2 (Accurate within 5 days).
  • C0300C (BIMS res interview: can report correct day of week): 0 (Incorrect or no answer).
  • C0400A (BIMS res interview: able to recall "sock"): 1 (Yes, after cueing ("something to wear")).
  • C0400B (BIMS res interview: able to recall "blue"): 2 (Yes, no cue required).
  • C0400C (BIMS res interview: able to recall "bed"): 0 (No - could not recall ).
  • C0500 (BIMS res interview: summary score): 9.
  • C0600 (Staff asmt mental status: conduct asmt): 1 (Yes (resident was unable to complete interview)).
  • C0700 (Staff asmt mental status: short-term memory OK): 1 (Memory problem).
  • C0800 (Staff asmt mental status: long-term memory OK): 0 (Memory OK).
  • C0900A (Staff asmt mental status: recall current season): true.
  • C0900B (Staff asmt mental status: recall location of room): true.
  • C0900C (Staff asmt mental status: recall staff names/faces): false.
  • C0900D (Staff asmt mental status: recall in nursing home): true.
  • C0900Z (Staff asmt mental status: none of above recalled): false.
  • C1000 (Cognitive skills for daily decision making): 1 (Modified independence - some difficulty in new situations only).
  • C1100 (Procedural memory): 1 (Memory problem).
  • C1300A (Signs of delirium: inattention): 2 (Behavior present, fluctuates (comes and goes, changes in severity)).
  • C1300B (Signs of delirium: disorganized thinking): 2 (Behavior present, fluctuates (comes and goes, changes in severity)).
  • C1300C (Signs of delirium: altered level of consciousness): 0 (Behavior not present).
  • C1300D (Signs of delirium: psychomotor retardation): 0 (Behavior not present).
  • C1600 (Acute onset mental status change): 1 (Yes).

Section D - Mood

  • D0100 (PHQ: should resident mood interview be conducted): 1 (Yes).
  • D0200A1 (PHQ res: little interest or pleasure - presence): 1 (Yes).
  • D0200A2 (PHQ res: little interest or pleasure - frequency): 1 (2-6 Days (Several days)).
  • D0200B1 (PHQ res: feeling down, depressed - presence): 1 (Yes).
  • D0200B2 (PHQ res: feeling down, depressed - frequency): 1 (2-6 Days (Several days)).
  • D0200C1 (PHQ res: trouble with sleep - presence): 0 (No).
  • D0200D1 (PHQ res: feeling tired/little energy - presence): 0 (No).
  • D0200E1 (PHQ res: poor appetite or overeating - presence): 0 (No).
  • D0200F1 (PHQ res: feeling bad about self - presence): 0 (No).
  • D0200G1 (PHQ res: trouble concentrating - presence): 1 (Yes).
  • D0200G2 (PHQ res: trouble concentrating - frequency): 2 (7-11 Days (Half or more of the days)).
  • D0200H1 (PHQ res: slow, fidgety, restless - presence): 0 (No).
  • D0200I1 (PHQ res: thoughts better off dead - presence): 0 (No).
  • D0300 (PHQ res: total mood severity score): 4.
  • D0500A1 (PHQ staff: little interest or pleasure - presence): 1 (Yes).
  • D0500A2 (PHQ staff: little interest or pleasure - frequency): 2 (7-11 Days (Half or more of the days)).
  • D0500B1 (PHQ staff: feeling down, depressed - presence): 1 (Yes).
  • D0500B2 (PHQ staff: feeling down, depressed - frequency): 1 (2-6 Days (Several days)).
  • D0500C1 (PHQ staff: trouble with sleep - presence): 0 (No).
  • D0500D1 (PHQ staff: feeling tired/little energy - presence): 0 (No).
  • D0500E1 (PHQ staff: poor appetite or overeating - presence): 0 (No).
  • D0500F1 (PHQ staff: feeling bad about self - presence): 0 (No).
  • D0500G1 (PHQ staff: trouble concentrating - presence): 0 (No).
  • D0500H1 (PHQ staff: slow, fidgety, restless - presence): 1 (Yes).
  • D0500H2 (PHQ staff: slow, fidgety, restless - frequency): 3 (12-14 Days (Nearly every day)).
  • D0500I1 (PHQ staff: thoughts better off dead - presence): 0 (No).
  • D0500J1 (PHQ staff: short-tempered - presence): 0 (No).
  • D0600 (PHQ staff: total mood score): 6.

