UK

Long Term Care

Resident
Assessment
Instrument
User’s
Manual
MDS/RAI UK

Adapted and edited for use in the UK by:

David Challis
Karen Stewart
Deborah Sturdy
Angela Worden

From the original US version by:

John N. Morris
Katharine Murphy
Sue Nonemaker

In addition to John N. Morris, Katharine Murphy and Sue Nonemaker,

other authors of the US HCFA 1990 training manual were
Catherine Hawes, Charles Phillips, Brant Fries and Vince Mor
 ©interRAI UK, 2000

The authors and editors of this publication assert their

moral rights in accordance with the
provisions of section 78 of the Copyright,
Designs and Patents Act, 1988

First published in Great Britain in 2000

Published by:
interRAI UK
Hartrigg Oaks
Haxby Road
New Earswick
York
YO32 4DS

ISBN 0-9538733-0-7

Printed in Great Britain by:

The JRW Group
Gatley, Cheadle, Cheshire SK8 4BE
 Contents

Page Nos

Acknowledgments 4

Chapter 1: MDS Assessment: Policy and Practice 5

Chapter 2: Overview of the MDS/RAI 13

Chapter 3: The Item-by-Item Guide to the MDS 17

Chapter 4: Completing the Resident Assessment Protocols (RAPs) 150

Chapter 5: Linking Assessment to Individualised Care Plans 211

Appendix A: MDS Assessment Forms 216

Appendix B: CPS Scoring Rules 245

Appendix C: Examples of ADL Self-Performance and Support Codings 246

Appendix D: References and Further Reading 254

MDS/RAI UK Licence 257

 Acknowledgments

This manual is a UK English translation/edition of the Health Care Financing Administration (HCFA) Resident
Assessment Instrument (RAI) training manual and resource guide, developed for use with version two of the Minimum
Data Set/Resident Assessment Instrument in the USA. As such it is important that we acknowledge colleagues both in
the US and the UK.

In the United States the authors of the original manual were John Morris, Katharine Murphy and Sue Nonemaker
along with Gloria Smit, Allan Stegemann, Janne Swearengen and David Zimmerman. We should also like to
acknowledge the continued thoughtful input from the other members of the group that developed the original version
of the MDS, Catherine Hawes, Charles Phillips, Brant Fries and Vince Mor. Many professional associations and clinical
experts have been involved in the Resident Assessment Initiative since its onset, although they are too numerous to
name individually. The continued support of management within the Health Standards and Quality Bureau at HCFA
has been crucial to its success. Finally, we wish to acknowledge the contributions of the RAI advisory panel, members
of the international community using the MDS through their interRAI association, key support staff at the Hebrew
Rehabilitation Centre for the Aged (HRCA) including, David Levine, Yvonne Anderson, Romanna Michajliw, Jon Wolf,
Wee Lock Ooi and other members of the HRCA research and clinical staff.

In the United Kingdom we are particularly grateful to the Joseph Rowntree Foundation for their continued financial
support including Dr Janet Lewis, Director of Research, and Cedric Dennis, Director of Care Services. The board at
interRAI UK have been a valuable source of support: Cedric Dennis and Michael Sturge of the Joseph Rowntree
Foundation; Hwyel Jones and David Birrell of Norwich Union; and Dr Iain Carpenter of the Centre for Health Services
Studies at the University of Kent. Abigail Masterson redrafted some of the Resident Assessment Protocols (RAPs); Kevin
Hope, Lecturer in Nursing at the University of Manchester and Dr Iain Carpenter wrote sections of chapter one. Kevin
Hope was also a particularly important contributor to reviewing and editing the RAPs in Chapter 4. Finally, several
people have made helpful criticisms of the content of the RAPs and have made more general observations about
layout, notably, Alistair Burns, Professor of Old Age Psychiatry at the University of Manchester.

David Challis
Karen Stewart
Deborah Sturdy
Angela Worden
 Chapter 1: MDS Assessment: Policy and Practice
Assessment is the key to good practice in long-term care.
This has become an increasing issue for a number of
professionals working within services for older people. It
is both a necessary and often time-consuming
undertaking, reliant on the assessor to elicit information
that can inform packages of care for individuals. The lack
of standardisation and consequent reliance upon
judgement of many such tools requires levels of expertise
and skill whose presence in fact varies across professions
and individuals. This is rendered more difficult by the
paucity of instruments designed for use in care homes
(Challis et al., 1996). The Minimum Data Set/Resident
Assessment Instrument (MDS/RAI) approach aims to level
that playing field allowing for a comprehensive, valid and
reliable assessment which permits comparison over time
in observing change in needs within individuals and
between settings.
The MDS/RAI was developed in the USA in the late
1980s following concern about a series of scandals
relating to quality of care which had arisen in the long
term care industry. As a result, the US Government
Health Care Finance Administration (HCFA) set out a
tender for a system which would record individual need,
provide reliable comparative data linked to quality and
act as a means of regulating costs. The Research Institute
at the Hebrew Rehabilitation Centre in Boston MA led
the national development of this work. The cumulative
effort produced the Minimum Data Set/Resident
Assessment Instrument (MDS/RAI). The aim of HCFA
was that the MDS/RAI should be used throughout the
USA under federal mandate and this has been achieved
under the Omnibus Reconciliation Act 1987 (OBRA).
The dissemination of this work was co-ordinated from
the centre in Boston and has been developed through a
number of other research institutions in the USA.
The MDS/RAI has two components, the Minimum Data
Set (MDS) and the Resident Assessment Protocols
(RAPs). These are described later in this chapter. The
institutional interest in the MDS has grown as
governments across the world face the common
challenge of an increase in numbers of frail older people
and the demands this places on resources. One outcome
has been the development of interRAI, an international
group of clinicians and researchers from some 16
countries who are using the MDS/RAI to make
comparisons within and between homes and across
countries. Beyond comparison, links may be made
between needs, problems and resource use from the
MDS through Resource Utilisation Groups (RUGs).
These constitute groups of cases whose dependency
patterns generate similar cost profiles. This makes it
possible to address issues such as linking dependency to
payment (casemix reimbursement) and staffing levels.
In this chapter three views from different authors, a social
care/social policy perspective, a geriatric medicine
perspective and a nursing perspective, are presented
regarding the potential value of the MDS for service
purchasers, providers and policy makers in the UK.
ASSESSMENT AND LONG TERM CARE. PROFESSOR
DAVID CHALLIS
The centrality of assessment in the care of vulnerable
older people was made explicit in the 1989 White Paper
Caring for People (Cm 849, 1989), where the third
objective for service delivery was:
“To make proper assessment of need and good case
management the cornerstone of high quality care”
(para. 1.11).
The importance of assessment is again evident in the
recent White Paper Modernising Social Services (Cm
4169, 1998) where the themes of fair access, consistency
and promotion of independence are noted. As a
consequence assessment has become one of the key
components of government policies which are designed
to avoid inappropriate placement and ensure cost
effective high quality long-term care. Much research and
activity has been focused upon assessment near, or at the
point of long-term care placement (Brocklehurst, 1978;
Stuck et al., 1993; Peet et al., 1994). More recently there
has been a stress placed upon multidisciplinary
assessment involving both health and social care
agencies (Department of Health, 1997). Assessment is
thus linked to four key areas in the development of
effective care policies and practices: firstly, determination
of eligibility for services; secondly, the identification of
care needs; thirdly, the decision whether or not to enter
care homes; and finally, regular review or re-assessment.
Hence, it is possible to see assessment as associated not
just with the initial judgement at the point of entry to care
homes or the provision of levels or types of care, but also
more broadly at other levels in the care process such as
eligibility for funding, levels of funding and re-
imbursement, and review and quality assurance within
 Chapter 1: MDS Assessment: Policy and Practice
homes (Challis et al., 1996).
In practice, the advent of the community care reforms
has led to a substantial investment in assessment
procedures and documentation. However, a number of
studies have identified similar areas of deficiency. These
include variation in content and quality, lack of reliability
and validity, insufficient coverage of domains of need - in
particular a focus on functional areas and neglect of
others such as depression and cognitive impairment, and
in general a tendency to describe rather than offer a
goal-focused analysis of need (Department of Health,
1993; Stewart et al., 1999).
Most investment in assessment activity has focused upon
community assessments and there has been little evidence
of assessment procedures developed for residential and
nursing homes. However, the same range of needs,
problems and risks are experienced by residents in homes
as by frail older people living in their own homes, albeit
frequently at a higher level of prevalence. For example,
incontinence is observed in between 30 and 40 per cent
of residents, depression in about 45 per cent, cognitive
impairment in 40 to 60 per cent and risk of falling in up
to one third of residents. From these few indicators it is
clear that the range of problems experienced are multiple
and wide-ranging and that, in order to provide high
quality care, assessment has to reflect the multiple
dimensions of need.
It is generally agreed that the process of comprehensive
geriatric assessment is the archetype of this wide-ranging
and multidimensional thorough and systematic
assessment. It covers functional status, both physical and
mental, the identification of disease and dysfunction,
selection of appropriate treatments and interventions,
assessment of the need for support resources, evaluation
of the impact of interventions and monitoring quality of
life (Rubenstein et al., 1988). Comprehensive geriatric
assessment has demonstrated improvements in the
outcome of health care in a number of settings (Stuck et
al., 1993). The underlying principles of this process are
suitable for addressing the needs of older people in long-
term care, and identifying who should receive which
services and where. This should ensure equity of access,
care and outcome in a way that is seen to be fair and in
the most cost effective and successful manner for
maximising quality of life and quality of care. However,
in practice, a full multi-disciplinary and multi-dimensional
assessment for all residents in long-term care settings can
be highly expensive and not necessarily yield the best
returns in terms of resident care. A less costly and less
intrusive approach is likely to be one where a single
assessor covers areas of potential need for residents and
uses such a comprehensive picture to access specialist
skills when appropriate.
The MDS/RAI
The MDS/RAI, developed in the US to attempt to achieve
greater consistency in the quality of care provided for
nursing home residents, offers a means of developing
such an approach to multi-disciplinary assessment in the
UK. The MDS/RAI consists of the Minimum Data Set, a
structured assessment tool, and the Resident Assessment
Protocols (RAPs) which guide the assessor through areas
of potential need so as to ascertain whether further
action is required. These are shown in Boxes 1.1 and
1.2.
Box 1.1: The Minimum Data Set/Resident Assessment
Instrument Assessment Domains
A. Identification and background information
B. Cognitive patterns
C. Communication/hearing patterns
D. Vision patterns
E. Mood and behaviour patterns
F. Psychosocial well-being
G. Mobility and activities of daily living
H. Continence in last 14 days
I. Disease diagnoses
J. Health conditions
K. Oral/nutritional status
L. Oral/dental status
M. Skin condition
N. Activity pursuit patterns
O. Medications
P. Special treatments and procedures
Q. Discharge potential/overall status
R. Assessment information
Box 1.2: The Minimum Data Set/Resident Assessment
Instrument Resident Assessment Protocols (RAPs)
 Chapter 1: MDS Assessment: Policy and Practice

