Toward a National Health Information Infrastructure: A Key Strategy for Improving Quality in Long-Term Care. APPENDIX F. Terms Abstracted from the MDS

MDS Terms Classified as "Administrative Information" (n=87)

  • MDS
  • Identification Information
  • Resident Name
  • First
  • Middle
  • Last
  • Jr/Sr
  • Gender
  • Birthdate
  • Race/ethnicity
  • Social security number and Medicare Number
  • Facility Provider Number
  • State number
  • Federal Number
  • Medicaid Number
  • Reasons for Assessment
  • Primary reason for assessment
  • Admission assessment
  • Annual assessment
  • Significant change in status assessment
  • Significant correction of prior full assessment
  • Quarterly review assessment
  • Significant correction of prior quarterly assessment
  • Medicare 5 day assessment
  • Medicare 30 day assessment
     
  • Medicare 60 day assessment
  • Medicare 90 day assessment
  • Medicare readmission/return assessment
  • Other state required assessment
  • Medicare 14 day assessment
  • Other Medicare required assessment
  • Signature of Persons Completing a Portion of the Assessment
  • Signature
  • Title
  • Date
  • Demographic Information
  • Date of Entry
  • Admitted from
  • Zip Code of Prior Primary Residence
  • Date Background Information Completed
  • Not applicable no MR/DD
  • Identification and Background Information
  • Middle initial
  • Room Number
  • Assessment Reference Date
  • Last day of MDS observation period
  • Marital Status
  • Medical Record Number
  • Current Payment Sources for NH Stay
  • Medicaid per diem
     
  • Medicare per diem
  • Medicare ancillary part A
  • Medicare ancillary part B
  • CHAMPUS per diem
  • VA per diem
  • Self or family pays for full per diem
  • Medicaid resident liability of Medicare co-payment
  • Private insurance per diem
  • Other per diem
  • Significant change in status assessment
  • Discharged return not anticipated
  • Discharged return anticipated
  • Discharged prior to completing initial assessment
  • Reentry
  • Codes for assessments required for Medicare PPS or the state
  • Responsibility/Legal Guardian
  • Legal guardian
  • Other legal oversight
  • Durable power of attorney/health care
  • Durable power attorney/financial
  • Family member responsible
  • Advanced Directives
  • Living will
  • Do not resuscitate
  • Do not hospitalize
     
  • Organ donation
  • Autopsy request
  • Hospital Stay(s)
  • Emergency Room (ER) Visit(s)
  • Physician Orders
  • Assessment Information
  • Participation in Assessment
  • Resident
  • Family
  • Significant other
  • Signature of Person Coordinating the Assessment
  • Patient responsible for self

MDS Terms Classified as "Resident History" (n=143 )

  • Private home without home health services
  • Private home with home health services
  • Board and care assisted living group home
  • Nursing home
  • Acute care hospital
  • Psychiatric hospital MR/DD facility
  • Rehabilitation hospital
  • Lived Alone (Prior to entry)
  • Residential History 5 Years Prior to Entry
  • Prior stay at this nursing home
  • Stay in other nursing home
  • Other residential facility - board and care home, assisted li
  • MH/psychiatric setting
  • MR/DD setting
  • Lifetime Occupation(s)
  • Education
  • No schooling
  • 8th grade/less
  • 9-11 grades
  • High school
  • Technical or trade school
  • Some college
  • Bachelor's degree
  • Graduate degree
  • Language
     
  • English
  • Spanish
  • French
  • Primary language
  • Down's syndrome
  • Autism
  • Epilepsy
  • Other organic condition related to MR/DD
  • MR/DD with no organic condition
  • Mental health history
  • Conditions related to MR/DD status
  • MR/DD with organic condition
  • Other organic condition related to MR/DD
  • MR/DD with no organic condition
  • Customary Routine
  • Cycle of Daily Events
  • Stays up late at night
  • Naps regularly during day
  • Goes out 1+ days a week
  • Stays busy with hobbies, reading or fixed daily routine
  • Spends most of time alone of watching TV
  • Moves independently indoors
  • Use of tobacco products at least daily
  • Eating Patterns
  • Distinct food preferences
     
  • Eats between meals all or most days
  • Use of alcoholic beverage(s) at least weekly
  • ADL Patterns
  • No change in ADL function
  • Improved
  • Deteriorated
  • In bedclothes much of day
  • Wakens to toilet all or most nights
  • Has irregular bowel movement patterns
  • Showers for bathing
  • Bathing in PM
  • Involvement Patterns
  • Daily contact with relatives/close friends
  • Usually attends church, temple, synagogue
  • Finds strength in faith
  • Daily animal companion/presence
  • Involved in group activities
  • Past Roles
  • Frequently incontinent
  • Incontinent
  • Disease Diagnosis
  • Diseases
  • Endocrine/metabolic/nutritional
  • Diabetes mellitus
  • Hyperthyroidism
     
