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Psychosocial Assessment Worksheet - Excel

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Psychosocial Assessment Worksheet - Excel Powered By Docstoc
					                                      Date:
                         Requestor Name:
                      Requestor Institution:
                               Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                    Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                            Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                     Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                         CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                      MDS                Use in analysis
                                                                Section A. Identification and Background Information
           (A2) Room Number                   A2_ROOM_NUM                            * * * * * *
           (A3A) Assessment Reference
           Date                               A3A_ASMT_REF_DT                        * * * * * *                     *     *
           (A4A) Reentry Date                 A4A_REENTRY_DT                         * * * * * *              *

           (A4B) Admitted From (at Reentry)     A4B_ADMIT_FROM                                                                                                                            *
           (A5) Marital Status                  A5_MARTIAL_STATUS                   *             *             *             *
           (A6) Medical Record Number           A6_MEDICAL_REC_NUM                  *             *             *             *     *               *                   *                 *                                                                                    *
           (A7A) Medicaid Per Diem              A7A_MCAID_PER_DIEM                  *             *             *
           (A7B) Medicare Per Diem              A7B_MCARE_PER_DIEM                  *             *             *
           (A7C) Medicare Ancillary Part A      A7C_MCARE_ANC_P_A                   *             *             *
           (A7D) Medicare Ancillary Part B      A7D_MCARE_ANC_P_B                   *             *             *
           (A7E) CHAMPUS Per Diem               A7E_CHAMPUS_P_D                     *             *             *
           (A7F) VA Per Diem                    A7F_VA_PER_DIEM                     *             *             *
           (A7G) Self/Family Pay Full Per
           Diem                                 A7G_SELF_FAM_PAY                    *             *             *
           (A7H) Medicaid Resident
           Liability/Medicare Co-Pay            A7H_MCAID_MCARE                     *             *             *
           (A7I) Private Insurance Per Diem     A7I_PRIVATE_PAY                     *             *             *
           (A7J) Other Per Diem                 A7J_OTHER                           *             *             *
           (A9A) Legal Guardian                 A9A_LEGAL_GUARDIAN                  *             *             *
           (A9B) Other Legal Oversight          A9B_OTH_LGL_OVRSGHT                 *             *             *
           (A9C) Durable Power of
           Attorney/Health Care                 A9C_DUR_POA_HTLCRE                  *             *             *
           (A9D) Durable Power of
           Attorney/Financial                   A9D_DUR_POA_FIN                     *             *             *
           (A9E) Family Member
           Responsible                          A9E_FAM_MEM_RESP                    *             *             *

           (A9F) Patient Responsible for Self   A9F_PAT_RESP_SELF                   *             *             *
           (A9G) Responsibility/guardian:
           None of the Above                    A9G_NONE_ABOVE                      *             *             *
           (A10A) Living Will                   A10A_LIVING_WILL                    *             *             *
           (A10B) Do Not Resuscitate            A10B_NOT_RECESS                     *             *             *             *
           (A10C) Do Not Hospitalize            A10C_NOT_HOSPTIAL                   *             *             *             *

        7/20/2011                                                                                     1 of 28                                                                                                                                                                 cc48b286-0e60-401b-844e-4262322d2eab.xls
                                     Date:
                        Requestor Name:
                     Requestor Institution:
                              Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                            Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                                Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                             Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                                 CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                              MDS                Use in analysis
           (A10D) Organ Donation              A10D_ORGAN_DONATE                     *             *             *
           (A10E) Autopsy Request             A10E_AUTOPSY_REQ                      *             *             *
           (A10F) Feeding Restrictions        A10F_FEED_RESTRICT                    *             *             *
           (A10G) Medication Restrictions     A10G_MED_RESTRICT                     *             *             *
           (A10H) Other Treatment
           Restrictions                       A10H_OTH_TRT_REST                     *             *             *
           (A10I) Advanced Directives: None
           of the Above                       A10I_NONE_ABOVE                      * * *
                                                                       Section AA. Identification Information
           (AA1A) Resident First Name         AA1A_FIRST_NM                        * * * * * *          * *                                                                                                                                                                            *        CMS WILL NOT RELEASE
           (AA1B) Resident Middlie Initial    AA1B_MIDDLE_INTIAL                   * * * * * *          * *                                                                                                                                                                            *        CMS WILL NOT RELEASE
           (AA1C) Resident Last Name          AA1C_LAST_NM                         * * * * * *          * *                                                                                                                                                                            *        CMS WILL NOT RELEASE
           (AA1D) Resident Name Suffix        AA1D_NAME_SUFFIX                     * * * * * *          * *                                                                                                                                                                            *        CMS WILL NOT RELEASE
           (AA2) Gender                       AA2_GENDER                           * * * * * *          * *
           (AA3) Birth Date                   AA3_BIRTH_DT                         * * * * * *          * *
           (AA4) Race/Ethnicity               AA4_RACE_ETH                         * * * * * *          * *
           (AA5A) Social Security Number      AA5A_SSN_NUM                         * * * * * *          * *                                                                                                                                                                            *
           (AA5B) Resident Medicare
           Number (or comparable number)      AA5B_PAT_MCARE_NBR                    *             *             *             *     *               *                   *                 *
           (AA6A) Facility State Number       AA6A_FAC_MCAID_NBR                    *             *             *             *     *               *                   *                 *

           (AA6B) Facility Federal Number     AA6B_FAC_MCARE_NBR                    *             *             *             *     *               *                   *                 *                                                                                                     Recommended if linking to OSCAR data


           (AA7) Resident Medicaid Number AA7_PAT_MCAID_NBR                         *             *             *             *     *               *                   *                 *                                                                                            *
           (AA8A) Primary Reason for
           Assessment                     AA8A_PRI_RFA                              *             *             *             *     *               *                   *                 *                                                                 *                     *             CMS Recommended

           (AA8B) Special Assessment Code AA8B_SPC_RFA                             * * * *                 *                                                                                                                                                *                                   CMS Recommended
                                                                       Section AB. Demographic Information
           (AB1) Date of Entry                AB1_ENTRY_DT                         *                 *
           (AB2) Admitted From (at Entry)     AB2_ADMIT_FROM                       *                 *

           (AB3) Lived Alone (Prior to Entry) AB3_LIVED_ALONE                       *
           (AB4) Zip Code of Prior Primary
           Residence                          AB4_PRIOR_ZIP                         *


        7/20/2011                                                                                     2 of 28                                                                                                                                                                         cc48b286-0e60-401b-844e-4262322d2eab.xls
                                      Date:
                         Requestor Name:
                      Requestor Institution:
                               Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                    Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                    Resident Profiles
                                                                                                                                                                    Track-Discharge




                                                                                                                                                                                                                                                            Quality Measure
                                                                                                                                                                                                                Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                      Track-Reentry
                                                                                                                                 used in




                                                                                                                                                    Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                     Not in




                                                                                                                                                                                                      RUG III
 Check to                                                                                                                           QI                                                                                                                                         CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                      MDS                Use in analysis
           (AB5A) Prior Stay in This Nursing
           Home                                  AB5A_PRIOR_THIS_NF                 *                                         *                                                                                                                         *
           (AB5B) Stay in Other Nursing
           Home                                  AB5B_PRIOR_OTH_NF                  *                                         *                                                                                                                         *

           (AB5C) Other Residential Facility     AB5C_OTH_RF                        *                                         *                                                                                                                         *
           (AB5D) MH/Psychiatric Setting         AB5D_PRIOR_PSHCH                   *                                         *                                                                                                                         *
           (AB5E) MR/DD Setting                  AB5E_PRIOR_MR_DD                   *                                         *                                                                                                                         *
           (AB5F) Residential History: None
           of Above                              AB5F_NONE_ABOVE                    *                                         *                                                                                                                         *
           (AB6) Lifetime Occupation(s)          AB6_LIFE_OCCUP                     *
           (AB7) Education (Highest Level
           Completed)                            AB7_EDUCATION                      *
           (AB8A) Primary Language               AB8A_PRI_LANG                      *

           (AB8B) If other (language), specify   AB8B_OTH_LANG                      *
           (AB9) Mental Health History           AB9_MH_HISTORY                     *
           (AB10A) Not applicable -- no
           MR/DD                                 AB10A_MR_DD_NA                     *
           (AB10B) Down's Syndrome               AB10B_MR_DD_DOWNS                  *
           (AB10C) Autism                        AB10C_MR_DD_AUTISM                 *
           (AB10D) Epilepsy                      AB10D_MR_DD_EPI                    *
           (AB10E) Other Organic Condition
           Related to MR/DD                      AB10E_MR_DD_OTH                    *
           (AB10F) MR/DD with No Organic
           Condition                             AB10F_MR_DD_NO_ORG                 *
           (AB11) Date Background
           Information Completed                 AB11_BACKGRD_CP_DT                *
                                                                          Section AC. Customary Routine
           (AC1A) Stays Up Late at Night         AC1A_LATE_NITE                    *
           (AC1B) Naps Regularly During
           Day                                   AC1B_NAPS                          *
           (AC1C) Goes Out 1+ Days a
           Week                                  AC1C_OUT_1_WEEK                    *
           (AC1D) Stays Busy With
           Hobbies/Fixed Routine                 AC1D_STAY_BUSY                     *

        7/20/2011                                                                                    3 of 28                                                                                                                                                                  cc48b286-0e60-401b-844e-4262322d2eab.xls
                                     Date:
                        Requestor Name:
                     Requestor Institution:
                              Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                    Resident Profiles
                                                                                                                                                                    Track-Discharge




                                                                                                                                                                                                                                                        Quality Measure
                                                                                                                                                                                                                Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                      Track-Reentry
                                                                                                                                 used in




                                                                                                                                                    Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                 Not in




                                                                                                                                                                                                      RUG III
 Check to                                                                                                                           QI                                                                                                                                     CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                  MDS                Use in analysis
           (AC1E) Spends Most Time Alone
           or TV                              AC1E_TIME_ALONE                       *
           (AC1F) Moves Independently
           Indoors                            AC1F_INDEP_INDOORS                    *
           (AC1G) Use of Tobacco Daily        AC1G_TOBAC_DAILY                      *
           (AC1H) Cycle of Daily
           Events:None of Above               AC1H_NONE_ABOVE                       *

