• Discipline Completing*
  • M0090 Date Assessment Completed*
     - -
    2 digit month, 2 digit day, 4 digit year
  • M0906 Date of the discharge, transfer, or death (at home) of the patient.*
     - -
    2 digit month, 2 digit day, 4 digit year
  • M2420. Discharge Disposition Where is the patient after discharge from your agency?*
  • M2301. Emergent Care At any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?*
  • M2310. Reason for Emergent Care
  • M2420. Discharge Disposition Where is the patient after discharge from your agency?*
  • M2410. To which Inpatient Facility has the patient been admitted?*
  • A2121. At the time of discharge to another provider, did your agency provide the patient's current reconciled medication list to the subsequent provider, family, and/or caregiver?
  • A2122. Route of Current Reconciled Medication List Transmission to Subsequent ProviderIndicate the route(s) of transmission of the current reconciled medication list to the subsequent provider
  • A2123 At the time of discharge, did your agency provide the patient's current reconciled medication list to the patient, family, and/or caregiver?
  • B1300. Health Literacy (From Creative Commons How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?*
  • A2124. Route of Current Reconciled Medication List Transmission to Subsequent Provider.Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider
  • Blood Pressure (1 ) Postion*
  • Blood Pressure (1) Arm*
  • Blood Pressure (1) Activity Level*
  • Blood Pressure (1) Time Taken *
  • Blood Pressure (2) Arm*
  • Blood Pressure (2) Position*
  • Blood Pressure (2) Activity Level*
  • Blood Pressure (2) Time Taken : *
  • Pulse 1 Time Taken *
  • Pulse 1 Location*
  • Pulse 1 Rhythm*
  • Pulse 1 Activity Level*
  • Pulse 2 Time Taken*
  • Pulse 2 Location*
  • Pulse 2 Rhythm*
  • Pulse 2 Activity Level*
  • Respiration Rate Time Taken*
  • Oxygen Use*
  • C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted? Attempt to conduct interview with all patients.*

  • Brief Interview for Mental Status (BIMS)

  • C0200. Repetition of Three Words Ask patient: "I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue, and bed. Now tell me the three words. "Number of words repeated after first attempt:
  • C0300. Temporal Orientation (Year) Ask patient "Please tell me what year it is right now.
  • C0300. Temporal Orientation (Month) Ask patient: "What month are we in right now?"
  • C0300. Temporal Orientation (Day) Ask patient: "What day of the week is today?"
  • C0400 Recall Ask patient " Let's go back to earlier question. What were those three words that I asked you to repeat?" If unable to remember a work , give a cue(something to wear, a color , a pierce of furniture for the word. A. Able to recall "sock"
  • B . Able to recall "Blue"
  • B . Able to recall "Bed"
  • C1310 Signs and Symptoms of Delirium A. Acute onset of mental status change
  • B. Inattention – Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping trackof what was being said?
  • C. Disorganized thinking – Was the patient’s thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?
  • D. Altered level of consciousness — Did the patient have altered level of consciousness, as indicated by any of the following criteria?• vigilant — startled easily to any sound or touch• lethargic — repeatedly dozed off when being asked questions
  • M1700. Cognitive Functioning Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.
  • M1710 . When Confused (Reported or Observed Within the Last 14 Days)
  • M1720 When Anxious (Reported or Observed Within the Last 14 Days):

  • D0150. Patient Mood Interview (PHQ-2 to 9)

  • A. Little interest or pleasure in doing things Symptoms Presence:*
  • Symptoms Frequency
  • B. Feeling down, depressed, or hopeless*
  • Symptoms Frequency
  • C. Trouble falling or staying asleep, or sleeping too much*
  • Symptoms Frequency
  • D. Feeling tired or having little energy*
  • Symptoms Frequency
  • E. Poor appetite or overeating*
  • Symptoms Frequency
  • F. Feeling bad about yourself - or that you are a failure or have let yourself or your family down*
  • Symptoms Frequency
  • G. Trouble concentrating on things, such as reading the newspaper or watching television*
  • Symptoms Frequency
  • H. Moving or speaking so slowly that the other people could have noticed. Or the opposite - - being so fidgety or restless that you have been moving around a lot more than usual*
  • Symptoms Frequency
  • I. Thoughts that you would be better off dead, or of hurting yourself in some way*
  • Symptoms Frequency

  • D0700. Social Isolation

  • How often do you feel lonely or isolated from those around you?*

  • Section E | Behavior

  • M1740. Cognitive, Behavioral, and Psychiatric Symptoms that are demonstrated at least once a week (Reported or Observed): Check all that apply*
  • M1745. Frequency of Disruptive Behavior Symptoms (Reported or Observed):Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.*
  • M2102. Types and Sources of Assistance
    Determine the ability and willingness of non-agency caregivers (such as family members, friends, or privately paid caregivers) to provide assistance for the following activities, if assistance is needed. Excludes all care by your agency staff.
  • a. ADL assistance (for example, transfer/ambulation, bathing, dressing, toileting, eating/feeding)*
  • c. Medication administration (for example, oral, inhaled, or injectable)*
  • d. Medical procedures/treatments (for example, changing wound dressing, home exercise program)*
  • f. Supervision and safety (due to cognitive impairment)*

  • Section G | Functional Status

  • M1800. Grooming Current ability to tend safely to personal hygiene needs*
  • M1810. Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps.*
  • M1820. Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, socks, nylons, shoes:*
  • M1830. Bathing Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair)*
  • M1840. Toilet Transferring Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.*
  • M1845. Toileting Hygiene Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, includes cleaning area around stoma, but not managing equipment.*
  • M1850. Transferring Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.*
  • M1860. Ambulation/Locomotion Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.*

  • GG0130. Self-Care

  • Code the patient's usual performance at Discharge for each activity using the 6-point scale. If activity was not attempted at Discharge, code the reason.

