MDS Assessment Section

0% complete (0 of 19 sections)

A B C D E F GG H I J K L M N O P Q V Z

Resident: Unnamed resident | Assessment ID: 70 | Status: In progress

Section A

Identification Information

MDS 3.0 NC Version 1.20.1 — Effective 10/01/2025

A0050

Type of Record

Select the action being taken on this record. For a new admission assessment, select "Add new record".

1. Add new record → Continue to A0100, Facility Provider Numbers

2. Modify existing record → Continue to A0100, Facility Provider Numbers

3. Inactivate existing record → Skip to X0150, Type of Provider

A0100. Facility Provider Numbers

A0100A

A. National Provider Identifier (NPI)

A0100B

B. CMS Certification Number (CCN)

The CCN is a 6-digit number assigned by CMS to identify the facility.

A0100C

C. State Provider Number

A0200

A0200. Type of Provider

1. Nursing home (SNF/NF)

2. Swing Bed

A0310. Type of Assessment

A0310A

A. Federal OBRA Reason for Assessment

For an admission assessment required by day 14, select 01.

01. Admission assessment (required by day 14)

02. Quarterly review assessment

03. Annual assessment

04. Significant change in status assessment

05. Significant correction to prior comprehensive assessment

06. Significant correction to prior quarterly assessment

99. None of the above

A0310B

B. PPS Assessment

Select 99 if this is an OBRA-only assessment with no Medicare Part A PPS component.

01. 5-day scheduled assessment (PPS Scheduled)

08. IPA — Interim Payment Assessment (PPS Unscheduled)

99. None of the above — Not a PPS Assessment

A0310E

E. Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry?

0. No

1. Yes

A0310F

F. Entry/discharge reporting

01. Entry tracking record

10. Discharge assessment — return not anticipated

11. Discharge assessment — return anticipated

12. Death in facility tracking record

99. None of the above

A0500. Legal Name of Resident

A0500_first

A. First name

A0500_mi

B. Middle initial

A0500_last

C. Last name

A0500_suffix

D. Suffix (Jr., Sr., etc.)

A0600. Social Security and Medicare Numbers

A0600A

A. Social Security Number

For training purposes, use a fictitious SSN. Format: XXX-XX-XXXX

A0600B

B. Medicare Number

A0700

A0700. Medicaid Number

Enter the Medicaid number, "+" if pending, or "N" if not a Medicaid recipient.

A0810

A0810. Sex

1. Male

2. Female

A0900

A0900. Birth Date

A1005

A1005. Ethnicity — Are you of Hispanic, Latino/a, or Spanish origin?

Resident self-report is preferred. Check all that apply.

A. No, not of Hispanic, Latino/a, or Spanish origin

B. Yes, Mexican, Mexican American, Chicano/a

C. Yes, Puerto Rican

D. Yes, Cuban

E. Yes, another Hispanic, Latino/a, or Spanish origin

X. Resident unable to respond

Y. Resident declines to respond

A1110. Language

A1110A

A. What is your preferred language?

A1110B

B. Do you need or want an interpreter to communicate with a doctor or health care staff?

0. No

1. Yes

9. Unable to determine

A1200

A1200. Marital Status

1. Never married

2. Married

3. Widowed

4. Separated

5. Divorced

A1300. Optional Resident Items

A1300A

A. Medical record number

A1300B

B. Room number

A1300C

C. Name by which resident prefers to be addressed

A1300D

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

A1500

A1500. Preadmission Screening and Resident Review (PASRR)

Complete only if A0310A = 01, 03, 04, or 05.

Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?

0. No → Skip to A1550, Conditions Related to ID/DD Status

1. Yes → Continue to A1510, Level II PASRR Conditions

9. Not a Medicaid-certified unit → Skip to A1550

A1510

A1510. Level II PASRR Conditions — Complete only if A1500 = 1

A. Serious mental illness

B. Intellectual Disability

C. Other related conditions

A1550

A1550. Conditions Related to ID/DD Status — Check all conditions related to ID/DD status manifested before age 22 and likely to continue indefinitely

A. Down syndrome

B. Autism

C. Epilepsy

D. Other organic condition related to ID/DD

E. ID/DD with no organic condition

Z. None of the above

Most Recent Admission/Entry or Reentry into this Facility

A1600

A1600. Entry Date

A1700

A1700. Type of Entry

1. Admission

2. Reentry

A1900

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

This is the date the current episode of care began — the day the resident was admitted to the facility.

A2300

A2300. Assessment Reference Date — Observation end date

The Assessment Reference Date (ARD) is the last day of the observation period. For admission assessments, the ARD must be no later than 14 days after the admission date (A1900).

A2400. Medicare Stay — Complete only if A0310G1 = 0

A2400A

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

0. No → Skip to B0100, Comatose

1. Yes → Continue to A2400B, Start date of most recent Medicare stay

A2400B

B. Start date of most recent Medicare stay

A2400C

C. End date of most recent Medicare stay (enter dashes if ongoing)