1.9 The Components of the Minimum Data Set (MDS)

Minimum Data Set

The MDS is completed on all residents in Medicare or Medicaid certified facilities. A mandated assessment schedule is discussed in Chapter 2. In addition, states may establish additional MDS requirements. For specific information on State requirements, contact your State RAI Coordinator (see Appendix B).

Since the requirements for Medicare PPS went into effect, assessments may be referred to as either a “comprehensive” or “full” assessment. To clarify this terminology, the comprehensive assessment is a clinical assessment that requires the full MDS, RAPs and Utilization Guidelines. Comprehensive assessments include all required MDS items (including State-designated sections), RAPs, and documentation in accordance with the Utilization Guidelines. Comprehensive assessments are required within 14 days of the admission, annually, when there has been a significant change in clinical status, and when the facility does a Significant Correction of a Prior Full assessment.

When the term “full assessment” is used, it includes the MDS required items A through R (plus any State-required items). A full assessment is distinguished from a comprehensive assessment (RAI) in that the RAPs and care planning are not completed when the full assessment is completed for a Medicare assessment.

Of course, the facility's right to care plan is Facilities may expand upon these requirements, when appropriate, to fully assess and care plan for an individual.  

The required components of the MDS are as follows:

SECTION AA - The Basic Assessment Tracking Form

This form contains Identification Information Items 1-9, which consists of identifying information needed to uniquely identify each resident, the nursing facility in which he or she resides, the reason(s) for assessment; and Items AA9 a-l, Signatures of Persons Completing a Portion of the MDS or Tracking form. The information contained on this form must accompany each comprehensive, full, MPAF, or Quarterly assessment, as well as every Distcharge and Reentry Tracking form, submitted electronically to the State MDS database. This includes Federally required assessment records, (e.g., Admission, Annual, Significant Change in Status, and Quarterly assessments), as well as assessments required for Medicare or by the State. This section also contains the Attestation Statement that staff members must sign and date attesting to the accuracy of the portions of the MDS completed by each member of the interdisciplinary team.

SECTIONS AB, AC, AD - Background (Face Sheet) Information at Admission Form

This form contains Sections AB (Demographic Information), Section AC (Customary Routine), and Section AD (Face Sheet Signatures). This information is to be completed at the time of the resident's initial admission to the nursing facility. A new Face Sheet is also required to be completed, along with an Admission assessment, for an individual who returns to the facility after a discharge in which return was not anticipated. CMS's clinical policies, as well as data specifications, allow Face Sheet information to be updated and submitted after the Admission assessment is completed and transmitted. This means that Face Sheet information can be transmitted with any of the Federally required records (those indicated by the codes under AA8a) or the assessments required for Medicare (those indicated by the codes under AA8b). The only instance in which Face Sheet information cannot be updated is from those assessments required by the State (AA8a = “0” and AA8b = “6”).

SECTIONS A-Q - Clinical Assessment

Sections A-Q contain the clinical data items used to assess residents in the nursing facility. Section A9 is where staff sign that they have completed portions of the assessment and agree to the Attestation Statement.

SECTION R – Signature and Completion Date

Section R contains the signature of the RN coordinating the assessment. This is the section that records participation of the resident, family and/or significant other in the assessment process.

SECTION S - State Section

Some states have added items to the core MDS that must be completed for each resident when a comprehensive assessment, full, MPAF, or Quarterly is required. Thus, while the basic MDS form is the standard foundation for states, you may find that other items have been added at the end of the form (in Section S) in your state. Contact your State RAI Coordinator for State-specific requirements. A list of State RAI Coordinators is found in the Appendix B.

to the facility after a discharge in which return was not anticipated. CMS's clinical policies, as well as data specifications, allow Face Sheet information to be updated and submitted after the Admission assessment is completed and transmitted. This means that Face Sheet information can be transmitted with any of the Federally required records (those indicated by the codes under AA8a) or the assessments required for Medicare (those indicated by the codes under AA8b). The only instance in which Face Sheet information cannot be updated is from those assessments required by the State (AA8a = “0” and AA8b = “6”).

SECTIONS A-Q - Clinical Assessment

Sections A-Q contain the clinical data items used to assess residents in the nursing facility. Section A9 is where staff sign that they have completed portions of the assessment and agree to the Attestation Statement.

SECTION R – Signature and Completion Date

Section R contains the signature of the RN coordinating the assessment. This is the section that records participation of the resident, family and/or significant other in the assessment process.

SECTION S - State Section

Some states have added items to the core MDS that must be completed for each resident when a comprehensive assessment, full, MPAF, or Quarterly is required. Thus, while the basic MDS form is the standard foundation for states, you may find that other items have been added at the end of the form (in Section S) in your state. Contact your State RAI Coordinator for State-specific requirements. A list of State RAI Coordinators is found in the Appendix B.

to the facility after a discharge in which return was not anticipated. CMS's clinical policies, as well as data specifications, allow Face Sheet information to be updated and submitted after the Admission assessment is completed and transmitted. This means that Face Sheet information can be transmitted with any of the Federally required records (those indicated by the codes under AA8a) or the assessments required for Medicare (those indicated by the codes under AA8b). The only instance in which Face Sheet information cannot be updated is from those assessments required by the State (AA8a = “0” and AA8b = “6”).

SECTIONS A-Q - Clinical Assessment

Sections A-Q contain the clinical data items used to assess residents in the nursing facility. Section A9 is where staff sign that they have completed portions of the assessment and agree to the Attestation Statement.

SECTION R – Signature and Completion Date

Section R contains the signature of the RN coordinating the assessment. This is the section that records participation of the resident, family and/or significant other in the assessment process.

SECTION S - State Section

Some states have added items to the core MDS that must be completed for each resident when a comprehensive assessment, full, MPAF, or Quarterly is required. Thus, while the basic MDS form is the standard foundation for states, you may find that other items have been added at the end of the form (in Section S) in your state. Contact your State RAI Coordinator for State-specific requirements. A list of State RAI Coordinators is found in the Appendix B.

SECTION V - Resident Assessment Protocol Summary

Section V contains the form used to document triggered RAPs, the location of documentation describing the resident's clinical status and factors that impact the care planning decision, and whether or not a care plan has been developed for each RAP area. Note that the RAP need not have triggered for a care plan to be developed for that particular area. A RAP Summary form must be completed each time a comprehensive RAI is required under the Federal schedule. If a care plan is written from a non-triggered RAP, it should be noted on the RAP Summary form.

Quarterly Assessments

Additionally, states must specify a Quarterly assessment form, for use by facilities that includes at least the items on the CMS-designated form. The Quarterly assessment contains the mandated subset of MDS items from Section A (Identification and Background Information) through Section R (Assessment Information) that serves as the minimum requirement for Quarterly assessments within each State's RAI. Some states have mandated an expanded Optional Quarterly assessment form. CMS has published two optional versions that states may require. A state may also require a full assessment on a quarterly basis. Again, contact your State RAI Coordinator for State specifics. States have the following options for the Quarterly Assessment:

Copies of the Quarterly assessment options available to the states are included at the end of this Chapter.

Discharge and Reentry Tracking Forms

Facilities are required to submit the information contained in two additional forms to notify the State if a resident is “discharged” or “reenters” the MDS system. Both the Discharge Tracking form and the Reentry Tracking form contain Section AA (Identification Information) Items 1-7, a subset of codes from Item 8 (Reason for Assessment), and Item 9. The Discharge Tracking form also contains items from Section R related to discharge status and date, along with two items from Section AB, that are required only for individuals whose stay is less than 14 days. The Reentry Tracking form contains items from Section A related to the date and point of reentry. States may opt to require Section S information to accompany Discharge and Reentry Tracking forms. A detailed discussion of the Discharge and Reentry Tracking process is in Chapter 2.

Medicare Assessments

Nursing facilities perform a comprehensive MDS assessment when the Medicare assessment is combined with any assessment required for clinical and/or care planning purposes, i.e., all OBRA assessments except the Quarterly. In 2002, a customized version of the MDS form was developed to minimize the facility's data collection requirements. This customized Medicare Prospective Payment System Assessment Form (MPAF) may be used when the assessment is performed solely for payment purposes (see Chapter 2 for details).

Resident Assessment Protocols (RAPs)

The triggers are specific resident responses for one or a combination of MDS elements. The triggers identify residents who either have or are at risk for developing specific functional problems and require further evaluation using Resident Assessment Protocols (RAPs) designated within the
State specified RAI. MDS item responses that define triggers are specified in each RAP and on the trigger legend form. Not all items assessed on the MDS are automatic triggers, e.g., use of side rails at P4. However, the RAP may be used to evaluate those items that are not automatic triggers. Turn to the RAPs (in Appendix C) to review these items and the accompanying RAP Guidelines. Once you are familiar with the RAP triggers and guidelines, the trigger legend form serves as a useful summary of all RAP triggers. The trigger legend summarizes which MDS item responses trigger individual RAPs and has been designed as a helpful tool for facilities if they choose to use it. It is a worksheet, not a required form, and does not need to be maintained in each resident's clinical record.

The RAPs provide structured, problem-oriented frameworks for organizing MDS information, and additional clinically relevant information about an individual's health problems or functional status. What are the problems that require immediate attention? What risk factors are important? Are there issues that might cause you to proceed in an Clinical staffs are responsible for answering questions such as these. The information from the MDS and RAPs forms the basis for individualized care planning. The RAPs Summary form documents the decisions made during this evaluation process whether or not to proceed to care planning.

Utilization Guidelines

The Utilization Guidelines are instructions concerning when and how to use the RAI. Once a RAP has been triggered, use the utilization guidelines to evaluate the problem and determine whether or not you continue to care plan for it. The Utilization Guidelines for Version 2.0 of the RAI were published by CMS in the State Operations Manual* Transmittal #272, and are discussed in detail in Chapter 4.

The individual resident's care plan must be evaluated and revised, if appropriate, each time a comprehensive or Quarterly assessment is completed. Facilities may either make changes to the original care plan or develop a new care plan.

Additional information relevant to a resident’s status, but not necessarily included on the RAI, may be documented in the resident’s active record. This documentation should include progress notes or facility specific flow sheets.