    Coding:
    Safety and Quality of Performance – If helper assistance is required because patient's performance is unsafe or of poor quality, score according to amount of assistance provided.
    Activities may be completed with or without assistive devices.
        06. Independent – Patient completes the activity by themself with no assistance from a helper.
        05. Setup or clean-up assistance – Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.
        04. Supervision or touching assistance – Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.
        03. Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.
        02. Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
        01. Dependent – Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.
    If activity was not attempted, code reason:
        07. Patient refused
        09. Not applicable – Not attempted and the patient did not perform this activity prior to the current illness, exacerbation or injury.
        10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
        88. Not attempted due to medical conditions or safety concerns
  • A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the patient.*
  • B. Oral Hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from mouth, and manage denture soaking and rinsing with use of equipment.*
  • C. Toileting Hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment.*
  • E. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower.*
  • F. Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable*
  • G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear.*
  • H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable.*
  • GG0170. Mobility
    Code the patient's usual performance at Discharge for each activity using the 6-point scale. If activity was not attempted at Discharge, code the reason.

    Coding:
    Safety and Quality of Performance – If helper assistance is required because patient's performance is unsafe or of poor quality, score according to amount of assistance provided.
    Activities may be completed with or without assistive devices.
    • 06. Independent – Patient completes the activity by himself with no assistance from a helper.
    • 05. Setup or clean-up assistance – Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.
    • 04. Supervision or touching assistance – Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.
    • 03. Partial/moderate assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.
    • 02. Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.
    • 01. Dependent – Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.
    If activity was not attempted, code reason:
    • 07. Patient refused
    • 09. Not applicable – Not attempted and the patient did not perform this activity prior to the current illness, exacerbation or injury.
    • 10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
    • 88. Not attempted due to medical conditions or safety concerns
  • A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed.*
  • B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.*
  • C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with no back support.*
  • D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.*
  • E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).*
  • F. Toilet transfer: The ability to get on and off a toilet or commode.*
  • G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt.*
  • I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. If Discharge performance is coded 07, 09, 10 or 88 -> Skip to GG0170M, 1 step (curb)*
  • J. Walk 50 feet with two turns: Once standing, the ability to walk 50 feet and make two turns.
  • K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.
  • L. Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel.
  • M. 1 step (curb): The ability to go up and down a curb or up and down one step. If Discharge performance is coded 07, 09, 10 or 88 -> Skip to GG0170P, Picking up object.*
  • N. 4 steps: The ability to go up and down four steps with or without a rail. If Discharge performance is coded 07, 09, 10 or 88 -> Skip to GG0170P, Picking up object.*
  • O. 12 steps: The ability to go up and down 12 steps with or without a rail.
  • P. Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor.*
  • Q. Does patient use wheelchair and/or scooter?*
  • R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns.
  • RR1. Indicate the type of wheelchair or scooter used
  • S. Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.
  • SS3. Indicate the type of wheelchair or scooter used
  • M1600. Has this patient been treated for a Urinary Tract Infection in the past 14 days?*
  • M1620. Bowel Incontinence Frequency*
  • J0510. Pain Effect on Sleep Ask patient: "Over the past 5 days, how much of the time has pain made it hard for you to sleep at night?*
  • J0520. Pain Interference with Therapy Activities Ask patient: "Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain?"*
  • J0530. Pain Interference with Day-to-Day Activities Ask patient: "Over the past 5 days, how often you have limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain?"*
  • J1800. Any Falls Since SOC/ROC, whichever is more recent*
  • J1900. Number of Falls Since SOC/ROC, whichever is more recent A. No injury
  • J1900. Number of Falls Since SOC/ROC, whichever is more recent B. Injury
  • J1900. Number of Falls Since SOC/ROC, whichever is more recent C. Major injury
  • M1400. When is the patient dyspneic or noticeably Short of Breath?*
  • Discharge Check all of the nutritional approaches that were received*
    Rows
  • M1870. Feeding or Eating Current ability to feed self meals and snacks safely.*
  • M1306. Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable?*
  • M1330. Does this patient have a Stasis Ulcer?*
  • M1340. Does this patient have a Surgical Wound?*

  • N0415. High-Risk Drug Classes: Use and Indication

    1. Is taking 2. Indication noted Column 1 is checked, check if there is an indication noted for all medications in the drug class
  • M2005. Medication Intervention Did the agency contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the SOC/ROC?
  • M2020. Management of Oral Medications Patient's current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. Excludes injectable and IV medications*
  • O0110. Special Treatments, Procedures, and ProgramsCheck all of the following treatments, procedures, and programs that apply on discharge.*

  • Section Q | Participation in Assessment and Goal Setting

  • M2401. Intervention Synopsis At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented? (Mark only one box in each row.)*
    Rows
  •  
  • Should be Empty: