-3808
| Property | Specification |
| Data System | MDS |
| Data Specs | V1.11.0 |
| Edit Type | Format |
| Severity | Warning |
| Edit Text | When this Section S item is required by a State, it should equal one of the valid values indicated in the data specifications for that item. Note that for numeric items, signed numbers (with a leading plus or minus sign) should not be submitted. |
| Version Notes |
| Item List | |
| Item ID | Description |
| S0101 | Admitted from Community |
| S0102 | Admitted from NH or SB |
| S0111 | Lived Alone |
| S0115 | Spouse Location |
| S0120 | Prior Residence ZIP Code |
| S0122 | Prior Residence State |
| S0123 | Prior Residence County |
| S0125 | Prior Residence Town Code |
| S0130 | Highest Education Completed |
| S0140 | Physician License Number |
| S0141 | Physician Name |
| S0150 | State Resident ID |
| S0160 | Specialty unit |
| S0170A | Advanced directive: Guardian |
| S0170B | Advanced directive: DPOA-HC |
| S0170C | Advanced directive: Living will |
| S0170D | Advanced directive: Do not resuscitate |
| S0170E | Advanced directive: Do not hospitalize |
| S0170F | Advanced directive: Do not intubate |
| S0170G | Advanced directive: Feeding restrictions |
| S0170H | Advanced directive: Other treatment restrictions |
| S0170Z | Advanced directive: None of the above |
| S0171A | Resident healthcare proxy exists |
| S0171B | Resident healthcare proxy invoked |
| S0172A | Goal discussion: documentation received |
| S0172B | Goal discussion: hospital |
| S0172C | Goal discussion: previous NH |
| S0172D | Goal discussion: Home without home health services |
| S0172E | Goal discussion: Home with home health services |
| S0172F | Goal discussion: PCP office |
| S0172G | Goal discussion: Other |
| S0172H | Goal discussion: Not occur reason |
| S0173 | Documentation of goals of care discussion |
| S0180 | Discharged to Community |
| S0183 | Discharged prior to admission assessment |
| S0500 | Level of Care |
| S0501 | CCNH RHNS Level of Care |
| S0510 | PASRR Screening Complete |
| S0511 | PASRR Date |
| S0512 | PASRR Level 1 |
| S0520 | Reason for Admission |
| S1000 | Local Health Department Reporting |
| S1001 | State Health Department Reporting |
| S1100A | Disease: Clostridium Difficile |
| S1100B | Disease: MRSA |
| S1100C | Disease: VRE |
| S1100D | Disease: VISA |
| S1100E | Disease: VRSA |
| S1100F | Disease: Other MDRO |
| S1100F1 | Disease: MDRO Name1 |
| S1100F2 | Disease: MDRO Name2 |
| S1100G | Disease: Tuberculosis |
| S1100H | Disease: Herpes Zoster |
| S1100I | Disease: Scabies |
| S1100Z | Disease: None of the Above |
| S1200A | Mental Health: Schizophrenia |
| S1200B | Mental Health: Delusional Disorder |
| S1200C | Mental Health: Schizoaffective Disorder |
| S1200D | Mental Health: Other Psychotic Disorder |
| S1200E | Mental Health: Bipolar I Mixed, Manic, & Depressed |
| S1200F | Mental Health: Bipolar Disorder II |
| S1200G | Mental Health: Cyclothymic Disorder |
| S1200H | Mental Health: Other Bipolar Disorder |
| S1200I | Mental Health: Major Depression, Recurrent |
| S1200Z | Mental Health: None of the above |
| S2000 | Capable of self-administration of medications |
| S2001 | Wishes to self-medicate |
| S2010 | Refused meds 3 days |
| S2011 | Staff support for meds 3 days |
| S2015 | Refused meds occasionally 30 days |
| S2016 | Refused meds frequently 30 days |
| S2040 | Behavior Management Program |
| S2050 | Resists grooming/hygiene |
| S3100A | Contractures: Hand |
| S3100B | Contractures: Wrist |
| S3100C | Contractures: Elbow |
| S3100D | Contractures: Shoulder |
| S3100E | Contractures: Neck |
| S3100F | Contractures: Ankle |
| S3100G | Contractures: Knee |
| S3100H | Contractures: Hip |
| S3100Z | Contractures: Other |
| S3200A | Dominant Side |
| S3200B | Use of dominant hand/arm |
| S4000A | Harm: Self Injury/Self-injurious attempt |
| S4000B | Harm: Attempt was to kill self |
| S4000C | Harm: Considered injuring self |
