MINIMUM DATA SET - HOME CARE (MDS-HC)© Unless otherwise noted, score for last 3 days Examples of exceptions include IADLs/Continence/Services/Treatments where status scored over last 7 days SECTION AA. NAME AND IDENTIFICATION NUMBERS 1.NAME OF CLIENT a. (Last/Family Name)b. (First Name)c. (Middle Initial) 2. CASE RECORD NO. 3. GOVERNMENT PENSION AND HEALTH INSURANCE NUMBERS a. Pension (Social Security) Number b. Health insurance number (or other comparable insurance number) SECTION BB.PERSONAL ITEMS (Complete at Intake Only) 1.GENDER 1. Male2. Female 2.BIRTHDATE Month Day Year 3.RACE/ETHNICITY (Check all that apply) RACE American Indian/Alaskan Native Asian Black or African American Native Hawaiian or other Pacific Islander White ETHNICITY: Hispanic or Latino 4.MARITALSTATUS 1. Never married 2. Married 3. Widowed 4. Separated 5. Divorced 6. Other 5. LANGUAGE Primary Language 0. English 1. Spanish 2. French 3. Other 6. EDUCATION (Highest Level Completed) 1. No schooling 2. 8th grade/less 3. 9-11 grades 4. High school 5.Technical or trade school 6. Some college 7. Bachelor's degree 8. Graduate degree 7. RESPONSI-BILITY/ ADVANCED DIRECTIVES a.Client has a legal guardian b.Client has advanced medical directives in place (for example, a do not hospitalize order) SECTION CC. REFERRAL ITEMS (Complete at Intake Only) 1. DATE CASE OPENED/ REOPENED Month Day Year 2. REASON FOR REFERRAL 1. Post hospital care 2. Community chronic care 3. Home placement screen 4. Eligibility for home care 5. Day care 6. Other 3. GOALS OF CARE (Code for client/family understanding of goals of care) 0. No 1. Yes a.Skilled nursing treatments b.Monitoring to avoid clinical complications c.Rehabilitation d.Client/family education e.Family respite f. Palliative care 4. TIME SINCE LAST HOSPITAL STAY Time since discharge from last in-patient setting (Code for most recent instance in LAST 180 DAYS) 0. No hospitalization within 180 days 1. Within last week 2. Within 8 to 14 days 3. Within 15 to 30 days 4. More than 30 days ago 5. WHERE LIVED AT TIME OF REFERRAL 1. Private home/apt. with no home care services 2. Private home/apt. with home care services 3. Board and care/assisted living/group home 4. Nursing home5. Other 6. WHO LIVED WITH AT REFERRAL 1. Lived alone 2. Lived with spouse only 3. Lived with spouse and other(s) 4. Lived with child (not spouse) 5. Lived with other(s) (not spouse or children) 6. Lived in group setting with non-relative(s) 7. PRIOR NH PLACEMENT Resided in a nursing home at anytime during 5 YEARS prior to caseopening 0. No 1. Yes 8. RESIDENTIAL HISTORY Moved to current residence within last two years 0. No 1. Yes SECTION A. ASSESSMENT INFORMATION 1.ASSESSMENT REFERENCE DATE Date of assessment Month Day Year 2.REASONS FOR ASSESSMENT Type of assessment 1.Initial assessment 2.Follow-up assessment 3.Routine assessment at fixed intervals 4.Review within 30-day period prior to discharge from the program 5.Review at return from hospital 6.Change in status 7.Other SECTION B. COGNITIVE PATTERNS 1. MEMORY RECALL ABILITY (Code for recall of what was learned or known) 0. Memory OK 1. Memory problem a.Short-term memory OK — seems/appears to recall after 5 minutes b.Procedural memory OK—Can perform all or almost all steps in a multi task sequence without cues for initiation 2.COGNITIVE SKILLS FOR DAILY DECISION-MAKING a.How well client made decisions about organizing the day (e.g., whento get up or have meals, which clothes to wear or activities to do) 0.INDEPENDENT—Decisions consistent/reasonable/safe 1.MODIFIED INDEPENDENCE—Some difficulty in new situations only 2.MINIMALLY IMPAIRED—In specific situations, decisions become poor or unsafe and cues/supervision necessary at those times3.MODERATELY IMPAIRED—Decisions consistently poor or un-safe, cues/supervision required at all times 4.SEVERELY IMPAIRED—Never/rarely made decisions b.Worsening of decision making as compared to status of 90 DAYSAGO (or since last assessment if less than 90 days) 0. No 1. Yes 3. INDICATORS OF DELIRIUM a.Sudden or new onset/change in mental function over LAST 7 DAYS(including ability to pay attention, awareness of surroundings, being coherent, unpredictable