           (AC1I) Distinct Food Preferences   AC1I_FOOD_PREF                        *
           (AC1J) Eats Between Meals Most
           Days                               AC1J_EAT_BTWN_MEAL                    *
           (AC1K) Use of Alcohol/Weekly       AC1K_ALC_WKLY                         *
           (AC1L) Eating Patterns: None of
           Above                              AC1L_NONE_ABOVE                       *
           (AC1M) In Bedclothes Much of
           Day                                AC1M_BEDCTHS_DAY                      *
           (AC1N) Wakens to Toilet Most
           Nights                             AC1N_TOLIET_NIGHT                     *
           (AC1O) Has Irregular Bowel
           Movement Pattern                   AC1O_IRREG_BOWEL                      *
           (AC1P) Showers for Bathing         AC1P_SHOWERS                          *
           (AC1Q) Bathing in PM               AC1Q_BATH_PM                          *
           (AC1R) ADL Patterns: None of
           Above                              AC1R_NONE_ABOVE                       *
           (AC1S) Daily Contact with
           Relatives/Friends                  AC1S_CONTACT_REL                      *
           (AC1T) Usually Attends
           Church/Temple, etc.                AC1T_ATTEND_CHURCH                    *
           (AC1U) Finds Strength in Faith     AC1U_STRNGTH_FAITH                    *
           (AC1V) Daily Animal Companion      AC1V_ANIMAL                           *
           (AC1W) Involved in Group
           Activities                         AC1W_GROUP_ACT                        *
           (AC1X) Involvement Patterns:
           None of Above                      AC1X_NONE_ABOVE                       *
           (AC1Y) Unknown Customary
           Routine                            AC1Y_UNKNOWN                          *

        7/20/2011                                                                                    4 of 28                                                                                                                                                              cc48b286-0e60-401b-844e-4262322d2eab.xls
                                     Date:
                        Requestor Name:
                     Requestor Institution:
                              Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                            Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                                Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                             Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                                 CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                              MDS                Use in analysis
                                                                           Section B. Cognitive Patterns
           (B1) Comatose                      B1_COMATOSE                          * * * * * *                                                                                                            *         *                                       *                     *
           (B2A) Short Term Memory OK         B2A_ST_MEMORY                        * * * * * *                                                                                                            *         *                   *                   *                     *
           (B2B) Long Term Memory OK          B2B_LT_MEMORY                        * * * * * *                                                                                                                                          *
           (B3A) Recall Current Season        B3A_CURNT_SEASON                     * * * *         *
           (B3B) Recall Location of Own
           Room                               B3B_LOC_OWN_ROOM                      *             *             *             *                     *
           (B3C) Recall Staff Names/Faces     B3C_STAFF                             *             *             *             *                     *
           (B3D) Recall That He/She in
           Nursing Home                       B3D_IN_HOME                           *             *             *             *                     *
           (B3E) Recall: None of the Above    B3E_NONE_ABOVE                        *             *             *             *                     *
           (B4) Cognitive Skills/Daily
           Decision Making                    B4_DAY_DCSN_MAKING                    *             *             *             *     *               *                                                     *         *                   *                   *                     *
           (B5A) Easily Distracted            B5A_DISTRACTED                        *             *             *             *     *               *                                                                                   *                   *                     *
           (B5B) Periods of Altered
           Perception/Awareness               B5B_ALTER_PERCEPT                     *             *             *             *     *               *                                                                                   *                   *                     *
           (B5C) Episodes of Disorganized
           Speech                             B5C_DISORG_SPEECH                     *             *             *             *     *               *                                                                                   *                   *                     *
           (B5D) Periods of Restlessness      B5D_RESTLESS                          *             *             *             *     *               *                                                                                   *                   *                     *
           (B5E) Periods of Lethargy          B5E_LETHARGY                          *             *             *             *     *               *                                                                                   *                   *                     *
           (B5F) Mental Function Varies
           During Day                         B5F_MENTAL_FUNC                * * * * * *                                                                                                                                                *                   *                     *
           (B6) Change in Cognitive Status    B6_CHANG_COG_STAT              * * *                                                                                                                                                      *
                                                               Section C. Communication/Hearing Patterns
           (C1) Hearing                       C1_HEARING                     * * *                                                                                                                                                      *
           (C2A) Hearing Aid Present/Used     C2A_HEARAID_USED               * * *
           (C2B) Hearing Aid Present/Not
           Used Regularly                     C2B_HRAID_NOT_USE                     *             *             *
           (C2C) Other Receptive
           Comm.Techniques Used               C2C_OTHER_RECPT                       *             *             *
           (C2D) Communication
           Devices:None of Above              C2D_NONE_ABOVE                        *             *             *
           (C3A) Speech                       C3A_SPEECH                            *             *             *
           (C3B) Writing Messages             C3B_WRITE                             *             *             *
           (C3C) Amer. Sign
           Language/Braille                   C3C_SIGN_LANG                         *             *             *

        7/20/2011                                                                                     5 of 28                                                                                                                                                                         cc48b286-0e60-401b-844e-4262322d2eab.xls
                                      Date:
                         Requestor Name:
                      Requestor Institution:
                               Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                            Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                                Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                             Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                                 CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                              MDS                Use in analysis
           (C3D) Signs/Gestures/Sounds         C3D_GESTURES                         *             *             *
           (C3E) Communication Board           C3E_COMM_BOARD                       *             *             *
           (C3F) Other                         C3F_OTHER                            *             *             *
           (C3G) Modes of Expression:None
           of Above                            C3G_NONE_ABOVE                       *             *             *
           (C4) Making Self Understood         C4_IS_UNDERSTOOD                     *             *             *             *     *               *                                                     *                             *
           (C5) Speech Clarity                 C5_SPEECH_CLARITY                    *             *             *

           (C6) Ability to Understand Others   C6_UNDERSTAND_OTH                    *             *             *             *     *               *                                                                                   *
           (C7) Change in
           Communication/Hearing               C7_CHANGE_IN_COMM                   * * *                                                                                                                                                *
                                                                             Section D. Vision Patterns
           (D1) Vision                         D1_VISION                           * * * *                                                                                                                                              *
           (D2A) Side Vision Problems          D2A_SIDE_VISN_PROB                  * * *                                                                                                                                                *
           (D2B) Sees
           Halos/Rings/Flashes/Curtains        D2B_FLASHES_LIGHT                    *             *             *
           (D2C) Visual Limitations: None of
           Above                               D2C_NONE_ABOVE                     * * *
           (D3) Visual Appliances              D3_VISUAL_APP                      * * *
                                                                      Section E. Mood and Behavior Patterns
           (E1A) Negative Statements           E1A_NEG_STATE                      * * * * * *               *                                                                                                       *                   *                   *                     *
           (E1B) Repetitive Questions          E1B_REPEAT_QUES                    * * * * * *               *                                                                                                                           *
           (E1C) Repetitive Verbalizations     E1C_REPEAT_VERB                    * * * * * *               *                                                                                                                           *                   *                     *
           (E1D) Persistent Anger with
           Self/Others                         E1D_PRST_ANGER                       *             *             *             *     *               *                                                     *                             *
           (E1E) Self Deprecation              E1E_SELF_DEPER                       *             *             *             *     *               *                                                     *                             *                   *                     *
           (E1F) Expression of Unrealistic
           Fears                               E1F_UNREAL_FEARS                     *             *             *             *     *               *                                                     *                             *                   *                     *
           (E1G) Recurrent Statemens of
           Terrible Future                     E1G_TERRIBLE_FEEL                    *             *             *             *     *               *                                                     *         *                   *                   *                     *
           (E1H) Repetitive Health
           Complaints                          E1H_HLTH_COMPLAIN                    *             *             *             *     *               *                                                     *                             *                   *                     *
           (E1I) Repetitive Anxious
           Complaints/Concerns                 E1I_ANX_COMP                         *             *             *             *     *               *                                                     *                             *

           (E1J) Unpleasant Mood in Morning E1J_UNPLEAS_MORN                        *             *             *             *     *               *                                                     *         *                   *

        7/20/2011                                                                                     6 of 28                                                                                                                                                                         cc48b286-0e60-401b-844e-4262322d2eab.xls
                                      Date:
                         Requestor Name:
                      Requestor Institution:
                               Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                            Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                                Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                             Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                                 CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                              MDS                Use in analysis
           (E1K) Insomnia/Change in
           Sleeping Pattern                      E1K_INSOMINA                       *             *             *             *     *               *                                                     *                             *
           (E1L) Sad/Pained/Worried Facial
           Expressions                           E1L_WORRIED_FACE                   *             *             *             *     *               *                                                     *                             *
           (E1M) Crying/Tearfulness              E1M_CRYING                         *             *             *             *     *               *                                                     *                             *                   *                     *
           (E1N) Repetitive Physical
           Movements                             E1N_REPEAT_MOVES                   *             *             *             *     *               *                                                     *         *                   *                   *                     *
           (E1O) Withdrawal from Activites of
           Interest                              E1O_WITHDRAWN                      *             *             *             *     *               *                                                     *         *                   *

           (E1P) Reduced Social Interaction      E1P_LESS_INTERACT                  *             *             *             *     *               *                                                     *         *                   *
           (E2) Mood Persistance                 E2_MOOD_PERSIST                    *             *             *             *     *               *                                                               *                   *                   *                     *
           (E3) Change in Mood                   E3_MOOD_CHANGE                     *             *             *                                                                                                                       *
           (E4AA) Wandering: Frequency           E4AA_WANDERS                       *             *             *             *     *               *                                                     *                             *
           (E4AB) Wandering: Alterability        E4AB_WANDERS_ALT                   *             *             *             *     *               *

           (E4BA) Verbal Abuse: Frequency        E4BA_VRBL_ABUSIVE                  *             *             *             *     *               *                                                     *         *                   *

           (E4BB) Verbal Abusive: Alterability   E4BB_VRBL_ABUS_ALT                 *             *             *             *     *               *
           (E4CA) Physical Abuse:
           Frequency                             E4CA_PHYS_ABUSIVE                  *             *             *             *     *               *                                                     *         *                   *
           (E4CB) Physical Abuse:
           Alterability                          E4CB_PHYS_ABUS_ALT                 *             *             *             *     *               *
           (E4DA) Socially Inappropriate:
           Frequency                             E4DA_DIS_BEHAVIOR                  *             *             *             *     *               *                                                     *         *                   *
           (E4DB) Socially Inappropriate:
           Alterability                          E4DB_DIS_BEHAV_ALT                 *             *             *             *     *               *
           (E4EA) Resist Care: Frequency         E4EA_RESIST_CARE                   *             *             *             *     *               *                                                     *         *                   *
           (E4EB) Resist Care: Alterability      E4EB_RESIST_ALT                    *             *             *             *     *               *
           (E5) Change in Behavioral
           Symptoms                              E5_CHANGE_BEHAVE                   * * *                                                                                                                                               *
                                                                         Section F. Psychosocial Well-being
           (F1A) At Ease Interacting with
           Others                                F1A_ACTIVE_OTHERS                  *             *             *
           (F1B) At Ease Doing
           Planned/Structured Activities         F1B_PLAN_ACTIVITY                  *             *             *