  • Hypothyroidism
  • Heart/circulation
  • ASHD
  • Cardiac dysrythmias
  • Congestive heart failure
  • Deep vein thrombosis
  • Hypertension
  • Hypotension
  • Peripheral vascular disease
  • Other cardiovascular disease
  • Musculoskeletal
  • Arthritis
  • Hip fracture
  • Missing limb
  • Osteoporosis
  • Pathological bone fracture
  • Neurological
  • Alzheimer's disease
  • Aphasia
  • Cerebral palsy
  • Cerebrovascular accident
  • Dementia other than Alzheimer's disease
  • Hemiplegia/hemiparesis
  • Multiple sclerosis
  • Paraplegia
     
  • Parkinson's disease
  • Quadriplegia
  • Seizure disorder
  • Transient ischemic attack
  • Traumatic brain injury
  • Psychiatric/mood
  • Anxiety disorder
  • Depression
  • Manic depression
  • Schizophrenia
  • Pulmonary
  • Asthma
  • Emphysema
  • Sensory
  • Cataracts
  • Diabetic retinopathy
  • Glaucoma
  • Macular degeneration
  • Allergies
  • Anemia
  • Cancer
  • Renal failure
  • Infections
  • Antibiotic resistant infection
  • Clostridium difficile
     
  • Conjunctivitis
  • HIV infection
  • Pneumonia
  • Respiratory infection
  • Septicemia
  • Sexually transmitted disease
  • Tuberculosis
  • Urinary tract infection in last 30 days
  • Viral hepatitis
  • Wound infection
  • Other Current or more Detailed Diagnoses and ICD-9 Codes
  • Accidents
  • Fell in past 30 days
  • Fell in past 31-180 days
  • Hip fracture in last 180 days
  • Other fracture in last 180 days
  • End-stage disease
  • History of Resolved Ulcers

MDS Terms Classified as "Assessments" (n=273)

  • Cognitive Patterns
  • Comatose
  • Memory
  • Short-term memory OK
  • Long-term memory OK
  • Memory/recall Ability
  • Current season
  • Location of own room
  • Staff names/faces
  • That he/she is in a nursing home
  • Cognitive skills for Daily Decision Making
  • Indicators of Delirium-Periodic Disordered Thinking/Awareness
  • Easily distracted
  • Periods of altered perception or awareness of surroundings
  • Episodes of disorganized speech
  • Periods of restlessness
  • Periods of lethargy
  • Mental function varies over the course of the day
  • Change in Cognitive Status
  • Communication/Hearing patterns
  • Hearing
  • Hears adequately
  • Minimal difficulty hearing
  • Hears in special situations only
  • Highly impaired hearing
     
  • Communication Devices/Techniques
  • Hearing aid present and used
  • Hearing aid present and not used regularly
  • Other receptive comm. Techniques used
  • Modes of Expression
  • Speech
  • Writing messages to express or clarify needs
  • American sign language or Braille
  • Signs/gestures/sounds
  • Communication board
  • Making Self Understood
  • Understood
  • Usually understood
  • Sometimes understood
  • Rarely/Never understood
  • Speech clarity
  • Clear speech
  • Unclear speech
  • No speech
  • Ability to Understand Others
  • Understands
  • Usually understands
  • Sometimes understands
  • Rarely/Never understands
  • Change in Communication/Hearing
     
  • Vision Patterns
  • Vision
  • Adequate
  • Impaired
  • Moderately impaired
  • Highly impaired
  • Severely impaired
  • Visual Limitations/Difficulties
  • Side vision problems
  • Experiences any of following:
  • Mood and Behavior Patterns
  • Indicators of Depression, Anxiety, Sad Mood
  • Verbal expressions of distress
  • Resident made negative statements
  • Repetitive questions
  • Repetitive verbalizations
  • Persistent anger with self or others
  • Self deprecation
  • Expressions of what appear to be unrealistic fears
  • Recurrent statements that something terrible is about to happen
  • Repetitive health complaints
  • Repetitive anxious complaints/concerns
  • Sleep cycle issues
  • Unpleasant mood in morning
  • Insomnia/change in usual sleep pattern
     
  • Sad, apathetic, anxious appearance
  • Sad, pained, worried facial expressions
  • Crying, tearfulness
  • Repetitive physical movements
  • Loss of interest
  • Withdrawal from activities of interest
  • Reduced social interaction
  • Mood Persistence
  • Change in Mood
  • Behavioral Symptoms
  • Wandering
  • Verbally abusive behavioral symptoms
  • Physically abusive behavioral symptoms
  • Socially inappropriate/disruptive behavioral symptoms
  • Resists care
  • Change in Behavioral Symptoms
  • Psychosocial Well-Being
  • Sense of Initiative/Involvement
  • At ease interacting with others
  • At ease doing planned or structured activities
  • At ease doing self-initiated activities
  • Establishes own goals
  • Pursues involvement in life of facility
  • Accepts invitations into most group activities
  • Unsettled Relationships
     