1. Acute confusional state resident level assessment can also be associated with
eligibility for different levels of funding for residents within
2. Cognitive loss/dementia
residential settings; for different levels of reimbursement to
3. Visual function homes according to levels of need and care requirements;
4. Communication and with more effective review and the development of
methods of quality assurance. There is therefore a close fit
5. ADL function/rehabilitation potential between the MDS approach and the new policy arena for
6. Urinary incontinence and indwelling catheter social and health care. Multi-disciplinary assessment and
rehabilitation were stressed as key themes in the circular
7. Psychosocial well-being
Better Services for Vulnerable People (Department of
8. Mood state Health, 1997). The need for greater consistency and for the
9. Behavioural symptoms promotion of fair access to care, thereby reducing
unnecessary variability in the provision of care, were
10. Activities stressed in the White Paper Modernising Social Services
11. Falls (Cm 4169, 1998). Again, with the development of a
National Performance Assessment Framework, regional
12. Nutritional status
levels of information will be needed for regulation by the
13. Feeding tubes Commissions for Care Standards described in the White
Paper Modernising Social Services (Cm 4169, 1998), and
14. Dehydration/fluid maintenance
this local performance measurement would benefit from
15. Dental care standard information generated by structured assessments.
16. Pressure sores Overall, the MDS/RAI appears to be a valuable
17. Psychotropic drug use assessment instrument with action-oriented links to care
planning protocols. As a comprehensive assessment, it
18. Physical restraints
aids the assessor in assuring them that the assessment is
adequate and assists in care plan development by means
Thus, the MDS is a collection of items covering the range
of the system of triggers and assessment protocols. This
of domains of need appropriate for assessing the needs of
takes assessment beyond the collection of descriptive
vulnerable older people in care homes, and for
information to formulation and activation of care plans.
developing the required care plans. It is completed as an
This process can encourage the development of greater
admission assessment and then periodically during the
independence for residents and the participation of their
course of care in a residential or nursing home, providing
carers in the assessment activity.
a baseline assessment and regular review. The RAPs are
a series of protocols which are designed to guide the MINIMUM DATA SET RESIDENT ASSESSMENT
assessor through good practice in ascertaining whether a
INSTRUMENT IN THE UNITED KINGDOM. DR IAIN
potential problem is in fact real, and then in care planning
CARPENTER
for the more common problems faced by older residents
such as vision problems or depression. The RAPs are In the industrialised countries of the world the number of
triggered by responses to individual items or sets of items old and very old people has increased very rapidly as a
within the MDS, thereby identifying areas of risk and proportion of the total population of these countries.
potential need. More and more older people are living in nursing and
residential care homes. With the increase in numbers of
From resident assessment to better regulation these institutions, there has been almost everywhere, an
and quality increase in concerns about the costs and quality of care
The MDS offers a tool for more effectively undertaking received by the residents and the skills, training and
assessment at the resident level. However, the collection of commitment of the people employed to care for them.
structured and standardised information makes it possible Every country has had its share of scandals relating to
to address issues at other levels in the care process. Thus matters of quality of care and the use of public and
 Chapter 1: MDS Assessment: Policy and Practice
private financial contributions to their care. In the United
States there was a series of legal actions in the late 1970s
and early 1980s which coincided with attempts by the
US government to reduce the regulatory burden on the
nursing home industry and widespread concerns from
older people and the advocates of nursing home
residents. In 1986, the US Institute of Medicine (IoM) was
asked by the Health Care Finance Administration
(HCFA) to report on existing nursing home regulations
and recommend changes to improve the care they
provided.
The Institute of Medicine report identified uniform
resident assessment as the cornerstone for efforts to
improve quality of care:
“providing high quality of care requires careful
assessment of each resident’s functional, medical,
mental and psychosocial status upon admission and
reassessment periodically thereafter with change in
status noted…”
High quality of care can only result from the
development of an individualised plan of care which
depends on a high quality assessment of a resident’s
strengths, needs and abilities.
The US Omnibus Reconciliation Act of 1987 (OBRA 87)
took account of the IoM report, acknowledged the
importance of assessment and required that all nursing
homes must conduct a “comprehensive accurate
standardised reproducible assessment of each resident’s
functional capacities”. Following this Act, HCFA
contracted with a group of research institutions to
develop and evaluate a new uniform resident assessment
instrument. The result was the Minimum Data Set
Resident Assessment Instrument (MDS/RAI) which
consists of two parts. The first, the Minimum Data Set
(MDS) contains the core items necessary for a
comprehensive assessment of the residents of nursing
homes. It contains triggers (individual items or
combinations of MDS elements) which identify residents
for whom specific resident assessment protocols (RAPs) -
the second part of the system - should be completed.
Each RAP is a structured framework for organising MDS
items that can be used to inform the care planning
process. The intent of these protocols is educational
rather than prescriptive. They give additional assessment
items and background information to develop a context
in which information about residents, their strengths,
preferences, and needs, is linked to the care plan options.
This structure was developed to meet four fundamental
goals in the development of the MDS. They were:
1 The MDS should replace non-uniform and cursory
assessment.
2 It should stimulate learning, change the ways in which
many nursing homes use resident specific information
and facilitate integration of assessment and care
planning information.
3 It should lead to improved care planning and care
provision which in turn can enhance quality of life.
4 Its development process should serve as a model for
the method by which it can continue to be updated in
the future.
The MDS/RAI was finally introduced into all United
States nursing homes in 1992 and since then it has
generated much interest and research in many countries
around the world. That this approach to assessment
should have struck so many chords is perhaps not
surprising, as its development included a wide range of
professionals and researchers at every stage of the
development process. The staff came from a wide
spectrum of disciplines including nursing, social work,
medicine, physiotherapy, occupational therapy, speech
therapy, activity co-ordinators and nutritionists. Also
represented were consumers, resident advocates,
providers, nursing home industry representatives and
regulators and measurement specialists. The MDS went
through over twenty major draft versions before it was
completed, and each draft had been reviewed and
commented on by many hundreds of people.
What then are the characteristics of this assessment
system that have attracted so much interest and also
generated so much debate?
The answer can be summed up in just a few words - the
MDS is a comprehensive, multi-dimensional,
standardised assessment instrument which links
problems, risk factors or potential for improvement,
identified in the assessment, to assessment protocols
which guide the assessor through best practice in
developing care plans for the triggered items.
Comprehensive multi-dimensional - it covers those areas
required to identify the needs of people requiring long
term nursing care, from their physical and cognitive
 Chapter 1: MDS Assessment: Policy and Practice
abilities, to their communication abilities and
psychosocial needs. It covers the minimum number of
assessment dimensions required to develop a
comprehensive assessment of those domains important
for their care.
Standardised - each assessment item and possible
response is precisely defined, requiring either a tick or a
number as a response.
The benefits of this approach to assessment are that:
■ All domains are covered.
■ Consistency in assessment is maintained.
■ A proper record of the assessment is made both to
support the decisions made on care and for future
reference.
■ The assessment information can be aggregated to
make comparisons.
■ Comparisons can be made of individuals over time
and between individuals in different places.
■ Comparisons can be made between homes, districts,
regions or even countries.
A further benefit of the assessment being standardised is
that scales can be constructed to measure areas of great
importance in care of older people such as scales for
measuring activities of daily living, cognitive function,
depression, psychosocial function and disturbed
behaviour patterns. Furthermore, as the time required for
caring for an old person is directly related to their
physical, mental and clinical state, a system for
comparing the time required to care for an individual has
been constructed from these assessment items - the
Resource Utilisation Groups (RUGs) casemix system.
These measurement scales are created directly from the
information gathered during the assessment of the older
person’s needs and only from the information that is
required to determine those needs. There is no need to
ask additional questions purely for the purpose of
constructing a scale.
What then are the benefits for the older people and their
relatives, for staff doing the assessment and providing
care, the managers and owners of homes, the purchasers
of the care, the policy makers and last but not least,
ourselves who have older relatives and who will in our
turn become old?
The assessor who uses the MDS will at first perhaps be
surprised and even intimidated by the detailed structure
with its boxes which require ticks and numbers as the
responses. At first it may seem complicated and
impersonal. How can such an apparently rigid
assessment system allow the assessor to develop a
holistic plan of care that can take into account the
individuality of the person for whom he or she is caring?
The answer is to recognise that the MDS is an instrument.
A parallel might be the assessment of someone with a
fever. By laying one’s hand on the forehead of a person
with a fever, it is easy to determine that they have a
temperature. However it requires a thermometer to
measure what their temperature is, how far above or
below normal it is and thus how severe is their illness.
Having determined the temperature a health professional
will go on to further assessment to determine what could
be the cause of the temperature, urinary tract infection, a
chest infection or some other cause. The instrument (the
thermometer) has determined that there is a problem and
the severity of the problem, and the staff member, by
calling on his or her professional training then determines
what is the cause and what needs to be done to address
it. In the same way the MDS measures precisely where
and to what extent an old person has specific care needs
by using this precisely recorded information. With the
assistance of the assessment protocols (when required),
the assessor can use his or her professional skills to
develop a care plan for that person which takes into
consideration all the personalised information and
personal preferences that lead to the highest quality care.
With experience in its use, the time required by an
assessor to complete a high quality comprehensive MDS
assessment will be optimised for the most cost effective
use of their time. By taking care to complete the
instrument accurately he or she will have the confidence
that they have done a good job for the old person in
their care.
The manager or owner of the home will have a clear
picture of the residents in the home by aggregating
information from the assessments of all the people in the
home. The total dependency of the residents in their care
and thus the cost of caring for those people is indicated
by the resource use casemix system, Resource Utilisation
Groups (RUGs). Quality of care is indicated by the extent
to which residents’ existing needs are met and the
development of new problems prevented. The
 Chapter 1: MDS Assessment: Policy and Practice
assessment items give an excellent quality assurance
system, prevalence of pressure sores, incontinence,
behavioural problems, use of physical restraints and
psychotropic medications can all be determined directly
from the information collected purely for caring for these
needs.
Purchasers of care can see the benefits of the money they
are spending. Different homes can be compared precisely
with respect to the dependency of the residents and the
quality of care, even taking into consideration the
proportion of residents who are at high or low risk of
developing particular problems. If a quarter of residents
in each of two homes have a pressure sore, they might
both be thought to be providing the same quality of care.
If however three-quarters of the residents of one of the
homes are very physically dependent and suffering from
severe dementia compared with just ten per cent in the
other home, one’s view of the quality of care provided by
the two homes will change dramatically.
Policy makers (and the rest of us!) know that there is
wide regional variation in the number of people and the
types of people cared for in nursing and residential
homes. We also know that the criteria set for eligibility for
local authority funding for care varies widely. It is only
with the use of structured standardised information that
one can determine whether access to funding is fair for
all and whether the care is of comparable quality. The
MDS provides most of this information as a result of the
routine assessment of need that should be carried out on
every person receiving nursing or residential home care.
Research using MDS information has already highlighted
new and important issues about the care of frail older
people. We now know that many old people suffering
from cancer and living in nursing homes have
inadequate pain control. We know that old people living
in nursing homes with heart failure do very much better
when treated with modern treatments for heart failure
compared with the traditional use of Digoxin and
diuretics. We also know that people in nursing homes in
Japan are far less likely to fall than people in nursing
homes in Western countries. Identifying these facts and
investigating the reasons underlying them will help us
continue to improve the quality of life of our elders.
The MDS has been scientifically developed and great
attention has been paid to ensure that if two different
people assess the same person, the resulting assessment
will be identical (it is reliable). Where, for example,
depression or cognitive function is being measured then
that really is what is being measured (it is valid). Finally,
all the questions asked in the assessment lead the
assessor to actually do something (there is no
redundancy).
Some of the benefits of using the MDS-RAI have been
described here. In the future information from the
assessments conducted in the community, hospital,
nursing or residential home may be used in such a way
that a complete picture of who is getting what and with
what effect can be constructed. By using the MDS/RAI for
those in your care in nursing and residential homes you
will be contributing to improving the quality of life not
only of your residents but also of all those in care and all
of those who will eventually need nursing and residential
care. The information generated from your routine
assessments can be aggregated to inform the
policymakers who create the laws and regulations to
ensure that we know how well our older people are being
treated and what we are getting for our money.
USING THE MDS: A NURSING PERSPECTIVE. KEVIN
HOPE
The spectrum of care for older people in this country has
undergone radical transformation since the introduction
of the NHS and Community Care Act 1990. In terms of
institutional care, there has been significant change in the
number of places available. Private sector residential
places grew from 44,000 in 1982 to 164,000 in 1994
and nursing home places grew from 18,000 to 150,000
in the same period (Health Select Committee, 1995).
More recently, the Royal Commission on Long Term Care
(Cm 4192, 1999) identifies 482,250 older people
receiving care in institutions which represents
approximately one in twenty of the older population.
Concern about the quality of care delivered to residents
has been associated with these trends. The United
Kingdom Central Council for Nursing, Midwifery and
Health Visiting (UKCC, 1994) for example, has reported
on, and expressed concern about, the growing
proportion of all cases appearing before their professional
misconduct committee arising from the nursing home
sector. In particular they noted that the nature of the
cases revealed “inadequate mechanisms for ensuring the
maintenance of standards and quality”.
 Chapter 1: MDS Assessment: Policy and Practice
Any attempt to improve and develop services for older
people in such settings is welcome, but it could be
argued that it is an opportune moment for taking a
confident stride in this area. The National Priorities
Guidance of 1999/00 - 2001/02 (Department of Health,
1998) identified the promotion of independence,
improved protection of vulnerable people and the raising
of standards across health and social services as specific
objectives. The subsequent fleshing out of the strategic
goals exemplified by the White Papers The New NHS
(Cm 3807,1997) and Modernising Social Services (Cm
4169, 1998) articulate a vision for their achievement.
More recently, the National Priorities Guidance of
2000/01 - 2002/03 (Department of Health, 1999)
identifies older people’s services as a specific area for
action on audit of current provision, raising standards
and improved rehabilitation for older people.
It is one thing to identify a strategic objective but another
to make it happen and it is in this respect that the
MDS/RAI offers exciting potential. It carries with it a
range of opportunities for the promotion of quality care
to older people. It recognises that assessment is a process
requiring information derived from several sources. In as
much it highlights the complex nature of the problems
that older people often present with and encourages a
broad ranging exploration to address such problems.
However, for any assessment to be helpful it needs to
progress beyond the descriptive and it is here that the
MDS has a particular appeal. The 18 resident assessment
protocols (RAPs) outline a set of guiding principles, upon
which the individual care plan for the older person can
be based. They provide information on problems
“triggered” by the assessment process and alert the user
to areas for consideration. In doing so, they present
information that the individual or team could usefully
consider prior to the decision/planning phase of care.
In Stockholm, staff in nursing homes have identified
improved quality of care, better documentation and
raised levels of co-operation as potential outcomes of
using the tool (Hansebo et al., 1998). Research plays its
own part in this process and the MDS/RAI has shown its
utility in assisting in the development of appropriate
responses to identified problems. In the United States it is
one of the few mandated clinical databases that captures
nursing care and, consequently, provides an opportunity
for its systematic evaluation. For example, Mentes et al.
(1999) used MDS data to test predictors of acute
confusion in long-term care residents and found
inadequate fluid intake to be the most powerful predictor.
Whereas medication has been found to be the most
frequent predictor of confusion in older hospital patients
this analysis suggests other causes may be as relevant
within residential/nursing homes.
A broader perspective can be taken. The introduction of
standardised assessment allows for comparison on a
larger scale and users should not underestimate their own
role in this process. The opportunity for a comparison of
the nature of care delivery is exciting. For example,
Challis et al. (1996) indicate the possibility of comparing
information on resident needs across homes, regions or
even wider areas.
Whilst such applications are intriguing, we should not
loose sight of the impact that such a tool can have at the
work place. In essence, the MDS/RAI alerts carers and
institutions to the possible. This is a fundamentally
important attribute of the tool and one which begins to
address and challenge the pervasive negative influences
that can operate in this field. Without the expenditure of
energy which counters such influences, there is a danger
of generating practitioners who are characterised by a
predilection to stereotypical and unimaginative care. The
MDS/RAI serves to highlight the complex nature of care
delivery to older people as well as offering the potential
to challenge assumptions or beliefs about what is
feasible. Many would argue that for too long the care of
older people in our society has been constrained by
artificial limits imposed often through ignorance or
pervasive negativity. The potential that the MDS/RAI
affords for a movement towards the possible is the
strongest argument for its implementation.
As users of the MDS/RAI become more comfortable and
familiar with the terminology and mechanics of its use,
they will come to value more being a part of this process.
For many, caring for older people is the real intensive
care.
USING THIS MANUAL
Identification of psychosocial, physical and psychological
needs is crucial in both building effective relationships
with individuals and their family and friends and
planning care to meet needs. Transition to a care home
can be a daunting and distressing time. This can often
lead to false impressions of the individual and the
 Chapter 1: MDS Assessment: Policy and Practice

MDS/RAI aims to provide an objective view of the needs not preclude the use of additional assessment tools.
of each person. This allows for a clear picture of past
abilities and lifestyle which can help in the planning of
care for their future. A full understanding of each
individual is crucial in the development of quality
services, ensuring that resources are effectively deployed
and that care needs are met.
Chapter 2 provides a detailed guide to the rest of the
A systematic approach such as this ensures that everyone
receives a reliable assessment and the degree of
subjectivity, that can bias outcomes in terms of
identifying needs, is limited.