        7/20/2011                                                                                     7 of 28                                                                                                                                                                         cc48b286-0e60-401b-844e-4262322d2eab.xls
                                      Date:
                         Requestor Name:
                      Requestor Institution:
                               Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                        Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                    Resident Profiles
                                                                                                                                                                    Track-Discharge




                                                                                                                                                                                                                                                            Quality Measure
                                                                                                                                                                                                                Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                      Track-Reentry
                                                                                                                                 used in




                                                                                                                                                    Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                         Not in




                                                                                                                                                                                                      RUG III
 Check to                                                                                                                           QI                                                                                                                                             CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                          MDS                Use in analysis
           (F1C) At Ease Doing Self-Initiated
           Activities                           F1C_SELF_ACTIVITY                   *             *             *
           (F1D) Establishes Own Goals          F1D_OWN_GOALS                       *             *             *                                                                                                                   *
           (F1E) Pursues Involvedment in
           Life of Facility                     F1E_DAY_ACTIVITY                    *             *             *
           (F1F) Accepts Invitations to Most
           Group Activities                     F1F_ACPT_INVITE                     *             *             *
           (F1G) Initiative/Involvement: None
           of Above                             F1G_NONE_ABOVE                      *             *             *
           (F2A) Covert/Open Conflict with
           Staff                                F2A_CONFLICT_STAFF                  *             *             *                                                                                                                   *
           (F2B) Unhappy With Roommate          F2B_CONFLCT_RMMATE                  *             *             *                                                                                                                   *
           (F2C) Unhappy With Residents         F2C_CONFLT_OTH_RES                  *             *             *                                                                                                                   *
           (F2D) Open Conflict/Anger with
           Family/Friends                       F2D_EXPRS_ANGER                     *             *             *                                                                                                                   *
           (F2E) Absence of Contact with
           Family/Friends                       F2E_NO_CNTCT_FAM                    *             *             *

           (F2F) Recent Loss Family/Friend      F2F_RECENT_LOSS                     *             *             *
           (F2G) Does Not Easily Adjust to
           Routine Change                       F2G_NOT_ADJUST                      *             *             *
           (F2H) Unsettled
           Relationships:None of Above          F2H_NONE_ABOVE                      *             *             *
           (F3A) Strong Identifications with
           Past Roles                           F3A_PAST_ROLES                      *             *             *                                                                                                                   *
           (F3B) Sadness/Anger Over Lost
           Roles/Status                         F3B_SADNESS                         *             *             *                                                                                                                   *
           (F3C) Perceives Daily Routine
           Very Different                       F3C_DIFFERENCE                      *             *             *                                                                                                                   *

           (F3D) Past Roles: None of Above F3D_NONE_ABOVE                   * * *
                                                       Section G. Physical Functioning and Structural Problems
           (G1AA) Bed Mobility: Self-
           Performance                     G1AA_SELF_BED                    * * * * * *                * * *                                                                                                                                            *                     *
           (G1AB) Bed Mobility: Support
           Provided                        G1AB_SUPP_BED                    * * * *         *          *

        7/20/2011                                                                                     8 of 28                                                                                                                                                                     cc48b286-0e60-401b-844e-4262322d2eab.xls
                                      Date:
                         Requestor Name:
                      Requestor Institution:
                               Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                            Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                                Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                             Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                                 CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                              MDS                Use in analysis
           (G1BA) Transfer: Self-
           Performance                         G1BA_SELF_TRANS                      *             *             *             *     *               *                                                     *         *                   *                   *                     *
           (G1BB) Transfer: Support
           Provided                            G1BB_SUPP_TRANS                      *             *             *             *                     *                                                     *
           (G1CA) Walk In Room: Self-
           Performance                         G1CA_SELF_WLK_RM                     *             *             *             *     *               *                                                               *                   *
           (G1CB) Walk in Room: Support
           Provided                            G1CB_SUPP_WLK_RM                     *             *             *             *                     *
           (G1DA) Walk In Corridor: Self-
           Performance                         G1DA_SELF_WLK_CORR                   *             *             *             *     *               *                                                               *                   *
           (G1DB) Walk in Corridor: Support
           Provided                            G1DB_SUPP_WLK_CORR                   *             *             *             *                     *
           (G1EA) Locomotion on Unit: Self-
           Performance                         G1EA_SELF_LOC_UNIT                   *             *             *             *     *               *                                                               *                   *                   *                     *
           (G1EB) Locomotion on Unit:
           Support Provided                    G1EB_SUPP_LOC_UNIT                   *             *             *             *                     *
           (G1FA) Locomotion off Unit: Self-
           Performance                         G1FA_SELF_LOC_OFFU                   *             *             *             *     *               *                                                               *                   *
           (G1FB) Locomotion off Unit:
           Support Provided                    G1FB_SUPP_LOC_OFFU                   *             *             *             *                     *
           (G1GA) Dressing: Self-
           Performance                         G1GA_SELF_DRESS                      *             *             *             *     *               *                                                               *                   *
           (G1GB) Dressing: Support
           Provided                            G1GB_SUPP_DRESS                      *             *             *             *                     *

           (G1HA) Eating: Self-Performance G1HA_SELF_EAT                            *             *             *             *     *               *                                                     *         *                   *                   *                     *

           (G1HB) Eating: Support Provided     G1HB_SUPP_EAT                        *             *             *             *                     *
           (G1IA) Toilet: Self-Performance     G1IA_SELF_TOLIET                     *             *             *             *     *               *                                                     *         *                   *                   *                     *
           (G1IB) Toilet: Support Provided     G1IB_SUPP_TOLIET                     *             *             *             *                     *                                                     *
           (G1JA) Personal Hygiene: Self-
           Performance                         G1JA_SELF_HYGIENE                    *             *             *             *     *               *                                                               *                   *
           (G1JB) Personal Hygiene: Support
           Provided                            G1JB_SUPP_HYGIENE                    *             *             *             *                     *
           (G2A) Bathing: Self-Performance     G2A_BATH_SELF                        *             *             *             *     *               *                                                                                   *
           (G2B) Bathing: Support Provided     G2B_BATH_SUPPORT                     *             *             *

        7/20/2011                                                                                     9 of 28                                                                                                                                                                         cc48b286-0e60-401b-844e-4262322d2eab.xls
                                     Date:
                        Requestor Name:
                     Requestor Institution:
                              Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                            Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                                Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                             Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                                 CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                              MDS                Use in analysis
           (G3A) Balance while Standing       G3A_BALANCE_STAND                     *             *             *             *                     *
           (G3B) Balance while Sitting        G3B_BALANCE_SIT                       *             *             *             *                     *                                                                                   *
           (G4AA) Neck: Range of Motion       G4AA_NECK_RANGE                       *             *             *             *     *               *                                                               *
           (G4AB) Neck: Voluntary
           Movement                           G4AB_NECK_MOVE                        *             *             *             *     *               *
           (G4BA) Arm: Range of Motion        G4BA_ARM_RANGE                        *             *             *             *     *               *                                                               *

           (G4BB) Arm: Voluntary Movement     G4BB_ARM_MOVE                         *             *             *             *     *               *
           (G4CA) Hand: Range of Motion       G4CA_HAND_RANGE                       *             *             *             *     *               *                                                               *
           (G4CB) Hand: Voluntary
           Movement                           G4CB_HAND_MOVE                        *             *             *             *     *               *
           (G4DA) Leg: Range of Motion        G4DA_LEG_RANGE                        *             *             *             *     *               *                                                               *

           (G4DB) Leg: Voluntary Movement G4DB_LEG_MOVE                             *             *             *             *     *               *
           (G4EA) Foot: Range of Motion   G4EA_FOOT_RANGE                           *             *             *             *     *               *                                                               *

           (G4EB) Foot: Voluntary Movement    G4EB_FOOT_MOVE                        *             *             *             *     *               *
           (G4FA) Other: Range of Motion      G4FA_OTH_RANGE                        *             *             *             *     *               *                                                               *
           (G4FB) Other: Voluntary
           Movement                           G4FB_OTH_MOVE                         *             *             *             *     *               *
           (G5A) Cane/Walker/Crutch           G5A_CANE_CRUTCH                       *             *             *
           (G5B) Wheeled Self                 G5B_SELF_WHEEL                        *             *             *             *
           (G5C) Other Person Wheeled         G5C_OTHER_WHEEL                       *             *             *
           (G5D) Wheelchair Primary
           Locomotion                         G5D_WHEELCHAIR                        *             *             *
           (G5E) Modes of Locomotion:
           None of Above                      G5E_NONE_ABOVE                        *             *             *
           (G6A) Bedfast All or Most of the
           Time                               G6A_BEDFAST                           *             *             *             *     *               *                                                               *                   *                   *                     *
           (G6B) Bed Rails for Bed
           Mobility/Transfer                  G6B_USE_BEDRAILS                      *             *             *             *     *               *
           (G6C) Lifted Manually              G6C_LIFTED_MAN                        *             *             *
           (G6D) Lifted Mechanically          G6D_LIFTED_MECH                       *             *             *
           (G6E) Transfer Aid                 G6E_TRANS_AID                         *             *             *
           (G6F) Modes of Transfer: None of
           Above                              G6F_NONE_ABOVE                        *             *             *                   *               *