  • Covert/open conflict with or repeated criticism of staff
  • Unhappy with roommate
  • Unhappy with residents other than roommate
  • Openly expressed conflict/anger with family/friends
  • Recent loss of close family member/friend
  • Does not adjust easily to change in routines
  • Strong identification with past roles and life status
  • Expresses sadness/anger/empty feeling over lost roles/status
  • Resident perceives that daily routine is very different from prior pattern in the community
  • Physical Functioning and Structural Problems
  • ADL Self Performance/ADL support provided
  • Bed mobility
  • Transfer
  • Walk in room
  • Walk in corridor
  • Locomotion off unit
  • Dressing
  • Eating
  • Toilet use
  • Personal hygiene
  • Bathing
  • ADL self-performance
  • Independent
  • Supervision
  • Limited assistance
     
  • Extensive assistance
  • Total dependence
  • Activity did not occur
  • ADL support provided
  • No setup or physical help from staff
  • One person physical assist
  • Two + person physical assist
  • Test for Balance
  • Balance while standing
  • Balance while sitting
  • Functional Limitation in Range of Motion
  • Neck
  • Arm
  • Hand
  • Leg
  • Foot
  • Other limitation or loss
  • Modes of Locomotion
  • Cane/walker/crutch
  • Wheeled self
  • Other person wheeled
  • Wheelchair primary mode of locomotion
  • Modes of Transfer
  • Bedfast all or most of time
  • Bed rails used for bed mobility or transfer
     
  • Lifted manually
  • Lifted mechanically
  • Transfer aid
  • Task Segmentation
  • ADL Functional Rehabilitation Potential
  • Resident believes he/she is capable of increased independence
  • Direct care staff believe resident is capable of increased in
  • Resident able to perform tasks/activity but is very slow
  • Difference in ADL self-performance or ADL support, comparing mornings to evenings
  • Change in Function
  • Continence in Last 14 Days
  • Continence Self-Control Categories
  • Continent
  • Usually Continent
  • Occasionally incontinent
  • Bowel continence
  • Bladder continence
  • Bowel elimination pattern
  • Regular
  • Constipation
  • Diarrhea
  • Fecal impaction
  • Did not use toilet room/commode/urinal
  • Change in urinary continence
  • Health Conditions
     
  • Problem Conditions
  • Indicators of fluid status
  • Weight gain or loss of 3 or more pounds within a 7 day period
  • Inability to lie flat due to shortness of breath
  • Dehydrated; output exceeds input
  • Insufficient fluid; did not consume all/almost all liquids provided during last 3 days
  • Delusions
  • Dizziness/vertigo
  • Edema
  • Fever
  • Hallucinating
  • Internal bleeding
  • Recurrent lung aspirations in last 90 days
  • Shortness of breath
  • Syncopy
  • Unsteady gait
  • Vomiting
  • Pain Symptoms
  • Frequency
  • Intensity
  • Pain Site
  • Back
  • Bone
  • Chest pain while doing usual activities
  • Headache
     
  • Hip
  • Incisional pain
  • Joint pain
  • Soft tissue pain
  • Stomach pain
  • Stability of Conditions
  • Conditions/diseases make resident's cognitive, ADL, mood or behavior patterns unstable
  • Resident experiencing an acute episode or a flare-up of a recurrent or chronic problem
  • Oral/Nutritional Status
  • Oral Problems
  • Chewing problem
  • Swallowing problem
  • Mouth pain
  • Height
  • Weight
  • Weight Change
  • Weight loss
  • Weight gain
  • Nutritional Problems
  • Complains about the taste of many foods
  • Regular or repetitive complaints of hunger
  • Leaves 25% or more of food uneaten at most meals
  • Oral/Dental Status
  • Oral Status and Disease Prevention
  • Debris present in mouth prior to going to bed at night
     
  • Has dentures or removable bridge
  • Some/all natural teeth lost
  • Broken, loose, or carious teeth
  • Inflamed gums
  • Daily cleaning of teeth/dentures or daily mouth care
  • Skin condition
  • Ulcers
  • Stage 1
  • Stage 2
  • Stage 3
  • Stage 4
  • Type of Ulcer
  • Pressure ulcer
  • Stasis ulcer
  • Other skin Problems or Lesions Present
  • Abrasions
  • Burns
  • Open lesions other than ulcers, rashes, cuts
  • Rashes
  • Skin desensitized to pain or pressure
  • Skin tears or cuts
  • Surgical wounds
  • Resident has one or more foot problems
  • Infection of the foot
  • Open lesions on the foot
     
  • Activity Pursuit Patterns
  • Time Awake
  • Average Time Involved in Activities
  • Preferred Activity Settings
  • General Activity Preferences
  • Prefers Change in Daily Routine
  • Type of activities in which resident is currently involved
  • Extent of resident involvement in activities
  • Intake/output
  • Evaluation by a licensed mental health specialist in last 90 days
  • Transfer
  • Walking
  • Dressing or grooming
  • Eating or swallowing
  • Amputation/prosthesis care
  • Communication
  • Abnormal Lab Values
  • Discharge Potential and Overall Status
  • Discharge Potential
  • Resident expresses/indicates preference to return to the community
  • Resident has a support person who is positive towards discharge
  • Stay projected to be of a short duration
  • Overall Change in Care Needs

MDS Terms Classified as "Treatments" (n= 93)

  • Feeding restrictions
  • Medication restrictions
  • Other treatment restrictions
  • Visual Appliances
  • Glasses
  • Contacts lenses
  • Magnifying glass
  • Appliances and programs
  • Any scheduled toileting plan
  • Bladder retraining program
  • External catheter
  • Indwelling catheter
  • Intermittent catheter
  • Pads/briefs used
  • Enemas/irrigation
  • Ostomy present
  • Nutritional Approaches
  • Parenteral/IV
  • Feeding tube
  • Mechanically altered diet
  • Syringe
  • Therapeutic diet
  • Dietary supplement between meals
  • Plate guard, stabilized built-up utensil
  • On a planned weight change program
     
  • Parenteral or Enteral Intake
  • Code the proportion of total calories the resident received through parenteral or tube feedings in the last 7 days
  • Skin Treatments
  • Pressure relieving device for chair
  • Pressure relieving device for bed
  • Turning/repositioning program
  • Nutrition or hydration intervention to manage skin problems
  • Ulcer care
  • Surgical wound care
  • Application of dressings
  • Application of ointments/ medications
  • Other preventative or protective skin care
  • Foot Problems and Care
  • Received preventive or protective foot care
  • Medications
  • Number of Medications
  • New Medications
  • Injections
  • Days Received the Following Medications
  • Antipsychotic
  • Antianxiety
  • Antidepressant
  • Hypnotic
  • Diuretic
  • Special Treatments and Procedures
     
  • Special Treatments, Procedures, and Programs
  • Special care
  • Treatments
  • Chemotherapy
  • Dialysis
  • IV medication
  • Monitoring acute medical condition
  • Ostomy care
  • Oxygen therapy
  • Radiation
  • Suctioning
  • Tracheostomy care
  • Transfusions
  • Ventilator or respirator
  • Programs
  • Alcohol/drug treatment program
  • Alzheimer's/dementia special care unit
  • Hospice care
  • Pediatric care
  • Respite care
  • Training in skills required to return to the community
  • Therapies
  • Occupational therapy
  • Physical therapy
  • Respiratory therapy
     
  • Psychological therapy
  • Intervention Programs for Mood, Behavior, Cognitive Loss
  • Special behavior symptoms evaluation program
  • Group therapy
  • Resident-specific deliberate changes in the environment to address mood/behavior patterns
  • Reorientation
  • Nursing Rehabilitation/Restorative Care
  • Range of motion (active)
  • Range of motion (passive)
  • Splint of brace assistance
  • Training and skill practice in:
  • Devices and Restraints
  • Bed rails
  • Full bed rails on all open sides of bed
  • Other types of side rails used
  • Trunk restraint
  • Limb restraint
  • Chair prevents rising

MDS Terms Classified as "Other" (n=43)

  • Section
  • If other, specify
  • Not applicable
  • Unknown
  • Face Sheet Signatures
  • Signatures of persons completing face sheet
  • Signature of RN assessment coordinator
  • Title
  • Original or corrected copy of form
  • Date of Reentry
  • other
  • none of above
  • None
  • 1% to 25%
  • 26% to 50%
  • 51% to 75%
  • 76% to 100%
  • Code the average fluid intake per day by IV or tube in last 7 days
  • 1 to 500 cc/day
  • 501 to 1000 cc/day
  • 1001 to 1500 cc/day
  • 1501 to 2000 cc/day
  • 2001 or more cc/day
  • Morning
  • Afternoon
     
  • Evening
  • Own room
  • Day/activity room
  • Inside NH/off unit
  • Outside facility
  • Cards/other games
  • Crafts/arts
  • Exercise/sports
  • Music
  • Reading/writing
  • Spiritual/religious activities
  • Trips/shopping
  • Walking/wheeling outdoors
  • Watching TV
  • Gardening or plants
  • Talking or conversing
  • Helping others
  • Physician visits

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