Section E - Behavior

  • E0100A (Psychosis: hallucinations): false.
  • E0100B (Psychosis: illusions): false.
  • E0100C (Psychosis: delusions): false.
  • E0100Z (Psychosis: none of the above): true.
  • E0200A (Physical behav symptoms directed toward others): 0 (Behavior not exhibited in last 7 days).
  • E0200B (Verbal behavioral symptoms directed toward others): 0 (Behavior not exhibited in last 7 days).
  • E0200C (Other behav symptoms not directed toward others): 0 (Behavior not exhibited in last 7 days).
  • E0300 (Overall presence of behavioral symptoms): 0 (No).
  • E0800 (Rejection of care: presence and frequency): 0 (Behavior not exhibited ).
  • E0900 (Wandering: presence and frequency): 0 (Behavior not exhibited ).
  • E1100 (Change in behavioral or other symptoms): 0 (Same).

Section F - Preferences for Customary Routine and Activities

  • F0300 (Conduct res interview for daily/activity prefs): 1 (Yes).
  • F0400A (Res interview: choose clothes to wear): 1 (Very important).
  • F0400B (Res interview: take care of personal belongings): 2 (Somewhat important).
  • F0400C (Res interview: choose tub, bath, shower, sponge): 2 (Somewhat important).
  • F0400D (Res interview: have snacks between meals): 3 (Not very important).
  • F0400E (Res interview: choose own bedtime): 1 (Very important).
  • F0400F (Res interview: discuss care with family/friend): 1 (Very important).
  • F0400G (Res interview: use phone in private): 1 (Very important).
  • F0400H (Res interview: lock things to keep them safe): 1 (Very important).
  • F0500A (Res interview: have books, newspaper, mags to read): 2 (Somewhat important).
  • F0500B (Res interview: listen to music): 3 (Not very important).
  • F0500C (Res interview: be around animals/pets): 3 (Not very important).
  • F0500D (Res interview: keep up with news): 2 (Somewhat important).
  • F0500E (Res interview: do things with groups of people): 3 (Not very important).
  • F0500F (Res interview: do favorite activities): 1 (Very important).
  • F0500G (Res interview: go outside when good weather): 1 (Very important).
  • F0500H (Res interview: participate in religious practices): 2 (Somewhat important).
  • F0600 (Primary respondent: daily/activities prefs): 1 (Resident).
  • F0700 (Conduct staff assessment for daily/activity prefs): 0 (No (because Interview for Daily and Activity Preferences (F0400 and F0500) was completed by resident or family/significant other)).

Section G - Functional Status

  • G0100A (ADL: bed mobility assistance): 0 (Independent - resident completes activity with no help or oversight).
  • G0100B (ADL: transfer assistance): 1 (Set up assistance).
  • G0100C (ADL: toilet transfer assistance): 1 (Set up assistance).
  • G0100D (ADL: toileting assistance): 1 (Set up assistance).
  • G0100E (ADL: walk in room assistance): 1 (Set up assistance).
  • G0100F (ADL: walk in facility assistance): 1 (Set up assistance).
  • G0100G (ADL: locomotion assistance): 3 (Limited assistance - guided maneuvering of limbs or other non-weight bearing assistance provided at least once).
  • G0100H (ADL: dressing upper body assistance): 3 (Limited assistance - guided maneuvering of limbs or other non-weight bearing assistance provided at least once).
  • G0100I (ADL: dressing lower body assistance): 3 (Limited assistance - guided maneuvering of limbs or other non-weight bearing assistance provided at least once).
  • G0100J (ADL: eating assistance): 1 (Set up assistance).
  • G0100K (ADL: grooming/personal hygiene assistance): 3 (Limited assistance - guided maneuvering of limbs or other non-weight bearing assistance provided at least once).
  • G0100L (ADL: bathing assistance): unknown.
  • G0300A (Balance: moving from seated to standing position): 1 (Not steady, but able to stabilize without human assistance).
  • G0300B (Balance: walking (with assistive device if used)): 2 (Not steady, only able to stabilize with human assistance).
  • G0300C (Balance: turning around while walking): 2 (Not steady, only able to stabilize with human assistance).
  • G0300D (Balance: moving on and off toilet): 1 (Not steady, but able to stabilize without human assistance).
  • G0300E (Balance: surface-to-surface transfer): 1 (Not steady, but able to stabilize without human assistance).
  • G0400A (ROM limitation: upper extremity): 0 (No impairment).
  • G0400B (ROM limitation: lower extremity): 1 (Impairment on one side).
  • G0600A (Mobility devices: cane/crutch used): unknown.
  • G0600B (Mobility devices: walker used): 1 (Yes).
  • G0600C (Mobility devices: wheelchair (manual or electric)): 1 (Yes).
  • G0600D (Mobility devices: lower extremity limb prosthesis): 0 (No).
  • G0800 (Bedfast): 0 (No).
  • G0900A (Resident believes capable of increased independ): 1 (Yes).
  • G0900B (Staff believes res capable of increased independ): 1 (Yes).