        7/20/2011                                                                                 10 of 28                                                                                                                                                                            cc48b286-0e60-401b-844e-4262322d2eab.xls
                                      Date:
                         Requestor Name:
                      Requestor Institution:
                               Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                            Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                                Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                             Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                                 CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                              MDS                Use in analysis
           (G7) Task Segmentation              G7_SEG_TASKS                         *             *             *             *                     *
           (G8A) Resident -- Increased
           Independence Capability             G8A_RES_INDEP                        *             *             *                                                                                                                       *
           (G8B) Staff -- Increased
           Independence Capability             G8B_STAFF_INDEP                      *             *             *                                                                                                                       *
           (G8C) Resident Slow Performing
           Task/Activity                       G8C_SLOW                             *             *             *
           (G8D) Morning to Evening
           Difference in ADLs                  G8D_ADL_DIFFERENCE                   *             *             *
           (G8E) ADL Rehabilitation
           Potential: None of Above            G8E_NONE_ABOVE                 * * *
           (G9) Change in ADL Function         G9_CHG_ADL                     * * *
                                                                  Section H. Continence in last 14 days
           (H1A) Bowel Continence              H1A_BOWEL_CONTRL               * * * * * *                                                                                                                           *                   *                   *                     *
           (H1B) Bladder Continence            H1B_BLADDER_CONTRL             * * * * * *                                                                                                                           *                   *                   *                     *
           (H2A) Bowel Elimination Pattern
           Regular                             H2A_REG_BOWEL_MOVE                   *             *             *
           (H2B) Constipation                  H2B_CONSTIPATION                     *             *             *                                                                                                                       *
           (H2C) Diarrhea                      H2C_DIARRHEA                         *             *             *             *                     *
           (H2D) Fecal Inpaction               H2D_FECAL_IMPACT                     *             *             *             *     *               *                                                               *                   *
           (H2E) Bowel Elimination Pattern:
           None of Above                       H2E_NONE_ABOVE                       *             *             *                   *               *
           (H3A) Any Scheduled Toileting
           Plan                                H3A_TOLIET_PLAN                      *             *             *             *     *               *                                                     *         *

           (H3B) Bladder Retraining Program    H3B_BLADDER_TR                       *             *             *             *     *               *                                                     *         *
           (H3C) External (Condom)
           Catheter                            H3C_EXTERN_CATH                      *             *             *             *     *               *                                                                                   *
           (H3D) Indwelling Catheter           H3D_INDWELL_CATH                     *             *             *             *     *               *                                                               *                   *                   *                     *
           (H3E) Intermittent Catheter         H3E_INTERMIT_CATH                    *             *             *                                                                                                                       *
           (H3F) Did Not Use
           Toilet/Commode/Urinal               H3F_NOT_USE_TOLIET                   *             *             *
           (H3G) Pads/Briefs Used              H3G_PADS_USED                        *             *             *                                                                                                                       *
           (H3H) Enemas/Irrigation             H3H_ENEMAS                           *             *             *
           (H3I) Ostomy Present                H3I_OSTOMY                           *             *             *             *     *               *                                                               *                                       *                     *


        7/20/2011                                                                                 11 of 28                                                                                                                                                                            cc48b286-0e60-401b-844e-4262322d2eab.xls
                                      Date:
                         Requestor Name:
                      Requestor Institution:
                               Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                        Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                                Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                         Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                             CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                          MDS                Use in analysis
           (H3J) Appliances and Programs:
           None of Above                       H3J_NONE_ABOVE                       *             *             *                   *               *
           (H4) Change in Urinary
           Continence                          H4_CHANGE_URINARY                   * * *
                                                                            Section I. Disease Diagnoses
           (I1A) Diabetes Mellitus             I1A_DIABETES                        * * * *          *                                                                                                     *                                                 *
           (I1B) Hyperthyroidism               I1B_HYPERTHYRD                      * * *
           (I1C) Hypothyroidism                I1C_HYPOTHYRD                       * * *
           (I1D) Arteriosclerotic Heart
           Disease (ASHD)                      I1D_ASHD                             *             *             *             *
           (I1E) Cardiac Dysrhythmias          I1E_CARD_DYSRH                       *             *             *
           (I1F) Cogestive Heart Failure       I1F_CON_HEART_FAIL                   *             *             *             *
           (I1G) Deep Vein Thrombosis          I1G_VEIN_THROMB                      *             *             *
           (I1H) Hypertension                  I1H_HYPERTENSION                     *             *             *
           (I1I) Hypotension                   I1I_HYOPTENSION                      *             *             *                                                                                                                       *

           (I1J) Peripheral Vascular Disease   I1J_PERI_VAC_DIS                     *             *             *                                                                                                                       *                   *
           (I1K) Other Cardiovascular
           Disease                             I1K_OTH_CARDIO_DIS                   *             *             *
           (I1L) Arthritis                     I1L_ARTHRITIS                        *             *             *
           (I1M) Hip Fracture                  I1M_HIP_FRAC                         *             *             *             *                     *
           (I1N) Missing Limb                  I1N_MISS_LIMB                        *             *             *
           (I1O) Osteoporosis                  I1O_OSTEOPORO                        *             *             *
           (I1P) Pathological Bone Fracture    I1P_PATH_BONE_FRAC                   *             *             *
           (I1Q) Alzheimers Disease            I1Q_ALZHEIMER                        *             *             *
           (I1R) Aphasia                       I1R_APHASIA                          *             *             *             *                     *                                                     *
           (I1S) Cerebral Palsy                I1S_CEREBRAL_PALSY                   *             *             *             *                     *                                                     *
           (I1T) Cerebrovascular Accident
           (Stroke)                            I1T_STROKE                           *             *             *             *                     *
           (I1U) Dementia Other than
           Alzheimer's                         I1U_DEMENTIA                         *             *             *
           (I1V) Hemiplegia/Hemiparesis        I1V_HEMIPLEGIA                       *             *             *             *                     *                                                     *
           (I1W) Multiple Sclerosis            I1W_M_S                              *             *             *             *                     *                                                     *
           (I1X) Paraplegia                    I1X_PARAPLEGIA                       *             *             *             *
           (I1Y) Parkinsons Disease            I1Y_PARKINSON                        *             *             *
           (I1Z) Quadriplegia                  I1Z_QUADRIPLEGIA                     *             *             *             *                     *                                                     *

        7/20/2011                                                                                 12 of 28                                                                                                                                                                        cc48b286-0e60-401b-844e-4262322d2eab.xls
                                       Date:
                          Requestor Name:
                       Requestor Institution:
                                Study Title:


                        Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                            Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                                Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                             Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                                 CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                              MDS                Use in analysis
           (I1AA) Seizure Disorder                 I1AA_SEIZURE_DIS                 *             *             *
           (I1BB) Transient Ischemic Attack
           (TIA)                                   I1BB_TIA                         *             *             *
           (I1CC) Traumatic Brain Injury           I1CC_BRAIN_INJURY                *             *             *
           (I1DD) Anxiety Disorder                 I1DD_ANX_DIS                     *             *             *
           (I1EE) Depression                       I1EE_DEPRESSION                  *             *             *             *                     *                                                                                   *
           (I1FF) Manic Depressive (Bipolar
           Disease)                                I1FF_MANIC_DEPRES                *             *             *             *                     *                                                               *
           (I1GG) Schizophrenia                    I1GG_SCHIZO                      *             *             *             *                                                                                     *
           (I1HH) Asthma                           I1HH_ASTHMA                      *             *             *             *
           (I1II) Emphysema/COPD                   I1II_COPD                        *             *             *             *
           (I1JJ) Cataracts                        I1JJ_CATARACTS                   *             *             *                                                                                                                       *
           (I1KK) Diabetic Retinopathy             I1KK_DIAB_RETIN                  *             *             *
           (I1LL) Glaucoma                         I1LL_GALUCOMA                    *             *             *                                                                                                                       *
           (I1MM) Macular Degeneration             I1MM_MACULAR_DEGN                *             *             *
           (I1NN) Allergies                        I1NN_ALLERGIES                   *             *             *
           (I1OO) Anemia                           I1OO_ANEMIA                      *             *             *
           (I1PP) Cancer                           I1PP_CANCER                      *             *             *
           (I1QQ) Renal Failure                    I1QQ_RENAL_FAIL                  *             *             *
           (I1RR) Diseases: None of Above          I1RR_NONE_ABOVE                  *             *             *                                   *

           (I2A) Antibiotic Resistant Infection    I2A_AB_RES_INFECT                *             *             *             *                     *
           (I2B) Clostridium Difficile (c.diff.)   I2B_CLOST_DIFF                   *             *             *             *                     *
           (I2C) Conjunctivities                   I2C_CONJUNCT                     *             *             *             *                     *
           (I2D) HIV Infection                     I2D_HIV                          *             *             *             *                     *
           (I2E) Pneumonia                         I2E_PNEUMONIA                    *             *             *             *                     *                                                     *
           (I2F) Respiratory Infection             I2F_RESP_INFECT                  *             *             *             *                     *
           (I2G) Septicemia                        I2G_SEPTICEMIA                   *             *             *             *                     *                                                     *
           (I2H) Sexually Transmitted
           Diseases                                I2H_STD                          *             *             *             *                     *
           (I2I) Tuberculosis                      I2I_TUBERCULOSIS                 *             *             *             *                     *
           (I2J) Urinary Tract Infection in Last
           30 Days                                 I2J_UTI_THRTY_DAYS               *             *             *             *     *               *                                                               *                   *                   *                     *
           (I2K) Viral Hepititis                   I2K_VIRAL_HEP                    *             *             *             *                     *
           (I2L) Wound Infection                   I2L_WOUND                        *             *             *             *                     *
           (I2M) Infections: None of Above         I2M_NONE_ABOVE                   *             *             *             *     *               *

        7/20/2011                                                                                 13 of 28                                                                                                                                                                            cc48b286-0e60-401b-844e-4262322d2eab.xls
                                      Date:
                         Requestor Name:
                      Requestor Institution:
                               Study Title:


                        Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                            Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                                Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                             Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                                 CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                              MDS                Use in analysis
           (I3A) Other Diagnosis A              I3A_OTHR_ICD9_CD                   * * * * * *                                                                                                                      *                   *                   *
           (I3B) Other Diagnosis B              I3B_OTHR_ICD9_CD                   * * * * * *                                                                                                                      *                   *                   *
           (I3C) Other Diagnosis C              I3C_OTHR_ICD9_CD                   * * *                                                                                                                            *                   *                   *
           (I3D) Other Diagnosis D              I3D_OTHR_ICD9_CD                   * * *                                                                                                                            *                   *                   *
           (I3E) Other Diagnosis E              I3E_OTHR_ICD9_CD                   * * *                                                                                                                            *                   *                   *
                                                                            Section J. Health Conditions
           (J1A) Weight Fluctuation of 3+
           Pounds                               J1A_WEIGHT_CHG                      *             *             *             *                     *                                                                                   *
           (J1B) Inability to Lie Flat--
           Shortness of Breath                  J1B_NOT_LIE_FLAT                    *             *             *             *                     *
           (J1C) Dehydrated--Output
           Excedes Input                        J1C_DEHYDRATED                      *             *             *             *     *               *                                                     *         *                   *
           (J1D) Insufficient Fluid in Last 3
           Days                                 J1D_INSUFF_FLUID                    *             *             *             *                     *                                                                                   *
           (J1E) Delusions                      J1E_DELUSIONS                       *             *             *             *                     *                                                     *
           (J1F) Dizziness/Vertigo              J1F_VERTIGO                         *             *             *                                                                                                                       *
           (J1G) Edema                          J1G_EDEMA                           *             *             *             *                     *
           (J1H) Fever                          J1H_FEVER                           *             *             *             *                     *                                                     *                             *
           (J1I) Hallucinations                 J1I_HALLUCINATIONS                  *             *             *             *     *               *                                                     *         *                   *
           (J1J) Internal Bleeding              J1J_INTERN_BLEED                    *             *             *             *                     *                                                     *                             *
           (J1K) Recurrent Lung Aspirations
           in Last 90 Days                      J1K_LUNG_ASPIR                      *             *             *             *                     *                                                                                   *
           (J1L) Shortness of Breath            J1L_SHORT_BREATH                    *             *             *             *                     *
           (J1M) Syncope (Fainting)             J1M_SYNCOPE                         *             *             *                                   *                                                                                   *
           (J1N) Unsteady Gait                  J1N_UNSTEADY_GAIT                   *             *             *             *                     *                                                                                   *
           (J1O) Vomiting                       J1O_VOMIT                           *             *             *             *                     *                                                     *
           (J1P) Problem Conditions: None
           of Above                             J1P_NONE_ABOVE                      *             *             *                   *               *
           (J2A) Pain: Frequency                J2A_PAIN_FREQUENCY                  *             *             *             *     *               *                                                                                                       *                     *
           (J2B) Pain: Intensity                J2B_PAIN_INTENSITY                  *             *             *             *     *               *                                                                                                       *                     *
           (J3A) Back Pain                      J3A_BACK_PAIN                       *             *             *
           (J3B) Bone Pain                      J3B_BONE_PAIN                       *             *             *
           (J3C) Chest Pain During Usual
           Activities                           J3C_CHEST_PAIN                      *             *             *
           (J3D) Headache                       J3D_HEADACHE                        *             *             *
           (J3E) Hip Pain                       J3E_HIP_PAIN                        *             *             *

        7/20/2011                                                                                 14 of 28                                                                                                                                                                            cc48b286-0e60-401b-844e-4262322d2eab.xls
                                      Date:
                         Requestor Name:
                      Requestor Institution:
                               Study Title:


                        Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                            Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                                Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                             Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                                 CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                              MDS                Use in analysis
           (J3F) Incisional Pain                 J3F_INCISION_PAIN                  *             *             *

           (J3G) Joint Pain (Other Than Hip)     J3G_JOINT_PAIN                     *             *             *
           (J3H) Soft Tissue Pain (Lesion)       J3H_TISSUE_PAIN                    *             *             *
           (J3I) Stomach Pain                    J3I_STOMACH_PAIN                   *             *             *
           (J3J) Other                           J3J_OTHER                          *             *             *
           (J4A) Fell in Past 30 Days            J4A_FELL_30_DAYS                   *             *             *             *     *               *                                                               *                   *                   *
           (J4B) Fell in Past 31-180 Days        J4B_FELL_OVR_31_DA                 *             *             *             *     *               *                                                                                   *                   *
           (J4C) Hip Fracture in Last 180
           Days                                  J4C_HIP_FRC_180_DA                 *             *             *             *     *               *                                                               *                   *
           (J4D) Other Fracture in Last 180
           Days                                  J4D_OTH_FRC_180_DA                 *             *             *             *     *               *                                                               *
           (J4E) Accidents: None of Above        J4E_NONE_ABOVE                     *             *             *             *     *               *
           (J5A) Conditions/Disease Lead to
           Instability                           J5A_UNSTABLE_COND                  *             *             *             *     *               *
           (J5B) Resident Experiencing
           Acute Episode/Flare-Up                J5B_ACUTE_EPISODE                  *             *             *             *     *               *
           (J5C) End-Stage Disease, 6 or
           Fewer Months to Live                  J5C_END_STG_DISEAS                 *             *             *             *     *               *                                                               *                                       *                     *
           (J5D) Stability of Conditions: None
           of Above                              J5D_NONE_ABOVE                    * * * * * *
                                                                          Section K. Oral/Nutritional Status
           (K1A) Chewing Problem                 K1A_CHEW_PROB                     * * * *           *
           (K1B) Swallowing Problem              K1B_SWALLOW_PROB                  * * * *           *                                                                                                                                  *
           (K1C) Mouth Pain                      K1C_MOUTH_PAIN                    * * *                                                                                                                                                *
           (K1D) Oral Problems: None of
           Above                                 K1D_NONE_ABOVE                     *             *             *                                   *
           (K2A) Height (Inches)                 K2A_HEIGHT                         *             *             *             *                     *                                                                                                       *
           (K2B) Weight (Pounds)                 K2B_WEIGHT                         *             *             *             *                     *                                                                                                       *
           (K3A) Weight Loss                     K3A_WEIGHT_LOSS                    *             *             *             *     *               *                                                     *         *                   *                   *                     *
           (K3B) Weight Gain                     K3B_WEIGHT_GAIN                    *             *             *                   *               *
           (K4A) Complains About Taste of
           Many Foods                            K4A_COMP_FOOD_TAST                 *             *             *                                                                                                                       *
           (K4B) Regular Complaints of
           Hunger                                K4B_CONSTANT_HUNGR                 *             *             *


        7/20/2011                                                                                 15 of 28                                                                                                                                                                            cc48b286-0e60-401b-844e-4262322d2eab.xls
                                      Date:
                         Requestor Name:
                      Requestor Institution:
                               Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                            Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                                Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                             Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                                 CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                              MDS                Use in analysis
           (K4C) Leaves 25%+ Food
           Uneaten at Most Meals                 K4C_NOT_EATING                     *             *             *                                                                                                                       *                   *                     *
           (K4D) Nutritional Problems: None
           of Above                              K4D_NONE_ABOVE                     *             *             *
           (K5A) Parenteral IV                   K5A_PARENTERAL_IV                  *             *             *             *                     *                                                     *                             *
           (K5B) Feeding Tube                    K5B_FEED_TUBE                      *             *             *             *     *               *                                                     *         *                   *
           (K5C) Mechanically Altered Diet       K5C_MECH_DIET                      *             *             *                                                                                                                       *
           (K5D) Syringe (Oral Feeding)          K5D_SYRINGE                        *             *             *                                                                                                                       *
           (K5E) Therapeutic Diet                K5E_THERAPY_DIET                   *             *             *                                                                                                                       *
           (K5F) Dietary Supplement
           Between Meals                         K5F_DIET_SUPP                      *             *             *
           (K5G) Plate Guard, Stabilized
           Utensil, Etc.                         K5G_PLATE_GRD                      *             *             *
           (K5H) On a Planned Weight
           Change Program                        K5H_WGT_PROG                       *             *             *             *     *               *
           (K5I) Nutritional Approaches:
           None of Above                         K5I_NONE_ABOVE                     *             *             *                   *               *
           (K6A) Total Calories (%) Recieved
           in Last 7 Days                        K6A_TOTAL_CALORIES                 *             *             *             *                     *                                                     *
           (K6B) Average Fluid (Daily) in Last
           7 Days                                K6B_FLUID_INTAKE                  * * * *           *                                                                                                    *
                                                                            Section L. Oral/Dental Status

           (L1A) Debris in Mouth Before Bed L1A_DEBRIS_B4_BED                       *             *             *                                                                                                                       *
           (L1B) Has Dentures or Removable
           Bridge                           L1B_DENTURES                            *             *             *

           (L1C) Some/All Natural Teeth Lost     L1C_LOST_TEETH                     *             *             *                                                                                                                       *
           (L1D) Broken, Loose, or Carious
           Teeth                                 L1D_LOOSE_TEETH                    *             *             *                                                                                                                       *
           (L1E) Inflamed/Bleeding Gums,
           Oral Abscesses, etc.                  L1E_INFLAMED_GUM                   *             *             *                                                                                                                       *
           (L1F) Daily Cleaning of
           Teeth/Dentures or Mouth Care          L1F_DAY_TEETH_CLEAN                *             *             *                                                                                                                       *

           (L1G) Oral Status: None of Above L1G_NONE_ABOVE                          *             *             *

        7/20/2011                                                                                 16 of 28                                                                                                                                                                            cc48b286-0e60-401b-844e-4262322d2eab.xls
                                     Date:
                        Requestor Name:
                     Requestor Institution:
                              Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                            Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                                Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                             Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                                 CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                              MDS                Use in analysis
                                                                             Section M. Skin Condition
           (M1A) Ulcers: Stage 1              M1A_STAGE_1_ULCER                    * * * * * *                                                                                                            *
           (M1B) Ulcers: Stage 2              M1B_STAGE_2_ULCER                    * * * * * *                                                                                                            *
           (M1C) Ulcers: Stage 3              M1C_STAGE_3_ULCER                    * * * * * *                                                                                                            *
           (M1D) Ulcers: Stage 4              M1D_STAGE_4_ULCER                    * * * * * *                                                                                                            *
           (M2A) Pressure Ulcer Highest
           Stage                              M2A_PRES_ULCER                        *             *             *             *     *               *                                                     *         *                   *                   *                     *

           (M2B) Stasis Ulcer Highest Stage   M2B_STASIS_ULCER                      *             *             *             *     *               *
           (M3) History of Resolved Ulcers    M3_HIST_ULCER                         *             *             *             *                                                                                                         *                   *
           (M4A) Abrasions,Bruises            M4A_ABRASIONS                         *             *             *             *                     *
           (M4B) Burns (Second or Third
           Degree)                            M4B_BURNS                             *             *             *             *                     *                                                     *
           (M4C) Open Lesions Other Than
           Ulcers, Rashes, Cuts               M4C_OPEN_LESIONS                      *             *             *             *                     *                                                     *
           (M4D) Rashes--e.g., interigo,
           eczema, etc.                       M4D_RASHES                            *             *             *             *                     *
           (M4E) Skin Desensitized to Pain
           or Pressure                        M4E_DESENSIT_SKIN                     *             *             *             *                     *                                                                                   *
           (M4F) Skin Tears or Cuts (Other
           Than Surgery)                      M4F_SKIN_TEAR_CUT                     *             *             *             *                     *
           (M4G) Surgical Wounds              M4G_SURG_WOUND                        *             *             *             *                     *                                                     *
           (M4H) Skin Problems: None of
           Above                              M4H_NONE_ABOVE                        *             *             *             *                     *
           (M5A) Pressure Relieving
           Device(s) for Chair                M5A_RELIEF_CHAIR                      *             *             *             *                     *                                                     *
           (M5B) Pressure Relieving
           Device(s) for Bed                  M5B_RELIEF_BED                        *             *             *             *                     *                                                     *
           (M5C) Turning/Repositioning
           Program                            M5C_TURN_REPO                         *             *             *             *                     *                                                     *
           (M5D) Nutrition/Hydration
           Intervention                       M5D_INTER_SKN_PROB                    *             *             *             *                     *                                                     *
           (M5E) Ulcer Care                   M5E_ULCER_CARE                        *             *             *             *                     *                                                     *
           (M5F) Surgical Wound Care          M5F_SURG_WOUND_CAR                    *             *             *             *                     *                                                     *
           (M5G) Application of Dressings     M5G_APP_DRESSINGS                     *             *             *             *                     *                                                     *