| S4000D | Harm: Self-injury caregiver concern |
| S4010A | Hourly Interval Observation |
| S4010B | 15- Min. Interval Observation |
| S4010C | 5- Min. Interval Observation |
| S4010D | Constant Observation for < 1 hr |
| S4010E | Constant Observation for > 1 hr |
| S4500 | Substance Abuse: Alcoholic Drinks |
| S4510A | Substance Abuse: Inhalants |
| S4510B | Substance Abuse: Hallucinogens |
| S4510C | Substance Abuse: Cocaine and Crack |
| S4510D | Substance Abuse: Stimulants |
| S4510E | Substance Abuse: Opiates |
| S4510F | Substance Abuse: Cannabis |
| S5000 | Number of New Pressure Ulcers |
| S5005 | New Pressure Ulcer setting |
| S5010A1 | Pressure ulcer 1 location |
| S5010A2 | Pressure ulcer 1 status |
| S5010B1 | Pressure ulcer 2 location |
| S5010B2 | Pressure ulcer 2 status |
| S5010C1 | Pressure ulcer 3 location |
| S5010C2 | Pressure ulcer 3 status |
| S5010D1 | Pressure ulcer 4 location |
| S5010D2 | Pressure ulcer 4 status |
| S5010E1 | Pressure ulcer 5 location |
| S5010E2 | Pressure ulcer 5 status |
| S5010F1 | Pressure ulcer 6 location |
| S5010F2 | Pressure ulcer 6 status |
| S5010G1 | Pressure ulcer 7 location |
| S5010G2 | Pressure ulcer 7 status |
| S5010H1 | Pressure ulcer 8 location |
| S5010H2 | Pressure ulcer 8 status |
| S5010I1 | Pressure ulcer 9 location |
| S5010I2 | Pressure ulcer 9 status |
| S6000 | Parenteral/IV feeding in NH |
| S6005 | IV meds in NH |
| S6010 | Oxygen Therapy in NH |
| S6050 | Isolation precautions needed |
| S6051A | Isolation Precaution: Airborne |
| S6051B | Isolation Precaution: Contact |
| S6051C | Isolation Precaution: Droplet |
| S6051D | Isolation Precaution: Protective |
| S6100A | Vaccination: Varicella |
| S6100B | Vaccination: Tetanus, diphtheria (Td) |
| S6100C | Vaccination: Tetanus, diphtheria, pertussis (Tdap) |
| S6100D | Vaccination: Measles, Mumps, Rubella (MMR) |
| S6100E | Vaccination: Other |
| S6100F1 | Vaccination: Other Name 1 |
| S6100F2 | Vaccination: Other Name 2 |
| S6100F3 | Vaccination: Other Name 3 |
| S6100Z | Vaccination: None of the above |
| S6200 | Number of Hospital Stays |
| S6210 | Number of ER visits |
| S6220 | Alzheimer"s/Dementia Special Care Unit |
| S8000A1 | Medicare - Primary Payor |
| S8000A2 | Medicare - Secondary Payor |
| S8000A3 | Medicare Payor |
| S8000B1 | Medicare Part A - Primary Payor |
| S8000B2 | Medicare Part A - Secondary Payor |
| S8000B3 | Medicare Part A Payor |
| S8000C1 | Medicare Part B - Primary Payor |
| S8000C2 | Medicare Part B - Secondary Payor |
| S8000C3 | Medicare Part B Payor |
| S8000D1 | Medicare Part C - Primary Payor |
| S8000D2 | Medicare Part C - Secondary Payor |
| S8000D3 | Medicare Part C Payor |
| S8000E1 | Medicare per diem - Primary Payor |
| S8000E2 | Medicare per diem - Secondary Payor |
| S8000E3 | Medicare per diem Payor |
| S8000Z | Medicare not a payment source |
| S8010A1 | In-state Medicaid - Primary Payor |
| S8010A2 | In-state Medicaid - Secondary Payor |
| S8010A3 | In-state Medicaid payor |
| S8010B1 | Out-of-state Medicaid - Primary Payor |
| S8010B2 | Out-of-state Medicaid - Secondary Payor |
| S8010B3 | Out-of-state Medicaid Payor |
| S8010C1 | Medicaid per diem - Primary Payor |
| S8010C2 | Medicaid per diem - Secondary Payor |
| S8010C3 | Medicaid per diem Payor |
| S8010D1 | Medicaid managed care per diem - Primary Payor |
| S8010D2 | Medicaid managed care per diem - Secondary Payor |
| S8010D3 | Medicaid managed care per diem Payor |
| S8010E1 | Medicaid per diem (not MC) - Primary Payor |
| S8010E2 | Medicaid per diem (not MC) - Secondary Payor |
| S8010E3 | Medicaid per diem (not MC) Payor |
| S8010F | Medicaid per diem type |
| S8010F1 | Medicaid Resident Liability - Primary Payor |
| S8010F2 | Medicaid Resident Liability - Secondary Payor |
| S8010F3 | Medicaid Resident Liability Payor |
| S8010G | Medicaid state source |
| S8010G1 | Medicare Co-Pay - Primary Payor |
| S8010G2 | Medicare Co-pay - Secondary Payor |
| S8010G3 | Medicare Co-pay Payor |
