Minimum Data Set (Mds) For Nursing Home Resident Assessment And Care Screening
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1Numeric Identifier___________________________________________________________
MINIMUM DATA SET (MDS) — VERSION 2.0
FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING
BASIC ASSESSMENT TRACKING FORM
SECTION AA. IDENTIFICATION INFORMATION
9. Signatures of Persons who Completed a Portion of the Accompanying Assessment or
1. RESIDENT
Tracking Form
NAME*
I certify that the accompanying information accurately reflects resident assessment or tracking
a. (First)
d. (Jr/Sr)
b. (Middle Initial)
c. (Last)
information for this resident and that I collected or coordinated collection of this information on the
2.
GENDER*
1. Male
2. Female
dates specified. To the best of my knowledge, this information was collected in accordance with
applicable Medicare and Medicaid requirements. I understand that this information is used as a
3.
BIRTHDATE*
basis for ensuring that residents receive appropriate and quality care, and as a basis for payment
from federal funds. I further understand that payment of such federal funds and continued partici
pation in the government-funded health care programs is conditioned on the accuracy and truthful
Month
Day
Y ear
ness of this information, and that I may be personally subject to or may subject my organization to
4.
RACE/
1. American Indian/Alaskan Native
4. Hispanic
*
substantial criminal, civil, and/or administrative penalties for submitting false information. I also
ETHNICITY
2. Asian/Pacific Islander
5.White, not of
certify that I am authorized to submit this information by this facility on its behalf.
3. Black, not of Hispanic origin
Hispanic origin
5.
SOCIAL
a. Social Security Number
Signature and Title
Sections
Date
SECURITY*
AND
a.
MEDICARE
b. Medicare number (or comparable railroad insurance number)
NUMBERS
*
b.
st
[C in 1
box if
non med. no.]
c.
6.
a. State No.
FACILITY
PROVIDER
d.
NO.*
e.
b. Federal No.
f.
7.
MEDICAID
g.
NO. [ "+" if
pending, "N"
*
h.
if not a
Medicaid
i.
recipient ] *
8. REASONS
[Note—Other codes do not apply to this form]
j.
FOR
a. Primary reason for assessment
ASSESS
k.
1. Admission assessment (required by day 14)
MENT
2. Annual assessment
3. Significant change in status assessment
l.
4. Significant correction of prior full assessment
5. Quarterly review assessment
10. Significant correction of prior quarterly assessment
0. NONE OF ABOVE
b. Codes for assessments required for Medicare PPS or the State
1
. Medicare 5 day assessment
2
. Medicare 30 day assessment
3
. Medicare 60 day assessment
4
. Medicare 90 day assessment
5
. Medicare readmission/return assessment
6
. Other state required assessment
7
. Medicare 14 day assessment
8
. Other Medicare required assessment
GENERAL INSTRUCTIONS
Complete this information for submission with all full and quarterly assessments
(Admission, Annual, Significant Change, State or Medicare required assessments, or
Quarterly Reviews, etc.)
* = Key items for computerized resident tracking
MDS 2.0 September, 2000
= When box blank, must enter number or letter
= When letter in box, check if condition applies
a.
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