        7/20/2011                                                                                 17 of 28                                                                                                                                                                            cc48b286-0e60-401b-844e-4262322d2eab.xls
                                      Date:
                         Requestor Name:
                      Requestor Institution:
                               Study Title:


                        Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                    Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                            Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                     Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                         CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                      MDS                Use in analysis
           (M5H) Application of
           Ointments/Medications               M5H_APP_MEDS                         *             *             *             *                     *                                                     *

           (M5I) Other
           Preventative/Protective Skin Care   M5I_PREVNT_SKIN_CARE                 *             *             *             *                     *
           (M5J) Skin Treatments: None of
           Above                               M5J_NONE_ABOVE                       *             *             *             *                     *
           (M6A) Resident Has One or More
           Foot Problems                       M6A_FOOT_PROB                        *             *             *             *                     *
           (M6B) Infection of Foot--e.g.,
           cellulitis, etc.                    M6B_INFECT_FOOT                      *             *             *             *                     *                                                     *
           (M6C) Open Lesions on Foot          M6C_LESIONS_FOOT                     *             *             *             *                     *                                                     *
           (M6D) Nails/Calluses Trimmed in
           Last 90 Days                        M6D_TRIMMED                          *             *             *             *                     *

           (M6E) Received
           Preventative/Protective Foot Care M6E_PRVENT_FT_CARE                     *             *             *             *                     *
           (M6F) Application of Dressings to
           Foot                              M6F_DRESSINGS_FOOT                     *             *             *             *                     *                                                     *
           (M6G) Foot Problems: None of
           Above                             M6G_NONE_ABOVE                         * * * *           *
                                                                         Section N. Activity Pursuit Patterns
           (N1A) Awake in Morning              N1A_MORNING                          * * * * * *                                                                                                           *         *                   *
           (N1B) Awake in Afternoon            N1B_AFTERNOON                        * * * * * *                                                                                                           *         *
           (N1C) Awake in Evening              N1C_EVENING                          * * * * * *                                                                                                           *         *
           (N1D) Awake: None of Above          N1D_NONE_ABOVE                       * * * * * *                                                                                                                     *
           (N2) Average Time Involved in
           Activities                          N2_TM_ACTIVITIES                     *             *             *             *     *               *                                                               *                   *
           (N3A) Own Room                      N3A_OWN_ROOM                         *             *             *
           (N3B) Day/Activity Room             N3B_ACTIVITY_RM                      *             *             *
           (N3C) Inside NH/Off Unit            N3C_INSIDE_NH                        *             *             *
           (N3D) Outside Activity              N3D_OUTSIDE                          *             *             *
           (N3E) Activity Settings: None of
           the Above                           N3E_NONE                             *             *             *
           (N4A) Cards/Other Games             N4A_CARDS                            *             *             *
           (N4B) Crafts/Arts                   N4B_CRAFTS                           *             *             *

        7/20/2011                                                                                 18 of 28                                                                                                                                                                    cc48b286-0e60-401b-844e-4262322d2eab.xls
                                       Date:
                          Requestor Name:
                       Requestor Institution:
                                Study Title:


                        Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                    Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                            Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                     Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                         CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                      MDS                Use in analysis
           (N4C) Exercises/Sports                 N4C_SPORTS                        *             *             *
           (N4D) Music                            N4D_MUSIC                         *             *             *
           (N4E) Reading/Writing                  N4E_READING                       *             *             *

           (N4F) Spiritual/Religious Activities   N4F_RELIGIOUS                     *             *             *
           (N4G) Trips/Shopping                   N4G_TRIPS                         *             *             *
           (N4H) Walking/Wheeling
           Outdoors                               N4H_WALKING                       *             *             *
           (N4I) Watching TV                      N4I_TV                            *             *             *
           (N4J) Gardening or Plants              N4J_GARDENING                     *             *             *
           (N4K) Talking or Conversing            N4K_TALKING                       *             *             *
           (N4L) Helping Others                   N4L_HELPING                       *             *             *
           (N4M) Activity Preferences: None
           of Above                               N4M_NONE_ABOVE                    *             *             *
           (N5A) Type of Activities In            N5A_CHG_TYPE_ACT                  *             *             *                                                                                                                       *
           (N5B) Extent of Involvement in
           Activities                             N5B_CHG_EXTENT_ACT               * * *                                                                                                                                                *
                                                                              Section O. Medications
           (O1) Number of Medications             O1_NUM_MEDS                      * * * * * *                                                                                                                      *
           (O2) New Medications                   O2_NEW_MEDS                      * * *
           (O3) Injections (Number Days)          O3_INJECTIONS                    * * * *         *        *
           (O4A) Antipsychotic                    O4A_ANTIPSYCHOTIC                * * * * * *                                                                                                                      *                   *
           (O4B) Antianxiety                      O4B_ANTIANXIETY                  * * * * * *                                                                                                                      *                   *
           (O4C) Antidepressants                  O4C_ANTIDEPRESS                  * * * * * *                                                                                                                      *                   *
           (O4D) Hypnotic                         O4D_HYPNOTIC                     * * * * * *                                                                                                                      *
           (O4E) Diuretic                         O4E_DIURETIC                     * * * * * *                                                                                                                                          *
                                                                   Section P. Special Treatment and Procedures
           (P1AA) Chemotherapy                    P1AA_CHEMO                       * * * *         *        *
           (P1AB) Dialysis                        P1AB_DIALYSIS                    * * * *         *        *
           (P1AC) IV Medication                   P1AC_IV_MED                      * * * *         *        *
           (P1AD) Intake/Outtake                  P1AD_INTAKE                      * * * *         *
           (P1AE) Monitoring Acute Medical
           Condition                              P1AE_ACUTE_COND                   *             *             *             *                     *
           (P1AF) Ostomy Care                     P1AF_OSTOMY                       *             *             *             *                     *
           (P1AG) Oxygen Therapy                  P1AG_OXYGEN                       *             *             *             *                     *                                                     *


        7/20/2011                                                                                 19 of 28                                                                                                                                                                    cc48b286-0e60-401b-844e-4262322d2eab.xls
                                     Date:
                        Requestor Name:
                     Requestor Institution:
                              Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                            Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                                Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                             Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                                 CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                              MDS                Use in analysis
           (P1AH) Radiation                   P1AH_RADIATION                        *             *             *             *                     *                                                     *
           (P1AI) Suctioning                  P1AI_SUCTION                          *             *             *             *                     *                                                     *
           (P1AJ) Tracheostomy Care           P1AJ_TRACH_CARE                       *             *             *             *                     *                                                     *
           (P1AK) Transfusions                P1AK_TRANSFUSION                      *             *             *             *                     *                                                     *
           (P1AL) Ventilator or Respirator    P1AL_VENTILATOR                       *             *             *             *                     *                                                     *
           (P1AM) Alcohol/Drug Treatment
           Program                            P1AM_ALC_ORG_TREAT                    *             *             *             *                     *
           (P1AN) Alzheimers/Dementia
           Special Care Unit                  P1AN_ALZHEIMER                        *             *             *             *                     *
           (P1AO) Hospice Care                P1AO_HOSPICE                          *             *             *             *                     *                                                                                                       *                     *
           (P1AP) Pediatric Unit              P1AP_PEDIATRIC                        *             *             *             *                     *
           (P1AQ) Respite Care                P1AQ_RESPITE                          *             *             *             *                     *
           (P1AR) Training in Community
           Skills                             P1AR_TRAINING                         *             *             *             *                     *
           (P1AS) Special Treatments: None
           of Above                           P1AS_NONE_ABOVE                       *             *             *             *                     *

           (P1BAA) Speech Therapy: # Days     P1BAA_SPCH_THR_DAY                    *             *             *             *                     *                                                     *
           (P1BAB) Speech Therapy: Total #
           Minutes                            P1BAB_SPCH_THR_MIN                    *             *             *             *                     *                                                     *
           (P1BBA) Occupational Therapy: #
           Days                               P1BBA_OCC_THPY_DAY                    *             *             *             *                     *                                                     *
           (P1BBB) Occupational Therapy:
           Total # Minutes                    P1BBB_OCC_THPY_MIN                    *             *             *             *                     *                                                     *
           (P1BCA) Physical Therapy: #
           Days                               P1BCA_PHY_THPY_DAY                    *             *             *             *                     *                                                     *
           (P1BCB) Physical Therapy: Total
           # Minutes                          P1BCB_PHY_THPY_MIN                    *             *             *             *                     *                                                     *
           (P1BDA) Respiratory Therapy: #
           Days                               P1BDA_RES_THPY_DAY                    *             *             *             *                     *                                                     *
           (P1BDB) Respiratory Therapy
           Minutes                            P1BDB_RES_THPY_MIN                    *             *             *             *                     *

           (P1BEA) Psychotherapy: # Days      P1BEA_PSY_THPY_DAY                    *             *             *             *                     *
           (P1BEB) Psychotherapy: Total #
           Minutes                            P1BEB_PSY_THPY_MIN                    *             *             *             *                     *