| S8010H1 | Picture Date reporting |
| S8010H2 | Medicaid Other - Secondary Payor |
| S8010H3 | Medicaid Other Payor |
| S8010I1 | Medicaid Pending - Primary Payor |
| S8010I2 | Medicaid Pending - Secondary Payor |
| S8010I3 | Medicaid Pending Payor |
| S8010Z | Medicaid not a payment source |
| S8020A1 | Private - Primary Payor |
| S8020A2 | Private - Secondary Payor |
| S8020A3 | Private Payor |
| S8020B1 | Private per diem - Primary Payor |
| S8020B2 | Private per diem - Secondary Payor |
| S8020B3 | Private per diem Payor |
| S8020C1 | Private LTC insurance policy - Primary Payor |
| S8020C2 | Private LTC insurance policy - Secondary Payor |
| S8020C3 | Private LTC insurance policy |
| S8020Z | Private insurance not a payment source |
| S8030A1 | Self-pay - Primary Payor |
| S8030A2 | Self-pay - Secondary Payor |
| S8030A3 | Self-pay Payor |
| S8030B1 | Family pay - Primary Payor |
| S8030B2 | Family pay - Secondary Payor |
| S8030B3 | Family pay Payor |
| S8030C | Self or Family pay for full per diem |
| S8030Z | Self or Family not a payment source |
| S8040A1 | State Run Medical Assistance - Primary Payor |
| S8040A2 | State Run Medical Assistance - Secondary Payor |
| S8040A3 | State Run Medical Assistance Payor |
| S8040B1 | Tricare per diem - Primary Payor |
| S8040B2 | Tricare per diem - Secondary Payor |
| S8040B3 | Tricare per diem Payor |
| S8040C1 | VA per diem - Primary Payor |
| S8040C2 | VA per diem - Secondary Payor |
| S8040C3 | VA per diem Payor |
| S8040D1 | Other Public - Primary Payor |
| S8040D2 | Other Public - Secondary Payor |
| S8040D3 | Other Public Payor |
| S8040Z | Other government not a payment source |
| S8050A1 | Other - Primary Payor |
| S8050A2 | Other - Secondary Payor |
| S8050A3 | Other Payor |
| S8050B | Other Payor Name 1 |
| S8050C | Other Payor Name 2 |
| S8050D | Other Payor Name 3 |
| S8055 | Primary payor |
| S8099 | Payor: None of the Above |
| S8500 | Medicaid begin date |
| S8510A | Medicaid Therapeutic bed-hold days since last asmt |
| S8510B | Medicaid Therapeutic bed-hold days - YTD |
| S8512A | Medicaid hospital bed-hold days since last asmt |
| S8512B | Medicaid hospital bed-hold days - YTD |
| S8520A | Medicaid Leave Days Type 1 |
| S8520B | Leave Days for Medicaid begin date 1 |
| S8520C | Leave Days for Medicaid end date 1 |
| S8521A | Medicaid Leave Days Type 2 |
| S8521B | Leave Days for Medicaid begin date 2 |
| S8521C | Leave Days for Medicaid end date 2 |
| S9000 | IL Skills Training |
| S9001 | IL IDPH Subpart S criteria |
| S9002A | IL IDPH Subpart S: Schizophrenia |
| S9002B | IL IDPH Subpart S: Delusional disorder |
| S9002C | IL IDPH Subpart S: Schizoaffective disorder |
| S9002D | IL IDPH Subpart S:Psychotic disorder not specified |
| S9002E | IL IDPH Subpart S: Bipolar I mixed, manic, & depr |
| S9002F | IL IDPH Subpart S: Bipolar disorder II |
| S9002G | IL IDPH Subpart S: Cyclothymic disorder |
| S9002H | IL IDPH Subpart S: Bipolar disorder not specified |
| S9002I | IL IDPH Subpart S: Major depression, recurrent |
| S9003 | IL IDPH Subpart S: Ancillary |
| S9020 | FL FRAES number |
| S9040A | CA POLST |
| S9040B | CA POLST Section A |
| S9040C | CA POLST Section B |
| S9040D | CA POLST Section C |
| S9040E | CA POLST D physician signature |
| S9040F | CA POLST D resident signature |
| S9040G | CA POLST D discussed with patient or decisionmaker |
| S9040H | CA POLST advanced directive |
| S9060 | NY Medicaid add-on eligibility |
| S9080A | PA MA CASE-MIX |
| S9080B | PA MA CASE-MIX Date |
| S9080C | PA MA CASE-MIX Access Card Number |
| S9080D | PA MA CASE-MIX MA NF Effective Date |
| S9080E | PA MA CASE-MIX Day One MA |
| S9100A | VA Room & Board Payment Assessment Reference Date |
| S9100B | VA Room & Board Payment Entry Date |
| S9100C | VA Medicaid Room & Board initial date |
| S9120 | CT Approved LTC |
NOTICE: These materials are in the public domain and cannot be copyrighted.
Generated: 06/04/2012 01:35:21 PM