variation over course of day) 0. No 1. Yes b. In the LAST 90 DAYS (or since last assessment if less than 90 days), client has become agitated or disoriented such that his orher safety is endangered or client requires protection by others 0. No 1. Yes SECTION C. COMMUNICATION/HEARING PATTERNS 1.HEARING (With hearing appliance if used) 0. HEARS ADEQUATELY—Normal talk, TV, phone, doorbell 1. MINIMAL DIFFICULTY—When not in quiet setting 2. HEARS IN SPECIAL SITUATIONS ONLY—Speaker has to adjusttonal quality and speak distinctly 3. HIGHLY IMPAIRED—Absence of useful hearing 2.MAKING SELF UNDERSTOOD (Expression) (Expressing information content—however able) 0. UNDERSTOOD—Expresses ideas without difficulty 1.USUALLY UNDERSTOOD—Difficulty finding words or finishing thoughtsBUT if given time, little or no prompting required 2.OFTEN UNDERSTOOD—Difficulty finding words or finishing thoughts,prompting usually required 3.SOMETIMES UNDERSTOOD—Ability is limited to making concreterequests 4.RARELY/NEVER UNDERSTOOD 3.ABILITY TO UNDER STAND OTHERS (Comprehension) (Understands verbal information— however able) 0.UNDERSTANDS—Clear comprehension 1.USUALLY UNDERSTANDS—Misses some part/intent of message, BUT comprehends most conversation with little or no prompting 2.OFTEN UNDERSTANDS—Misses some part/intent of message; with prompting can often comprehend conversation 3.SOMETIMES UNDERSTANDS—Responds adequately to simple, direct communication 4.RARELY/NEVER UNDERSTANDS 4.COMMUNICATION DECLINE Worsening in communication (making self understood or understanding others)as compared to status of 90 DAYS AGO (or since last assessment if less than 90 days) 0. No 1. Yes SECTION D. VISION PATTERNS 1. VISION (Ability to see in adequate light and with glasses if used) 0.ADEQUATE—Sees fine detail, including regular print in newspapers/books 1.IMPAIRED—Sees large print, but not regular print in newspapers/books 2.MODERATELY IMPAIRED—Limited vision; not able to see newspaper headlines, but can identify objects 3.HIGHLY IMPAIRED—Object identification in question, but eyes appear to follow objects 4.SEVERELY IMPAIRED—No vision or sees only light, colors, or shapes; eyes do not appear to follow objects 2. VISUAL LIMITATION/DIFFICULTIES Saw halos or rings around lights, curtains over eyes, or flashes of lights 0. No 1. Yes 3. VISION DECLINE Worsening of vision as compared to status of 90 DAYS AGO (or since last assessment if less than 90 days) 0. No 1. Yes MDS-HC Version 2.0 — July 21, 1999 MDS-HC-Pg 1 SECTION E. MOOD AND BEHAVIOR PATTERNS INDICATORS OF DEPRESSION,ANXIETY,SAD MOOD (Code for observed indicators irrespective of the assumed cause 0. Indicator not exhibited in last 3 days 1. Exhibited 1-2 of last 3 days 2. Exhibited on each of last 3 days a.A FEELING OF SADNESSOR BEING DEPRESSED,that life is not worth living,that nothing matters, that he or she is of no use to anyone or would rather be dead b.PERSISTENT ANGER WITH SELF OR OTHERS—e.g., easily annoyed, anger at care received c.EXPRESSIONS OF WHAT APPEAR TO BE UNREALISTIC FEARS—e.g., fear of being abandoned, left alone, being with others d.REPETITIVE HEALTH COM-PLAINTS—e.g., persistently seeks medical attention, obsessive concern with body functions e.REPETITIVE ANXIOUS COM-PLAINTS, CONCERNS—e.g.,persistently seeks attention/reassurance regarding sched-ules, meals, laundry, clothing,relationship issues f.SAD, PAINED, WORRIED FACIAL EXPRESSIONS — e.g., furrowed brows g.RECURRENT CRYING, TEAR-FULNESS h.WITHDRAWAL FROM ACTIVITIES OF INTEREST—e.g., no interest in long standing activities or being with family/friends i.REDUCED SOCIAL INTER ACTION 2. MOOD DECLINE Mood indicators have become worse as compared to status of 90 days ago (or since last assessment if less than 90 days) 0. No 1. Yes 3.BEHAVIORAL SYMPTOMS Instances when client exhibited behavioral symptoms. If EXHIBITED, ease of altering the symptom when it occurred. 