**APPENDIX D: OUTCOME AND ASSESSMENT INFORMATION SET**

Outcome and Assessment Information Set OASIS-B1 (August 2000)

**START OF CARE VERSION**

(also used for Resumption of Care Following Inpatient Stay)

  -----------------------------------------------------------------------
  **[Items to be Used at this Time Point]{.underline}** M0010-M0825

  -----------------------------------------------------------------------

CLINICAL RECORD ITEMS

**(M0010) Agency Medicare Provider Number:** \_\_ \_\_ \_\_ \_\_ \_\_
\_\_

**(M0012) Agency Medicaid Provider Number:** \_\_ \_\_ \_\_ \_\_ \_\_
\_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_

+-----------------------------------------------------------------------+
| **[Branch Identification]{.underline} (Optional, for Agency Use)**    |
|                                                                       |
| **(M0014) Branch State:** \_\_ \_\_                                   |
|                                                                       |
| **(M0016) Branch ID Number:** \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ |
| \_\_ \_\_                                                             |
|                                                                       |
| (Agency-assigned)                                                     |
+-----------------------------------------------------------------------+

**(M0020) Patient ID Number:** \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_
\_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_

**(M0030) Start of Care Date:** \_\_ \_\_ /\_\_ \_\_ /\_\_ \_\_ \_\_
\_\_

month day year

**(M0032) Resumption of Care Date:** \_\_ \_\_ /\_\_ \_\_ /\_\_ \_\_
\_\_ \_\_  **NA -- Not Applicable**

month day year

**(M0040) Patient Name:**

\_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_
\_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_
\_\_ \_\_ \_\_ \_\_ \_\_ \_\_

(First) (MI) (Last) (Suffix)

**(M0050) Patient State of Residence:** \_\_ \_\_

**(M0060) Patient Zip Code: \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_
\_\_**

**(M0063) Medicare Number: \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_
\_\_ \_\_ \_\_  NA -- No Medicare**

(including suffix)

**(M0064) Social Security Number:** \_\_ \_\_ \_\_ - \_\_ \_\_ - \_\_
\_\_ \_\_ \_\_  **UK -- Unknown or Not Available**

**(M0065) Medicaid Number: \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_
\_\_ \_\_ \_\_ \_\_ \_\_  NA -- No Medicaid**

**(M0066) Birth Date: \_\_ \_\_ /\_\_ \_\_ /\_\_ \_\_ \_\_ \_\_**

month day year

**(M0069) Gender:**

 1 - Male

 2 - Female

**(M0072) Primary Referring Physician ID:**

\_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_ \_\_  **UK -- Unknown or
Not Available**

**(M0080) Discipline of Person Completing Assessment:**

 1-RN  2-PT  3-SLP/ST  4-OT

**(M0090) Date Assessment Completed: \_\_ \_\_ /\_\_ \_\_ /\_\_ \_\_
\_\_ \_\_**

month day year

(M0100) This Assessment is Currently Being Completed for the Following
Reason:

+-----------------------------------------------------------------------+
| > **[Start/Resumption of Care]{.underline}**                          |
|                                                                       |
| ** 1 -- Start of care---further visits planned**                     |
|                                                                       |
| ** 2 -- Start of care---no further visits planned**                  |
|                                                                       |
| ** 3 -- Resumption of care (after inpatient stay)**                  |
+-----------------------------------------------------------------------+
| > [Follow-Up]{.underline}                                             |
|                                                                       |
|  4 -- Recertification (follow-up) reassessment \[ Go to *M0150* \]   |
|                                                                       |
|  5 -- Other follow-up \[ Go to *M0150* \]                            |
+-----------------------------------------------------------------------+
| > [Transfer to an Inpatient Facility]{.underline}                     |
|                                                                       |
|  6 -- Transferred to an inpatient facility---patient not discharged  |
| from agency \[ Go to *M0150* \]                                       |
|                                                                       |
|  7 -- Transferred to an inpatient facility---patient discharged from |
| agency \[ Go to *M0150* \]                                            |
|                                                                       |
| > [Discharge from Agency --- Not to an Inpatient                      |
| > Facility]{.underline}                                               |
|                                                                       |
|  8 -- Death at home \[ Go to *M0150* \]                              |
|                                                                       |
|  9 -- Discharge from agency \[ Go to *M0150* \]                      |
|                                                                       |
|  10 -- Discharge from agency---no visits completed after             |
| start/resumption of care assessment\                                  |
| \[ Go to *M0150*** **\]                                               |
+-----------------------------------------------------------------------+

DEMOGRAPHICS AND PATIENT HISTORY

**(M0140) Race/Ethnicity** (as identified by patient): **(Mark all that
apply.)**

 1 - American Indian or Alaska Native

 2 - Asian

 3 - Black or African-American

 4 - Hispanic or Latino

 5 - Native Hawaiian or Pacific Islander

 6 - White

 UK - Unknown

**(M0150) Current Payment Sources for Home Care:** **(Mark all that
apply.)**

 0 - None; no charge for current services

 1 - Medicare (traditional fee-for-service)

 2 - Medicare (HMO/managed care)

 3 - Medicaid (traditional fee-for-service)

 4 - Medicaid (HMO/managed care)

 5 - Workers\' compensation

 6 - Title programs (e.g., Title III, V, or XX)

 7 - Other government (e.g., CHAMPUS, VA, etc.)