Section H - Bladder and Bowel

  • H0100A (Applicances: indwelling bladder catheter): false.
  • H0100B (Appliances: external (condom) catheter): false.
  • H0100C (Appliances: ostomy): false.
  • H0100D (Applicances: intermittent catheterization): false.
  • H0100Z (Appliances: none of the above): true.
  • H0200A (Urinary toileting program: has been attempted): 0 (No).
  • H0300 (Urinary continence): 0 (Always continent).
  • H0400 (Bowel continence): 0 (0).
  • H0500 (Bowel toileting program being used): 0 (No).
  • H0600 (Constipation): 0 (No).

Section I - Active Disease Diagnosis

  • I0100 (Cancer (with or without metastasis)): false.
  • I0200 (Anemia): false.
  • I0300 (Atrial fibrillation and other dysrhythmias): false.
  • I0400 (Coronary artery disease (CAD)): false.
  • I0500 (Deep venous thrombosis/pulmonary embolus): false.
  • I0600 (Heart failure): false.
  • I0700 (Hypertension): true.
  • I0900 (Peripheral vascular/arterial disease): true.
  • I1100 (Cirrhosis): false.
  • I1200 (GERD/ulcer): false.
  • I1300 (Ulcerative colitis/Chrohn's/inflam bowel disease): false.
  • I1400 (Benign prostatic hyperplasia (BPH)): unknown.
  • I1500 (Renal insufficiency or renal failure/ESRD): false.
  • I1600 (HIV (includes AIDS)): false.
  • I1700 (MRSA/VRE/clostridium diff. infection/colonization): false.
  • I2000 (Pneumonia): false.
  • I2100 (Septicemia): false.
  • I2200 (Tuberculosis): false.
  • I2300 (Urinary tract infection (UTI)): false.
  • I2400 (Viral hepatitis (includes type A, B, C, D, and E)): false.
  • I2900 (Diabetes mellitus (DM)): true.
  • I3100 (Hyponatremia): unknown.
  • I3200 (Hyperkalemia): unknown.
  • I3300 (Hyperlipidemia (includes hypercholesterolemia)): false.
  • I3400 (Thyroid disorder): false.
  • I3700 (Arthritis): unknown.
  • I3800 (Osteoporosis): false.
  • I3900 (Hip fracture): false.
  • I4000 (Other fracture): unknown.
  • I4200 (Alzheimer's disease): false.
  • I4300 (Aphasia): false.
  • I4400 (Cerebral palsy): false.
  • I4500 (CVA/TIA/stroke): false.
  • I4800 (Dementia): true.
  • I4900 (Hemiplegia/hemiparesis): false.
  • I5000 (Paraplegia): false.
  • I5100 (Quadriplegia): false.
  • I5200 (Multiple sclerosis): false.
  • I5300 (Parkinson's disease): false.
  • I5400 (Seizure disorder): false.
  • I5500 (Traumatic brain injury): false.
  • I5600 (Malnutrition (protein, calorie)/risk for malnutrit): unknown.
  • I5700 (Anxiety disorder): false.
  • I5800 (Depression (other than bipolar)): false.
  • I5900 (Manic depression (bipolar disease)): false.
  • I6000 (Schizophrenia): false.
  • I6100 (Post-traumatic stress disorder): false.
  • I6200 (Asthma/COPD or chronic lung disease): false.
  • I6500 (Cataracts, glaucoma, or macular degeneration): false.
  • I7900 (None of the above active diseases): false.
  • I8000A (Additional ICD diagnosis 1): No value (No display text).

