CLINICAL RECORDS/RAI RUG AUDIT MDS 3.0

RESIDENT IDENTIFIER ______A2300 MDS ARD ______

KEY: Shaded area indicates interview items; asterisk (*) indicates difference in RUG application between RUG III and RUG IV

MDS

/

ITEM

/ LOOK BACK / CODE / NOTES / FOLLOW UP NEEDED
A0310A / Asmt Type Fed / 7 days
A0310B / PPS Assmt / 7 days
A0310C / PPS OMRA / 7 days
A2400B / MC Start Date / 7 days
A2400C / MC End Date / 7 days
B0100 / Comatose / 7 days
B0700 / Self Undstd / 7 days
C0200 / Repeat 3 Word / 7 days
C0300A / CorrectYear / 7 days
C0300B / Correct Month / 7 days
C0300C / Correct Week Day / 7 days
C0400A / Recall sock / 7 days
C0400B / Recall blue / 7 days
C0400C / Recall bed / 7 days
C0700 / ST Memory / 7 days
C1000 / Decis Making / 7 days
D0200A / Little interest / 14 days
D0200B / Feeling down / 14 days
D0200C / Trouble sleeping / 14 days
D0200D / Tired, no energy / 14 days
D0200E / Poor appet/ovr eat / 14 days
D0200F / Feeling a failure / 14 days
D0200G / Trble concentrate / 14 days
D0200H / Slow/Fidgety / 14 days
D0200I / Better off dead / 14 days
D0300 / Total Sev Score / 7 days
E0100A / Hallucinations / 7 days
E0100C / Delusions / 7 days
E0200A / Physical Behav Sx / 7 days
E0200B / Verbal Behav Sx / 7 days
E0200C / Other Behav Sx / 7 days
E0800 / Care Rejection / 7 days
E0900 / Wandering / 7 days
G0110A / Bed Mobility / 7 days / /
G0110B / Transfer / 7 days / /
G0110H / Eating / 7 days / /
G0110I / Toilet Use / 7 days / /
H0200C / Curr Toilet Prog / 7 days
H0500 / Curr Bwel Prog / 7 days
I2000 / Pneumonia * / 7 days
I2100 / Septicemia / 7 days
I2300 / UTI RUG III only / 30 days
I2900 / Diabetes / 7 days
I4300 / Aphasia RUG III only / 7 days
I4400 / Cerebral Palsy / 7 days
I4900 / Hemiplegia / 7 days
I5100 / Quadriplegia / 7 days
I5200 / Multiple Sclerosis / 7 days
I5300 / Parkinson’s / 7 days
I6200 / Asthma, COPD / 7 days
I6300 / Resp Failure / 7 days
J1550A / Fever +* / 7 days
J1550B / Vomiting * / 7 days
J1550C / Dehydr RUG III only / 7 days
J1550D / Int Bldg RUG III only / 7 days

CLINICAL RECORDS/RAI RUG AUDIT MDS 3.0

RESIDENT IDENTIFIER ______A2300 MDS ARD ______

KEY: Shaded area indicates interview items; asterisk (*) indicates difference in RUG application between RUG III and RUG IV

MDS /

ITEM

/ LOOK BACK / CODE / NOTES / FOLLOW UP NEEDED
K0300 / Weight Loss * / 1/6 months
K0500A / Parental/IV Fdg / 7 days
K0500B / Fdg Tube NG/PEG / 7 days
K0700A / % calories / 7 days
K0700B / Fluid Intake / 7 days
M0300 / PU Stg 1 RUG III / 7 days
M0300B / PU Multi Stage 2 / 7 days
M0300C / PU Stage 3 / 7 days
M0300D / PU Stage 4 / 7 days
M0300G / PU Unstageable / 7 days
M1030 / # Ven/Art Ulcers / 7 days
M1040A / Foot Infections / 7 days
M1040B / Diabetic Ft Ulcer / 7 days
M1040C / Open Foot Lesion / 7 days
M1040D / Open Lesion other / 7 days
M1040E / Surgical Wnds / 7 days
M1040F / Burns / 7 days
M1200A / Pres Reduc Chair / 7 days
M1200B / Pres Reduc Bed / 7 days
M1200C / T&P Program / 7 days
M1200D / Nutr/Hydr Progr / 7 days
M1200E / Ulcer Care / 7 days
M1200F / Surg Wnd Care / 7 days
M1200G / Appl Drsg / 7 days
M1200H / Appl Oint/Med / 7 days
M1200I / Appl foot Dsg / 7 days
M0300 / InjectionsRUG III / 7 days
M0350A / Days Insulin Inject / 7 days
M0350B / Days PO Insulin / 7 days
O0100A / Chemo as resid * / 14 days
O0100B / Radiatas resid * / 14 days
O0100C / O2 Tx as resid * / 14 days
O0100D / Suction RUG III only / 14 days
O0100E / Trache as resid * / 14 days
O0100F / Vent/Resp as resid * / 14 days
O0100H / IV Med as resid * / 14 days
O0100J / Dialysis as resid * / 14 days
O0100M / Isolation as resid / 14 days
O0400A / SpeechTx / 7 days / Individual * / Concurrent * / Group * /
O0400B / Occupational Tx / 7 days / Individual * / Concurrent * / Group * /
O0400C / Physical Tx / 7 days / Individual * / Concurrent * / Group * /
O0400D / Respiratory Tx / 7 days / /
O0500A / RNP PROM / 7 days
O0500B / RNP AROM / 7 days
O0500C / RNP Splint/Brace / 7 days
O0500D / RNP Bed Mobility / 7 days
O0500E / RNP Transfer / 7 days
O0500F / RNP Walking / 7 days
O0500G / RNP Dsg/Groom / 7 days
O0500H / RNP Eat/Swallow / 7 days
O0500I / RNP Amp/Prosth / 7 days
O0500J / RNP Commun / 7 days
O0600 / Phys Days Exam / 14 days
O0700 / Phys Days Orders / 14 days

CLINICAL RECORDS/RAI RUG AUDIT MDS 3.0

RESIDENT IDENTIFIER __12345______A2300 MDS ARD __6/17/10______

KEY: Shaded area indicates interview items; asterisk (*) indicates difference in RUG application between RUG III and RUG IV

MDS

/

ITEM

/ LOOK BACK / CODE / NOTES / FOLLOW UP NEEDED
A0310A / Asmt Type Fed / 7 days
A0310B / PPS Assmt / 7 days
A0310C / PPS OMRA / 7 days
A2400B / MC Start Date / 7 days / 6/12/10
A2400C / MC End Date / 7 days / -
B0100 / Comatose / 7 days / 0 / NN, H&P – alert, oriented
B0700 / Self Undstd / 7 days / 0 / SS, NN, RT
C0200 / Repeat 3 Word / 7 days / 3 / SS – No problem
C0300A / CorrectYear / 7 days / 3 / SS – No problem
C0300B / Correct Month / 7 days / 3 / SS – No problem
C0300C / Correct Week Day / 7 days / 3 / SS – No problem
C0400A / Recall sock / 7 days / 2 / SS – No problem
C0400B / Recall blue / 7 days / 2 / SS – No problem
C0400C / Recall bed / 7 days / 2 / SS – No problem
C0500 / Summary Score / 7 days / 15
C0700 / ST Memory / 7 days / 0 / SS, NN – remembered what was served for breakfast, CNA, etc.
C1000 / Decis Making / 7 days / 0 / SS, NN, RT, family - Makes all decisions regarding life
D0200A / Little interest / 14 days / 0
D0200B / Feeling down / 14 days / 1 / SS – “I’m a little bummed I’m in here but I am getting better”
D0200C / Trouble sleeping / 14 days / 1 / SS – “Usually it’s not bad but it is noisy in here and I’m not used to it”
D0200D / Tired, no energy / 14 days / 0
D0200E / Poor appet/ovr eat / 14 days / 0
D0200F / Feeling a failure / 14 days / 0
D0200G / Trble concentrate / 14 days / 1 / SS – “There’s always so much going on, it’s hard to keep it all straight”
D0200H / Slow/Fidgety / 14 days / 0
D0200I / Better off dead / 14 days / 0
D0300 / Total Sev Score / 7 days / 03
E0100A / Hallucinations / 7 days
E0100C / Delusions / 7 days
E0200A / Physical Behav Sx / 7 days / 0
E0200B / Verbal Behav Sx / 7 days / 0
E0200C / Other Behav Sx / 7 days / 0
E0800 / Care Rejection / 7 days / 0
E0900 / Wandering / 7 days / 0
G0110A / Bed Mobility / 7 days / 3/2 / 3/2, 2/2
G0110B / Transfer / 7 days / 3/3 / 3/2, 2/2, 3/3, 2/3
G0110H / Eating / 7 days / 1/1 / 0/1, 1/, 1/0
G0110I / Toilet Use / 7 days / 3/2 / 2/2, 3/2
H0200C / Curr Toilet Prog / 7 days / 1 / Care plan, CNA record, NN
H0500 / Curr Bwel Prog / 7 days / 0
I2000 / Pneumonia * / 7 days
I2100 / Septicemia / 7 days
I2300 / UTI RUG III only / 30 days / √ / No tx, no labs available, H&P states Hx of UTI / √
I2900 / Diabetes / 7 days / √ / H&P, PN,PO, hospital record
I4300 / Aphasia RUG III only / 7 days
I4400 / Cerebral Palsy / 7 days
I4900 / Hemiplegia / 7 days
I5100 / Quadriplegia / 7 days
I5200 / Multiple Sclerosis / 7 days
I5300 / Parkinson’s / 7 days
I6200 / Asthma, COPD / 7 days
I6300 / Resp Failure / 7 days
J1550A / Fever +* / 7 days
J1550B / Vomiting * / 7 days
J1550C / Dehydr RUG III only / 7 days
J1550D / Int Bldg RUG III only / 7 days

CLINICAL RECORDS/RAI RUG AUDIT MDS 3.0

RESIDENT IDENTIFIER ____12345______A2300 MDS ARD __6/17/10______

KEY: Shaded area indicates interview items; asterisk (*) indicates difference in RUG application between RUG III and RUG IV

MDS /

ITEM

/ LOOK BACK / CODE / NOTES / FOLLOW UP NEEDED
K0300 / Weight Loss * / 1/6 months / 1 / Information provided by daughter, not sure of weight, used visual clues / √
K0500A / Parental/IV Fdg / 7 days
K0500B / Fdg Tube NG/PEG / 7 days
K0700A / % calories / 7 days
K0700B / Fluid Intake / 7 days
M0300 / PU Stg 1 RUG III / 7 days / 2 / Sacral area, Nsg assessment, NN, treatment cardex
M0300B / PU Multi Stage 2 / 7 days / 0
M0300C / PU Stage 3 / 7 days / 0
M0300D / PU Stage 4 / 7 days / 0
M0300G / PU Unstageable / 7 days / 0
M1030 / # Ven/Art Ulcers / 7 days / 0
M1040A / Foot Infections / 7 days / 0
M1040B / Diabetic Ft Ulcer / 7 days / 0
M1040C / Open Foot Lesion / 7 days / 0
M1040D / Open Lesion other / 7 days / 0
M1040E / Surgical Wnds / 7 days
M1040F / Burns / 7 days
M1200A / Pres Reduc Chair / 7 days / √ / Care Plan, NN
M1200B / Pres Reduc Bed / 7 days / √ / Care Plan, NN
M1200C / T&P Program / 7 days / √ / Not documented / √
M1200D / Nutr/Hydr Progr / 7 days / √ / Not documented – Dietary, PO, NN regular diet, no supplements, etc. / √
M1200E / Ulcer Care / 7 days
M1200F / Surg Wnd Care / 7 days
M1200G / Appl Drsg / 7 days
M1200H / Appl Oint/Med / 7 days / √ / A&D ointment to sacrum
M1200I / Appl foot Dsg / 7 days
M0300 / InjectionsRUG III / 7 days / 7 / Rec’d ea. AM, no sliding scale order
M0350A / Days Insulin Inject / 7 days / 7 / “ “ “ , no order for changes in tx
M0350B / Days PO Insulin / 7 days / 0 / “ “ “ “
O0100A / Chemo as resid * / 14 days
O0100B / Radiatas resid * / 14 days
O0100C / O2 Tx as resid * / 14 days
O0100D / Suction RUG III only / 14 days
O0100E / Trache as resid * / 14 days
O0100F / Vent/Resp as resid * / 14 days
O0100H / IV Med as resid * / 14 days
O0100J / Dialysis as resid * / 14 days
O0100M / Isolation as resid / 14 days
O0400A / SpeechTx / 7 days / Individual * / Concurrent * / Group * /
O0400B / Occupational Tx / 7 days / Individual * 5/265 Concurrent * 5/100 Group * /
O0400C / Physical Tx / 7 days / Individual * 6/310 Concurrent * 6/125 Group * /
O0400D / Respiratory Tx / 7 days / 0/0
O0500A / RNP PROM / 7 days / 0
O0500B / RNP AROM / 7 days / 0
O0500C / RNP Splint/Brace / 7 days / 0
O0500D / RNP Bed Mobility / 7 days / 0
O0500E / RNP Transfer / 7 days / 0
O0500F / RNP Walking / 7 days / 0
O0500G / RNP Dsg/Groom / 7 days / 0
O0500H / RNP Eat/Swallow / 7 days / 0
O0500I / RNP Amp/Prosth / 7 days / 0
O0500J / RNP Commun / 7 days / 0
O0600 / Phys Days Exam / 14 days / 1 / 6/9 H&P and PN
O0700 / Phys Days Orders / 14 days / 1 / 6/17 VO not signed