This manual is intended to assist practitioners to improve

assessment skills in identifying the needs of older people.
This approach to assessment is not exhaustive and does manual and the use of the MDS in day-to-day practice.
 Chapter 2: Overview of the MDS/RAI
This chapter provides a broad overview of the style and
form of assessment which the MDS/RAI brings to long
term care. In the following sections the MDS is described
and introduced along with some observations about its
employment in UK residential and nursing homes. Finally
the structure of this manual is explained so as to guide
the reader through its use in the most effective fashion.
WHAT IS THE MDS/RAI?
The MDS/RAI process
Providing high quality long term care for older people is
complex and challenging. A variety of skills are necessary
to elicit information from a number of sources in order to
develop an individual care plan, taking account of
information about a resident’s strengths and needs which
must be addressed so as to provide individualised care.
The MDS/RAI process helps staff to evaluate resident
care goals, revise care plans and also to track changes in
the resident’s status over time.
Using this assessment approach allows for a holistic
assessment of residents’ needs. The involvement of all
professional disciplines relevant to the care of residents
makes best use of the MDS/RAI. These could include
general practitioners, community nurses, social workers,
physiotherapists, occupational therapists and speech
therapists. The approach can also aid communication
amongst the interdisciplinary team. All necessary
resources and disciplines must be used to ensure that
residents achieve the highest level of functioning possible
(Quality of Care) and maintain their sense of
individuality (Quality of Life). This is as true for long stay
residents, as for those for whom a return to their own
home is envisaged.
Clinicians, nurses and other professionals are generally
taught a problem identification process as part of their
training. For example, the nursing profession’s problem
identification model is called the nursing process, which
consists of assessment, planning, implementation and
evaluation. The MDS simply provides a structured,
standardised approach for applying a problem
identification process in long term care facilities.
As explained in the first chapter, the MDS/RAI relies upon
the use of a standardised assessment tool covering a
wide range of domains which can trigger more detailed
evaluation of potential problems (see Box 1.1). The
triggers are specific resident responses to one or a
combination of MDS assessment items. The triggers
identify residents who either have, or are at risk of
developing, specific functional problems and require
further evaluation. The triggers are indicated on the MDS
assessment form as a hand . Guidance for the
evaluation of these potential problems, identified by the
triggers, and for deciding whether an intervention is
appropriate is given in the Resident Assessment Protocols
(RAPs). These are listed in Box 1.2.
The process of using the MDS/RAI consists of:
Assessment
Taking stock of all observations, information and
knowledge about a resident; understanding the resident’s
limitations and strengths; finding out who the resident is.
Decision making
Determining the severity, functional impact, and scope of
a resident’s problems; understanding the causes and
relationships between a resident’s problems; discovering
the “what’s” and “whys” of resident problems.
Care planning
Establishing a course of action that moves a resident
toward a specific goal utilising individual resident
strengths and team expertise; crafting the “how” of
resident care.
Implementation
Putting the course of action into motion (specific
interventions on the care plan) by staff knowledgeable
about the resident’s care goals and approaches; carrying
out the “how” and “when” of resident care.
Evaluation
Critically reviewing care plan goals, interventions and
implementation in terms of achieved resident outcomes
and assessing the need to modify the care plan (i.e. change
interventions) to adjust to changes in the resident’s status
whether these are improvement or decline.
Below is how the problem identification process would
look as a pathway.
Assessment (MDS) → Decision Making (RAPs) →
Care Plan Development → Care Plan Implementation
→ Evaluation
The MDS/RAI is a dynamic and solution orientated
approach, assisting staff to gather and analyse
information in order to improve the resident’s quality of
 Chapter 2: Overview of the MDS/RAI
care and quality of life. The involvement of all staff
allows for an interdisciplinary approach to problem
solving. The result is that the process flows smoothly from
one component to the next and allows for good
communication, which is the essence of good practice
and positive resident outcome. The evaluation stage
recommences the cycle by again invoking assessment.
Impact of the MDS/RAI
Over the course of the years since the MDS/RAI has been
implemented in the USA, homes have discovered that it
has had impact in the following ways.
Residents respond to individualised care
Home after home has found that when the care plan
reflects careful consideration of individual problems and
their causes, together with appropriate resident specific
approaches to care, resident care goals have been
achieved and either the level of functioning has improved
or deteriorated at a slower rate.
Staff communication has become more effective
When staff are involved in a resident’s ongoing
assessment and have input into the determination and
development of a resident’s care plan, the commitment
to and the understanding of that care plan is enhanced.
Resident and family involvement in care has increased
There has been a dramatic increase in the frequency and
nature of resident and family involvement in the care
planning process.
Documentation has become clearer
When the approaches to achieving a specific goal are
understood and distinct, the need for voluminous
documentation diminishes.
APPLICATION OF THE MDS IN THE UK
In the USA the MDS is embedded in statute with rules
regarding its frequency of use and staff who are
responsible for its co-ordination being clearly prescribed.
In addition to the annual full assessment form, quarterly
assessments are required using an abbreviated form.
When there is a significant change in the resident’s status
a full assessment is required. In the USA regulations
require that the full initial assessment is completed by the
14th day of the resident’s stay.
At the present time in the UK the use of the MDS is
dependent upon good practice and the development of
norms over frequency of use. These will differ according
to the practices of individual homes, groups of homes,
and the requirements of registration authorities.
However, by way of guidance it is reasonable to suggest
that a full assessment of residents should take place at
least on an annual basis or when a significant change
occurs in a resident’s condition. The discharge tracking
form must always be completed when a resident is
discharged from the home for reasons other than a
temporary visit to their own home or family. The re-entry
tracking form is completed whenever a resident re-enters
the home following temporary admission to hospital. At
present the quarterly assessment form has not been
incorporated into this manual.
Good practice dictates that some MDS items be assessed
within the first hours after admission although not
necessarily documented at that time (e.g. nutritional
status and needs). Other MDS items can best be
observed with the passage of time (e.g. resident or staff
interaction patterns). The resident’s needs will dictate the
order and manner in which the interdisciplinary team
proceeds through the assessment. For example, if a new
resident is admitted short of breath and with low blood
pressure, it is imperative to conduct an assessment of the
resident’s acute cardiorespiratory needs. Likewise, a new
resident who is angry with his or her family for admitting
him or her to the nursing home, and is actively grieving
over losses, will benefit from an early assessment of
Customary Routine, Psychosocial Well-Being, and
Depression, Anxiety and Sad Mood MDS items.
It is considered good practice to reassess a resident
following a significant change in the resident’s status. A
“significant change” is defined as a major change that: i)
is not self-limiting; ii) impacts on more than one area of
the resident’s health status; and iii) requires
interdisciplinary review or revision of the care plan.
A condition is defined as “self-limiting” when the
condition will normally resolve itself without further
intervention or by staff implementing standard disease
related clinical interventions. Other conditions may not
be permanent but would have such an impact on the
resident’s overall status that they would require a
comprehensive assessment and care plan revision. For
example a hip fracture may be viewed as a transient
condition but it would generally have a major impact on
 Chapter 2: Overview of the MDS/RAI
the resident’s functional status in more than one area.
Therefore, concepts associated with significant change
are “major” or “appears to be permanent” but a change
does not need to be both major and permanent.
The process of performing an accurate and
comprehensive assessment requires that information
about residents be gathered from multiple sources. It is the
role of the individual interdisciplinary team members
completing the assessment to validate the information
obtained from the resident, resident’s family, or other staff
members through observation, interviewing, reviewing
records and so forth to ensure accuracy. Similarly,
information in the resident’s record is validated by
interacting with the resident and care staff. In some care
homes an assessment coordinator may be appointed to
act as the responsible member of staff to bring together
the different contributions and information essential for
the assessment. It is also helpful to remember that in good
quality care settings assessment is not just an “event” but
an ongoing process and this is reiterated at various points
in the manual.
Finally, the individual resident’s care plan must be
evaluated and revised, if appropriate, each time an RAI
comprehensive assessment is completed. Homes may
either make changes on the original care plan or develop
a new care plan.
The MDS offers a means of moving towards improved and
more consistent individual assessment for older people within
homes and subsequently the provision of information about
the quality and consistency of care provision.
USES OF INFORMATION FROM THE MDS
The primary role of the MDS/RAI is of course the
assessment of residents on admission to a home and
their reassessment at regular intervals, or where a
significant change occurs in a resident’s status. This is to
permit effective planning, organisation and review of
appropriate forms of care. However, information
collected from the use of the instrument also has value in
a wide range of other areas. These include resource use
and casemix analysis, monitoring quality of care and
assessment of risk, training and comparative research and
monitoring.
■ Resource utilisation and casemix analysis -
Classification of residents in terms of their expected care
requirements and levels of resource use permits better
understanding of the relationship between needs and
costs and therefore more precise reimbursement of
homes with different mixes of resident. Residents may
be classified into casemix groupings, such as Resource
Utilisation Groups (RUGs) (Schneider et al., 1988),
which predict resource use at the level of the individual
resident. Such information can inform decisions about
staffing patterns within homes, as well as contracting
arrangements between homes and those purchasing
care.
■ Quality of care and risk assessment - The MDS/RAI
data permits the development of quality of care
indicators through aggregating information about
individual residents (Phillips et al., 1997). Quality
indicators are organised into 12 care domains:
accidents, physical functioning, behaviour and
emotional patterns, psychotropic drug use, clinical
management, quality of life, cognitive function,
sensory function and communication, continence,
infection control, skin care and nutrition and eating.
■ Training - The use of the MDS manual can contribute
to staff training by enhancing the knowledge of staff
about common risks, needs and conditions and their
management for vulnerable older people.
■ Research and monitoring - Information regarding large
numbers of residents in different types of care homes
with different regimes, staffing systems and cost
structures permits research on a comparative basis.
This may be on an international basis, between types
of homes, between homes managed by one
proprietor and the comparisons may be on the basis
of needs, outcomes, or costs, allowing for resident
mix. Standardised scales, such as the cognitive
performance scale have been developed, which assist
such comparisons.
THE STRUCTURE OF THE MANUAL
Figure 2.1 provides a guide to the structure of the
manual. On the left hand side are key tasks in the
resident assessment process from the initial assessment
through triggering of certain areas for further assessment
using the Resident Assessment Protocols (RAPs) to the
completion of a care plan. On the right hand side are
pointers to the relevant sections of the manual for each
stage of the RAI process. Chapter 3 provides an item-by-
item description and guide to the assessment form.
 Chapter 2: Overview of the MDS/RAI

Chapter 4 describes the individual RAPs and their use in

assessment. Chapter 5 describes the care planning
process, moving from problem identification to problem
resolution strategies.

Figure 2.1: A guide to the structure of the manual

The MDS/RAI Process The Manual

Carry out the MDS Assessment. The MDS Assessment form can be found in
Involve other professionals as appropriate Appendix A. A loose black and white copy for
photocopying is at the back of the manual

Need help to complete the forms? See Chapter 3 for the item-by-item guide

Find out by looking at the trigger legend at

Have you answered any questions in
a way that triggers a RAP?
Yes
the end of Chapter 4. The triggers are also
shown as hands on the MDS form and
in the tables at the end of each section in
the item-by-item guide
No (Chapter 3).

Does your professional judgement

suggest that there are problems
identified even though RAPs have
not been triggered?

Yes No

Review RAP, involve other professionals as appropriate RAPs can be found in Chapter 4 of the manual

Chapter 5 can help with care planning.

Use this and other sources of information
Further reading can also be found at the end
to complete a care plan
of this manual

Document your decision making process The RAP Summary Sheet can be found at the
and complete the RAP Summary Sheet end of Chapter 4
 Chapter 3: The Item-by-Item Guide to the MDS
Effective assessment should be both reliable and valid.
This chapter provides information to facilitate an
accurate and uniform resident assessment using the
MDS. Item-by-item instructions focus on:
■ The purpose of items included in the MDS.
■ Definitions and instructions for completing MDS
items.
■ Reminders of which MDS items require observation of
the resident for other than a standard 7-day
observation period.
■ Sources of information to be consulted for specific
MDS questions.
This chapter is divided into 22 sections (AA to R) each
representing sections of the MDS assessment form.
Within each section guidance is provided for the
completion of the relevant questions.
What is the standard format used in the guidance for
each question?
The information is presented under the following
headings for many (but not all) questions:
Purpose
Reason(s) for including the question (or set of questions)
in the MDS, including discussions of how the information
will be used by staff to identify resident problems and
develop the plan of care.
Definition
Explanation of key terms.
Process
Sources of information and methods for determining the
correct response for questions. Sources include:
■ Discussion with staff
■ Resident interview and observation
■ Clinical records, personal records, admission records
professional referrals, laboratory data, investigations,
medication records, care plans, and any similar
documents available
■ Discussion with the resident’s family
Coding
The proper method of recording each response, with
explanations of response categories.
The appropriate section of the MDS assessment form is
also included for reference. A full version of the MDS
form can be found in Appendix A. For sections B to P
the questions which trigger individual RAPs are also
summarised at the end.
A recommended approach to assist staff in becoming
familiar with the MDS assessment form is shown in the
box below. This initial investment of time in reviewing the
document is likely to pay dividends.
Recommended approach for becoming familiar with the
MDS
First, read the MDS form itself
■ Notice how sections are organised and where
information is to be recorded.
■ Work through one section at a time.
■ Examine section definitions and response codes.
■ Review procedural instructions, time frames, and
general coding conventions.
■ Are the definitions and instructions clear? Do they
differ from current practice at your home? What areas
require further clarification?
■ Complete the MDS assessment for a resident. Draw
only on your knowledge of this individual. Enter the
appropriate responses on the MDS form. Where your
review could benefit from additional information,
make note of that fact. Where might you secure
additional information?
Complete the initial review of this chapter
■ Go on to this step only after first reviewing the MDS
form and trying to complete all items for a resident
who is well known to you.
■ As you read this chapter, clarify questions that arose
as you used the MDS for the first time to assess a
resident. Note sections of this manual that help to
clarify recording information and procedural questions
you may have had.
■ Once again, read the instructions that apply to a
single section of the MDS. Make sure you understand
this information before going on to another section.
Review the test case you completed. Would you still
code it the same? It will take time to go through all
this material. Do it slowly. Do not rush. Work through
 Chapter 3: The Item-by-Item Guide to the MDS
the manual one section at a time.
■ Are you surprised by any MDS definitions,
instructions, or case examples? For example, do you
understand how to code ADLs? Or Mood?
■ Do any definitions or instructions differ from what you
thought you learned when you reviewed the MDS
form?
■ Would you now complete your initial case differently?
■ Are there definitions or instructions that differ from
current practice patterns in your home?
■ Make notes next to any section(s) of this manual you
have questions about. Be prepared to discuss these
issues during any formal training programme you
attend, or with colleagues.
In a second read through this chapter, focus on issues
that were more difficult or problematic in your first
attempt
■ Make notes on the MDS form of issues that warrant
attention.
■ Further familiarise yourself with definitions and
procedures that differ from current practice or seem to
raise questions.
■ Reread each of the case examples presented
throughout this chapter.
Future use of information in this chapter
■ Keep this chapter at hand during the assessment
process.
■ Where necessary, review the purpose of each
question.
■ This manual is a source of information. Use it to
increase the accuracy of your assessments.
INTERVIEWING TECHNIQUES
Performing an accurate and comprehensive assessment
requires that the assessor communicate effectively with a
number of individuals. The following suggestions can be
used by an individual assessor to obtain information
from residents, staff and residents’ families.
Finding an appropriate place that ensures privacy and
quiet for the interview to be conducted is essential for all
residents and ensures time is invested in what is an
important opportunity for gathering information that will
affect the resident’s experience of the care home setting.
When completing an MDS assessment the following
should be considered:
First, emphasise to all individuals you interview (i.e.
residents, families and staff) that the assessment provides
valuable information that will be used to develop a care
plan for the resident so that their individual needs can be
met. This is an opportunity to bring residents and families
into the assessment and care planning process.
Second, be flexible as to how you conduct the
assessment with each resident. It is not necessary to
complete the assessment in the same order sequence as
sections appear in the MDS. The MDS is not a
questionnaire; it is a set of common items and definitions
for assessment, which provides a structure for
systematically recording the information obtained. You
should let the resident’s needs guide you during the
assessment process.
You may wish to use the following general techniques, if
appropriate, when conducting interviews:
To elicit complete and satisfactory answers you will often
need to ask neutral or non-directive questions. Examples
of these are:
“What do you mean?”
“Tell me what you have in mind”
“Tell me more about that”
“Please, be more specific”
“Give me an example”
Repeat questions if you think they have been
misunderstood or misinterpreted.
Pause or hesitate to indicate that you are listening and
need more or better information. This is a good
technique to use while you are determining the
individual’s response pattern. Some sections will require
special sensitivity during the questioning process (e.g.
Section B dealing with memory).
Some residents may be eager to talk to you and will stray
from the topic. When a person strays, you should gently
guide them back to the question. For example.
“That’s interesting.”
“Now I need to know...”
 Chapter 3: The Item-by-Item Guide to the MDS
“Let’s get back to....”
“Tell me about....”
Validate your understanding of what is being said to you.
Be careful that you do not appear to be challenging a
respondent when clarifying a statement. For example you
may say:
“I think I hear you saying that....”
“Let’s see if I understood you correctly. You said.......... Is
that right?”
When respondents disagree or when a resident (who you
believe is capable of rational judgement) says something
contrary to information contained in the record, you
should clarify the information. Ultimately, use your best
clinical judgement to weigh all the information.
Consider developing your own home based
questionnaires for families to complete such as
preferences in routine, food likes/dislikes, family history
etc. This will give insight into the resident’s personal
history, which is invaluable in the understanding of who
they are. This also allows carers to have an important
role as their family member/friend enters into a long term
care setting.
It is important that you validate with the resident,
through observation or interview, what you have heard
from other staff, family members or what is written in the
record.
Finally, when collecting information from other staff, you
should respect the professional status of staff and
consider their need to perform their other duties in
addition to providing necessary assessment information
for you.
 Chapter 3: The Item-by-Item Guide to the MDS Basic Assessment Tracking Form - Section AA

Section AA: Identification Information

The purpose of this section is to provide key information within 14 days). [Note – this code is used if resident is
necessary to identify and track residents in homes. being readmitted subsequent to a discharge where return
was not anticipated.]
1. Resident name
Annual assessment – A comprehensive reassessment
Definition
required within 12 months of the most recent full
Legal name in record
assessment. If significant change is noted, code 3
Coding (significant change in status assessment). Do not code as
Use printed letters. If the resident goes by his or her an annual assessment.
middle name, enter the full middle name. If the resident
Significant change in status assessment – A
has no middle initial, leave item (b) blank.
comprehensive reassessment prompted by a ‘major
2. Gender change’ that is not self-limited, that impacts on more than
Coding one area of the resident’s clinical status, and that requires
Enter “1” for Male or “2” for Female. interdisciplinary review or revision of the care plan to
ensure that appropriate care is given. When there is a
3. Date of birth significant change, the assessment is usually completed
Coding within 14 days following the determination that a
For example: 2 January, 1925 should be entered as: significant change has occurred. Staff have the
responsibility of deciding whether a change they have
0 2 0 1 1 9 2 5
noted (either an improvement or decline) is significant. A
Day Month Year
significant change is defined as a major change in the
4. Race/ethnicity resident’s status that:
Process ■ Is not self-limiting
Enter the race or ethnic category the resident uses to
■ Impacts on more than one area of the resident’s
identify him or herself. Consult the resident, as necessary.
health status
Coding ■ Requires interdisciplinary review and/or revision of the
Choose only one answer. care plan
5. National Health Service number Significant correction of prior assessment – A
Coding comprehensive assessment completed at the discretion of
Enter the resident’s National Health Service number. the home, because the previous assessment was
inaccurate or completed incorrectly. This differs from a
6. National Insurance number
significant change in status assessment, in which there
Coding has been an actual change in the resident’s health status.
Enter the resident’s National Insurance number
Review assessment – This assessment ensures that the
7. Reason for assessment care plan is correct and up to date. In the US system
Purpose reviews of the resident using the MDS are recommended
To document the reason for completing the assessment on at least a quarterly basis using a subset of items from
using the various categories of assessment types. Most of the full assessment form. In the UK version review refers
to a routine reassessment at a prescribed interval to
the types of assessments listed below will require
conform to home procedures.
completion of the MDS, review of the triggered RAPs,
and development or review of a comprehensive care None of above – This is used where none of the above
plan. factors apply.