0. Did not occur in last 3 days 1. Occurred, easily altered 2. Occurred, not easily altered a.WANDERING—Moved with no rational purpose, seemingly oblivious to needs or safety b.VERBALLY ABUSIVE BEHAVIORAL SYMPTOMS—Threatened,screamed at, cursed at others c.PHYSICALLY ABUSIVE BEHAVIORAL SYMPTOMS—Hit, shoved,scratched, sexually abused others d.SOCIALLY INAPPROPRIATE/DISRUPTIVE BEHAVIORAL SYMPTOMS—Disruptive sounds, noisiness, screaming, self-abusive acts, sexual behavior or disrobing in public, smears/throws food/feces,rummaging, repetitive behavior, rises early and causes disruption e.RESISTS CARE—Resisted taking medications/injections, ADL assistance, eating, or changes in position 4. CHANGES IN BEHAVIOR SYMPTOMS Behavioral symptoms have become worse or are less well toleratedby family as compared to 90 DAYS AGO (or since last assessment if less than 90 days) 0. No, or no change in behavioral symptoms 1. Yes SECTION F. SOCIAL FUNCTIONING 1. INVOLVEMENT a. At ease interacting with others (e.g., likes to spend time with others) 0. At ease 1. Not at ease b.Openly expresses conflict or anger with family/friends 0. No 1. Yes 2. CHANGE IN SOCIAL ACTIVITIES As compared to 90 DAYS AGO (or since last assessment if less than90 days ago), decline in the client's level of participation in social,religious, occupational or other preferred activities. IF THERE WAS ADECLINE, client distressed by this fact0. No decline 1. Decline, not distressed 2. Decline, distressed 3. ISOLATION a.Length of time client is alone during the day (morning and afternoon) 0. Never or hardly ever 1. About one hour2. Long periods of time—e.g., all morning 3. All of the timeb. Client says or indicates that he/she feels lonely 0. No 1. Yes SECTION G. INFORMAL SUPPORT SERVICES 1.TWO KEY INFORMAL HELPERS Primary (A)and Secondary(B) NAME OF PRIMARY AND SECONDARY HELPERS a. (Last/Family Name) b. (First) c. (Last/Family Name) d. (First) (A) Prim (B) Secn e.Lives with client 0. Yes 1. No 2. No such helper [skip other items in the appropriate column] f.Relationship to client 0. Child or child-in-law 1. Spouse 2. Other Relative 3. Friend/neighbor Areas of help: 0. Yes 1. No g.— Advice or emotional support h.— IADL care i.— ADL care TWO KEY INFORMAL HELPERS Primary (A)and Secondary (B)(cont) If needed, willingness (with ability) to increase help: 0. More than 2 hours 1. 1-2 hours per day2. No j.— Advice or emotional support k.— IADL care l.— ADL care 2.CAREGIVER STATUS (Check all that apply) A caregiver is unable to continue in caring activities—e.g., decline inthe health of the caregiver makes it difficult to continue Primary caregiver is not satisfied with support received from family and friends (e.g., other children of client)Primary caregiver expresses feelings of distress, anger or depression NONE OF ABOVE a. b. c. d. 3.EXTENT OFINFORMAL HELP(HOURS OF CARE,ROUNDED) a.Sum of time across five weekdays b.Sum of time across two weekend days HOURS SECTION H.PHYSICAL FUNCTIONING: • IADL PERFORMANCE IN 7 DAYS • ADL PERFORMANCE IN 3 DAYS 1. IADL SELF PERFORMANCE—Code for functioning in routine activities around the home or in the community during the LAST 7 DAYS, (A)IADL SELF PERFORMANCE CODE (Code for client's performance during LAST 7 DAYS)0. INDEPENDENT—did on own 1. SOME HELP—help some of the time 2. FULL HELP—performed with help all of the time 3. BY OTHERS—performed by others 8. ACTIVITY DID NOT OCCUR (B)IADL DIFFICULTY CODE How difficult it is (or would it be) for client to doactivity on own 0. NO DIFFICULTY 1. SOME DIFFICULTY—e.g., needs some help, is very slow, or fatigues 2. GREAT DIFFICULTY—e.g., little or no involvement in the activity is possible (A) Performance (B)Difficulty a.MEAL PREPARATION—How meals are prepared (e.g., planning meals, cooking,assembling ingredients, setting out food and utensils) b.ORDINARY HOUSE WORK—How ordinary work around the house is performed (e.g.,doing dishes, dusting, making bed, tidying up, laundry) c.MANAGING FINANCE—How bills are paid, checkbook is balanced, householdexpenses are balanced d.MANAGING MEDICATIONS—How medications are managed (e.g., remembering totake medicines, opening bottles, taking correct drug dosages, giving injections,applying ointments) e.PHONE USE—How telephone calls are made or received (with assistive devices suchas large numbers on telephone, amplification as needed) f.SHOPPING—How shopping is performed for food and household items (e.g., selectingitems, managing money) g.TRANSPORTATION—How client travels by vehicle (e.g., gets to places beyond walk-ing distance) 2. ADL SELF-PERFORMANCE—The following address the client's physical functioning in routine personal activities of daily life, for example, dressing, eating, etc. during the LAST 3 DAYS,considering all episodes of these activities. For clients who performed an activity independently, be sure to determine and record whether others encouraged the activity or were present to supervise or oversee the activity [Note—For bathing, code for most dependent single episode in LAST 7 DAYS] 0.INDEPENDENT—No help, setup, or oversight —OR— Help, setup, oversight providedonly 1 or 2 times (with any task or subtask) 1.SETUP HELP ONLY—Article or device provided within reach of client 3 or more times 2.SUPERVISION—Oversight, encouragement or cueing provided 3 or more times during last 3 days —OR— Supervision (1 or more times) plus physical assistance provided only 1 or2 times (for a total of 3 or more episodes of help or supervision) 3.LIMITED ASSISTANCE—Client highly involved in activity; received physical help in guidedmaneuvering of limbs or other non-weight bearing assistance 3 or more times —OR—Combination of non-weight bearing help with more help provided only 1 or 2 times duringperiod (for a total of 3 or more episodes of physical help) 4.EXTENSIVE ASSISTANCE—Client performed part of activity on own (50% or more ofsubtasks), but help of following type(s) were provided 3 or more times:— Weight-bearing support —OR—— Full performance by another during part (but not all) of last 3 days 5.MAXIMAL ASSISTANCE—Client involved and completed less than 50% of subtasks onown (includes 2+ person assist), received weight bearing help or full performance of certainsubtasks 3 or more times 6.TOTAL DEPENDENCE—Full performance of activity by another 8.ACTIVITY DID NOT OCCUR (regardless of ability) MDS-HC Version 2.0 — July 21, 1999 MDS-HC - Pg 2 2. ADL SELF-PERFORMANCE (cont) a.MOBILITY IN BED—Including moving to and from lying position, turning side to side, andpositioning body while in bed. b.TRANSFER—Including moving to and between surfaces—to/from bed, chair, wheelchair,standing position. [Note—Excludes to/from bath/toilet] c.LOCOMOTION IN HOME—[Note—If in wheelchair, self-sufficiency once in chair] d.LOCOMOTION OUTSIDE OF HOME—[Note—If in wheelchair, self-sufficiency once inchair] e.DRESSING UPPER BODY—How client dresses and undresses (street clothes, under- wear) above the waist, includes prostheses, orthotics, fasteners, pullovers, etc. f.DRESSING LOWER BODY—How client dresses and undresses (street clothes, under- wear) from the waist down, includes prostheses, orthotics, belts, pants, skirts, shoes,and fasteners g.EATING—Including taking in food by any method, including tube feedings. h.TOILET USE—Including using the toilet room or commode, bedpan, urinal, transferringon/off toilet, cleaning self after toilet use or incontinent episode, changing pad, managingany special devices required (ostomy or catheter), and adjusting clothes. i.PERSONAL HYGIENE—Including combing hair, brushing teeth, shaving, applying makeup,washing/drying face and hands (EXCLUDE baths and showers) j.BATHING—How client takes full-body bath/shower or sponge bath (EXCLUDE washing ofback and hair). Includes how each part of body is bathed: arms, upper and lower legs,chest, abdomen, perineal area. Code for most dependent episode in LAST 7 DAYS 3.ADL DECLINE ADL status has become worse (i.e., now more impaired in self perfor-mance) as compared to status 90 days ago (or since last assessmentif less than 90 days) 0. No 1. Yes 4.PRIMARY MODES OF LOCOMOTION 0. No assistive device 1. Cane 2. Walker/crutch 3. Scooter (e.g., Amigo) 4. Wheelchair 8. ACTIVITY DID NOT OCCUR a. Indoors b. Outdoors 5. STAIR CLIMBING In the last 3 days, how client went up and down stairs (e.g., single or multiple steps, using handrail as needed) 0.Up and down stairs without help 1.Up and down stairs with help 2.Not go up and down stairs 6. STAMINA a.In a typical week, during the LAST 30 DAYS (or since last assess-ment), code the number of days client usually went out of the houseor building in which client lives (no matter how short a time period ) 0.Every day 1.2-6 days a week 2. 