9e28c7c5-a3a8-4791-abb6-649d1a976d99.xls
A B C D E F
1 MDS 3.0 Data Element Documentation Support Location Hard Copy Electronic I/O
2 A0100A Facility Provider Numbers NPI
3 A0100B Facility Provider Numbers CCN
4 A0100C Facility Providers Numbers State
5 A0200 Type of Provider
6 A0310A Type of Assessment Federal OBRA
7 A0300B Type of Assessment PPS Assessment
8 A0300C Type of Assessment OMRA
9 A0300D Type of Assessment Swing Bed Change
10 A0300E Type of Assessment First Assessment
11 A0300F Type of Assessment Entry/Discharge Reporting
12 A0410 Submission Requirement
13 A0500A-D Legal Name of Resident
14 A0600A Social Security Number
15 A0600B Medicare Number
16 A0700 Medicaid Number
17 A0800 Gender
18 A0900 Birth Date
19 A1000A-F Race/Ethnicity
20 A1100A Language interpreter needed
21 A1100B Preferred Language
22 A1200 Marital Status
23 A1300A Medical Record Number
24 A1300B Room Number
25 A1300C Preferred Name
26 A1300D Lifetime Occupation/s
27 A1500 PASRR
28 A1550A-Z Conditions Related tp MR/DD Status
29 A1600 Entry Date
30 A1700 Type of Entry
31 A1800 Entered From
32 A2000 Discharge Date
33 A2100 Discharge Status
34 A2200 Previous ARD for Significant Correction
35 A2300 Assessment Reference Date
36 A2400A Medicare Stay since most recent entry
9e28c7c5-a3a8-4791-abb6-649d1a976d99.xls
A B C D E F
37 A2400B Start Date of Most recent MC stay
38 A2400C End date of most recent MC stay
39 B0100 Comatose
40 B0200 Hearing
41 B0300 Hearing Aid
42 B0600 Speech Clarity
43 B0700 Makes Self Understood
44 B0800 Ability to Understand Others
45 B1000 Vision
46 B1200 Corrective Lenses
47 BC0100 Should BIMS be Conducted
48 C0200 Repetition of Three Words
49 C0300A-C Temporal Orientation
50 C0400A-C Recall
51 C0500 Summary Score BIMS
52 C0600 Should Staff Assess Mental Status
53 C0700 Short Term Memory OK
54 C0800 Long Term Memory OK
55 C0900A-Z Memory/Recall Ability
56 C1000 Cognitive Skills for Decision Making
57 C1300A-D Delirium S/S CAM
58 C1600 Acute Onset of Mental Change
59 D0100 Should Resident Mood Interview Be Conducted
60 D0200A-I Resident Mood PHQ9
61 D0300 Total Severity Score
62 D0350 Safety Notification
63 D0500A-J Staff Assessment for Mood
64 D0600 Total Severity Score
65 D0650 Safety Notification
66 E0100A-Z Psychosis
67 E0200A-C Behavioral Symptoms
68 E0300 Overall Presence of Behavioral Symptoms
69 E0500A-C Impact on Resident
70 E0600A-C Impact on Others
71 E0800 Rejection of Care
72 E0900 Wandering
9e28c7c5-a3a8-4791-abb6-649d1a976d99.xls
A B C D E F
73 E1000A-B Wandering Impact
74 E1100 Change in Behavioral Symptoms
75 F0300 Should Interview for customary routine
76 F0400A-H Interview for Daily Preferences
77 FO500A-H Interview for Activity Preferences
78 F0600 Daily and Activity Preferences Primary Respondent
79 F0700 Shaould Staff Assessment for Preferences be Conducted
80 F0800A-Z Staff Assessment of Daily and Activity Preferences
81 G0110A Activities of Daily Living Bed Mobility
82 G0110B Activities of Daily Living Transfer
83 G0110C Activities of Daily Living Walk in Room
84 G0110D Activities of Daily Living Walk in Corridor
85 G0110E Actvities of Daily Living Locomotion On Unit
86 G0110F Activities of Daily Living Locomotion Off Unit
87 G0110G Activities of Daily Living Dressing
88 G0110H Activities of Daily Living Eating
89 G0110I Activities of Daily Living Toilet Use