Definitions
Admission assessment – A comprehensive assessment Coding
using the MDS and RAPs required on admission (usually Choose the number that applies to the appropriate
 Chapter 3: The Item-by-Item Guide to the MDS Basic Assessment Tracking Form - Section AA

category. 10. Signatures of persons completing these items

8. Name of home Coding

Staff who completed parts of Section AA: Identification
Coding
information must enter their signatures, titles, and date
Enter the name of the home.
they completed the section.
9. Home identifier

Coding
Enter the appropriate home number.
 UK Minimum Data Set (MDS)
For Home Resident Assessment and Care Screening
Basic Assessment Tracking Form

Section AA. Identification Information

1 Resident name a. (First name)

b. (Middle initial)

c. (Last name)

d. (Title)

2 Gender 1. Male

2. Female

3 Date of birth
Day Month Year

4 Race 1. European-Caucasian 7. Chinese

2. African-Caribbean 8. Other Asian
3. African
9. Other ethnic minority
4. Pakistani
5. Bangladeshi (specify)
6. Indian 10. Not known

5 N.H.S. number

6 N.I. number

7 Reason for Primary reason for assessment:

1. Admission assessment (usually within 14 days)
assessment 2. Annual assessment
3. Significant change in status assessment
4. Significant correction of prior assessment
5. Review assessment
0. NONE OF ABOVE

8 Name of home

9 Home identifier

10 Signatures Signatures Title Date

of persons
completing
these items 22
 Chapter 3: The Item-by-Item Guide to the MDS
Section AB: Demographic Information
1. Date of entry
Purpose
Normally, the MDS Face Sheet (Sections AB and AC) is
completed once, when an individual first enters the
home. However, the face sheet is also required if the
person is re-entering your home after a discharge where
return had not previously been expected. Do not
complete the face sheet following temporary discharges
to hospitals or after therapeutic leaves/home visits. Given
this definition, enter the date the person first became a
resident/patient in your home.
Definition
Date the stay began – The date the resident was most
recently admitted to your home. For example: if the
resident was officially discharged in the past without the
expectation of return (e.g. discharged home or to another
care home), enter the most recent admission date.
However, if your home begins a new record on each
return from a temporary hospital stay or temporary
leave, you will complete the face sheet only at the
original assessment. Do not complete the face sheet at
the time of return from a temporary leave.
Process
Review the records.
Coding
Use all boxes. For a one-digit month or day, place a zero
in the first box. For example: 3 February, 1999, should
be entered as:
0 3 0 2 1 9 9 9
Day Month Year
Example
Mrs. F, a diabetic, had been living with her daughter
when she fractured her left hip during a fall off a
footstool. She spent a few days in the local hospital after
surgery, followed by an admission to a nursing home on
26/5/99 for rehabilitation. Three weeks later (16/6/99),
Mrs. F was transferred back to the hospital for an infected
incision site over her left hip and general state of decline.
Mrs. F returned to the nursing home eight days later. In
this instance, code the following date on the original face
sheet.
2 6 0 5 1 9 9 9
Day Month Year
Rationale: The face sheet sections of the MDS – AB and
Background Information at Admission: Section AB
AC are completed only when the resident first becomes a
resident of the home. In this case there is no need to
complete a new face sheet upon return readmission from
a temporary hospital stay where the resident is expected
to return to the home.
2. Admitted from (at entry)
Purpose
To facilitate care planning by documenting the place from
which the resident was admitted to the home on the date
given in item AB1. For example, if the admission was
from an acute care hospital, an immediate review of
current medications might be warranted since the
resident could be at a higher risk or recovering from
acute confusional state associated with acute illness,
medications or anaesthesia. Or, if admission was from
home, the resident could be grieving due to losses
associated with giving up one’s home and independence.
Whatever the individual circumstances, the resident’s
prior location can also suggest a list of contact persons
who might be available for further information. For
example, if the resident was admitted from a private
home with community nursing services, telephone
contact with a community nurse can provide insight into
the resident’s situation, beyond that provided in the
written records.
Definition
Private home or flat – Any house, or flat in the
community whether owned by the resident or another
person. Also included in this category are retirement
communities, and independent housing for the elderly.
Sheltered housing – Warden controlled accommodation.
Other – e.g. Hospice
Process
Review admission records. Consult the resident and the
resident’s family.
Coding
Choose only one answer.
Example
Mr. F, who had been living in his own home with his
wife, was admitted to hospital with a stroke. From the
hospital, Mr. F was transferred to this nursing home for
rehabilitation. Because Mr. F was admitted to your home
from the acute care hospital, “7” is the appropriate code.
3. Lived alone (prior to entry)
 Chapter 3: The Item-by-Item Guide to the MDS
Purpose
To document the resident’s living arrangements prior to
admission.
Definition
In other home – Any institutional/supportive setting, such
as a nursing home, sheltered care or residential care
home.
Process
Review admission records. Consult the resident and the
resident’s family.
Coding
If living in another home (i.e. nursing home, residential
home, warden controlled home) prior to admission to
the nursing home, enter “2”.
If the resident was not living in another home prior to
admission to the home, enter “0” or “1”, as appropriate.
Examples
Mrs. H lived on her own and her daughters took turns
sleeping in her home so she would never be alone at
night. Code “0” for No (did not live alone). If, however,
her daughters stayed with her only 3-4 nights per week,
Code “1” for Yes (lived alone).
Mr. J lived in his own first-floor flat of a two-family home
and received constant attention from his family, who
lived on the ground floor. Code “0” for No (did not live
alone).
Mr. D lived with his wife in housing for older people prior
to admission. Code “0” for No (did not live alone).
Mrs. X was the primary caregiver for her two young
grandchildren, who lived with her after their parent’s
divorce. Code “0” for No (did not live alone).
Mrs. K was admitted directly from an acute care hospital.
She had been living alone in her own flat prior to
hospital stay. Code “1” for Yes (lived alone).
Mr. G lived in a residential home. Code “2” (in other
home).
4. Post code (prior to entry)
Definition
Post code – The post code for the address where the
resident last resided prior to admission to the home. If
the resident was admitted to your home from another
nursing home or institutional setting, the prior primary
residence is the address of the resident’s home prior to
Background Information at Admission: Section AB
entering the other care home.
Process
Review resident’s admission records as necessary. Ask
resident and family members as appropriate.
5. Residential history 5 years prior to entry
Purpose
To document the resident’s previous experience living in
institutional or group settings.
Definition
Prior stay at this home – Resident’s prior stay was
terminated by discharge (without an expected return) to
the community, another long-term care home, or (in
some cases) hospitalisation.
Stay in other home – Prior stay in one or more care
homes other than current home.
Other residential facility – Examples include group home.
Mental health setting – Examples include psychiatric
hospital, psychiatric ward of a general hospital or
psychiatric community home.
Process
Review the admission record. Consult the resident or
family.
Coding
Tick all institutional or group settings in which the
resident lived for the five years prior to the current date
of entry (as entered in AB1). Exclude limited stays for
treatment or rehabilitation when the resident had a
primary residence to return to (i.e. the place the resident
called “home” at that time). If the resident has not lived
in any of these settings in the past five years, tick NONE
OF ABOVE.
6. Lifetime occupation(s)
Purpose
To identify the resident’s role or past role in life and to
establish familiarity in how staff should address the
resident. For example, a doctor might appreciate being
referred to as “Doctor”. Knowing a person’s lifetime
occupation is also helpful for care-planning purposes. For
example, a carpenter might enjoy pursuing appropriate
hobby activities.
Coding
Enter the job title or profession that describes the
resident’s main occupation(s) before retiring or entering
 Chapter 3: The Item-by-Item Guide to the MDS
the home.
The lifetime occupation of a person whose primary work
was in the home should be recorded. When two
occupations are identified, place a slash (/) between each
occupation. A person who had two careers (e.g.
carpenter and security guard) should be recorded as
“Carpenter/Security Guard”.
7. Education
Purpose
To record the age of leaving full time schooling and if the
resident attended college or took an apprenticeship or
has a university level education. Knowing this
information may be useful for assessment (e.g.
interpreting cognitive patterns or language skills), care
planning (e.g. deciding how to focus a planned activity
programme) and planning for resident education in self-
care skills.
Definition
Age of leaving full time schooling – age of leaving
secondary education in full time school. Doesn’t include
years at college or university (tertiary education).
College/apprenticeship – Education leading to a
recognised qualification whether full or part time
(includes those taken in the evenings) at further
education college or an apprenticeship in work e.g. RSA,
Pitmans, City and Guilds.
University level education – undergraduate or post
graduate qualification.
Process
Ask the resident and significant other(s). Review the
resident’s record.
Coding
Code for the best response.
8. Language
Definition
Primary language – The language the resident primarily
speaks or understands.
Process
Interview the resident and family. Observe and listen.
Review the resident’s record.
Coding
Background Information at Admission: Section AB
Enter “0” for English, “1” for Other and specify.
Example
Mrs. F. emigrated with her family from East Africa several
years ago. She is able to speak and understand very little
English. She depends on her family to translate
information in Swahili.
Primary language “1” Other
If other, specify: SWAHILI
9. Mental health history and learning disability
Purpose
To document a primary or secondary diagnosis of
psychiatric illness or learning disability.
Definition
Resident has one of the following:
■ A schizophrenic, mood, paranoid, panic or other
severe anxiety disorder; personality disorder; other
psychotic disorder; another mental disorder or a
learning disability that may lead to chronic disability;
but
■ Not a primary diagnosis of dementia, including
Alzheimer’s disease or a related disorder, or a non-
primary diagnosis of dementia unless the primary
diagnosis is a major mental disorder;
and
■ Within the past 3 to 6 months the disorder has
resulted in functional limitations in major life activities
that would otherwise be appropriate for a resident of
that age;
and
■ The treatment history indicates that the individual has
experienced either: (a) psychiatric treatment more
intensive than outpatient care more than once in the
past 2 years (e.g. partial hospitalisation or inpatient
hospitalisation); or (b) within the last 2 years due to
the mental illness, experienced an episode of
significant disruption to the normal living situation, for
which formal support services were required to
maintain functioning at home, or in a residential
treatment environment
Process
Review the resident’s record only. For a ‘Yes’ response to
be entered, there must be written documentation (i.e.
verbal reports from the resident or resident’s family are
 Chapter 3: The Item-by-Item Guide to the MDS
not sufficient).
Coding
Enter “1” for Yes or “0” for No.
10. Date background information completed
Purpose
For tracking purposes, this item should reflect the date
that the Background (Face Sheet) Information at
Admission form (Sections AB to AD) is completed or
amended.
Coding
Enter the date the Background (Face Sheet) Information
at Admission form is originally completed. In some
circumstances (e.g. if a knowledgeable family member is
not available during the assessment period), it is difficult
to fill in all the background information requested on this
form. However, the information is often obtained at a
later date. As new or clarifying information becomes
available, the home may record additional information
on the form or enter data into a computerised record.
This question (AB10) should then reflect the date that
new information is recorded or existing information is
Background Information at Admission: Section AB
revised.
Examples
Mr. B was admitted to the home on 3/12/98 in a
comatose state and therefore, unable to communicate on
his own behalf. By reviewing transfer records that
accompanied him from the acute care hospital, you find
that you are only able to partially complete Section AB
(Demographic Information), and you are unable to
complete Section AC (Daily Routine) because the records
are scanty in these areas. You decide to complete what
you can by the 14th day of Mr. B’s residency (the date
the MDS assessment is to be completed) and enter the
date 17/12/98 for item AB10. On 24/12/98 Mr. B’s only
relative, a daughter, visits and you are able to obtain
more information from her. Enter the new information
(e.g. demographic or daily routines) on the form and
then enter the date 24/12/98 for item AB10.
 UK Minimum Data Set (MDS)
For Home Resident Assessment and Care Screening
Background (Face Sheet) Information at Admission

Section AB. Demographic Information

1 Date of entry Date the stay began. Note - Does not include readmission if record was closed at time of
temporary discharge to hospital, etc. In such cases, use prior admission date.

Day Month Year

2 Admitted from 1. Private home/flat with no health/personal social services 6. Nursing home
2. Private home/flat with health/personal social services 7. Acute care hospital
(at entry)
3. Sheltered housing 8. Psychiatric hospital
4. Board and care/assisted living/group home 9. Rehabilitation hospital
5. Residential home 10. Other

3 Lived alone 0. No 2. In other home

1. Yes 7. Unknown
(prior to entry)
4 Postcode
(prior to entry)
5 Residential history 5 (Tick all settings resident lived in during 5 years prior to date of entry given in item AB1 above)

years prior to entry ■ a. Prior stay at this home

■ b. Stay in other home
■ c. Other residential facility - board and care home, assissted living, group home
■ d. Mental health setting
■ e. NONE OF ABOVE