1 day a week 3. No days b.Hours of physical activities in the last 3 days (e.g., walking, cleaninghouse, exercise) 0.Two or more hours 1. Less than two hours 7.FUNCTIONAL POTENTIAL Client believes he/she capable of increased functional independence(ADL, IADL, mobility) Caregivers believe client is capable of increased functional independence (ADL, IADL, mobility) Good prospects of recovery from current disease or conditions, improved health status expected NONE OF ABOVE SECTION I. CONTINENCE IN LAST 7 DAYS 1. BLADDER CONTINENCE a.In LAST 7 DAYS control of urinary bladder function (with appliances such as catheters or incontinence program employed) [Note—if dribbles, volume insufficient to soak through underpants] 0.CONTINENT —Complete control; DOES NOT USE any type of catheter or other urinary collection device 1.CONTINENT WITH CATHETER—Complete control with use of anytype of catheter or urinary collection device that does not leakurine 2.USUALLY CONTINENT—Incontinent episodes once a week orless 3.OCCASIONALLY INCONTINENT—Incontinent episodes 2 or moretimes a week but not daily 4.FREQUENTLY INCONTINENT—Tends to be incontinent daily, butsome control present 5.INCONTINENT—Inadequate control, multiple daily episodes 8.DID NOT OCCUR —No urine output from bladder b.Worsening of bladder incontinence as compared to status 90 DAYS AGO (or since last assessment if less than 90 days) 0. No 1. Yes 2. BLADDER DEVICES (Check all that apply in LAST 7 DAYS) Use of pads or briefs to protect against wetness Use of an indwelling urinary catheter NONE OF ABOVE 3.BOWEL CONTINENCE In LAST 7 DAYS, control of bowel movement (with appliance or bowel continence program if employed) 0.CONTINENT—Complete control; DOES NOT USE ostomy device 1.CONTINENT WITH OSTOMY—Complete control with use ofostomy device that does not leak stool 2.USUALLY CONTINENT—Bowel incontinent episodes less than weekly 3.OCCASIONALLY INCONTINENT—Bowel incontinent episode oncea week 4.FREQUENTLY INCONTINENT—Bowel incontinent episodes 2-3times a week 5.INCONTINENT—Bowel incontinent all (or almost all) of the time 8.DID NOT OCCUR—No bowel movement during entire 7 day assessment period SECTION J. DISEASE DIAGNOSESDisease/infection that doctor has indicated is present and affects client's status, requires treatment, or symptom management. Also include if disease is monitored by a home care professional or is the reason for a hospitalization in LAST 90 DAYS (or since last assessment if less than 90 days) [blank]. Not present 1. Present—not subject to focused treatment or monitoring by home care professional 2. Present—monitored or treated by home care professional [If no disease in list, check J1ac, None of Above] 1. DISEASES HEART/CIRCULATION a.Cerebrovascular accident(stroke) b.Congestive heart failure c.Coronary artery disease d.Hypertension e.Irregularly irregular pulse f.Peripheral vascular disease NEUROLOGICAL g.Alzheimer's h.Dementia other than Alzheimer's disease i.Head trauma j.Hemiplegia/hemiparesis k.Multiple sclerosis l.ParkinsonismMUSCULO-SKELETAL m.Arthritis n.Hip fracture o.Other fractures (e.g., wrist,vertebral) p.Osteoporosis SENSES q.Cataract r.Glaucoma PSYCHIATRIC/MOOD s.Any psychiatric diagnosis INFECTIONS t.HIV infection u.Pneumonia v.Tuberculosis w. Urinary tract infection (in LAST 30 DAYS) OTHER DISEASES x.Cancer—(in past 5 years)not including skin cancer y.Diabetes z.Emphysema/COPD/asthma aa. Renal Failure ab.Thyroid disease (hyper or hypo) ac.NONE OF ABOVE ac. 2.OTHER CURRENTOR MORE DETAILED DIAGNOSES AND ICD-9 CODES a. b. c. d. e. SECTION K. HEALTH CONDITIONS AND PREVENTIVE HEALTH MEASURES 1.PREVENTIVE HEALTH(PAST TWO YEARS) (Check all that apply—in PAST 2 YEARS) Blood pressure measured Received influenza vaccination Test for blood in stool or screening endoscopy IF FEMALE: Received breast examination or mammography NONE OF ABOVE a. b. c. d. e. 2.PROBLEM CONDITIONS PRESENT ON 2 OR MORE DAYS (Check all that were present on at least 2 of the last 3 days) Diarrhea Difficulty urinating or urinating 3 or more