 8 - Private insurance

 9 - Private HMO/managed care

 10 - Self-pay

 11 - Other (specify)

 UK - Unknown

**(M0160) Financial Factors** limiting the ability of the patient/family
to meet basic health needs: **(Mark all that apply.)**

 0 - None

 1 - Unable to afford medicine or medical supplies

 2 - Unable to afford medical expenses that are not covered by
insurance/Medicare (e.g., copayments)

 3 - Unable to afford rent/utility bills

 4 - Unable to afford food

 5 - Other (specify)

**(M0175)** From which of the following **Inpatient Facilities** was the
patient discharged [during the past 14 days]{.underline}? **(Mark all
that apply.)**

 1 - Hospital

 2 - Rehabilitation facility

 3 - Skilled nursing facility

 4 - Other nursing home

 5 - Other (specify)

 NA - Patient was not discharged from an inpatient facility **\[ If NA,
go to *M0200* \]**

**(M0180) Inpatient Discharge Date** (most recent):

\_\_ \_\_ /\_\_ \_\_ / \_\_ \_\_ \_\_ \_\_

month day year

 UK - Unknown

**(M0190) Inpatient Diagnoses** and ICD code categories (three digits
required; five digits optional) [for only those conditions treated
during an inpatient facility stay within the last 14 days]{.underline}
(no surgical or V-codes):

  --------------------------------------------------- -------------------
  [Inpatient Facility Diagnosis]{.underline}          [ICD]{.underline}

  a\.                                                 (\_\_ \_\_ \_\_ ~•~
                                                      \_\_ \_\_)

  b\.                                                 (\_\_ \_\_ \_\_ ~•~
                                                      \_\_ \_\_)
  --------------------------------------------------- -------------------

**(M0200) Medical or Treatment Regimen Change Within Past 14 Days:** Has
this patient exper­ienced a change in medical or treatment regimen (e.g.,
medication, treatment, or service change due to new or additional
diagnosis, etc.) within the last 14 days?

 0 - No **\[ If No, go to *M0220* \]**

 1 - Yes

**(M0210)** List the patient\'s **Medical Diagnoses** and ICD code
categories (three digits required; five digits optional) [for those
conditions requiring changed medical or treatment regimen]{.underline}
(no surgical or V-codes):

  --------------------------------------------------- -------------------
  [Changed Medical Regimen Diagnosis]{.underline}     [ICD]{.underline}

  a\.                                                 (\_\_ \_\_ \_\_ ~•~
                                                      \_\_ \_\_)

  b\.                                                 (\_\_ \_\_ \_\_ ~•~
                                                      \_\_ \_\_)

  c\.                                                 (\_\_ \_\_ \_\_ ~•~
                                                      \_\_ \_\_)

  d\.                                                 (\_\_ \_\_ \_\_ ~•~
                                                      \_\_ \_\_)
  --------------------------------------------------- -------------------

**(M0220) Conditions Prior to Medical or Treatment Regimen Change or
Inpatient Stay Within Past 14 Days**: If this patient experienced an
inpatient facility discharge or change in medical or treatment regimen
within the past 14 days, indicate any conditions which existed [prior
to]{.underline} the inpatient stay or change in medical or treatment
regimen. **(Mark all that apply.)**

 1 - Urinary incontinence

 2 - Indwelling/suprapubic catheter

 3 - Intractable pain

 4 - Impaired decision-making

 5 - Disruptive or socially inappropriate behavior

 6 - Memory loss to the extent that supervision required

 7 - None of the above

 NA - No inpatient facility discharge [and]{.underline} no change in
medical or treatment regimen in past 14 days

 UK - Unknown

**(M0230/M0240) Diagnoses and Severity Index**: List each medical
diagnosis or problem for which the patient is receiving home care and
ICD code category (three digits required; five digits optional -- no
surgical or V-codes) and rate them using the following severity index.
(Choose one value that represents the most severe rating appropriate for
each diagnosis.)

0 - Asymptomatic, no treatment needed at this time

1 - Symptoms well controlled with current therapy

2 - Symptoms controlled with difficulty, affecting daily functioning;
patient needs ongoing monitoring

3 - Symptoms poorly controlled, patient needs frequent adjustment in
treatment and dose monitoring

4 - Symptoms poorly controlled, history of rehospitalizations

  ----------------------------- ------------------- ----------------------------
  [(M0230) Primary              [ICD]{.underline}   [Severity
  Diagnosis]{.underline}                            Rating]{.underline}

  a\.                           (\_\_ \_\_ \_\_ ~•~  0  1  2  3  4
                                \_\_ \_\_)          

  [(M0240) Other                [ICD]{.underline}   [Severity
  Diagnoses]{.underline}                            Rating]{.underline}

  b\.                           (\_\_ \_\_ \_\_ ~•~  0  1  2  3  4
                                \_\_ \_\_)          

  c\.                           (\_\_ \_\_ \_\_ ~•~  0  1  2  3  4
                                \_\_ \_\_)          

  d\.                           (\_\_ \_\_ \_\_ ~•~  0  1  2  3  4
                                \_\_ \_\_)          

  e\.                           (\_\_ \_\_ \_\_ ~•~  0  1  2  3  4
                                \_\_ \_\_)          

  f\.                           (\_\_ \_\_ \_\_ ~•~  0  1  2  3  4
                                \_\_ \_\_)          
  ----------------------------- ------------------- ----------------------------

**(M0250) Therapies** the patient receives [at home]{.underline}:
**(Mark all that apply.)**

 1 - Intravenous or infusion therapy (excludes TPN)

 2 - Parenteral nutrition (TPN or lipids)

 3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any
other artificial entry into the alimentary canal)

 4 - None of the above

**(M0260) Overall Prognosis:** BEST description of patient\'s overall
prognosis for [recovery from this episode of illness]{.underline}.

 0 - Poor: little or no recovery is expected and/or further decline is
imminent

 1 - Good/Fair: partial to full recovery is expected

 UK - Unknown

**(M0270) Rehabilitative Prognosis:** BEST description of patient\'s
prognosis for [functional status]{.underline}.

 0 - Guarded: minimal improvement in functional status is expected;
decline is possible

 1 - Good: marked improvement in functional status is expected

 UK - Unknown

**(M0280) Life Expectancy:** (Physician documentation is not required.)

 0 - Life expectancy is greater than 6 months

 1 - Life expectancy is 6 months or fewer

**(M0290) High Risk Factors** characterizing this patient: **(Mark all
that apply.)**

 1 - Heavy smoking

 2 - Obesity

 3 - Alcohol dependency

 4 - Drug dependency

 5 - None of the above

 UK - Unknown

LIVING ARRANGEMENTS

**(M0300) Current Residence:**

 1 - Patient\'s owned or rented residence (house, apartment, or mobile
home owned or rented by patient/couple/significant other)

 2 - Family member\'s residence

 3 - Boarding home or rented room

 4 - Board and care or assisted living facility

 5 - Other (specify)

**(M0310) Structural Barriers** in the patient\'s environment limiting
independent mobility: **(Mark all that apply.)**

 0 - None

 1 - Stairs inside home which [must]{.underline} be used by the patient
(e.g., to get to toileting, sleeping, eating areas)

 2 - Stairs inside home which are used optionally (e.g., to get to
laundry facilities)

 3 - Stairs leading from inside house to outside

 4 - Narrow or obstructed doorways

**(M0320) Safety Hazards** found in the patient\'s current place of
residence: **(Mark all that apply.)**

 0 - None

 1 - Inadequate floor, roof, or windows

 2 - Inadequate lighting

 3 - Unsafe gas/electric appliance

 4 - Inadequate heating

 5 - Inadequate cooling

 6 - Lack of fire safety devices

 7 - Unsafe floor coverings

 8 - Inadequate stair railings

 9 - Improperly stored hazardous materials

 10 - Lead-based paint

 11 - Other (specify)

**(M0330) Sanitation Hazards** found in the patient\'s current place of
residence: **(Mark all that apply.)**

 0 - None

 1 - No running water

 2 - Contaminated water

 3 - No toileting facilities

 4 - Outdoor toileting facilities only

 5 - Inadequate sewage disposal

 6 - Inadequate/improper food storage

 7 - No food refrigeration

 8 - No cooking facilities

 9 - Insects/rodents present

 10 - No scheduled trash pickup

 11 - Cluttered/soiled living area

 12 - Other (specify)

**(M0340) Patient Lives With:** **(Mark all that apply.)**

 1 - Lives alone

 2 - With spouse or significant other

 3 - With other family member

 4 - With a friend

 5 - With paid help (other than home care agency staff)

 6 - With other than above

SUPPORTIVE ASSISTANCE

**(M0350) Assisting Person(s) Other than Home Care Agency Staff:**
**(Mark all that apply.)**

 1 - Relatives, friends, or neighbors living outside the home

 2 - Person residing in the home (EXCLUDING paid help)

 3 - Paid help

 4 - None of the above **\[ If None of the above, go to *M0390* \]**

 UK - Unknown **\[ If Unknown, go to *M0390 *\]**

**(M0360) Primary Caregiver** taking [lead]{.underline} responsibility
for providing or managing the patient\'s care, providing the most
frequent assistance, etc. (other than home care agency staff):

 0 - No one person **\[ If No one person, go to *M0390* \]**

 1 - Spouse or significant other

 2 - Daughter or son

 3 - Other family member

 4 - Friend or neighbor or community or church member

 5 - Paid help

 UK - Unknown **\[ If Unknown, go to *M0390* \]**

**(M0370) How Often** does the patient receive assistance from the
primary caregiver?

 1 - Several times during day and night

 2 - Several times during day

 3 - Once daily

 4 - Three or more times per week

 5 - One to 2 times per week

 6 - Less often than weekly

 UK - Unknown

**(M0380) Type of Primary Caregiver Assistance:** **(Mark all that
apply.)**

 1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder,
eating/feeding)

 2 - IADL assistance (e.g., meds, meals, housekeeping, laundry,
telephone, shopping, finances)

 3 - Environmental support (housing, home maintenance)

 4 - Psychosocial support (socialization, companionship, recreation)

 5 - Advocates or facilitates patient\'s participation in appropriate
medical care

 6 - Financial agent, power of attorney, or conservator of finance

 7 - Health care agent, conservator of person, or medical power of
attorney

 UK - Unknown

SENSORY STATUS

**(M0390) Vision** with corrective lenses if the patient usually wears
them:

 0 - Normal vision: sees adequately in most situations; can see
medication labels, newsprint.

 1 - Partially impaired: cannot see medication labels or newsprint, but
[can]{.underline} see obstacles in path, and the surrounding layout; can
count fingers at arm\'s length.

 2 - Severely impaired: cannot locate objects without hearing or
touching them [or]{.underline} patient nonresponsive.

**(M0400) Hearing and Ability to Understand Spoken Language** in
patient\'s own language (with hearing aids if the patient usually uses
them):

 0 - No observable impairment. Able to hear and understand complex or
detailed instructions and extended or abstract conversation.

 1 - With minimal difficulty, able to hear and understand most
multi-step instructions and ordinary conversation. May need occasional
repetition, extra time, or louder voice.

 2 - Has moderate difficulty hearing and understanding simple, one-step
instructions and brief conversation; needs frequent prompting or
assistance.

 3 - Has severe difficulty hearing and understanding simple greetings
and short comments. Requires multiple repetitions, restatements,
demonstrations, additional time.

 4 - [Unable]{.underline} to hear and understand familiar words or
common expressions consistently, [or]{.underline} patient nonresponsive.

**(M0410) Speech and Oral (Verbal) Expression of Language** (in
patient\'s own language):

 0 - Expresses complex ideas, feelings, and needs clearly, completely,
and easily in all situations with no observable impairment.

 1 - Minimal difficulty in expressing ideas and needs (may take extra
time; makes occasional errors in word choice, grammar or speech
intelligibility; needs minimal prompting or assistance).

 2 - Expresses simple ideas or needs with moderate difficulty (needs
prompting or assistance, errors in word choice, organization or speech
intelligibility). Speaks in phrases or short sentences.

 3 - Has severe difficulty expressing basic ideas or needs and requires
maximal assistance or guessing by listener. Speech limited to single
words or short phrases.

 4 - [Unable]{.underline} to express basic needs even with maximal
prompting or assistance but is not comatose or unresponsive (e.g.,
speech is nonsensical or unintelligible).

 5 - Patient nonresponsive or unable to speak.

**(M0420) Frequency of Pain** interfering with patient\'s activity or
movement:

 0 - Patient has no pain or pain does not interfere with activity or
movement

 1 - Less often than daily

 2 - Daily, but not constantly

 3 - All of the time

**(M0430) Intractable Pain:** Is the patient experiencing pain that is
[not easily relieved]{.underline}, occurs at least daily, and affects
the patient\'s sleep, appetite, physical or emotional energy,
concentration, personal relationships, emotions, or ability or desire to
perform physical activity?

 0 - No

 1 - Yes

INTEGUMENTARY STATUS

**(M0440)** Does this patient have a **Skin Lesion** or an **Open
Wound**? This excludes \"OSTOMIES.\"

 0 - No **\[ If No, go to *M0490* \]**

 1 - Yes

**(M0445)** Does this patient have a **Pressure Ulcer**?

 0 - No **\[ If No, go to *M0468* \]**

 1 - Yes

> **(M0450) Current Number of Pressure Ulcers at Each Stage:** (Circle
> one response for each stage.)

+-------------------------------------------------+---+---+---+---+---+
| Pressure Ulcer Stages                           | N |   |   |   |   |
|                                                 | u |   |   |   |   |
|                                                 | m |   |   |   |   |
|                                                 | b |   |   |   |   |
|                                                 | e |   |   |   |   |
|                                                 | r |   |   |   |   |
|                                                 | o |   |   |   |   |
|                                                 | f |   |   |   |   |
|                                                 | P |   |   |   |   |
|                                                 | r |   |   |   |   |
|                                                 | e |   |   |   |   |
|                                                 | s |   |   |   |   |
|                                                 | s |   |   |   |   |
|                                                 | u |   |   |   |   |
|                                                 | r |   |   |   |   |
|                                                 | e |   |   |   |   |
|                                                 | U |   |   |   |   |
|                                                 | l |   |   |   |   |
|                                                 | c |   |   |   |   |
|                                                 | e |   |   |   |   |
|                                                 | r |   |   |   |   |
|                                                 | s |   |   |   |   |
+-------------------------------------------------+---+---+---+---+---+
| a\) Stage 1: Nonblanchable erythema of intact   | 0 | 1 | 2 | 3 | 4 |
| skin; the heralding of skin ulceration. In      |   |   |   |   | o |
| darker-pigmented skin, warmth, edema, hardness, |   |   |   |   | r |
| or discolored skin may be indicators.           |   |   |   |   | m |
|                                                 |   |   |   |   | o |
|                                                 |   |   |   |   | r |
|                                                 |   |   |   |   | e |
+-------------------------------------------------+---+---+---+---+---+
| b\) Stage 2: Partial thickness skin loss        | 0 | 1 | 2 | 3 | 4 |
| involving epidermis and/or dermis. The ulcer is |   |   |   |   | o |
| superficial and presents clinically as an       |   |   |   |   | r |
| abrasion, blister, or shallow crater.           |   |   |   |   | m |
|                                                 |   |   |   |   | o |
|                                                 |   |   |   |   | r |
|                                                 |   |   |   |   | e |
+-------------------------------------------------+---+---+---+---+---+
| c\) Stage 3: Full-thickness skin loss involving | 0 | 1 | 2 | 3 | 4 |
| damage or necrosis of subcutaneous tissue which |   |   |   |   | o |
| may extend down to, but not through, underlying |   |   |   |   | r |
| fascia. The ulcer presents clinically as a deep |   |   |   |   | m |
| crater with or without undermining of adjacent  |   |   |   |   | o |
| tissue.                                         |   |   |   |   | r |
|                                                 |   |   |   |   | e |
+-------------------------------------------------+---+---+---+---+---+
| d\) Stage 4: Full-thickness skin loss with      | 0 | 1 | 2 | 3 | 4 |
| extensive destruction, tissue necrosis, or      |   |   |   |   | o |
| damage to muscle, bone, or supporting           |   |   |   |   | r |
| structures (e.g., tendon, joint capsule, etc.)  |   |   |   |   | m |
|                                                 |   |   |   |   | o |
|                                                 |   |   |   |   | r |
|                                                 |   |   |   |   | e |
+-------------------------------------------------+---+---+---+---+---+
| e\) In addition to the above, is there at least |   |   |   |   |   |
| one pressure ulcer that cannot be observed due  |   |   |   |   |   |
| to the presence of eschar or a nonremovable     |   |   |   |   |   |
| dressing, including casts?                      |   |   |   |   |   |
|                                                 |   |   |   |   |   |
|  0 - No                                        |   |   |   |   |   |
|                                                 |   |   |   |   |   |
|  1 - Yes                                       |   |   |   |   |   |
+-------------------------------------------------+---+---+---+---+---+

**(M0460) Stage of Most Problematic (Observable) Pressure Ulcer:**

 1 - Stage 1

 2 - Stage 2

 3 - Stage 3

 4 - Stage 4

 NA - No observable pressure ulcer

**(M0464) Status of Most Problematic (Observable) Pressure Ulcer:**

 1 - Fully granulating

 2 - Early/partial granulation

 3 - Not healing

 NA - No observable pressure ulcer

**(M0468)** Does this patient have a **Stasis Ulcer**?

 0 - No **\[ If No, go to *M0482* \]**

 1 - Yes

**(M0470) Current Number of Observable Stasis Ulcer(s):**

 0 - Zero

 1 - One

 2 - 2

 3 - Three

 4 - Four or more

**(M0474)** Does this patient have at least one **Stasis Ulcer that
Cannot be Observed** due to the presence of a nonremovable dressing?

 0 - No

 1 - Yes

**(M0476) Status of Most Problematic (Observable) Stasis Ulcer:**

 1 - Fully granulating

 2 - Early/partial granulation

 3 - Not healing

 NA - No observable stasis ulcer

**(M0482)** Does this patient have a **Surgical Wound?**

 0 - No **\[ If No, go to *M0490* \]**

 1 - Yes

**(M0484) Current Number of (Observable) Surgical Wounds:** (If a wound
is partially closed but has [more]{.underline} than one opening,
consider each opening as a separate wound.)

 0 - Zero

 1 - One

 2 - 2

 3 - Three

 4 - Four or more

**(M0486)** Does this patient have at least one **Surgical Wound that
Cannot be Observed** due to the presence of a nonremovable dressing?

 0 - No

 1 - Yes

**(M0488) Status of Most Problematic (Observable) Surgical Wound:**

 1 - Fully granulating

 2 - Early/partial granulation

 3 - Not healing

 NA - No observable surgical wound

RESPIRATORY STATUS

**(M0490)** When is the patient dyspneic or noticeably **Short of
Breath**?

 0 - Never, patient is not short of breath

 1 - When walking more than 20 feet, climbing stairs

 2 - With moderate exertion (e.g., while dressing, using commode or
bedpan, walking distances less than 20 feet)

 3 - With minimal exertion (e.g., while eating, talking, or performing
other ADLs) or with agitation

 4 - At rest (during day or night)

**(M0500) Respiratory Treatments** utilized at home: **(Mark all that
apply.)**

 1 - Oxygen (intermittent or continuous)

 2 - Ventilator (continually or at night)

 3 - Continuous positive airway pressure

 4 - None of the above

ELIMINATION STATUS

**(M0510)** Has this patient been treated for a **Urinary Tract
Infection** in the past 14 days?

 0 - No

 1 - Yes

 NA - Patient on prophylactic treatment

 UK - Unknown

**(M0520) Urinary Incontinence or Urinary Catheter Presence:**

 0 - No incontinence or catheter (includes anuria or ostomy for urinary
drainage) **\[ If No, go to *M0540* \]**

 1 - Patient is incontinent

 2 - Patient requires a urinary catheter (i.e., external, indwelling,
intermittent, suprapubic) **\[ Go to *M0540* \]**

**(M0530) When** does **Urinary Incontinence** occur?

 0 - Timed-voiding defers incontinence

 1 - During the night only

 2 - During the day and night

**(M0540) Bowel Incontinence Frequency:**

 0 - Very rarely or never has bowel incontinence

 1 - Less than once weekly

 2 - One to three times weekly

 3 - Four to six times weekly

 4 - On a daily basis

 5 - More often than once daily

 NA - Patient has ostomy for bowel elimination

 UK - Unknown

**(M0550) Ostomy for Bowel Elimination:** Does this patient have an
ostomy for bowel elimination that (within the last 14 days): a) was
related to an inpatient facility stay, [or]{.underline} b) necessitated
a change in medical or treatment regimen?

 0 - Patient does [not]{.underline} have an ostomy for bowel
elimination.

 1 - Patient\'s ostomy was [not]{.underline} related to an inpatient
stay and did [not]{.underline} necessitate change in medical or
treatment regimen.

 2 - The ostomy [was]{.underline} related to an inpatient stay or
[did]{.underline} necessitate change in medical or treatment regimen.

NEURO/EMOTIONAL/BEHAVIORAL STATUS

**(M0560) Cognitive Functioning:** (Patient\'s current level of
alertness, orientation, comprehension, concentration, and immediate
memory for simple commands.)

 0 - Alert/oriented, able to focus and shift attention, comprehends and
recalls task directions independently.

 1 - Requires prompting (cuing, repetition, reminders) only under
stressful or unfamiliar conditions.

 2 - Requires assistance and some direction in specific situations
(e.g., on all tasks involving shifting of attention), or consistently
requires low stimulus environment due to distractibility.

 3 - Requires considerable assistance in routine situations. Is not
alert and oriented or is unable to shift attention and recall directions
more than half the time.

 4 - Totally dependent due to disturbances such as constant
disorientation, coma, persistent vegetative state, or delirium.

**(M0570) When Confused (Reported or Observed):**

 0 - Never

 1 - In new or complex situations only

 2 - On awakening or at night only

 3 - During the day and evening, but not constantly

 4 - Constantly

 NA - Patient nonresponsive

**(M0580) When Anxious (Reported or Observed):**

 0 - None of the time

 1 - Less often than daily

 2 - Daily, but not constantly

 3 - All of the time

 NA - Patient nonresponsive

**(M0590) Depressive Feelings Reported or Observed in Patient:** **(Mark
all that apply.)**

 1 - Depressed mood (e.g., feeling sad, tearful)

 2 - Sense of failure or self reproach

 3 - Hopelessness

 4 - Recurrent thoughts of death

 5 - Thoughts of suicide

 6 - None of the above feelings observed or reported

**(M0600) Patient Behaviors (Reported or Observed):** **(Mark all that
apply.)**

 1 - Indecisiveness, lack of concentration

 2 - Diminished interest in most activities

 3 - Sleep disturbances

 4 - Recent change in appetite or weight

 5 - Agitation

 6 - A suicide attempt

 7 - None of the above behaviors observed or reported

**(M0610) Behaviors Demonstrated [at Least Once a Week]{.underline}
(Reported or Observed):** **(Mark all that apply.)**

 1 - Memory deficit: failure to recognize familiar persons/places,
inability to recall events of past 24 hours, significant memory loss so
that supervision is required

 2 - Impaired decision-making: failure to perform usual ADLs or IADLs,
in­ability to appropriately stop activities, jeopardizes safety through
actions

 3 - Verbal disruption: yelling, threatening, excessive profanity,
sexual references, etc.

 4 - Physical aggression: aggressive or combative to self and others
(e.g., hits self, throws objects, punches, dangerous maneuvers with
wheelchair or other objects)

 5 - Disruptive, infantile, or socially inappropriate behavior
(**excludes** verbal actions)

 6 - Delusional, hallucinatory, or paranoid behavior

 7 - None of the above behaviors demonstrated

**(M0620) Frequency of Behavior Problems (Reported or Observed)** (e.g.,
wandering episodes, self abuse, verbal disruption, physical aggression,
etc.):

 0 - Never

 1 - Less than once a month

 2 - Once a month

 3 - Several times each month

 4 - Several times a week

 5 - At least daily

**(M0630)** Is this patient receiving **Psychiatric Nursing Services**
at home provided by a qualified psychiatric nurse?

 0 - No

 1 - Yes

ADL/IADLs

  -----------------------------------------------------------------------
  **For M0640-M0800, complete the \"Current\" column for all patients.
  For these same items, complete the \"Prior\" column only at start of
  care and at resumption of care; mark the level that corresponds to the
  patient\'s condition 14 days prior to start of care date (M0030) or
  resumption of care date (M0032). In all cases, record what the patient
  is *able to do*.**

  -----------------------------------------------------------------------

**(M0640) Grooming:** Ability to tend to personal hygiene needs (i.e.,
washing face and hands, hair care, shaving or make up, teeth or denture
care, fingernail care).

[Prior Current]{.underline}

  0 - Able to groom self unaided, with or without the use of assistive
devices or adapted methods.

  1 - Grooming utensils must be placed within reach before able to
complete grooming activities.

  2 - Someone must assist the patient to groom self.

  3 - Patient depends entirely upon someone else for grooming needs.

 UK - Unknown

**(M0650) Ability to Dress [Upper]{.underline} Body** (with or without
dressing aids) including undergarments, pullovers, front-opening shirts
and blouses, managing zippers, buttons, and snaps:

[Prior Current]{.underline}

  0 - Able to get clothes out of closets and drawers, put them on and
remove them from the up­per body without assistance.

  1 - Able to dress upper body without assistance if clothing is laid
out or handed to the patient.

  2 - Someone must help the patient put on upper body clothing.

  3 - Patient depends entirely upon another person to dress the upper
body.

 UK - Unknown

**(M0660) Ability to Dress [Lower]{.underline} Body** (with or without
dressing aids) including undergarments, slacks, socks or nylons, shoes:

[Prior Current]{.underline}

  0 - Able to obtain, put on, and remove clothing and shoes without
assistance.

  1 - Able to dress lower body without assistance if clothing and
shoes are laid out or handed to the patient.

  2 - Someone must help the patient put on under­garments, slacks,
socks or nylons, and shoes.

  3 - Patient depends entirely upon another person to dress lower
body.

 UK - Unknown

**(M0670) Bathing:** Ability to wash entire body.
**[Excludes]{.underline} grooming (washing face and hands only).**

[Prior Current]{.underline}

  0 - Able to bathe self in [shower or tub]{.underline} independently.

  1 - With the use of devices, is able to bathe self in shower or tub
independently.

  2 - Able to bathe in shower or tub with the assistance of another
person:

\(a\) for intermittent supervision or encouragement or reminders,
[OR]{.underline}

\(b\) to get in and out of the shower or tub, [OR]{.underline}

\(c\) for washing difficult to reach areas.

  3 - Participates in bathing self in shower or tub, [but]{.underline}
requires presence of another person throughout the bath for assistance
or supervision.

  4 - [Unable]{.underline} to use the shower or tub and is bathed in
[bed or bedside chair]{.underline}.

  5 - Unable to effectively participate in bathing and is totally
bathed by another person.

 UK - Unknown

**(M0680) Toileting:** Ability to get to and from the toilet or bedside
commode.

[Prior Current]{.underline}

  0 - Able to get to and from the toilet independently with or without
a device.

  1 - When reminded, assisted, or supervised by another person, able
to get to and from the toilet.

  2 - [Unable]{.underline} to get to and from the toilet but is able
to use a bedside commode (with or without assistance).

  3 - [Unable]{.underline} to get to and from the toilet or bedside
com­mode but is able to use a bedpan/urinal independently.

  4 - Is totally dependent in toileting.

 UK - Unknown

**(M0690) Transferring:** Ability to move from bed to chair, on and off
toilet or commode, into and out of tub or shower, and ability to turn
and position self in bed if patient is bedfast.

[Prior Current]{.underline}

  0 - Able to independently transfer.

  1 - Transfers with minimal human assistance or with use of an
assistive device.

  2 - [Unable]{.underline} to transfer self but is able to bear weight
and pivot during the transfer process.

  3 - Unable to transfer self and is [unable]{.underline} to bear
weight or pivot when transferred by another person.

  4 - Bedfast, unable to transfer but is able to turn and position
self in bed.

  5 - Bedfast, unable to transfer and is [unable]{.underline} to turn
and position self.

 UK - Unknown

**(M0700) Ambulation/Locomotion:** Ability to [SAFELY]{.underline} walk,
once in a standing position, or use a wheelchair, once in a seated
position, on a variety of surfaces.

[Prior Current]{.underline}

  0 - Able to independently walk on even and uneven surfaces and climb
stairs with or without railings (i.e., needs no human assistance or
assistive device).

  1 - Requires use of a device (e.g., cane, walker) to walk alone
[or]{.underline} requires human supervision or assistance to negotiate
stairs or steps or uneven surfaces.

  2 - Able to walk only with the supervision or assistance of another
person at all times.

  3 - Chairfast, [unable]{.underline} to ambulate but is able to wheel
self independently.

  4 - Chairfast, unable to ambulate and is [unable]{.underline} to
wheel self.

  5 - Bedfast, unable to ambulate or be up in a chair.

 UK - Unknown

**(M0710) Feeding or Eating:** Ability to feed self meals and snacks.
**Note: This refers only to the process of [eating]{.underline},
[chewing]{.underline}, and [swallowing]{.underline}, [not
preparing]{.underline} the food to be eaten.**

[Prior Current]{.underline}

  0 - Able to independently feed self.

  1 - Able to feed self independently but requires:

\(a\) meal set-up; [OR]{.underline}

\(b\) intermittent assistance or supervision from another person;
[OR]{.underline}

\(c\) a liquid, pureed or ground meat diet.

  2 - [Unable]{.underline} to feed self and must be assisted or
supervised through­out the meal/snack.

  3 - Able to take in nutrients orally [and]{.underline} receives
supplemental nutrients through a nasogastric tube or gastrostomy.

  4 - [Unable]{.underline} to take in nutrients orally and is fed
nutrients through a nasogastric tube or gastrostomy.

  5 - Unable to take in nutrients orally or by tube feeding.

 UK - Unknown

**(M0720) Planning and Preparing Light Meals** (e.g., cereal, sandwich)
or reheat delivered meals:

[Prior Current]{.underline}

  0 - (a) Able to independently plan and prepare all light meals for
self or reheat delivered meals; [OR]{.underline}

\(b\) Is physically, cognitively, and mentally able to prepare light
meals on a regular basis but has not routine­ly performed light meal
preparation in the past (i.e., prior to this home care admission).

  1 - [Unable]{.underline} to prepare light meals on a regular basis
due to physical, cognitive, or mental limitations.

  2 - Unable to prepare any light meals or reheat any delivered meals.

 UK - Unknown

**(M0730) Transportation:** Physical and mental ability to
[safely]{.underline} use a car, taxi, or public transportation (bus,
train, subway).

[Prior Current]{.underline}

  0 - Able to independently drive a regular or adapted car;
[OR]{.underline} uses a regular or handicap-accessible public bus.

  1 - Able to ride in a car only when driven by another person;
[OR]{.underline} able to use a bus or handicap van only when assisted or
accompanied by another person.

  2 - [Unable]{.underline} to ride in a car, taxi, bus, or van, and
requires transportation by ambulance.

 UK - Unknown

**(M0740) Laundry:** Ability to do own laundry ‑‑ to carry laundry to
and from washing machine, to use washer and dryer, to wash small items
by hand.

[Prior Current]{.underline}

  0 - (a) Able to independently take care of all laundry tasks;
[OR]{.underline}

\(b\) Physically, cognitively, and mentally able to do laundry and
access facilities, [but]{.underline} has not routinely performed laundry
tasks in the past (i.e., prior to this home care admission).

  1 - Able to do only light laundry, such as minor hand wash or light
washer loads. Due to physical, cognitive, or mental limitations, needs
assistance with heavy laundry such as carrying large loads of laundry.

  2 - [Unable]{.underline} to do any laundry due to physical
limitation or needs continual supervision and assistance due to
cognitive or mental limitation.

 UK - Unknown

**(M0750) Housekeeping:** Ability to safely and effectively perform
light housekeeping and heavier cleaning tasks.

[Prior Current]{.underline}

  0 - (a) Able to independently perform all housekeeping tasks;
[OR]{.underline}

\(b\) Physically, cognitively, and mentally able to perform
[all]{.underline} housekeeping tasks but has not routinely participated
in house­keeping tasks in the past (i.e., prior to this home care
admission).

  1 - Able to perform only [light]{.underline} housekeeping (e.g.,
dusting, wiping kitchen counters) tasks independently.

  2 - Able to perform housekeeping tasks with intermittent assistance
or supervision from another person.

  3 - [Unable]{.underline} to consistently perform any housekeeping
tasks unless assisted by another person throughout the process.

  4 - Unable to effectively participate in any housekeeping tasks.

 UK - Unknown

**(M0760) Shopping:** Ability to plan for, select, and purchase items in
a store and to carry them home or arrange delivery.

[Prior Current]{.underline}

  0 - (a) Able to plan for shopping needs and independently perform
shopping tasks, including carrying packages; [OR]{.underline}

\(b\) Physically, cognitively, and mentally able to take care of
shopping, but has not done shopping in the past (i.e., prior to this
home care admission).

  1 - Able to go shopping, but needs some assistance:

\(a\) By self is able to do only light shopping and carry small
packages, but needs some­one to do occasional major shopping;
[OR]{.underline}

\(b\) [Unable]{.underline} to go shopping alone, but can go with someone
to assist.

  2 - [Unable]{.underline} to go shopping, but is able to identify
items needed, place orders, and arrange home delivery.

  3 - Needs someone to do all shopping and errands.

 UK - Unknown

**(M0770) Ability to Use Telephone:** Ability to answer the phone, dial
numbers, and [effectively]{.underline} use the telephone to communicate.

[Prior Current]{.underline}

  0 - Able to dial numbers and answer calls appropriately and as
desired.

  1 - Able to use a specially adapted telephone (i.e., large numbers
on the dial, teletype phone for the deaf) and call essential numbers.

  2 - Able to answer the telephone and carry on a normal conversation
but has difficulty with placing calls.

  3 - Able to answer the telephone only some of the time or is able to
carry on only a limited conversation.

  4 - [Unable]{.underline} to answer the telephone at all but can
listen if assisted with equipment.

  5 - Totally unable to use the telephone.

  NA - Patient does not have a telephone.

 UK - Unknown

MEDICATIONS

**(M0780) Management of Oral Medications:** [Patient\'s
ability]{.underline} to prepare and take [all]{.underline} prescribed
oral medications reliably and safely, including administration of the
correct dosage at the appropriate times/intervals.
**[Excludes]{.underline} injectable and IV medications. (NOTE: This
refers to ability, not compliance or willingness.)**

[Prior Current]{.underline}

  0 - Able to independently take the correct oral medication(s) and
proper dosage(s) at the correct times.

  1 - Able to take medication(s) at the correct times if:

\(a\) individual dosages are prepared in advance by another person;
[OR]{.underline}

\(b\) given daily reminders; [OR]{.underline}

\(c\) someone develops a drug diary or chart.

  2 - [Unable]{.underline} to take medication unless administered by
someone else.

  NA - No oral medications prescribed.

 UK - Unknown

**(M0790) Management of Inhalant/Mist Medications:** [Patient\'s
ability]{.underline} to prepare and take [all]{.underline} prescribed
inhalant/mist medications (nebulizers, metered dose devices) reliably
and safely, in­clud­ing administration of the correct dosage at the
appropriate times/intervals. **[Excludes]{.underline} all other forms of
medication (oral tablets, injectable and IV medications).**

[Prior Current]{.underline}

  0 - Able to independently take the correct medication and proper
dosage at the correct times.

  1 - Able to take medication at the correct times if:

\(a\) individual dosages are prepared in advance by another person,
[OR]{.underline}

\(b\) given daily reminders.

  2 - [Unable]{.underline} to take medication unless administered by
someone else.

  NA - No inhalant/mist medications prescribed.

 UK - Unknown

**(M0800) Management of Injectable Medications:** [Patient\'s
ability]{.underline} to prepare and take [all]{.underline} prescribed
injectable medications reliably and safely, including administration of
correct dosage at the appropriate times/intervals.
**[Excludes]{.underline} IV medications.**

[Prior Current]{.underline}

  0 - Able to independently take the correct medication and proper
dosage at the correct times.

  1 - Able to take injectable medication at correct times if:

\(a\) individual syringes are prepared in advance by another person,
[OR]{.underline}

\(b\) given daily reminders.

  2 - [Unable]{.underline} to take injectable medications unless
administered by someone else.

  NA - No injectable medications prescribed.

 UK - Unknown

EQUIPMENT MANAGEMENT

**(M0810) Patient Management of Equipment (includes [ONLY]{.underline}
oxygen, IV/infusion therapy, enteral/parenteral nutrition equipment or
supplies):** [Patient\'s ability]{.underline} to set up, monitor and
change equipment reliably and safely, add appropriate fluids or
medication, clean/store/dispose of equipment or supplies using proper
technique. **(NOTE: This refers to ability, not compliance or
willingness.)**

 0 - Patient manages all tasks related to equipment completely
independently.

 1 - If someone else sets up equipment (i.e., fills portable oxygen
tank, provides patient with prepared solutions), patient is able to
manage all other aspects of equipment.

 2 - Patient requires considerable assistance from another person to
manage equipment, but independently completes portions of the task.

 3 - Patient is only able to monitor equipment (e.g., liter flow, fluid
in bag) and must call someone else to manage the equipment.

 4 - Patient is completely dependent on someone else to manage all
equipment.

 NA - No equipment of this type used in care **\[ If NA, go to
*M0825* \]**

**(M0820) Caregiver Management of Equipment (includes [ONLY]{.underline}
oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator
therapy equipment or supplies):** [Care­giver\'s ability]{.underline} to
set up, monitor, and change equipment reliably and safely, add
appropriate fluids or medication, clean/store/dispose of equipment or
supplies using proper technique. **(NOTE: This refers to ability, not
compliance or willingness.)**

 0 - Caregiver manages all tasks related to equipment completely
independently.

 1 - If someone else sets up equipment, caregiver is able to manage all
other aspects.

 2 - Caregiver requires considerable assistance from another person to
manage equipment, but independently completes significant portions of
task.

 3 - Caregiver is only able to complete small portions of task (e.g.,
administer nebulizer treatment, clean/store/dispose of equipment or
supplies).

 4 - Caregiver is completely dependent on someone else to manage all
equipment.

 NA - No caregiver

 UK - Unknown

THERAPY NEED

**(M0825)** **Therapy Need:** Does the care plan of the Medicare payment
period for which this assessment will define a case mix group indicate a
need for therapy (physical, occupational, or speech therapy) that meets
the threshold for a Medicare high-therapy case mix group?

 0 - No

 1 - Yes

 NA - Not applicable