6 Lifetime occupation(s)
(Put “/” between two
occupations)

7 Education Age at leaving full time schooling. Tick if applicable

■ a. College/apprenticeship
■ b. University level education

8 Language Primary language

0. English
1. Other (specify)

9 Mental health history Does resident’s record indicate any history of mental illness or learning disability?
0. No 1. Yes
& learning disability
10 Date background
information completed Day Month Year
 Chapter 3:The Item-by-Item Guide to the MDS
Section AC: Daily Routine
1. Daily routine (In the year prior to DATE OF ENTRY to
this home or year last in community if now being admit-
ted from another home)
Purpose
These items provide information on the resident’s usual
lifestyle and daily routine in the year prior to DATE OF
ENTRY (item AB1) to the home. If the resident is being
admitted from another home, review the resident’s
routine during the last year the resident lived in the
community. The items should initiate a flow of
information about cognitive patterns, activity preferences,
nutritional preferences and problems, ADL scheduling
and performance, psychosocial well-being, mood,
continence issues, etc. The resident’s responses to these
items also provide the interviewer with “clues” to
understanding other areas of the resident’s function.
These clues can be further explored in other sections of
the MDS that focus on particular functional domains.
Taken in their entirety, the data gathered will be
extremely useful in designing an individualised plan
of care.
Process
Engage the resident in conversation. A comprehensive
review can be facilitated by a questioning process such as
that described below in the Guidelines For Interviewing
Resident.
If the resident cannot respond (e.g. has severe dementia),
ask a family member or other representative of the
resident (e.g. legal guardian). For some residents you
may be unable to obtain this information (e.g. resident
with dementia who first entered the home many years
ago and has no family to provide accurate information)
Guidelines for interviewing resident
Staff should regard this step in the assessment process as
a good time to get to know the resident as an individual
and an opportunity to set a positive tone for the future
relationship. It is also a useful starting point for building
trust prior to asking difficult questions about such factors
as urinary incontinence.
The interview should be done in a quiet, private area
where you are not likely to be interrupted. Use a
conversational style to put the resident at ease. Explain at
the outset why you are asking these questions (“Staff
want to know more about you so you can have a
comfortable stay with us.” “These are things that many
Background Information at Admission: Section AC
older people find important.” “I’m going to ask a little bit
about how you usually spend your day.”)
Begin with a general question – e.g. “Tell me, how did
you spend a typical day before coming here (or before
going to the first home)?” or “What were some of the
things you liked to do?” Listen for specific information
about sleep patterns, eating patterns, preferences for
timing of baths or showers, and social and leisure
activities involvements. As the resident becomes engaged
in the discussion, probe for information on each item of
the routine section (i.e. cycle of daily events, eating
patterns, Activities of Daily Living (ADL) patterns,
involvement patterns). Realise, however, that a resident
who has been in an institutional setting for many years
prior to coming to your home may no longer be able to
give an accurate description of pre-institutional routines.
Some residents will persist in describing their experience
in the long-term care setting, and will need to be
reminded by the interviewer to focus on their usual
routines prior to admission. Ask the resident, “Is this what
you did before you came to live here?”
If the resident has difficulty responding to prompts
regarding particular items, backtrack by re-explaining that
you are asking these questions to help you understand
how the resident’s usual day was spent and how certain
things were done. It may be necessary to ask a number
of open-ended questions in order to obtain the necessary
information. Prompts should be highly individualised.
Ask the resident to describe a typical day. Focus on usual
habits, involvement with others, and activities. Phrase
questions in the past tense. Periodically reiterate to the
resident that you are interested in the resident’s routine
before home admission, and that you want to know what
he or she actually did, not what he or she might like to
do.
For example:
■ After you retired from your job, did you get up at a
regular time in the morning?
■ When did you usually get up in the morning?
■ What was the first thing you did after you got up?
■ What time did you usually have breakfast?
■ What kind of food did you like for breakfast?
■ What happened after breakfast? (Probe for naps or
regular post-breakfast activity such as reading the
 Chapter 3:The Item-by-Item Guide to the MDS
paper, taking a walk, doing housework, washing
dishes.)
■ When did you have lunch? Was it usually a big meal
or just a snack?
■ What did you do after lunch? Did you take a short
rest? Did you often go out or have friends in to visit?
■ Did you ever have a drink before dinner? Every day?
Weekly?
■ What time did you usually bathe? Did you usually
take a shower or a bath? How often did you bathe?
Did you prefer AM or PM?
■ Did you snack in the evening?
■ What time did you usually go to bed? Did you usually
wake up during the night?
Definition
Goes out 1+ days a week – Went outside for any reason
(e.g. socialisation, fresh air etc.).
Use of tobacco at least daily – Smoked any type of
tobacco (e.g. cigarettes, cigars, pipe) at least once daily.
This item also includes sniffing or chewing tobacco.
Distinct food preferences – This item is ticked to indicate
the presence of specific food preferences, with details
recorded elsewhere in the clinical record (e.g. was a
vegetarian; observed kosher dietary laws; avoided red
meat for health reasons; allergic to wheat and avoids
bread). Do not tick this item for simple likes and dislikes.
Use of alcoholic beverage(s) at least weekly – Drank at
least one alcoholic drink per week.
Wakens to toilet all or most nights – Awoke to use the
toilet at least once during the night all or most of the
time.
Has irregular bowel movement pattern – Refers to an
unpredictable or variable pattern of bowel elimination,
regardless of whether the resident prefers a different
pattern.
Bathing in PM – Took shower or bath in the evening.
Background Information at Admission: Section AC
Daily contact with relatives/close friends – Includes visits
and telephone calls. Does not include exchange of letters
only.
Usually attends church, chapel, synagogue (etc) – Refers
to interaction regardless of type (e.g. regular churchgoer,
involved in church committees or groups).
Daily animal companion/presence – Refers to
involvement with animals (e.g. pet, guide dog, fed birds
daily in garden or park).
Unknown – If the resident cannot provide any
information, no family members are available, and the
admission record does not contain relevant information,
tick the last box in the category (“UNKNOWN”), leave all
other boxes in Section AC blank.
Coding
Coding is limited to selected routines in the year prior to
the resident’s first admission to a care home. Code the
resident’s actual routine rather than his or her goals or
preferences (e.g. if the resident would have liked daily
contact with relatives but did not have it, do not tick
“Daily contact with relatives/close friends”).
Under each major category (Cycle of Daily Events,
Eating Patterns, ADL Patterns, and Involvement Patterns)
a NONE OF ABOVE choice is available. For example, if
the resident did not engage in any of the items listed
under Cycle of Daily Events, indicate this by ticking
NONE OF ABOVE for Cycle of Daily Events.
If an individual item in a particular category is not known
(e.g. ”Finds strength in faith,” under Involvement
Patterns), enter “NA” alongside the specific item.
If information is unavailable for all the items in the entire
Daily Routine section, tick the final box “UNKNOWN –
Resident/family unable to provide information”. If
UNKNOWN is ticked, no other boxes in the Daily
Routine section should be ticked.
 UK Minimum Data Set (MDS)
For Home Resident Assessment and Care Screening
Background (Face Sheet) Information at Admission

Section AC. Daily Routine

1 Daily routine (Tick all that apply. If all information UNKNOWN, tick last box only.)
(In year prior to
Cycle of daily events
DATE OF ENTRY)
■ a. Stays up late at night (e.g. after 9pm)
■ b. Naps regularly during day (at least 1 hour)
■ c. Goes out 1+ days a week
■ d. Stays busy with hobbies, reading, or fixed daily routine
■ e. Spends most of time alone or watching TV
■ f. Moves independently indoors (with appliances, if used)
■ g. Use of tobacco products at least daily.
■ h. NONE OF ABOVE

Eating patterns

■ i. Distinct food preferences

■ j. Eats between meals all or most days
■ k. Use of alcoholic beverage(s) at least weekly.
■ l. NONE OF ABOVE

ADL patterns

■ m. In bedclothes much of the day

■ n. Wakens to toilet all or most nights
■ o. Has irregular bowel movement pattern
■ p. Showers for bathing
■ q. Bathing in PM
■ r. NONE OF ABOVE

Involvement patterns

■ s. Daily contact with relatives/close friends.

■ t. Usually attends church, chapel, synagogue (etc).
■ u. Finds strength in faith
■ v. Daily animal companion/presence
■ w. Involved in group activities.
■ x. NONE OF ABOVE

■ y. Unknown - Resident/family unable to provide information

 Chapter 3:The Item-by-Item Guide to the MDS
Section AD: Face Sheet Signatures
a. Signature of assessment coordinator
Coding
The person who worked on the Background (Face Sheet)
Information at Admission sections of the MDS must enter
his or her signature on the day this part of the MDS form
is completed.
b. Date assessment coordinator signed as
complete
Background Information at Admission: Section AD
Coding
Enter date the form was signed.
c. Signature of others who completed part of background
assessment sections AB and AC.
Coding
Other staff who completed parts of the background
sections of the MDS must enter their signatures, the
sections they completed, and the date they completed
their assigned sections.
 UK Minimum Data Set (MDS)
For Home Resident Assessment and Care Screening
Background (Face Sheet) Information at Admission

Section AD. Face Sheet Signatures

a. Signature of Assessment Coordinator

b. Date Assessment Coordinator signed as complete

Day Month Year

c. Other signatures Title Sections Date

 Chapter 3: The Item-by-Item guide to the MDS
Section A: Identification and Background Information
1. Resident name
Definition
Legal name in record.
Coding
Print the resident’s name in the following order – a. first
name, b. middle initial, c. last name, d. title. If resident
goes by his or her middle name, enter the full middle
name. If the resident has no middle initial, leave (b)
blank.
2. Room number
Purpose
Another identifying number for tracking purposes.
Definition
The number of resident’s room in the home.
Coding
Start in the left most box, use as many boxes as needed.
3. Assessment reference date
Purpose
To establish a common temporal reference point for all
staff participating in the resident’s assessment. Although
staff members may work on completing a resident’s MDS
on different days, establishment of the assessment period
is important (i.e. “starting the clock”) so that all
assessment items refer to the resident’s objective
performance and health status during the same period of
time.
Definition
Last day of MDS observation period – This date refers to
a specific end point in the MDS assessment process.
Almost all MDS items refer to the resident’s status over a
designated time period, most frequently the 7-day period
ending on this date. The date sets the designated
endpoint of the common observation period, all MDS
items refer back in time from this point. Some MDS items
cover the 14 days ending on this date, some one month
ending on this date, and so forth.
Coding
The first coding task is to enter the observation reference
date (i.e. the end point date of the observation period).
For an admission assessment, this date should ideally be
any day up to the 14th day following admission. For a
follow up assessment, select a common reference date
within the period the assessment must be completed.
Full Assessment Form: Section A
This date is the end point to which all MDS items must
refer.
Examples of assessment reference date for an admission
assessment
Mrs. M was admitted to your home on 20th August
1998. Your home’s policy states that all MDS
assessments for new admissions shall be completed by
the 7th day of residency. Therefore, staff decided to
conduct their observations, tests, interviews with resident,
family and other staff, and chart reviews during the first 7
days of the resident’s stay. During this time they record
pertinent findings in the resident’s record and, where
appropriate, on the MDS form. They record the endpoint
of the MDS observation period as follows, giving staff
another 7 days in which to complete the RAPs:
2 6 0 8 1 9 9 8
Date Month Year
Mr. S was admitted to your home on 20th August 1998.
Your home policy states that all MDS assessments for
new admissions shall be completed by the 14th day of
residency. The interdisciplinary team on the new
resident’s unit decides to take the full 14 days to
complete the assessment. Of course they conduct
observations, tests and necessary interviews and chart
reviews necessary for care planning. During this time they
record pertinent findings in the resident’s record. They
record the endpoint of the MDS observation period as
follows, with the stipulation that the RAPs must also be
completed on that date:
0 2 0 9 1 9 9 8
Date Month Year
Rationale: As 2nd September 1998 is the 14th day of
residency, the period of review for the MDS items will be
the 7 days prior to that date, (or the period from 27th
August 1998 through to 2nd September 1998).
For an annual assessment, staff are likely to have
extensive data on hand. In such cases, a designated
observation period of 7 days is usually established. The
date on which the observation period ends is the
assessment reference date. All staff who participate in the
assessment must, however, agree that their description of
the resident reflects the resident’s status in this 7-day
period.
For the day and month of the assessment, enter two
 Chapter 3: The Item-by-Item guide to the MDS Full Assessment Form: Section A

digits each using zero, (“0”) as a filler. Use four digits for Tick all the current payment sources that are applicable.
the year.
7. Reason for assessment
Example of assessment reference date for an annual Purpose
assessment To document the reason for completing the assessment
Mr. X has been living in your nursing home for the past 2 using the various categories of assessment types. Most of
years. The date of his last full MDS assessment was the types of assessments listed below will require
approximately 1 year ago (27/9/97). It is time to think completion of the MDS, review of the triggered RAPs, and
about scheduling another full assessment. The MDS development or review of a comprehensive care plan.
assessment coordinator sends a notice to the
Definitions
interdisciplinary team stating that Mr. X’s next full
Admission assessment – A comprehensive assessment
assessment date is 20/9/98. This means that the team using the MDS and RAPs required on admission (usually
should be evaluating Mr. X during the 7-day period that within 14 days). [Note - this code is used if resident is
ends on this date for most MDS items (i.e. from 14/9/98 being readmitted subsequent to a discharge where return
to 20/9/98). Record the end point of the MDS was not anticipated.]
observation period as:
Annual assessment – A comprehensive reassessment
2 0 0 9 1 9 9 8 required within 12 months of the most recent full
Date Month Year assessment. If significant change is noted, code 3
(significant change in status assessment). Do not code as
4a. Date of re-entry an annual assessment.
Purpose Significant change in status assessment – A
To track the date of the resident’s readmission to the comprehensive reassessment prompted by a ‘major
home following a temporary discharge to a hospital. change’ that is not self-limited, that impacts on more than
Definition one area of the resident’s clinical status, and that requires
The date the resident was most recently readmitted to interdisciplinary review or revision of the care plan to
your home after being temporarily discharged for ensure that appropriate care is given. When there is a
hospital stay in last 3 months (or since last assessment if significant change, the assessment is usually completed
less than 3 months) within 14 days following the determination that a
significant change has occurred. Staff have the
Process responsibility of deciding whether a change they have
Review the records. noted (either an improvement or decline) is significant. A
Coding significant change is defined as a major change in the
If the resident has not been hospitalised in the last 3 resident’s status that:
months, leave blank. Otherwise, use all boxes. For a one- ■ Is not self-limiting
digit month or day, place a zero in the first box. For
■ Impacts on more than one area of the resident’s
example: February 3, 1998, should be entered as:
health status
0 3 0 2 1 9 9 8 ■ Requires interdisciplinary review and/or revision of the
Date Month Year care plan

5. Marital status Significant correction of prior assessment – A

comprehensive assessment completed at the discretion of
Coding
the home, because the previous assessment was
Choose the answer that describes the current marital
inaccurate or completed incorrectly. This differs from a
status of the resident.
significant change in status assessment, in which there has
6. Current payment sources been an actual change in the resident’s health status.
Coding Review assessment – This assessment ensures that the
 Chapter 3: The Item-by-Item guide to the MDS
care plan is correct and up to date. In the US system
reviews of the resident using the MDS are recommended
on at least a quarterly basis using a subset of items from
the full assessment form. In the UK version review refers
to a routine reassessment at a prescribed interval to
conform to home procedures.
None of above – This is used where none of the above
factors apply.
Coding
Choose the number that applies to the appropriate
category.
8. Responsibility/legal guardian
Purpose
To record who is appropriately involved in decisions
about the resident’s care, treatment, financial affairs and
legal affairs. Depending on the resident’s condition,
multiple options may apply. For example, a resident with
moderate dementia may be competent to make decisions
in certain areas, although in other areas a family member
may assume some decision-making responsibility. Or a
resident may have executed a limited power of attorney
to someone responsible for legal affairs.
Definition
Legal guardian – Someone who has been appointed after
a court hearing and is authorised to make decisions for
the resident.
Enduring power of attorney – Documentation that
someone other than the resident is legally responsible for
financial decisions if the resident becomes unable to
make decisions.
Court of protection – Where a receiver has been
appointed by the court to manage and administer the
property and affairs of the resident.
Family member responsible – Includes immediate family
or significant other(s) as designated by the resident.
Responsibility for decision-making may be shared by
both resident and family.
Patient responsible for self – Resident retains
responsibility for decisions. In the absence of
guardianship or legal documents indicating that decision
making has been delegated to others, always assume that
the resident is the responsible party.
Process
Full Assessment Form: Section A
Legal oversight such as guardianship or enduring power
of attorney are generally governed by law. The
descriptions provided here are for general information
only. Legal advice on these issues should be sought.
Relevant references that provide useful information are
cited at the end of this manual.
Consult the resident and the resident’s family. Review the
records. Where oversight or guardianship is court
ordered, evidence of this should be included in the
resident’s record in order for the item to be ticked on the
MDS form.
Coding
Tick all that apply.
9. Advanced directives
Purpose
To record the existence of directives regarding treatment
options for the resident. Documentation must be
available in the record for a directive to be considered
current. The absence of pre-existing directives for the
resident should prompt discussion by clinical staff with
the resident and family regarding the resident’s wishes.
Even though an advanced directive may be specified the
legal status of the directive may not be binding.
Definition
Living will – A document specifying the resident’s
preferences regarding measures used to prolong life when
there is a terminal prognosis.
Do not resuscitate – In the event of respiratory or cardiac
failure, the resident, or clinician has directed that no
cardiopulmonary resuscitation or other life-saving
methods will be used to attempt to restore the resident’s
respiratory or circulatory function.
Do not hospitalise – A document specifying that the
resident is not to be hospitalised even after developing a
medical condition that usually requires hospitalisation.
Organ donation – Instructions indicating that the resident
wishes to make organs available for transplantation,
research or medical education upon death.
Feeding restrictions – The resident does not wish to be
fed by artificial means (e.g. tube, intravenous nutrition) if
unable to be nourished by oral means.
Medication restrictions – The resident does not wish to
receive life-sustaining medications (e.g. antibiotics,
 Chapter 3: The Item-by-Item guide to the MDS
chemotherapy). These restrictions may not be
appropriate, however, when such medications could be
used to ensure the resident’s comfort. In these cases, the
directive should be reviewed with the responsible medical
practitioner.
Other treatment restrictions – The resident does not wish
to receive certain medical treatments. Examples include,
but are not limited to, blood transfusions, tracheotomy,
respiratory intubation and restraints. Such restrictions
may not be appropriate to treatments given for palliative
reasons (e.g. reducing pain or distressing physical
symptoms such as nausea or vomiting).
Process
Review the resident’s record for documentation of the
resident’s advanced directives. Documentation must be
available in the record for a directive to be considered
current.
Staff should make a reasonable attempt to determine
whether a new resident has ever created an advanced
directive (e.g. ask family members, check with the
responsible physician). Clearly sensitivity is required in
any discussions with the resident and family. This
information is usually more appropriately obtained once
a relationship has been established between staff and the
resident.
Full Assessment Form: Section A
Coding
The following comments provide further guidance on
how to code these directives. You will also need to
consider legal implications and the home policy.
The resident should always be involved in the discussion
to ensure informed decision making. If the resident’s
preference is known and the attending doctor is aware of
the preference, but the preference is not recorded in the
record, tick the MDS item only after the preference has
been documented.
If the resident’s preference is in areas that require
supporting instructions by the attending doctor (e.g. do
not resuscitate, do not hospitalise, feeding restrictions),
tick the MDS item only if the document has been
recorded or after the doctor provides the necessary
instructions. Where a doctor’s current instruction is
recorded but the resident’s preference is not indicated,
discuss with the resident’s doctor and tick the MDS item
only after documentation confirming that the resident’s
wishes have been entered into the record.
Tick all that apply. If none of the directives are verified by
documentation in the resident’s records, tick NONE OF
ABOVE.
 UK Minimum Data Set (MDS)
For Home Resident Assessment and Care Screening
Full Assessment Form
(Status in last 7 days unless other time frame indicated)

Section A. Identification and Background Information

1 Resident name a. (First name)

b. (Middle initial)

c. (Last name)

d. (Title)

2 Room number

3 Assessment Last date of MDS observation period

reference date
Day Month Year

4a Date of re-entry Date of re-entry from most recent temporary discharge to a hospital in last 3 months (or since
last assessment or admission if less than 3 months)

Day Month Year

5 Marital status ■ a. Never married ■ d. Separated

■ b. Married ■ e. Divorced
■ c. Widowed

6 Current payment (Tick all that apply)

sources ■ a. National Health Service ■ f. Self or family pays

■ b. Social Services ■ g. Private long term care insurance
■ c. DSS ■ h. Other (Specify)
■ d. Charity
7 Reason for ■ e. Third party top up
Primary reason for assessment:

assessment 1. Admission assessment (usually within 14 days) 4. Significant correction of prior assessment
2. Annual assessment 5. Review assessment
3. Significant change in status assessment 0. NONE OF ABOVE

8 Responsibility/ legal (Tick all that apply)

guardian ■ a. Legal guardian ■ d. Family member responsible

■ b. Enduring power of attorney ■ e. Patient responsible for self
■ c. Court of protection ■ f. NONE OF ABOVE

9 Advanced Check the resident’s record for supporting documentation on the following
(see notes for guidance):
directives
■ a. Living will ■ e. Feeding restrictions
■ b. Do not resuscitate ■ f. Medication restrictions
■ c. Do not hospitalise ■ g. Other treatment restrictions
■ d. Organ donation ■ h. NONE OF ABOVE
 Chapter 3: The Item-by-Item Guide to the MDS
Section B: Cognitive Patterns
The purpose of this section is to determine the resident’s
ability to remember, think coherently, and organise daily
self-care activities. This information is crucial in many
care-planning decisions. The focus is on resident
performance, including an ability to remember recent
and long-past events and to perform key decision making
skills.
Questions about cognitive function and memory can be
sensitive issues for some residents who may become
defensive or agitated or very emotional. These are not
uncommon reactions to performance anxiety and feelings
of being exposed, embarrassed, or frustrated if the
resident knows he or she cannot answer the questions
cogently.
Be sure to interview the resident in a private, quiet area
without distractions – i.e. not in the presence of other
residents or family, unless the resident is too agitated to
be left alone. Using a nonjudgmental approach to
questioning will help create a needed sense of trust
between staff and resident. After eliciting the resident’s
responses to the questions, return to the resident’s family
or others, as appropriate, to clarify or validate
information regarding the resident’s cognitive function
over the last seven days. For residents with limited
communication skills or who are best understood by
family or specific care givers, you will need to carefully
consider their insights in this area.
■ Engage the resident in general conversation to help
establish rapport.
■ Actively listen and observe for clues to help you
structure your assessment. Remember – repetitiveness,
inattention, rambling speech, defensiveness, or
agitation may be challenging to deal with during an
interview, but they provide important information
about cognitive function.
■ Be open, supportive, and reassuring during your
conversation with the resident (e.g. “Do you
sometimes have trouble remembering things? Tell me
what happens. We will try to help you”).
If the resident becomes really agitated, sympathetically
respond to his or her feelings of agitation and STOP
discussing cognitive function. The information-gathering
process does not need to be completed in one sitting but
may be ongoing during the entire assessment period. Say
to the agitated resident, for example, “Let’s talk about
something else now,” or “We don’t need to talk about
Full Assessment Form: Section B
that now. We can do it later”. Observe the resident’s
cognitive performance over the next few hours and days
and come back to ask more questions when he or she is
feeling more comfortable.
1.Comatose
Purpose
To record whether the resident’s clinical record includes a
documented neurological diagnosis of coma or persistent
vegetative state.
Coding
Enter the appropriate number in the box.
If the resident has been diagnosed as comatose or in a
persistent vegetative state, code “1”. Skip to Section G.
If the resident is not comatose or is semi-comatose, code
“0” and proceed to the next item (B2).
2. Memory
Purpose
To determine the resident’s functional capacity to
remember both recent and long-past events (i.e. short-
term and long-term memory).
Process
a. Short-term memory
Ask the resident to describe a recent event that both of
you had the opportunity to remember. Or, you could use
a more structured short-term memory test. For residents
with limited communication skills, ask staff and family
about the resident’s memory. Remember, if there is no
positive indication of memory ability, (e.g. remembering
multiple items over time or following through on a
direction given five minutes earlier) the correct response
is “1”, Memory Problem.
Examples
Ask the resident to describe the breakfast meal or an
activity just completed.
Ask the resident to remember three items (e.g. book,
watch, table) for a few minutes. After you have stated all
three items, ask the resident to repeat them (to verify that
you were heard and understood). Then proceed to talk
about something else – do not be silent, do not leave the
room. In five minutes, ask the resident to repeat the
name of each item. If the resident is unable to recall all
three items, code “1”. For persons with verbal
communication problems, non-verbal responses are
acceptable (e.g. when asked how many children they
 Chapter 3: The Item-by-Item Guide to the MDS
have, they can tap out a response of the appropriate
number).
b. Long-term memory
Engage in conversation that is meaningful to the resident.
Ask questions for which you can validate the answers
(from your review of record, general knowledge, the
resident’s family). For residents with limited
communication skills, ask staff and family about the
resident’s memory status. Remember, if there is no
positive indication of memory ability, the correct
response is “1”, Memory Problem.
Example
Ask the resident, “Where did you live just before you
came here?” If “at home” is the reply, ask “What was
your address?” If “another home” is the reply, ask “What
was the name of the place?” Then ask: “Are you
married?” “What is your spouse’s name?” “Do you have
any children?” “How many?” “When is your birthday?”
“In what year were you born?”
Coding
Enter the numbers that correspond to the observed
responses.
3. Memory/recall ability
Purpose
To determine the resident’s memory/recall performance
within the environmental setting. A resident may have
intact social graces and respond to staff and others with a
look of recognition, yet have no idea who they are. This
item will enable staff to probe beyond first, perhaps
mistaken, impressions.
Definition
Current season – Able to identify the current season (e.g.
correctly refers to weather for the time of year, bank
holidays, religious celebrations, etc.).
Location of own room – Able to locate and recognise
own room. It is not necessary for the resident to know
the room number, but he or she should be able to find
the way to the room.
Staff names/faces – Able to distinguish staff members
from family members, strangers, visitors, and other
residents. It is not necessary for the resident to know the
staff member’s name, but he or she should recognise that
the person is a staff member and not the resident’s son or
daughter, etc.
Full Assessment Form: Section B
That he/she is in a care home – Able to determine that he
or she is currently living in a home. To tick this question
it is not necessary that the resident be able to state the
name of the home, but he/she should be able to refer to
the home by a term such as a “home for older people”, a
“hospital for the elderly”, “a place where older people
live”, etc.
Process
Test memory/recall. Use information obtained from
records or staff. Ask the resident about each item. For
example, “What is the current season? “What is the
name of this place?” “What is this kind of place?” If the
resident is not in his or her room, ask “Will you show me
to your room?” Observe the resident’s ability to find the
way.
Coding
For each item that the resident can recall, tick the
corresponding answer box. If the resident can recall
none, tick NONE OF ABOVE.
4. Cognitive skills for daily decision-making
Purpose
To record the resident’s actual performance in making
everyday decisions about tasks or activities of daily living.
Examples
Choosing items of clothing; knowing when to go to
meals; using environmental cues to organise and plan
(e.g. clocks, calendars, posted listings of upcoming
events); in the absence of environmental cues, seeking
information appropriately (i.e. not repetitively) from
others in order to plan the day; using awareness of one’s
own strengths and limitations in regulating the day’s
events (e.g. asks for help when necessary); making the
correct decision concerning how to get to the dining
room; acknowledging need to use a zimmer frame and
using it faithfully.
Process
Review the clinical record. Consult family and staff.
Observe the resident. The questioning should focus on
whether the resident is actively making these decisions,
and not whether staff believe the resident might be
capable of doing so. Remember the purpose of this item
is to record what the resident is doing (performance).
Where a staff member takes decision-making
responsibility away from the resident regarding tasks of
everyday living, or the resident does not participate in
 Chapter 3: The Item-by-Item Guide to the MDS
decision-making, whatever his or her level of capability
may be, the resident should be considered to have
impaired performance in decision-making.
This item is especially important for further assessment
and care planning in that it can alert staff to a mismatch
between a resident’s abilities and his or her current level
of performance, or that staff may be inadvertently
fostering the resident’s dependence.
Coding
Enter one number that corresponds to the most correct
response.
0. Independent – The resident’s decisions in organising
daily routine and making decisions were consistent,
reasonable, and organised reflecting lifestyle, culture and
values.
1. Modified independence – The resident organised daily
routine and made safe decisions in familiar situations,
but experienced some difficulty in decision-making when
faced with new tasks or situations.
2. Moderately impaired – The resident’s decisions were
poor; the resident required reminders, cues, and
supervision in planning, organising, and correcting daily
routines.
3. Severely impaired – The resident’s decision-making
was severely impaired; the resident never (or rarely)
made decisions.
5. Indicators of acute confusion – periodic disordered
thinking/awareness
Purpose
To record behavioural signs that may indicate that acute
confusional state is present. Frequently, acute
confusional state is caused by a treatable illness such as
infection or reaction to medications.
The characteristics of acute confusional state are often
manifested behaviourally and therefore can be observed.
For example, disordered thinking may be manifested by
rambling, irrelevant, or incoherent speech. Other
behaviours are described in the definitions below.
A recent change (deterioration) in cognitive (awareness)
function is indicative of acute confusional state, which
may be reversible if detected and treated in a timely
fashion. Signs of acute confusional state can be easier to
detect in a person with intact cognitive function at
Full Assessment Form: Section B
baseline. However, when a resident has a pre-existing
cognitive impairment or pre-existing behaviours such as
restlessness, calling out, etc. detecting signs of acute
confusional state is more difficult. Despite this difficulty, it
is possible to detect signs of acute confusional state in
these residents by being attuned to recent changes in their
usual functioning. For example, a resident who is usually
noisy or belligerent may suddenly become quiet, lethargic,
and inattentive. Or, conversely, one who is normally quiet
and content may suddenly become restless and noisy. Or,
one who is usually able to find his or her way around the
home may begin to get “lost”.
Definitions
a. Easily distracted – (e.g. difficulty paying attention; gets
sidetracked)
b. Periods of altered perception or awareness of
surroundings – (e.g. moves lips or talks to someone not
present; believes he/she is somewhere else; confuses
night and day)
c. Episodes of disorganised speech – (e.g. speech is
incoherent, nonsensical, irrelevant, or rambling from
subject to subject; loses train of thought)
d. Periods of restlessness – (e.g. fidgeting or picking at
skin, clothing, napkins, etc.; frequent position changes;
repetitive physical movements or calling out)
e. Periods of lethargy – (e.g. sluggishness, staring into
space; difficult to arouse; little body movement)
f. Mental function varies over the course of the day –
(e.g. sometimes better, sometimes worse; behaviours
sometimes present, sometimes not)
Coding
Code for resident’s behaviour in the last 7 days
regardless of what you believe the cause to be – focusing
on when the manifested behaviour first occurred.
0. Behaviour not present
1. Behaviour present, not of recent onset
2. Behaviour present over last 7 days appears different
from resident’s usual functioning (e.g. new onset or
worsening)
Case example 1
Mrs. K is a 92 year old widow of 30 years who has
severe functional dependency secondary to heart
disease. Her primary carer has reported during the last
 Chapter 3: The Item-by-Item Guide to the MDS Full Assessment Form: Section B

two days Mrs. K has “not been herself.” She has been
sleeping more frequently and for longer periods during
the day. She is difficult to arouse and has mumbling
speech upon awakening. She also has difficulty paying
attention to what she is doing. For example, at meals
instead of eating as she usually does, she picks at her
food as if she doesn’t know what to do with a fork. Then
stops and closes her eyes after a few minutes.
Alternatively, Mrs. K has been waking up at night
believing it to be daytime. She has been calling out to
staff demanding to be taken to see her husband
(although he is deceased). On 3 occasions Mrs. K was
observed attempting to climb out of bed over the foot of
the bed.
Indicators Coding
a. Easily distracted 2 (present, new)
f. Mental function varies over 1 (present, not new)
course of day
6. Change in cognitive status
Purpose
To document changes in the resident’s cognitive status,
skills, or abilities as compared to his or her status of three
months ago (or since last assessment if less than three
months ago). These can include, but are not limited to,
changes in level of consciousness, cognitive skills for daily
decision-making, short-term or long-term memory,
thinking or awareness, or recall. Such changes may be
permanent or temporary; their causes may be known
(e.g. a new pain or psychotropic medication) or
unknown. If the resident is a new admission to the home,
this item includes changes during the period prior to
admission.

b. Periods of altered perception or 2 (present, new) Coding

awareness of surroundings Record the number corresponding to the most correct
response. Enter “0” for No change, “1” for Improved, or
c. Episodes of disorganised speech 2 (present, new)
“2” for Deteriorated.
d. Periods of restlessness 2 (present, new)
Examples of change in cognitive status
e. Periods of lethargy 2 (present, new)
Mrs. G suffered from an acute confusional state
f. Mental function varies over 2 (present, new) secondary to pneumonia approximately one month ago.
course of day With appropriate antibiotic therapy, hydration, and a
quiet supportive surroundings, she recovered. Although
Case example 2 Mrs. G’s cognitive skills did not increase beyond the level
Mr. D has a history of Alzheimer’s disease. His skills for that existed prior to her pneumonia, and she remains
decision making have been poor for a long time. He unable to make daily decisions, she has steadily
often has difficulty paying attention to tasks and activities improved to her pre-pneumonia status. Code “0” for No
and usually wanders away from them. He rarely speaks change.
to others, and when he does it is garbled and the Ms. P is intellectually intact. About two and a half months
contents are nonsensical. He is often observed mumbling ago she was informed by her daughter that her
and moving his lips as if he’s talking to someone. neighbour and lifelong friend had died while on a trip to
Although Mr. D is often restless and fidgety this America. Ms. P took the news very hard; she was
behaviour is not new for him and it rarely interferes with stunned and seemed to be confused and bewildered for
a good night’s sleep. days. With support of family and staff, confusion passed.
Indicators Coding Although she continued to grieve, her cognitive status
returned to what it was prior to her receiving the bad
a. Easily distracted 1 (present, not new)
news. Code “0” for No change.
b. Periods of altered perception or 1 (present, not new)
Mr. D was admitted to the nursing home 3 months ago
awareness of surroundings
upon discharge from the hospital with signs of post-
c. Episodes of disorganised speech 1 (present, not new) operative acute confusional state. Since that time he no
d. Periods of restlessness 1 (present, not new) longer requires frequent reminders and re-orientation
throughout each day. His decision-making skills have
e. Periods of lethargy 0 (behaviour not
improved. Code “1” for Improved.
present)
 Chapter 3: The Item-by-item Guide to the MDS Full Assessment Form: Section B

Mr. F has Alzheimer’s disease. He did well until two Some homes will find it useful to combine MDS items
months ago, when a member of staff reported that he into a simple summary scale, so as to provide a profile of
can no longer find his way back to his room, which he residents for comparison between different homes or
was able to do 3 months ago. He often gets lost now within units in an individual home. Such a scale has
while trying to find his way to the home’s dining room. been produced – The MDS Cognitive Performance Scale
Code “2” for Deteriorated. (CPS)© [see Appendix B]. Five MDS items are used in
assigning residents to one of seven CPS categories. The
Mrs. F was admitted to the home 6 weeks ago. Upon
CPS categories are highly related to residents’ average
admission she had modified independence in daily
scores on the Folstein Mini-Mental Status Examination
decision-making skills, intact short and long term
(MMSE), which has a score range of zero (worst) to thirty
memory, and good recall abilities. Since that time, Mrs. F
(best). According to Folstein, an MMSE score of 23 or
has had a stroke, which has left her with deficits in these
lower usually suggests cognitive impairment but it may
areas. Within the assessment period, her decisions have
be lower for persons with limited education.
become poor. She is not aware of her new physical
limitations and has taken unreasonable safety risks in
transferring and locomotion. She receives supervision at
all times. Code “2” for Deteriorated.

MDS Cognitive Performance Scale©

 Section B. Cognitive Patterns

1 Comatose (Persistant vegetative state/unconscious)

0. No
1. Yes (If yes, skip to section G)

2 Memory (Recall of what was learned or known)

a. Short-term memory OK - seems/appears to recall after 5 minutes
0. Memory OK
2
1. Memory Problem

b. Long-term memory OK - seems/appears to recall long past

0. Memory OK
2
1. Memory Problem

3 Memory/recall (Tick all that resident was normally able to recall during last 7 days)

ability ■ a. Current season

■ b. Location of own room
■ c. Staff names/faces
■ d. That he/she is in a care home
■ e. NONE OF ABOVE are recalled

4 Cognitive skills for (Made decisions regarding tasks of daily life)

daily decision- 0. Independent - decisions consistent/reasonable

2
making 1. Modified independence - some difficulty in new situations only
2
2. Moderately impaired - decisions poor; cues/supervision required
2,5
3. Severely impaired - never/rarely made decision
 Section B. Cognitive Patterns Continued

5 Indicators of (Code for behaviour in the last 7 days.) [note: accurate assessment requires conversations
with staff and family who have direct knowledge of resident’s behaviour over this time].
acute confusion -
0. Behaviour not present
periodic disordered
1. Behaviour present, not of recent onset
thinking/awareness 2. Behaviour present, over last 7 days appears different from resident’s usual functioning
1,17
(eg. new onset or worsening)

■ a. Easily distracted -
1,17
(eg. difficulty paying attention; gets sidetracked)

■ b. Periods of altered perception or awareness of surroundings -

(eg moves lips or talks to someone not present; believes he/she is
1,17
somewhere else; confuses night and day)

■ c. Episodes of disorganised speech -

(eg. speech is incoherent, nonsensical, irrelevant, or rambling from
1,17
subject to subject; loses train of thought)

■ d. Periods of restlessness -
(eg. fidgeting or picking at skin, clothing, napkins, etc; frequent
1,17
position changes; repetitive physical movements or calling out)

■ e. Periods of lethargy -
(eg. sluggishness; staring into space; difficult to arouse;
1,17
little body movement)

■ f. Mental function varies over the course of the day -

(eg. sometimes better, sometimes worse; behaviours sometimes
present, sometimes not) 1,17

6 Change in Resident’s cognitive status, skills, or abilities have changed as compared to status of 3
months ago (or since last assessment if less than 3 months ago)
cognitive status
0. No change
1. Improved
1,17
2. Deteriorated
 Section B: Cognitive Patterns
Triggers for Resident Assessment Protocols

Question MDS Item Code RAPs

Number

2
B2a Short-term memory 1 Cognitive Loss/Dementia

2
B2b Long-term memory 1 Cognitive Loss/Dementia

2
B4Decision making 1, 2, 3 Congitive Loss/Dementia

5
B4Decision making 3 ADL - Maintenance Trigger B

1
B5a to B5f Indicators of acute confusion 2 Acute Confusional State
17
Psychotropic Drug Use

1
B6Change in cognitive status 2 Acute Confusional State
17
Psychotropic Drug Use
 Chapter 3: The Item-by-Item Guide to the MDS
Section C: Communication/Hearing Patterns
The purpose of this section is to document the
resident’s ability to hear (with hearing aids, if they are
used), understand and communicate with others.
There are many possible causes for the communication
problems experienced by older people in nursing or
residential homes. Some can be attributed to the ageing
process; others are associated with progressive physical
and neurological disorders. Usually the communication
problem is caused by more than one factor. For
example, a resident might have aphasia (inability to
express self through speech) as well as long standing
hearing loss; or he or she might have dementia, word
finding difficulties and a hearing loss. The resident’s
physical, emotional and social situation may also
complicate communication problems. Additionally, a
noisy or isolating environment can inhibit opportunities
for effective communication.
Deficits in one’s ability to understand (receptive
communication deficits) can involve decline in hearing,
comprehension (spoken or written), or recognition of
facial expressions. Deficits in ability to make one’s self
understood (expressive communication deficits) can
include reduced voice volume and difficulty in
producing sounds, or difficulty in finding the right word,
making sentences, writing and gesturing.
1. Hearing
Purpose
To evaluate the resident’s ability to hear (with
environmental adjustments, if necessary) during the
past 7-day period.
Process
Evaluate hearing ability after the resident has a hearing
aid in place, if the resident uses an appliance. Review the
record. Interview and observe the resident, and ask
about the hearing function. Consult the resident’s family,
care staff and speech or hearing specialists. Test the
accuracy of your findings by observing the resident
during your verbal interactions.
Be alert to what you have to do to communicate with the
resident. For example, if you have to speak more clearly,
use a louder tone, speak more slowly, or use more
gestures, or if the resident needs to see your face to know
what you are saying, or if you have to take the resident
to a more quiet area to conduct the interview – all of
these are cues that there is a hearing problem, and
Full Assessment Form: Section C
should be indicated in the coding.
Also, observe the resident interacting with others and in
group activities. Ask the staff how the resident hears
during group leisure activities.
Coding
Enter one number that corresponds to the most correct
response.
0. Hears adequately – The resident hears all normal
conversational speech, including when using the
telephone, watching television and engaged in group
activities.
1. Minimal difficulty – The resident hears speech at
conversational levels but has difficulty hearing when not
in quiet settings or when not in one-to-one situations.
2. Hears in special situations only – Although hearing-
deficient, the resident compensates when the speaker
adjusts tonal quality and speaks distinctly; or the resident
can hear only when the speaker’s face is clearly visible.
3. Highly impaired/absence of useful hearing – The
resident hears only some sounds and frequently fails to
respond even when the speaker adjusts tonal quality,
speaks distinctly, or is positioned face to face. There is no
comprehension of conversational speech, even when the
speaker makes maximum adjustments.
2. Communication devices/techniques
Definition
Hearing aid, present and used – A hearing aid or other
assistive listening device is available to the resident and is
used regularly.
Hearing aid, present and not used regularly – A hearing
aid or other assistive listening device is available to the
resident and is not regularly used (e.g. resident has a
hearing aid that is broken or is used only occasionally).
Other receptive communication technique used (e.g. lip
reading) – A mechanism or process is used by the
resident to enhance interaction with others (e.g. reading
lips, touching to compensate for hearing deficit, writing
by staff, use of communication board).
Process
Consult with the resident and care staff. Observe the
resident closely during your interaction.
Coding
Tick all that apply. If the resident does not have a hearing
 Chapter 3: The Item-by-Item Guide to the MDS
aid or does not regularly use compensatory
communication techniques, tick NONE OF ABOVE.
3. Modes of expression
Purpose
To record the types of communication techniques (verbal
and non-verbal) used by the resident to make his or her
needs and wishes known.
Definition
Writing messages to express or clarify needs – Resident
writes notes to communicate with others.
Signs/gestures/sounds – This category includes non-
verbal expressions used by the resident to communicate
with others.
■ Actions may include pointing to words, objects,
people; facial expressions; using physical gestures
such as nodding head twice for “yes” and once for
“no” or squeezing another’s hand in the same
manner.
■ Sounds may include grunting, banging, ringing a bell,
etc.
Communication board – An electronic, computerised or
other home-made device used by the resident to convey
verbal information, wishes, or commands to others.
Other – Examples include flash cards or various
electronic assistive devices.
Process
Ask staff from all shifts, if available. Consult with the
resident’s family. Interact with the resident and observe
for any reliance on non-verbal expression (physical
gestures, such as pointing to objects), either in one-to-
one communication or in group situations.
Coding
Tick for each method used by the resident to
communicate his or her needs. If the resident does not
use any of the listed items, tick NONE OF ABOVE.
4. Making self understood
Purpose
To document the resident’s ability to express or
communicate requests, needs, opinions, urgent problems
and social conversation, whether in speech, writing, sign
language, or a combination of these.
Process
Full Assessment Form: Section C
Observe and listen to the resident’s efforts to
communicate with you. Observe his or her interactions
with others in different settings (e.g. one-to-one, groups)
and different circumstances (e.g. when calm, when
agitated). Ask care staff (over all shifts), if available, the
resident’s family and speech therapist.
Coding
Enter the number corresponding to the most correct
response.
Understood – The resident expresses ideas clearly.
Usually understood – The resident has difficulty finding
the right words or finishing thoughts, resulting in delayed
responses; or the resident requires some prompting (e.g.
direct questioning “would you like a drink?”) to make self
understood.
Sometimes understood – The resident has limited ability,
but is able to express concrete requests regarding at least
basic needs (e.g. food, drink, sleep, toilet).
Rarely or never understood – At best, understanding is
limited to staff interpretation of highly individual,
resident-specific sounds or body language (e.g. indicated
presence of pain or need to toilet).
5. Speech clarity
Purpose
To document the quality of the resident’s speech.
Definition
Speech – the expression of articulate words.
Process
Listen to the resident. Ask care staff.
Coding
Enter the number corresponding to the most correct
response.
0. Clear speech – utters distinct, intelligible words.
1. Unclear speech – utters slurred or mumbled words.
2. No speech – absence of spoken words.
6. Ability to understand others
Purpose
To describe the resident’s ability to comprehend verbal
information whether communicated to the resident orally,
by writing, or in sign language or Braille. This item
measures not only the resident’s ability to hear messages
but also to process and understand language.
 Chapter 3: The Item-by-Item Guide to the MDS
Process
Talk with and observe the resident. Ask care staff over all
shifts, if possible, the resident’s family, and speech
therapist if appropriate.
Coding
Enter the number corresponding to the most appropriate
response.
0. Understands – The resident clearly comprehends the
speaker’s message(s) and demonstrates comprehension
by words or actions/behaviours.
1. Usually understands – The resident may miss some
part or purpose of the message but comprehends most of
it. The resident may have periodic difficulties interpreting
information but generally demonstrates comprehension
by responding in words or actions.
2. Sometimes understands – The resident demonstrates
frequent difficulties interpreting information, and
responds adequately only to simple and direct questions
or directions. When staff rephrase or simplify the
message(s) and/or use gestures, the resident’s
comprehension is enhanced.
3. Rarely/never understands – The resident demonstrates
very limited ability to understand communication. Or,
staff have difficulty determining whether the resident
comprehends messages, based on verbal and non verbal
responses. Or, the resident can hear sounds but does not
understand messages.
7. Change in communication/hearing
Purpose
To document any change in the resident’s ability to
express, understand, or hear information compared to his
or her status of 3 months ago (or since last assessment if
less than 3 months ago). If resident is a new admission to
the home, this item includes changes during the period
prior to admission.
Process
In addition to consulting care staff (over all shifts if
possible), consult the family of new residents, and review
Full Assessment Form: Section C
prior assessments when available, ask the resident if he
or she has noticed any changes in the ability to hear, talk
or understand others. Sometimes, residents do not
complain of changes being experienced because they
attribute them to ‘old age’. Therefore,
it is important that they be asked directly. Some types of
deterioration are easily corrected (e.g. by new hearing
aid batteries or removal of ear wax).
Coding
Enter the number corresponding to the most correct
response. Enter “0” for No change, “1” for Improved, or
“2” for Deteriorated.
Examples of change in communication/hearing
Mrs. L has had expressive aphasia for two years.
Although she periodically says a word or phrase that is
understood by others, this is not new for her. During the
last 3 months her communication status has essentially
remained unchanged. Code “0” for No change.
Mrs. R’s hearing is severely impaired. Five months ago
the occupational therapist developed word cards for staff
to use when communicating with her. This was a
tremendous boost for both Mrs. R and staff. Her ability to
understand others continues to improve. Code “1” for
Improved.
Mr. S has complained for the last two weeks of ringing in
his ears, saying “Please do something, it’s driving me
crazy!” Code “2” for Deteriorated.
Upon admission four months ago Mrs. T had difficulty
hearing unless the speaker adjusted his or her tone of
voice and spoke more distinctly. She has worn hearing
aids in the past but lost them during a hospital
admission. Since admission to the home, Mrs. T was
tested and fitted with new hearing aids. She hears much
better with the aids though she is still trying to adjust to
wearing them. Code “1” for Improved.
 Section C. Communication/Hearing Patterns

1 Hearing (With hearing appliance, if used)

0. Hears adequately - normal talk, TV, phone
4
1. Minimal difficulty - when not in quiet setting
2. Hears in special situations only -
4
speaker has to adjust tonal quality and speak distinctly
4
3. Highly impaired - absence of useful hearing

2 Communication (Tick all that apply during last 7 days)

devices/techniques ■ a. Hearing aid, present and used

■ b. Hearing aid, present and not used regularly

■ c. Other receptive communication techniques used (eg. lip reading)

■ d. NONE OF ABOVE

3 Modes of (Tick all used by resident to make needs known)

expression ■ a. Speech

■ b. Writing messages to express or clarify needs

■ c. Sign language or Braille

■ d. Signs/gestures/sounds

■ e. Communication board

■ f. Other

■ g. NONE OF ABOVE

4 Making self 0. Understood

4
understood 1. Usually understood - difficulty finding words or finishing thoughts
4
2. Sometimes understood - ability is limited to making concrete requests
4
3. Rarely/never understood

5 Speech clarity (Code for speech in the last 7 days)

0. Clear speech - distinct intelligible words
1. Unclear speech - slurred, mumbled words
2. No speech - absence of spoken words

6 Ability to (Understanding verbal information content - however able)

understand others 0. Understands

2,4
1. Usually understands - may miss some part/intent of message
2. Sometimes understands - responds adequately to simple,
2,4
direct communication
2,4
3. Rarely/never understands

7 Change in Resident’s ability to express, understand, or hear information has changed as

compared to status of 3 months ago (or since last assessment if less than 3 months)
communication/
0. No change
hearing
1. Improved
17
2. Deteriorated
 Section C:
Communication/Hearing Patterns
Triggers for Resident Assessment Protocols

Question MDS Item Code RAPs

Number

4
C1Hearing 1, 2, 3 Communication

4
C4Understood by others 1, 2, 3 Communication

2
C6Understand others1, 2, 3 Congitive Loss/Dementia
4
Communication

17
C7Change in communication 2 Psychotropic Drug Use
 Chapter 3: The Item-by-Item Guide to the MDS
Section D: Vision Patterns
The purpose of this section is to record the resident’s
visual abilities and limitations over the past 7 days,
assuming adequate lighting and assistance of visual
appliances, if used.
1. Vision
Purpose
To evaluate the resident’s ability to see close objects in
adequate lighting, using the resident’s visual appliances
for close vision (e.g. glasses, magnifying glass).
Definition
“Adequate” lighting – What is sufficient or comfortable
for a person with normal vision.
Process
■ Ask staff over all shifts if possible, if the resident has
shown any change in usual vision patterns over the
past 7 days e.g. is the resident still able to read
newsprint, menus, greeting cards, etc.?
■ Then ask the resident about his or her visual abilities.
■ Test the accuracy of your findings by asking the
resident to look at regular-size print in a book or
newspaper with whatever visual appliance he or she
uses for close vision (e.g. glasses, magnifying glass).
Then ask the resident to read aloud, starting with
larger headlines and ending with the finest, smallest
print.
■ Be sensitive to the fact that some residents are not
literate or are unable to read English. In such cases,
ask the resident to read aloud individual letters of
different size print or numbers, such as dates or page
numbers, or to name items in small pictures.
■ If the resident is unable to communicate or follow
your directions for testing vision, observe the
resident’s eye movements to see if his or her eyes
seem to follow movement and objects. Though these
are gross measurements of visual acuity, they may
assist you in assessing whether the resident has any
visual ability.
Coding
Enter the number corresponding to the most correct
response.
0. Adequate – The resident sees fine detail, including
regular print in newspapers/books.
1. Impaired – The resident sees large print, but not
regular print in newspapers/books.
Full Assessment Form: Section D
2. Moderately impaired – The resident has limited vision,
is not able to see newspaper headlines, but can identify
objects in his or her environment.
3. Highly impaired – The resident’s ability to identify
objects in his or her environment is in question, but the
resident’s eye movements appear to be following objects
(especially people walking by).
Note: Many residents with severe cognitive impairment
are unable to participate in vision screening because they
are unable to follow directions or are unable to tell you
what they see. However, many such residents appear to
“track” or follow moving objects in their environment
with their eyes. For residents who appear to do this, use
code “3”, Highly impaired.
4. Severely impaired – The resident has no vision; sees
only light, colours or shapes; or eyes do not appear to be
following objects (especially people walking by).
2. Visual limitations/difficulties
Purpose
To document whether the resident experiences visual
limitations or difficulties related to diseases common in
older persons (e.g. cataracts, glaucoma, diabetic
retinopathy, neurological diseases). It is important to
identify whether these conditions are present. Some eye
problems may be treatable and reversible; others, though
not reversible, may be managed by treatment aimed at
maintaining or improving the resident’s residual visual
abilities.
Process
Side vision problems – Observe the resident during his or
her daily routine (e.g. eating meals, walking down a
corridor). Also, ask the resident about any vision
problems (e.g. spilling food, bumping into objects and
people). Ask the staff on each shift if possible, whether
the resident appears to have difficulties related to
decreased peripheral vision (e.g. leaves food on one side
of plate, has difficulty moving, bumps into people and
objects, misjudges placement of chair when seating self).
Experiences any of the following – Ask the resident
directly if he or she is seeing halos or rings around lights,
flashes of light, or “curtains” over the eyes. Ask staff
members if the resident complains about any of these
problems.
Coding
Tick all that apply. If none apply, tick NONE OF ABOVE.
 Chapter 3: The Item-by-Item Guide to the MDS Full Assessment Form: Section D