90 G0110J Activities of Daily Living Personal Hygiene
91 GP120G Bathing
92 G0300A-E Balance During Transitions and Walking
93 G0400A-B Functional Limitation in Range of Motion
94 G0600A-Z Mobility Devices
95 G0900A-B Functional Rehabilitation Potential
96 H0100A-Z Appliances
97 H0200A-C Urinary Toileting Program
98 H0300 Urinary Continence
99 H0400 Bowel Continence
100 H0500 Bowel Toileting Program
101 H0600 Bowel Patterns
102 I0100-I8000 Active Diagnoses
103 J0100A-C Pain Management
104 J0200 Should Pain Assessment Interview Be Conducted
105 J0300 Pain Presence
106 J0400 Pain Frequency
107 J0500A-B Pain Effect in Function
108 J0600A-B Pain Intesity
9e28c7c5-a3a8-4791-abb6-649d1a976d99.xls
A B C D E F
109 J0700 Should the Staff Assessment for Pain Be Conducted
110 J0800A-Z Indicators of Pain or Possible Pain
111 J0850 Frequency of Indicator of Pain or Possible Pain
112 J1100A-Z Shortness of Breath
113 J1300 Current Tobacco Use
114 J1400 Prognosis
115 J1550A-Z Problem Condition
116 J1700A-C Fall History on Admission
117 J1800 Any Falls Since Admission or Prior Assessment
118 J1900A-C Numner of Falls Since Admission or Prior Assessment
119 K0100A-Z Swallowing Disorder
120 K0200A-B Height and Weight
121 K0300 Weight Loss
122 K0500A-Z Nutritional Approaches
123 K0700A-B Percent Intake by Artifical Route
124 L0200A-Z Dental
125 M0100A-Z Determination of Pressure Ulcer Risk
126 M0150 Risk of Pressure Ulcers
127 M0210 Unhealed Pressure Ulcer(s)
128 M0300A-G Current Number of Unhealed Pressure Ulcer(s) at Each Stage
129 M0610A-C Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar
130 M0700 Most Severe Tissue Type for Any Pressure Ulcer
131 M0800A-C Worsening in Pressure Ulcer Status Since Prior Assessment
132 M0900A-D Healed Pressure Ulcers
133 M1030 Number of Venous and Arterial Ulcers
134 M1040A-Z Other Ulcers, Wounds and Skin Problems
135 M1200A-Z Skin and Ulcer Treatments
136 N0300 Injections
137 N0350 Insulin
138 N0400 Medications Received
139 O0100A-Z1 Special Treatments, Procedures and Programs While Not A Res
140 O0100A-Z2 Special Treatments, Procedures and Programs While A Res
141 O0250A-C Inflenza Vaccine
142 O0300A-B Penuomococcal Vaccine
143 O0400A Speech Language Pathology and Audiology Services
144 O0400B Occupational Therapy
9e28c7c5-a3a8-4791-abb6-649d1a976d99.xls
A B C D E F
145 O0400C Physical Therapy
146 O0400D Respiratory Therapy
147 O0400E Psychological Therapy
148 O0400F Recreational Therapy
149 O0500A-J Restorative Nursing Programs
150 O0600 Physician Examinations
151 O0700 Physician Orders
152 P0100A-H Physical Restraints
153 Q0100A-C Participation in Assessment
154 Q0300A-B Resident's Overall Expectation
155 Q0400A-B Discharge Plan
156 Q0500A-B Return to Community
157 Q0600 Referral
158 V0100A Items from Most Recent Prior OBRA or Scheduled PPS Assess
159 X0100 Type of Record
160 X0150 Type of Provider
161 X0200 Name of Resident
162 X0300 Gender
163 X0400 Birth Date
164 X0500 Social Security Number
165 X0600 A-F Type of Assessment
166 X0700 A-C Date
167 C0800 Correction Number
168 CX0900 Reasons for Modification
169 X1050 Reasons for Inactivation
170 Z0100A-C Medicare Part A Billing
171 Z0150A-B Medicare Part A Non Therapy Billing
172 Z0200A-B State Medicaid Billing
173 Z0250A-B Alternate State Medicaid Billing
174 Z0300A-B Insurance Billing