The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in
Medicare or
Medicaid
Medicaid in the United States is a federal and state program that helps with healthcare costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and per ...
certified
nursing homes and non-critical access hospitals with Medicare swing bed agreements. (The term "swing bed" refers to the Social Security Act's authorizing small, rural hospitals to use their beds in both an acute care and
Skilled Nursing Facility
A nursing home is a facility for the residential care of elderly or disabled people. Nursing homes may also be referred to as skilled nursing facility (SNF) or long-term care facilities. Often, these terms have slightly different meanings to in ...
(SNF) capacity, as needed.)
This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home and SNF staff identify health problems.
Resource Utilization Groups (RUG) are part of this process, and provide the foundation upon which a resident's individual care plan is formulated. MDS assessment forms are completed for all residents in certified nursing homes, including SNFs, regardless of source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. Participants in the assessment process are health care professionals and direct care staff such as
Registered Nurses
A registered nurse (RN) is a nurse who has graduated or successfully passed a nursing program from a recognized nursing school and met the requirements outlined by a country, state, province or similar government-authorized licensing body to o ...
, Licensed Practical/Vocational Nurses, Therapists, Social Services, Activities and Dietary staff employed by the nursing home. MDS information is transmitted electronically by nursing homes to the MDS database in their respective states. MDS information from the state databases is captured into the national MDS database at
Centers for Medicare and Medicaid Services (CMS).
Sections of MDS (Minimum Data Set):
# Identification Information
# Hearing, Speech and Vision
# Cognitive Patterns
# Mood
# Behavior
# Preferences for Customary Routine and Activities
# Functional Status
# Functional Abilities and Goals
# Bladder and Bowel
# Active Diagnoses
# Health Conditions
# Swallowing/Nutritional Status
# Oral/Dental Status
# Skin Conditions
# Medications
# Special Treatments, Procedures and Programs
# Restraints
# Participation in Assessment and Goal Setting
# Care Area Assessment (CAA) Summary
# Correction Request
# Assessment Administration
The MDS is updated by the Centers for Medicare and Medicaid Services. Specific coding regulations in completing the MDS can be found in the Resident Assessment Instrument User's Guide. Versions of the Minimum Data Set has been used or is being utilized in other countries.
References
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CMS - MDS Quality Indicator and Resident Reports
Centers for Medicare & Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.16 October 2018
Health informatics
Medicare and Medicaid (United States)