Section J - Health Conditions

  • J0100A (Pain: been on scheduled pain med regimen): 0 (No).
  • J0100B (Pain: received PRN pain medications): 1 (Yes).
  • J0100C (Pain: received non-medication intervention): 0 (No).
  • J0200 (Should pain assessment interview be conducted): 1 (Yes).
  • J0300 (Res pain interview: presence): 1 (Yes).
  • J0400 (Res pain interview: frequency): 3 (Occasionally).
  • J0500A (Res pain interview: made it hard to sleep): 0 (No).
  • J0500B (Res pain interview: limited daily activities): 1 (Yes).
  • J0600A (Res pain interview: intensity rating scale): 4.
  • J0600B (Res pain interview: verbal descriptor scale): 2 (Moderate).
  • J0800A (Staff pain asmt: non-verbal sounds): false.
  • J0800B (Staff pain asmt: vocal complaints of pain): true.
  • J0800C (Staff pain asmt: facial expressions): true.
  • J0800D (Staff pain asmt: protective movements/postures): false.
  • J0800Z (Staff pain asmt: none of these signs observed): false.
  • J0900 (Adequacy of current pain control): 2 (Controlled adequately by therapeutic regimen).
  • J1100A (Short breath/trouble breathing: with exertion): true.
  • J1100B (Short breath/trouble breathing: sitting at rest): false.
  • J1100C (Short breath/trouble breathing: lying flat): false.
  • J1100Z (Short breath/trouble breathing: none of above): false.
  • J1300 (Current tobacco use): 0 (No).
  • J1400 (Prognosis: life expectancy of less than 6 months): 0 (No).
  • J1500A (Problem conditions: fever): false.
  • J1500B (Problem conditions: vomiting): false.
  • J1500D (Problem conditions: dehydrated): false.
  • J1500H (Problem conditions: internal bleeding): false.
  • J1500Z (Problem conditions: none of the above): true.
  • J1700A (Fall history: fall during month before entry): 0 (No).
  • J1700B (Fall history: fall during 6 months before entry): 0 (No).
  • J1700C (Fall history: fracture from fall 6 month pre entry): 0 (No).
  • J1800 (Falls since admit/prior asmt: any falls): 0 (No).
  • J1900A (Falls since admit/prior asmt: no injury): 0 (None ).
  • J1900B (Falls since admit/prior asmt: injury (not major)): 0 (None ).
  • J1900C (Falls since admit/prior asmt: major injury): 0 (None ).

Section K - Swallowing/Nutritional Status

  • K0100A (Swallow disorder: loss liquids/solids from mouth): false.
  • K0100B (Swallow disorder: holds food in mouth/cheeks): false.
  • K0100C (Swallow disorder: cough/choke with meals/meds): false.
  • K0100D (Swallow disorder: difficulty or pain swallowing): false.
  • K0100Z (Swallow disorder: none of the above): true.
  • K0200A (Height (in inches)): 71[in_i].
  • K0200B (Weight (in pounds)): 175[lb_av].
  • K0200C (Body Mass Index (BMI)): 24.4.
  • K0300 (Weight loss): 0 (No, or unknown).
  • K0500A (Nutritional approaches: parenteral /IV feeding): false.
  • K0500B (Nutritional approaches: feeding tube): false.
  • K0500C (Nutritional approaches: mechanically altered diet): false.
  • K0500D (Nutritional approaches: therapeutic diet): false.
  • K0500Z (Nutritional approaches: none of the above): true.
  • K0700A (Proportion total calories via parenteral/tube feed): unknown.
  • K0700B (Average fluid intake per day by parenteral or tube): unknown.

Section L - Oral/Dental Status

  • L0200A (Dental: broken or loosely fitting denture): false.
  • L0200B (Dental: no natural teeth or tooth fragment(s)): false.
  • L0200C (Dental: abnormal mouth tissue): false.
  • L0200D (Dental: cavity or broken natural teeth): false.
  • L0200E (Dental: inflamed/bleeding gums or loose teeth): false.
  • L0200F (Dental: pain, discomfort, difficulty chewing): false.
  • L0200Z (Dental: none of the above): true.

Section M - Skin Conditions

  • M0100A (Risk determination: has ulcer, scar, or dressing): false.
  • M0100B (Risk determination: formal assessment): false.
  • M0100C (Risk determination: clinical judgment): false.
  • M0100Z (Risk determination: none of the above): true.
  • M0150 (Is resident at risk of developing pressure ulcer): 0 (No).
  • M0200A (Date of most recent pressure ulcer assessment): November 29, 2007 .
  • M0200B (Number of Stage 1 pressure ulcers): 0.
  • M0200C (Presence of Stage 2 or higher or of unstageable): 0 (No).
  • M0900A (Pressure ulcers on prior assessment): 0 (No).
  • M1020A (Other skin probs: venous or arterial ulcer(s)): false.
  • M1020B (Other skin probs: diabetic foot ulcer(s)): false.
  • M1020C (Other skin probs: other foot/lower extremity): false.
  • M1020D (Other skin probs: wound infect not foot/low extrem): false.
  • M1020E (Other skin probs: surgical wound(s)): false.
  • M1020F (Other skin probs: open lesion(s)): true.
  • M1020G (Other skin probs: burn(s) (second or third degree)): false.
  • M1020Z (Other skin probs: none of the above): false.
  • M1100 (Number of venous and arterial ulcers): 0.
  • M1200A (Skin/ulcer treat: pressure reduce device for chair): false.
  • M1200B (Skin/ulcer treat: pressure reducing device for bed): true.
  • M1200C (Skin/ulcer treat: turning/repositioning): false.
  • M1200D (Skin/ulcer treat: nutrition/hydration): false.
  • M1200E (Skin/ulcer treat: ulcer care): false.
  • M1200F (Skin/ulcer treat: surgical wound care): true.
  • M1200G (Skin/ulcer treat: application of dressings): true.
  • M1200H (Skin/ulcer treat: apply ointments/medications): false.
  • M1200I (Skin/ulcer treat: apply dressings to feet): false.
  • M1200Z (Skin/ulcer treat: none of the above): false.

Section N - Medications

  • N0300 (Number of days injectable medications received): 1d.
  • N0400A (Medications: antipsychotic): false.
  • N0400B (Medications: antianxiety): false.
  • N0400C (Medications: antidepressant): false.
  • N0400D (Medications: hypnotic): false.
  • N0400E (Medications: anticoagulant): false.
  • N0400Z (Medications: none of the above): true.

Section O - Special Treatments and Procedures

  • O0100A1 (Treatment: chemotherapy - while not resident): 0 (No).
  • O0100A2 (Treatment: chemotherapy - while resident): 0 (No).
  • O0100B1 (Treatment: radiation - while not resident): 0 (No).
  • O0100B2 (Treatment: radiation - while resident): 0 (No).
  • O0100C1 (Treatment: oxygen therapy - while not resident): 1 (Yes).
  • O0100C2 (Treatment: oxygen therapy - while resident): 1 (Yes).
  • O0100D1 (Treatment: suctioning - while not resident): 0 (No).
  • O0100D2 (Treatment: suctioning - while resident): 0 (No).
  • O0100E1 (Treatment: tracheostomy care - while not resident): 0 (No).
  • O0100E2 (Treatment: tracheostomy care - while resident): 0 (No).
  • O0100F1 (Treatment: vent/respirator - while not resident): 0 (No).
  • O0100G1 (Treatment: BIPAP/CPAP machine - while not resident): 0 (No).
  • O0100G2 (Treatment: BIPAP/CPAP machine - while resident): 0 (No).
  • O0100H1 (Treatment: IV medications - while not resident): 1 (Yes).
  • O0100H2 (Treatment: IV medications - while resident): 0 (No).
  • O0100I1 (Treatment: transfusions - while not resident): 0 (No).
  • O0100I2 (Treatment: transfusions - while resident): 0 (No).
  • O0100J1 (Treatment: dialysis - while not resident): 0 (No).
  • O0100J2 (Treatment: dialysis - while resident): 0 (No).
  • O0100K1 (Treatment: hospice care - while not resident): 0 (No).
  • O0100K2 (Treatment: hospice care - while resident): 0 (No).
  • O0100L1 (Treatment: respite care - while not resident): 0 (No).
  • O0100L2 (Treatment: respite care - while resident): 0 (No).
  • O0100M1 (Treatment: isolate/quarantine - while not resident): 0 (No).
  • O0100M2 (Treatment: isolate/quarantine - while resident): 0 (No).
  • O0200A (Was influenza vaccine received): 0 (No).
  • O0200B (If influenza vaccine not received, state reason): 2 (Received outside of this facility).
  • O0300A (Is pneumococcal vaccination up to date): 1 (Yes).
  • O0400B1 (Occupational therapy: number of minutes): 225min.
  • O0400B2 (Occupational therapy: number of days): 5d.
  • O0400B3 (Occupational therapy: start date): November 25, 2007 .
  • O0400B4 (Occupational therapy: end date): November 28, 2007, 09:19:14 .
  • O0400C1 (Physical therapy: number of minutes): 315min.
  • O0400C2 (Physical therapy: number of days): 7d.
  • O0400C3 (Physical therapy: start date): November 25, 2007 .
  • O0400C4 (Physical therapy: end date): November 28, 2007, 14:04:02 .
  • O0500A (Range of motion (passive): number of days): 0d.
  • O0500B (Range of motion (active): number of days): 7d.
  • O0500C (Splint or brace assistance: number of days): 0d.
  • O0500D (Bed mobility training: number of days): 0d.
  • O0500E (Transfer training: number of days): 7d.
  • O0500F (Walking training: number of days): 7d.
  • O0500G (Dressing or grooming training: number of days): 0d.
  • O0500H (Eating or swallowing training: number of days): 0d.
  • O0500I (Amputation/prosthesis training: number of days): 7d.
  • O0500J (Communication training: number of days): 0d.
  • O0600 (Physician examinations: number of days): 1d.
  • O0700 (Physician orders: number of days): 1d.

Section P - Restraints

  • P0100A (Restraints used in bed: bed rail (any type)): 1 (Used less than daily).
  • P0100B (Restraints used in bed: trunk restraint): 0 (Not used).
  • P0100C (Restraints used in bed: limb restraint): 0 (Not used).
  • P0100D (Restraints used in bed: other): 0 (Not used).
  • P0100E (Restraints in chair/out of bed: trunk restraint): 0 (Not used).
  • P0100F (Restraints in chair/out of bed: limb restraint): 0 (Not used).
  • P0100G (Restraints in chair/out of bed: chair stops rising): 0 (Not used).
  • P0100H (Restraints in chair/out of bed: other): 0 (Not used).

Section Q - Participation in Assessment and Goal Setting

  • Q0100A (Resident participated in assessment): 1 (Yes).
  • Q0100B (Family/signif other participated in assessment): 1 (Yes).
  • Q0200 (Wants to return to community): 1 (Yes).
  • Q0300A (Resident's goals: established during assessment): 1 (Post acute care - expects to return to live in community).
  • Q0300B (Resident's goals: source for information): 1 (Resident).

Section S - State-Specific Questions

 

Section T - Therapy Supplement for Medicare PPS

  • T0100A (Has the physician ordered rehabilitation therapies): 1 (Yes).
  • T0100B (Have therapy evaluations been completed): 1 (Yes).
  • T0100C (Estimated number of days of therapy): 15d.
  • T0100D (Estimated number of minutes of therapy): 1080min.

Section Z - Assessment Administration

  • Z0500A (Signature of RN Assessment Coordinator Verifying Assessment Completion): Nancy Nightingale, RN (33333333 2.16.840.1.113883.4.6.9999999999) signed.
  • Z0500B (Date RN signed assessment as complete): March 1, 2008, 08:30 .

CMS Control Elements

  • FAC_ID (State assigned facility submission ID): 1234512345123451.
  • ITM_SBST_CD (Item subset code): NCN (Nursing home comprehensive assessment ).
  • PROD_NAME (Software product name): MyProduct.
  • PROD_VRSN_CD (Software product version code): 2.0.1.3.
  • PRODN_TEST_CD (Production/test indicator): P (Product submission).
  • SPEC_VRSN_CD (Specifications version code): 1.00.
  • TRANS_CD (Transaction code): A (Addition).
  • VNDR_EMAIL_ADR (Software vendor email address): MyProductVendor@MyEmailAddress.com.
  • VNDR_EMPLR_ID (Software vendor federal employer tax ID): 11-1111111.
  • VNDR_NAME (Software vendor company name): MyProductVendor.

 


 

 

Encounter Location Room 222

 

Document maintained by Green Acres Retirement Home
Contact info 4444 Nursinghome Drive
Ann Arbor, MI 99999
Telecom information not available
Legal authenticator Nancy Nightingale, RN signed at March 1, 2008, 08:30

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