times at night Fever a. b. c. Loss of appetite Vomiting NONE OF ABOVE d. e. f. 3.PROBLEM CONDITIONS (Check all present at any point during last 3 days) PHYSICAL HEALTH Chest pain/pressure at rest or on exertion No bowel movement in 3 days Dizziness or lightheadedness Edema a. b. c. d. Shortness of breath MENTAL HEALTH Delusions Hallucinations NONE OF ABOVE f. g. h. MDS-HC Version 2.0 — July 21, 1999 MDS-HC - Pg 3 4.PAIN a. Frequency with which client complains or shows evidence of pain 0. No pain (score b-e as 0)2. Daily - one period 1. Less than daily 3. Daily - multiple periods (e.g., morning and evening) b. Intensity of pain 0. No pain 2. Moderate 4. Times when pain is horrible 1. Mild 3. Severe or excruciating c.From client's point of view, pain intensity disrupts usual activities 0. No 1. Yes d. Character of pain 0. No pain 1. Localized - single site 2. Multiple sites e.From client's point of view, medications adequately control pain 0.Yes or no pain 1.Medications do not 2.Pain present,adequately control pain medication not taken 5.FALLS FREQUENCY Number of times fell in LAST 90 DAYS (or since last assessment ifless than 90 days) If none, code "0"; if more than 9, code "9 6.DANGER OF FALL(Code for danger of falling) 0. No 1. Yes a.Unsteady gait b.Client limits going outdoors due to fear of falling (e.g., stoppedusing bus, goes out only with others) 7. LIFE STYLE(Drinking/Smoking) (Code for drinking or smoking)0. No 1. Yes a.In the LAST 90 DAYS (or since last assessment if less than 90 days),client felt the need or was told by others to cut down on drinking, or others were concerned with client's drinking b.In the LAST 90 DAYS (or since last assessment if less than 90 days),client had to have a drink first thing in the morning to steady nerves(i.e., an "eye opener") or has been in trouble because of drinking c.Smoked or chewed tobacco daily 8.HEALTH STATUS INDICATORS (Check all that apply) Client feels he/she has poor health (when asked) Has conditions or diseases that make cognition, ADL, mood, or behavior patterns unstable (fluctuations, precarious, or deteriorating) Experiencing a flare-up of a recurrent or chronic problem Treatments changed in LAST 30 DAYS (or since last assessment if less than 30 days) because of a new acute episode or condition Prognosis of less than six months to live—e.g., physician has told client or client's family that client has end-stage disease NONE OF ABOVE 9.OTHER STATUS INDICATORS (Check all that apply) Fearful of a family member or caregiver Unusually poor hygiene Unexplained injuries, broken bones, or burns Neglected, abused, or mistreated Physically restrained (e.g., limbs restrained, used bed rails,constrained to chair when sitting) NONE OF ABOVE SECTION L. NUTRITION/HYDRATION STATUS 1.WEIGHT (Code for weight items) 0. No 1. Yes a.Unintended weight loss of 5% or more in the LAST 30 DAYS [or 10%or more in the LAST 180 DAYS] b.Severe malnutrion (cachexia) c.Morbid obesity 2.CONSUMPTION Code for consumption) 0. No 1. Yes (Code for consumption) 0. No 1. Yes a.In at least 2 of the last 3 days, ate one or fewer meals a day b.In last 3 days, noticeable decrease in the amount of food clientusually eats or fluids usually consumes c.Insufficient fluid—did not consume all/almost all fluids during last3 days d.Enteral tube feeding 3.SWALLOWING 0.NORMAL—Safe and efficient swallowing of all diet consistencies 1.REQUIRES DIET MODIFICATION TO SWALLOW SOLID FOODS(mechanical diet or able to ingest specific foods only) 2.REQUIRES MODIFICATION TO SWALLOW SOLID FOODS AND LIQUIDS (puree, thickened liquids) 3.COMBINED ORAL AND TUBE FEEDING 4.NO ORAL INTAKE(NPO) SECTION M. DENTAL STATUS (ORAL HEALTH) 1.ORAL STATUS (Check all that apply) Problem chewing (e.g., poor mastication, immobile jaw, surgical resec-tion, decreased sensation/motor control, pain while eating) Mouth is "dry" when eating a meal Problem brushing teeth or dentures NONE OF ABOVE a. b. c. d. SECTION N. SKIN CONDITION 1.SKIN PROBLEMS Any troubling skin conditions or changes in skin condition (e.g., burns,bruises, rashes, itchiness, body lice, scabies) 0. No 1. Yes 2.ULCERS(Pressure/Stasis) Presence of an ulcer anywhere on the body. Ulcers include any area ofpersistent skin redness (Stage 1); partial loss of skin layers (Stage 2);deep craters in the skin (Stage 3); breaks in skin exposing muscle orbone (Stage 4). [Code 0 if no ulcer, otherwise record the highest ulcerstage (Stage 1-4).] a.Pressure ulcer—any lesion caused by pressure, shear forces, resulting in damage of underlying tissues b.Stasis ulcer—open lesion caused by poor circulation in the lower extremities 3.OTHER SKIN PROBLEMS REQUIRING TREATMENT (Check all that apply) Burns (second or third degree) Open lesions other tha nulcers, rashes, cuts (e.g.,cancer) Skin tears or cuts Surgical wound Corns, calluses, structural prob-lems, infections, fungi NONE OF ABOVE a. b. c. d. e. f. 4.HISTORY OF RESOLVED PRESSURE ULCERS Client previously had (at any time) or has an ulcer anywhere on the body 0. No 1. Yes 5.WOUND/ULCER CARE (Check for formal care in LAST 7 DAYS) Antibiotics, systemic or topical Dressings Surgical wound care Other wound/ulcer care (e.g., pressure relieving device, nutrition, turning, debridement) NONE OF ABOVE a. b. c. d. e. SECTION O. ENVIRONMENTAL ASSESSMENT 1.HOME ENVIRONMENT [Check any of following that make home environment hazardous or uninhabitable (if none apply, check NONE OF ABOVE; if temporarily in institution, base assessment on home visit)] Lighting in evening (including inadequate or no lighting in living room, sleeping room, kitchen, toilet, corridors)Flooring and carpeting (e.g., holes in floor, electric wires where client walks, scatter rugs)Bathroom and toiletroom (e.g., non-operating toilet, leaking pipes, no rails though needed, slippery bathtub, outside toilet)Kitchen (e.g., dangerous stove, inoperative refrigerator, infestation by rats or bugs)Heating and cooling (e.g., too hot in summer, too cold in winter, woodstove in a home with an asthmatic)Personal safety (e.g., fear of violence, safety problem in going to mailbox or visiting neighbors, heavy traffic in street)Access to home (e.g., difficulty entering/leaving home)Access to rooms in house (e.g., unable to climb stairs) NONE OF ABOVE 2.LIVING ARRANGEMENT a.As compared to 90 DAYS AGO (or since last assessment), client now lives with other persons—e.g., moved in with another person, other moved in with client 0. No 1. Yes b. Client or primary caregiver feels that client would be better off in another living environment 0. No 1. Client only 2. Caregiver only 3. Client and caregiver SECTION P. SERVICE UTILIZATION (IN LAST 7 DAYS) FORMAL CARE(Minutes rounded to even 10 minutes) Extent of care or care management in LAST 7 DAYS (or since last assessment if less than 7 days) involving a. Home health aides b. Visiting nurses c. Homemaking services d. Meals e. Volunteer services f. Physical therapyg. Occupational therapy h. Speech therapy i.Day care or day hospital j.Social worker in home MDS-HC Version 2.0 — July 21, 1999MDS-HC - Pg 4 2. SPECIALTREATMENTS,THERAPIES,PROGRAMS Special treatments, therapies, and programs received or scheduled during theLAST 7 DAYS (or since last assessment if less than 7 days) and adherence tothe required schedule. Includes services received in the home or on anoutpatient basis. [Blank]. Not applicable 2. Scheduled, partial adherence 1. Scheduled, full adherence as prescribed 3. Scheduled, not received[If no treatments provided, check NONE OF ABOVE P2aa] RESPIRATORY TREATMENTS a.Oxygen b.Respirator for assistive breathing c.All other respiratory treatments OTHER TREATMENTS d.Alcohol/drug treatmentprogram e.Blood transfusion(s) f.Chemotherapy g.Dialysis h.IV infusion – central i.IV infusion – peripheral j.Medication by injection k.Ostomy carel.Radiation m.Tracheostomy care THERAPIES n.Exercise therapy o.Occupational therapy p.Physical therapy PROGRAMS q.Day center r.Day hospital s.Hospice care t.Physician or clinic visit u.Respite care SPECIAL PROCEDURES DONE IN HOME v.Daily nurse monitoring (e.g.,EKG, urinary output) w.Nurse monitoring less than daily x.Medical alert bracelet or electronic security alert y.Skin treatment z.Special diet aa.NONE OF ABOVE 3.MANAGEMENT OF EQUIPMENT(In Last 3Days) Management codes: 0.Not used 1.Managed on own 2.Managed on own if laid out or with verbal reminders 3.Partially performed by others 4.Fully performed by others a. Oxygen b.IV c. Catheter d.Ostomy 4. VISITS INLAST 90 DAYSOR SINCE LAST ASSESSMENT Enter 0 if none, if more than 9, code "9" a.Number of times ADMITTED TO HOSPITAL with an overnight stay b.Number of times VISITED EMERGENCY ROOM without an over night stay c.EMERGENT CARE—including unscheduled nursing, physician, or therapeutic visits to office or home 5. TREATMENT GOALS Any treatment goals that have been met in the LAST 90 DAYS (or since last assessment if less than 90 days) 0. No 1. Yes 6. OVERALL CHANGE IN CARE NEEDS Overall self sufficiency has changed significantly as compared tostatus of 90 DAYS AGO (or since last assessment if less than 90 days) 0. No change 1.Improved—receives 2.Deteriorated—fewer supports receives more support 7. TRADE OFFS Because of limited funds, during the last month, client made trade-offs among purchasing any of the following: prescribed medications, sufficient home heat, necessary physician care, adequate food, home care 0. No 1. Yes SECTION Q.MEDICATIONS 1. NUMBER OF MEDICATIONS Record the number of different medicines (prescriptions and over thecounter), including eye drops, taken regularly or on an occasional basisin the LAST 7 DAYS (or since last assessment)[If none, code "0", ifmore than 9, code "9"] 2.RECEIPT OF PSYCHO-TROPIC MEDICATION Psychotropic medications taken in the LAST 7 DAYS (or since last assesssment) [Note—Review client's medications with the list thatapplies to the following categories] 0. No 1. Yes a.Antipsychotic/neuroleptic b.Anxiolytic c.Antidepressant d.Hypnotic 3.MEDICAL OVERSIGHT Physician reviewed client's medications as a whole in LAST 180 DAYS(or since last assessment) 0. Discussed with at least one physician (or no medication taken) 1. No single physician reviewed all medications 4. COMPLIANCE/ADHERENCE WITH MEDICATIONS Compliant all or most of time with medications prescribed by physician(both during and between therapy visits) in LAST 7 DAYS 0.Always compliant 1.Compliant 80% of time or more 2.Compliant less than 80% of time, including failure to purchase prescribed medications 3.NO MEDICATIONS PRESCRIBED 5.LIST OF ALL MEDICATIONS List prescribed and nonprescribed medications taken in LAST 7 DAYS (or sincelast assessment) a. Name and Dose—Record the name of the medication and dose ordered. b. Form: Code the route of Administration using the following list: 1.By mouth (PO)5.Subcutaneous (SQ)9.Enteral tube2.Sub lingual (SL)6.Rectal (R)10.Other3.Intramuscular (IM)7.Topical4.Intravenous (IV)8.Inhalation c.Number taken—Record the amount of medication administered each time the medication is given d.Freq: Code the number of times per day, week, or month the medication isadministered using the following list: PRN.As necessary 5D.Five times daily QH.Every hour QOD.Every other day Q2H.Every two hours QW.Once each wk Q3H.Every three hours 2W.Two times every week Q4H.Every four hours 3W.Three times every week Q6H.Every six hours 4W.Four times each week Q8H.Every eight hours 5W.Five times each week QD.Once daily 6W.Six times each week BID.Two times daily 1M.Once every month (includes every 12 hrs) 2 M.Twice every month TID. Three times daily C.Continuous QID.Four times daily O.Other a. Name and Dose b. Form c. Number Taken d. Freq. a. b. c. d. e. f. g. h. i. j. k. SECTION R. ASSESSMENT INFORMATION 1. SIGNATURES OF PERSONS COMPLETING THE ASSESSMENT: a. Signature of Assessment Coordinator b. Title of Assessment Coordinator c. Date Assessment Coordinator signed as complete Month Day Year d. Other Signatures Title Sections Date e. Date f. Date g. Date h. Date i. Date Although reproduction of the blank forms included herein is not permitted, blank and completed forms may be photocopied for patient clinical assessment purposes related to the administration of the MassHealth program. All other uses are not permitted. = When box blank, must enter number or letter = When letter in box, check if condition applies MDS-HC Version 2.0 — July 21, 1999 Copyright interRAI, 1994,1996, 1997, 1999 Country specific MDS-HC Version 2.0 — July 21, 1999MDS-HC - Pg 5