        7/20/2011                                                                                 20 of 28                                                                                                                                                                            cc48b286-0e60-401b-844e-4262322d2eab.xls
                                     Date:
                        Requestor Name:
                     Requestor Institution:
                              Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                            Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                                Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                             Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                                 CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                              MDS                Use in analysis
           (P2A) Special Behavioral
           Symptom Evaluation Program          P2A_BEHAVIOR                         *             *             *
           (P2B) Evaluation by Licensed MH
           Specialist                          P2B_EVALUATED                        *             *             *
           (P2C) Group Therapy                 P2C_GROUP_THRPY                      *             *             *
           (P2D) Resident-Specific Changes
           in Environment                      P2D_EN_CHG_4_MOOD                    *             *             *
           (P2E) Reorientation--e.g., cueing   P2E_REORIENT                         *             *             *
           (P2F) Intervention Programs:
           None of Above                       P2F_NONE_ABOVE                       *             *             *
           (P3A) Nursing Rehab: Range of
           Motion (Passive)                    P3A_NR_MOTION_PASS                   *             *             *             *                     *                                                     *
           (P3B) Nursing Rehab: Range of
           Motion (Active)                     P3B_NR_MOTION_ACTV                   *             *             *             *                     *                                                     *
           (P3C) Nursing Rehab: Splint or
           Brace Assistance                    P3C_NR_SPLINT                        *             *             *             *                     *                                                     *
           (P3D) Nursing Rehab: Bed
           Mobility                            P3D_NR_BED_MOBILE                    *             *             *             *                     *                                                     *
           (P3E) Nursing Rehab: Transfer       P3E_NR_TRANSFER                      *             *             *             *                     *                                                     *
           (P3F) Nursing Rehab: Walking        P3F_NR_WALKING                       *             *             *             *                     *                                                     *
           (P3G) Nursing Rehab: Dressing or
           Grooming                            P3G_NR_DRESS_GROOM                   *             *             *             *                     *                                                     *
           (P3H) Nursing Rehab: Eating or
           Swallowing                          P3H_NR_EATING                        *             *             *             *                     *                                                     *
           (P3I) Nursing Rehab:
           Amputation/Prosthesis Care          P3I_NR_AMPUTA_CARE                   *             *             *             *                     *                                                     *
           (P3J) Nursing Rehab:
           Communication                       P3J_NR_COMMUNICAT                    *             *             *             *                     *                                                     *
           (P3K) Nursing Rehab: Other          P3K_NR_OTHER                         *             *             *             *                     *
           (P4A) Full Bed Rails on All Sides
           of Bed                              P4A_BED_RAILS                        *             *             *             *     *               *
           (P4B) Other Types of Side Rails
           Used                                P4B_OTH_RAILS                        *             *             *             *     *               *
           (P4C) Trunk Restraint               P4C_TRUNK_REST                       *             *             *             *     *               *                                                               *                   *                   *                     *
           (P4D) Limb Restraint                P4D_LIMB_REST                        *             *             *             *     *               *                                                               *                   *                   *                     *
           (P4E) Chair Prevents Rising         P4E_CHR_PRVNT_RISE                   *             *             *             *     *               *                                                               *                   *                   *                     *

        7/20/2011                                                                                 21 of 28                                                                                                                                                                            cc48b286-0e60-401b-844e-4262322d2eab.xls
                                      Date:
                         Requestor Name:
                      Requestor Institution:
                               Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                    Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                            Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                     Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                         CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                      MDS                Use in analysis
           (P5) Hospital Stays                 P5_HOSP_STAY                         *             *             *

           (P6) Emergency Room (ER) Visits     P6_ER_VISIT                     * * *
           (P7) Physician Visits               P7_PHYS_VISIT                   * * * *          *          *
           (P8) Physicians Orders              P8_PHYS_ORDERS                  * * * *          *          *
           (P9) Abnormal Lab Values            P9_AB_LAB_VALUES                * * *
                                                              Section Q. Discharge Potential and Overall Status
           (Q2) Overall Change in Care
           Needs                               Q2_OVERALL_CHG                       * * * * * *
                                                                         Section R. Assessment Information
           (R1A) Participate in Assessment:
           Resident                            R1A_ASMT_PART_RES                    *             *             *
           (R1B) Participate in Assessment:
           Family                              R1B_ASMT_PART_FAM                    *             *             *
           (R1C) Participate in Assessment:
           Significant Other                   R1C_ASMT_PART_SIGO                   *             *             *

           (R2B) Date RN Coordinator
           Signed Assessment as Complete       R2B_COMPLETE_DT                      *             *             *             *     *               *
           (R3A) Code for Resident
           Discharge Disposition               R3A_DISCHARGE_CD                                                                                                         *
           (R3B) Optional State Discharge
           Code                                R3B_STATE_CD                                           *
           (R4) Discharge Date                 R4_DISCHARGE_DT                                        *
                                               Section T. Supplement - Special Treatments and Procedures (not avaiable for all states)
           (T1AA) Recreation Therapy: # of
           Days                                T1AA_REC_THPY_DAYS
           (T1AB) Recreation Therapy: Total
           # Minutes                           T1AB_REC_THPY_MIN
           (T1B) Ordered Therapies             T1B_ORDER_THPY                                                                 *                                                                           *
           (T1C) Ordered Therapy:
           Estimated Days Until Day 15         T1C_THPY_DAYS                                                                  *                                                                           *
           (T1D) Ordered Therapy:
           Estimated Minutes Until Day 15      T1D_THPY_MIN                                                                   *                                                                           *
           (T2A) Furthest Distance Walked      T2A_WALK


        7/20/2011                                                                                 22 of 28                                                                                                                                                                    cc48b286-0e60-401b-844e-4262322d2eab.xls
                                     Date:
                        Requestor Name:
                     Requestor Institution:
                              Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                    Resident Profiles
                                                                                                                                                                    Track-Discharge




                                                                                                                                                                                                                                                        Quality Measure
                                                                                                                                                                                                                Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                      Track-Reentry
                                                                                                                                 used in




                                                                                                                                                    Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                 Not in




                                                                                                                                                                                                      RUG III
 Check to                                                                                                                           QI                                                                                                                                     CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                  MDS                Use in analysis
           (T2B) Time Walked Without
           Sitting Down                        T2B_TIME_WALK
           (T2C) Self-Performance in
           Walking                             T2C_SELF_WALK
           (T2D) Walking Support Provided      T2D_SUPORT_WALK
           (T2E) Parallel Bars Used            T2E_PARA_BARS
                                                           Section V. Resident Assessment Protocol (RAP) Summary
           (VA01A) Delirium: Triggered         VA01A_DELIURIUM_TR                * *
           (VA01B) Delirium: Proceed With
           Care                                VA01B_DELIURIUM_PC                   *             *
           (VA02A) Cognitive Loss:
           Triggered                           VA02A_COG_LOSS_TR                    *             *
           (VA02B) Cognitive Loss: Proceed
           With Care                           VA02B_COG_LOSS_PC                    *             *
           (VA03A) Visual Function:
           Triggered                           VA03A_VISUAL_TR                      *             *
           (VA03B) Visual Function: Proceed
           With Care                           VA03B_VISUAL_PC                      *             *
           (VA04A) Communication:
           Triggered                           VA04A_COMM_TR                        *             *
           (VA04B) Communication: Proceed
           With Care                           VA04B_COMM_PC                        *             *
           (VA05A) ADL Functional Potential:
           Triggered                           VA05A_ADL_TR                         *             *
           (VA05B) ADL Function: Proceed
           With Care                           VA05B_ADL_PC                         *             *
           (VA06A) Urinary Incontinence:
           Triggered                           VA06A_INCONT_TR                      *             *
           (VA06B) Urinary Incontinence:
           Proceed With Care                   VA06B_INCONT_PC                      *             *
           (VA07A) Psychosocial Well-being:
           Triggered                           VA07A_PSYCH_TR                       *             *
           (VA07B) Psychosocial Well-being:
           Proceed With Care                   VA07B_PSYCH_PC                       *             *
           (VA08A) Mood State: Triggered       VA08A_MOOD_TR                        *             *


        7/20/2011                                                                                 23 of 28                                                                                                                                                                cc48b286-0e60-401b-844e-4262322d2eab.xls
                                      Date:
                         Requestor Name:
                      Requestor Institution:
                               Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                    Resident Profiles
                                                                                                                                                                    Track-Discharge




                                                                                                                                                                                                                                                        Quality Measure
                                                                                                                                                                                                                Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                      Track-Reentry
                                                                                                                                 used in




                                                                                                                                                    Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                 Not in




                                                                                                                                                                                                      RUG III
 Check to                                                                                                                           QI                                                                                                                                     CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                  MDS                Use in analysis
           (VA08B) Mood State: Proceed
           With Care                           VA08B_MOOD_PC                        *             *
           (VA09A) Behavioral Symptoms:
           Triggered                           VA09A_BEHAVE_TR                      *             *
           (VA09B) Behavioral Symptoms:
           Proceed With Care                   VA09B_BEHAVE_PC                      *             *
           (VA10A) Activities: Triggered       VA10A_ACTIV_TR                       *             *
           (VA10B) Activities: Proceed With
           Care                                VA10B_ACTIV_PC                       *             *
           (VA11A) Falls: Triggered            VA11A_FALLS_TR                       *             *

           (VA11B) Falls: Proceed With Care    VA11B_FALLS_PC                       *             *
           (VA12A) Nutritional Status:
           Triggered                           VA12A_NUTRITION_TR                   *             *
           (VA12B) Nutritional Status:
           Proceed With Care                   VA12B_NUTRITION_PC                   *             *
           (VA13A) Feeding Tubes:
           Triggered                           VA13A_FEED_TUBE_TR                   *             *
           (VA13B) Feeding Tubes: Proceed
           With Care                           VA13B_FEED_TUBE_PC                   *             *
           (VA14A) Dehydration: Triggered      VA14A_DEHYDRAT_TR                    *             *
           (VA14B) Dehydration: Proceed
           With Care                           VA14B_DEHYDRAT_PC                    *             *
           (VA15A) Dental Care: Triggered      VA15A_DENTAL_TR                      *             *
           (VA15B) Dental Care: Proceed
           With Care                           VA15B_DENTAL_PC                      *             *
           (VA16A) Pressure Ulcers:
           Triggered                           VA16A_PRS_ULCER_TR                   *             *
           (VA16B) Pressure Ulcers:
           Proceed With Care                   VA16B_PRS_ULCER_PC                   *             *
           (VA17A) Psychotropic Drug Use:
           Triggered                           VA17A_DRUG_USER_TR                   *             *
           (VA17B) Psychotropic Drug Use:
           Proceed With Care                   VA17B_DRUP_USER_PC                   *             *
           (VA18A) Physical Restraints:
           Triggered                           VA18A_RESTRAINT_TR                   *             *

        7/20/2011                                                                                 24 of 28                                                                                                                                                                cc48b286-0e60-401b-844e-4262322d2eab.xls
                                      Date:
                         Requestor Name:
                      Requestor Institution:
                               Study Title:


                        Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                    Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                            Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                     Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                         CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                      MDS                  Use in analysis
           (VA18B) Physical Restraints:
           Proceed With Care              VA18B_RESTRAINT_PC                        *             *
           (VB2) RAP Assessment Signature
           Date                           VB2_RAP_DT                                *             *
           (VB4) RAP Care Plan Signature
           Date                           VB4_CARE_PLAN_DT                        * *
                                                                       Section W. Additional items collected

           (W1) National Provider ID           W1_NATL_PRVDR_ID                     *             *             *             *     *               *                   *                 *                                                                                             Field not edited & may not be correct NPI.
           (W2a) Influenza vaccine received
           in facility                         W2A_INFLNZ_STUS_SW                   *             *             *             *     *               *                   *                                                                                      *
           (W2b) Reason influenza vaccine
           not received                        W2B_INFLNZ_NOT_RCVD_RSN_ID           *             *             *             *     *               *                   *
           (W3a) Resident up to date with
           PPV status                          W3A_PPV_STUS_SW                  * * * * * *         *                *
           (W3b) Reason PPV not received       W3B_PPV_NOT_RCVD_RSN_ID          * * * * * *         *
                                                                   *END OF RAI ASSESSMENT VARIABLES*
                                                        Imputed or added variables, not coded on RAI assessment form
           Assessment Beginning Version
           Date                                AST_BEG_VER_DT

                                                                                                                                                                                                                                                                                        Used to determine whether the
                                                                                                                                                                                                                                                                                        assessment is a corrected assessment.
                                                                                                                                                                                                                                                                                        Original records will have a value of '00'
                                                                                                                                                                                                                                                                                        with corrected records having numbers
           Assessment Correction Version AST_CORR_VER                                                                                                                                                                                                                                   starting at '01'
           Assessment Correction Version
           Date                          AST_END_VER_DT

           Assessment Modification Indicator   AST_MOD_IND
           Care Planning Lock Date             CARE_LOCK
           Created Date                        CREATED_DATE
           Effective Date                      EFFECTIVE_DATE
                                                                                                                                                                                                                                                                                        System generated unique facility
                                                                                                                                                                                                                                                                                        identifier, Used in combination with
                                                                                                                                                                                                                                                                                        STATE_ID to create a unique facility
           Facility Internal ID                FAC_INT_ID                                                                                                                                                                                                                               number


        7/20/2011                                                                                 25 of 28                                                                                                                                                                    cc48b286-0e60-401b-844e-4262322d2eab.xls
                                     Date:
                        Requestor Name:
                     Requestor Institution:
                              Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                    Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                        Resident Profiles
                                                                                                                                                                        Track-Discharge




                                                                                                                                                                                                                                                            Quality Measure
                                                                                                                                                                                                                    Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                          Track-Reentry
                                                                                                                                 used in




                                                                                                                                                        Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                     Not in




                                                                                                                                                                                                          RUG III
 Check to                                                                                                                           QI                                                                                                                                         CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                      MDS                  Use in analysis

                                                                                                                                                                                                                                                                                        System generated unique assessment
                                                                                                                                                                                                                                                                                        identifier, Used in combination with
                                                                                                                                                                                                                                                                                        STATE_ID to create a unique assessment
           MDS Assessment Internal ID         MDS_ASMT_INT_ID                                                                                                                                                                                                                           number
           MDS Layout Submitted Version
           Code                               VCODE2                                *             *             *             *     *               *                   *                 *
           MDS Submission Sequence
           Number                             MDS_SUBM_SEQ_NBR
           MDS Version Completed Code         VCODE1                                *             *             *             *     *               *                   *                 *
           Medicaid CMI Value for RUG
           Group                              MCD_CMI
           Medicaid RUG CMI Set Used          MCD_SET_CODE
           Medicaid RUG Group                 MCD_GP
           Medicaid RUG Version               MCD_VR
           Medicare CMI Value for RUG
           Group                              MCR_CMI
           Medicare Case Mix Group            T3MCARE_CALC_RUG
           Medicare RUG CMI Set Used          MCR_SET_CODE
           Medicare RUG Group                 MCR_GP
           Medicare RUG Version               MCR_VR

                                                                                                                                                                                                                                                                                        If the record is a correction, the Original
                                                                                                                                                                                                                                                                                        Assessment ID is the Assessment Internal
           Original Assessment Internal ID    ORIG_ASMT_INT_ID                                                                                                                                                                                                                          ID of the record being corrected
           Previous Record Date               P_REC_DT                                            *
           Record Type Code                   REC_TYPE                              *             *             *             *     *               *                   *                 *                                                                                    *
           Resident Change Timestamp          RES_CHG_TIMESTAMP

                                                                                                                                                                                                                                                                                        Used in combination with state_ID to
                                                                                                                                                                                                                                                                                        create a unique resident identifier. Note,
                                                                                                                                                                                                                                                                                        residents that move to a facility in another
                                                                                                                                                                                                                                                                                        state will not have the same identifier.
                                                                                                                                                                                                                                                                                        PLEASE NOTE: If requesting MDS data
                                                                                                                                                                                                                                                                                        from CCW and researcher would like the
                                                                                                                                                                                                                                                                                        Resident id, request the Identifier
                                                                                                                                                                                                                                                                                        crosswalk Buccaneer Bene ID to Resident
           Resident Internal ID               RES_INT_ID                                                                                                                                                                                                                       *        id + State id


        7/20/2011                                                                                 26 of 28                                                                                                                                                                    cc48b286-0e60-401b-844e-4262322d2eab.xls
                                      Date:
                         Requestor Name:
                      Requestor Institution:
                               Study Title:


                        Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                       Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                           Resident Profiles
                                                                                                                                                                           Track-Discharge




                                                                                                                                                                                                                                                               Quality Measure
                                                                                                                                                                                                                       Quality Indicator
                                                                                                                                       Qtrly-Minimum




                                                                                                                                                                                             Track-Reentry
                                                                                                                                 used in




                                                                                                                                                           Qtrly-RUG III
                                                                                                                   Full-No RAP
                                                                                       Full-Annual
                                                                                                     Full-Yearly
                                                                                                                               calculating                                                                                                                                        Not in




                                                                                                                                                                                                             RUG III
 Check to                                                                                                                           QI                                                                                                                                            CCW




                                                                                                                                 PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                         MDS                  Use in analysis
           Resident Match Criteria             RES_MATCH_CRITERIA

           Software Vendor Or Agent Tax ID SFTW_ID                                     *             *             *             *     *               *                   *                 *
           Software Version                SFT_VER                                     *             *             *             *     *               *                   *                 *
           State Case Mix Group            T3STATE_CALC_RUG

                                                                                                                                                                                                                                                                                           The state where the assessment was
                                                                                                                                                                                                                                                                                           submitted. Used in combination with
                                                                                                                                                                                                                                                                                           unique keys (Assessment Internal ID,
                                                                                                                                                                                                                                                                                           Original Assessment Internal ID, Facility
                                                                                                                                                                                                                                                                                           Internal ID and Resident Internal ID) to
           State ID                            STATE_ID                                                                                                                                                                                                                                    create a unique identifier.
           State Prepared Date                 ST_PREPD_DT
                                                                                                                                                                                                                                                                                           Date the facility submitted the
           Submission Date                     SUBMISSION_DATE                                                                                                                                                                                                                             assessment to the State
           Requirement for Submitting This
           MDS Record                          SUB_REQ                                 *             *             *             *     *               *                   *                 *

                                                                                                                                                                                                                                                                                           The A3A date on all assessments except
                                                                                                                                                                                                                                                                                           for discharges or re-entries. The target
                                                                                                                                                                                                                                                                                           date on a discharge is the R4 date and on
           Target Date                         TARGET_DATE                                                                                                                                                                                                                                 a re-entry is the A4A date.
           Updated Date                        UPDATED_DATE

Abbreviation List
     A = Admission Assessment
     Y = Comprehensive Assessment (Annual, Significant Change, Significant Correction of Prior Full)
     N = Full Assessment with no RAPs (Full Quarterly where required by State)
    M = Minimum Quarterly (HCFA Standard 2-page Quarterly)
     P = Medicare PPS Assessment form (MPAF)
   RQ = RUG-III Quarterly (Optional Version for RUG-III 1997 Update)
     D = Discharge Tracking Form
     R = Reentry Tracking Form
  RGs = RUG-III Case Mix Classification, Version 5.20
          CHSRA Quality Indicators as defined in "Nursing Facility Quality Indicator Definitions: 11/25/97" from the Center for Health Science Research and Analysis, The University of
   QIs = Wisconsin at Madison


        7/20/2011                                                                                    27 of 28                                                                                                                                                                    cc48b286-0e60-401b-844e-4262322d2eab.xls
                                     Date:
                        Requestor Name:
                     Requestor Institution:
                              Study Title:


                       Long Term Care MDS Workbench Variable Selection & Justification Worksheet (updated 9/2008)
Directions: Indicate variables to include in the output and justify the need for each. For variable definition see the MDS data dictionary.                                                                                                                                Bolded variables indicate CMS
recommended variables.
                                                                                                                                 Variable




                                                                                                                                                                                                                                    Resident Profiles
                                                                                                                                                                    Track-Discharge




                                                                                                                                                                                                                                                        Quality Measure
                                                                                                                                                                                                                Quality Indicator
                                                                                                                                    Qtrly-Minimum




                                                                                                                                                                                      Track-Reentry
                                                                                                                                 used in




                                                                                                                                                    Qtrly-RUG III
                                                                                                                Full-No RAP
                                                                                    Full-Annual
                                                                                                  Full-Yearly
                                                                                                                               calculating                                                                                                                                 Not in




                                                                                                                                                                                                      RUG III
 Check to                                                                                                                           QI                                                                                                                                     CCW




                                                                                                                              PPS
 request      Section and variable name               Variable SAS name                                                         exclusion                                                                                                                                  MDS                Use in analysis


  RPs = Resident Assessment Profiles as defined in the "Long-Term Care Resident Assessment User's Manual: Version 2.0", CMS, 1995 and in the MDS Data Specifications Version 1.30
  QMs = Quality Measures publicly reported in 11/2004 (15 QMs)
Date Selection Criteria:
          Target vs. Submission Date and Date Range




        7/20/2011                                                                                 28 of 28                                                                                                                                                                cc48b286-0e60-401b-844e-4262322d2eab.xls

				
DOCUMENT INFO
Description: Psychosocial Assessment Worksheet document sample