3. Visual appliances type of corrective device used at any time during the last 7
Purpose days.
To determine if the resident uses visual appliances Coding
regularly.
Enter “1” if the resident used glasses, contact lenses, or a
Definition magnifying glass during the pasts 7 days. Enter “0” if none
Glasses; contact lenses; magnifying glass – Includes any apply.
 Section D. Vision Patterns

1 Vision (Ability to see in adequate light and with glasses if used)

0. Adequate - sees fine detail, including regular print in newspapers/books
3
1. Impaired - sees large print, but not regular print in newspapers/books
2. Moderately impaired - limited vision; not able to see newspaper headlines,
3
but can identify objects
3. Highly impaired - object identification in question, but eyes appear to
3
follow objects
4. Severely impaired - no vision or sees only light, colours, or shapes;
eyes do not appear to follow objects

2 Visual limitations/ ■ a. Side vision problems - decreased peripheral vision (eg. leaves food on one side of
difficulties tray, difficulty travelling, bumps into people and objects, misjudges placement of chair
3
when seating self)

■ b. Experiences any of the following: sees halos or rings around lights; sees flashes of
light; sees ‘curtains’ over eyes

■ c. NONE OF ABOVE

3 Visual appliances Glasses; contact lenses; magnifying glass

0. No
1. Yes
Specify

Section D: Vision Patterns

Triggers for Resident Assessment Protocols

Question MDS Item Code RAPs

Number

3
D1 Vision 1, 2, 3 Visual Function

D2a Side vision problem ✓ Visual Function

3
 Chapter 3: The Item-by-Item Guide to the MDS
Section E: Mood and Behaviour Patterns
Mood distress is a serious condition and is associated
with significant effects on health and well-being.
Associated factors include poor adjustment to the care
home setting, functional impairment, resistance to daily
care, inability to participate in activities, isolation,
increased risk of medical illness, cognitive impairment,
and an increased sensitivity to physical pain. It is
particularly important to identify signs and symptoms of
mood distress among residents because they are often
very treatable.
In many homes, staff have not received specific training
in how to evaluate residents who have distressed mood
or behavioural symptoms. Therefore, many problems are
not recognised and undertreated. In homes where such
training has not occurred, an in-service programme
under the direction of a professional mental health
specialist is recommended. At a minimum, staff in such
homes should find the various mental health RAPs (e.g.
mood, behaviour) to be helpful and these should be
carefully reviewed.
1. Indicators of depression, anxiety, sad mood
Purpose
To record the frequency of indicators of depression,
anxiety and sad mood observed in the last month.
Definition
Feelings of distress may be expressed directly by the
resident who is depressed, anxious, or sad. However,
statements such as “I’m so depressed” are rare in the
care home population. Rather, distress is more commonly
expressed in the following ways:
Verbal expressions of distress
a. Resident made negative statements – e.g. “Nothing
matters; Would rather be dead; What’s the use; Regrets
having lived so long; Let me die.”
b. Repetitive questions – e.g. “Where do I go; What do I
do?”
c. Repetitive verbalisations – e.g. Calling out for help,
(“God help me”).
d. Persistent anger with self or others – e.g. easily
annoyed, anger at placement in home; anger at care
received.
e. Self-deprecation – e.g. “I am nothing; I am of no use
to anyone”.
Full Assessment Form: Section E
f. Expressions of what appear to be unrealistic fears – e.g.
fear of being abandoned, left alone, being with others.
g. Recurrent statements that something terrible is about to
happen – e.g. believes he or she is about to die, have a
heart attack.
h. Repetitive health complaints – e.g. persistently seeks
medical attention, obsessive concern with body functions.
i. Repetitive anxious complaints/concerns (non-health
related) – e.g. persistently seeks attention/reassurance
regarding schedules, meals, laundry, clothing, relationship
issues.
Distress may also be expressed non-verbally and
identified through observation of the resident in the
following areas during usual daily routines:
Sleep cycle issues
Distress can also be manifested through disturbed sleep
patterns.
j. Unpleasant mood in morning
k. Insomnia/change in usual sleep pattern – e.g. difficulty
falling asleep, fewer or more hours of sleep than usual,
waking up too early and unable to fall back to sleep.
Sad, apathetic, anxious appearance
l. Sad, pained, worried facial expressions – e.g. furrowed
brows.
m. Crying, tearfulness
n. Repetitive physical movements – e.g. pacing, hand
wringing, restlessness, fidgeting, picking.
Loss of interest
These items refer to a change in resident’s usual pattern
of behaviour.
o. Withdrawal from activities of interest – e.g. no interest
in long standing activities or being with family/friends.
p. Reduced social interaction – e.g. less talkative, more
isolated.
Process
Initiate a conversation with the resident. Some residents
are more verbal about their feelings than others and will
either tell someone about their distress, or tell someone
only when directly asked how they feel. Other residents
may be unable to articulate their feelings (i.e. cannot find
the words to describe how they feel, or lack insight or
 Chapter 3: The Item-by-Item Guide to the MDS
cognitive capacity). Observe residents carefully for these.
Consult with care staff over all shifts, if possible, and
family who have direct knowledge of the resident’s
behaviour. Relevant information may also be found in
the resident record.
Coding
For each indicator apply one of the following codes
based on interactions with and observations of the
resident in the last month. Remember, code regardless of
what you believe the cause to be.
0. Indicator not exhibited in last month
1. Indicator of this type exhibited up to five days a week
(i.e. exhibited at least once during the last month but less
than 6 days a week)
2. Indicator of this type exhibited daily or almost daily (6,
7 days a week)
Example
Mr. F is a new admission who becomes upset and angry
when his daughter visits (3 times a week). He complains
to her and staff that “she put me in this terrible dump.”
He chastises her “for not taking him into her home”, and
berates her “for being an ungrateful daughter”. After she
leaves, he becomes remorseful, sad looking, tearful, and
says “What’s the use. I’m no good. I wish I died when my
wife did”. Coding “1” for a. (Resident made negative
statements), d. (Persistent anger with self or others), e.
(Self-deprecation), m. (Crying, tearfulness); remaining
Mood items would be coded “0”.
2. Mood persistence
Purpose
To identify if one or more indicators of depressed, sad or
anxious mood in section 1 above were not easily altered
by attempts to “cheer up”, console, or reassure the
resident over the last 7 days.
Process
Observe the resident and discuss the situation with staff
over all shifts, if possible, and family members or friends
who visit frequently or have frequent telephone contact
with the resident.
Coding
Enter “0” if the resident did not exhibit any mood
indicators over last 7 days, “1” if indicators were present
and easily altered by staff interactions with the resident or
“2” if any indicator was present but not easily altered
Full Assessment Form: Section E
(e.g. behaviour persisted despite staff efforts to console
resident).
3. Change in mood
Purpose
To document changes in the resident’s mood as
compared to his or her status of 3 months ago (or since
last assessment if less than 3 months ago). If the resident
is a new admission to the home, this item includes
changes during the period prior to admission.
Definition
Change in mood – Refers to status of any of the
symptoms (new onset, improvement, worsening)
described in item E1 (verbal expressions of distress, sleep
cycle issues, sad apathetic, anxious appearance, loss of
interest or other signs) and item E2 (mood persistence).
Such changes include:
■ increased or decreased numbers of expressions or
signs of distress
■ increased or decreased frequency of distress
occurrence
■ increased or decreased intensity of expressions or
signs of distress
Process
Review the resident records. Interview and observe the
resident. Consult with staff from all shifts, if possible, to
clarify your observations.
Coding
Code “0” if No Change, “1” if Improved, or “2” if
Deteriorated as compared to status of 3 months ago.
Examples of changes in mood
Mrs. Y has manic depression. Historically, she has
responded well to drug therapy and her mood state has
been stable for almost a year. About two months ago, she
became extremely sad and withdrawn, expressed the
wish that she were dead, and stopped eating. She was
transferred to a psychiatric hospital for review and
treatment. Since her return to the home three weeks ago,
her mood and appetite have improved while on a new
lithium dose and an additional antidepressant drug. She
is back to her “old self” of 3 months ago. Code “0” for
No change.
During the admission assessment period of 3 months
ago, Mr. M was tearful and expressed great sadness and
anger over entering the home. He had difficulties falling
 Chapter 3: The Item-by-Item Guide to the MDS
asleep at night, was restless off and on during the night,
and awakened too early in the morning, upset that he
couldn’t fall back to sleep. Since that time, Mr. M has
been involved in a twice weekly support group, and has
been enjoying socialising in activities with new friends.
He is currently sleeping through the night and feels well
in the morning. Although he still expresses sadness and
anger over his need for being in a home, it is less
frequent and intense. Code “1” for Improved.
Mrs. D has a long history of depression. Two months ago
she had an adverse reaction to a drug. She expressed
fears that she was going out of her mind and was
observed to be quite agitated. Her attention span
diminished and she stopped attending group activities
because she was too restless. After the medication was
discontinued, intensity of feelings and behaviours
diminished and she has less frequent episodes of
agitation. Mrs. D is better than she was, but she still has
feelings of sadness. Mrs. D is now better than her worst
status two months ago, but she has not fully recovered to
her former self of 3 months ago. Code “2” for
Deteriorated.
4. Behavioural symptoms
Purpose
To identify a) the frequency and b) alterability of
behavioural symptoms in the last 7 days that cause
distress to the resident, or are distressing or disruptive to
other residents or staff. Such behaviours include those
that are potentially harmful to the resident himself or
herself or disruptive in the environment, even if staff and
other residents appear to have adjusted to them (e.g.
“Mrs. R’s calling out isn’t much different than others on
the unit. There are many noisy residents;” or “Mrs. L
doesn’t mean to hit me. She does it because she’s
confused”).
Acknowledging and documenting the resident’s
behavioural patterns on the MDS provides a basis for
further evaluation, care planning, and delivery of
consistent, appropriate care towards resolving the
behavioural symptoms. Documentation in the resident
record of the current status may not be accurate or valid,
and it is not intended to be the one and only source of
information. (See Process below). However, once the
frequency and change of behavioural symptoms is
determined, documentation should more accurately
reflect the resident’s behaviour and response to
Full Assessment Form: Section E
interventions.
Definition
Wandering – Locomotion with no discernible, rational
purpose. A wandering resident may be oblivious to his or
her physical or safety needs. Wandering behaviour
should be differentiated from purposeful movement (e.g.
a hungry person going to the kitchen in search of food).
Do not include pacing as wandering behaviour. Pacing
back and forth is not considered wandering, and if it
occurs, it should be documented in Item E1n, “Repetitive
physical movements”.
Verbally abusive behavioural symptoms – Other residents
or staff were threatened, screamed at, or sworn at.
Physically abusive behavioural symptoms – Other
residents or staff were hit, shoved, scratched, or sexually
abused.
Socially inappropriate/disruptive behavioural symptoms –
Includes disruptive sounds, excessive noise, screams, self-
abusive acts, or sexual behaviour or disrobing in public,
smearing or throwing food or faeces, hoarding,
rummaging through others’ belongings.
Resists care – Resists taking medications/injections,
assistance or help with eating, washing dressing etc. This
category does not include instances where the resident
has made an informed choice not to follow a course of
care (e.g. resident has exercised his or her right to refuse
treatment, and reacts negatively as staff try to re-institute
treatment).
Signs of resistance may be verbal and/or physical (e.g.
verbally refusing care, pushing caregiver away, scratching
caregiver). These behaviours are not necessarily positive
or negative, but are intended to provide information
about the resident’s responses to care interventions and
to prompt further investigation of causes for care
planning purposes (e.g. fear of pain, fear of falling, poor
comprehension, anger, poor relationships, eagerness for
greater participation in care decisions, past experience
with medication errors and unacceptable care, desire to
modify care being provided).
Process
Take an objective view of the resident’s behavioural
symptoms. The coding for this question focuses on the
resident’s actions not intent. It is often difficult to
determine the meaning behind a particular behavioural
 Chapter 3: The Item-by-Item Guide to the MDS Full Assessment Form: Section E

symptom. Therefore, it is important to start the
assessment by recording any behavioural symptoms. The
fact that staff have become used to the behaviour and
minimise the resident’s presumed intention (“He doesn’t
really mean to hurt anyone. He’s just frightened.”) is not
important to the coding. Does the resident show the
behavioural symptom or not? Is the resident restless
during personal care and strikes out at staff or not?
Observe the resident. Observe how the resident responds
to staff members’ attempts to deliver care to him or her.
Consult with staff who provide care on all three shifts. A
symptomatic behaviour can be present and the carer
completing the assessment might not see it because it
occurs during intimate care on another shift. Therefore, it
is especially important that input from all staff having
contact with the resident be solicited.
Also, be alert to the possibility that staff might not think
to report a behavioural symptom if it is part of the unit
norm (e.g. staff are working with severely cognitively and
functionally impaired residents and are used to residents’
wandering, noisiness, etc.). Focus staff attention on what
has been the individual resident’s actual behaviour over
the last 7 days. Finally, although it may not be complete,
review the record for documentation.
Code “1” if the described behavioural symptom occurred
1 to 3 days, in last 7 days.
Code “2” if the described behavioural symptom occurred
4 to 6 days, but less than daily.
Code “3” if the described behavioural symptom occurred
daily or more frequently (i.e. multiple times each day).
B Behavioural symptom alterability in last 7 days.
Code “0” if either the behavioural symptom was not
present or the behavioural symptom was easily altered
with current interventions.
Code “1” if the described behavioural symptom occurred
with a degree of intensity that is not responsive to staff
attempts to reduce the behavioural symptom through
limit setting, diversion, adapting home routines to the
resident’s needs, environmental modification, activity
programmes, comfort measures, appropriate drug
treatment, etc. For example: A cognitively impaired
resident who hits staff during morning care and swears at
staff with each physical contact on multiple occasions per
day, and the behaviour is not easily altered, would be
coded “1”.
For examples for wandering see Figure 3.1.

Coding
A Behavioural symptom frequency in last 7 days.
Record the frequency of behavioural symptoms of the
resident across all three shifts.
Code “0” if the described behavioural symptom was not
exhibited in last 7 days.
For each type of behaviour described on the MDS form,
Code “0” if the resident did not exhibit that type of
symptom in the last 7 days. This code applies to residents 5. Change in behavioural symptoms
who have never exhibited the behavioural symptom or
Purpose
those who have previously exhibited the symptom but
To document whether the behavioural symptoms or
now no longer exhibit it, including those whose
resistance to care exhibited by the resident remained
behavioural symptoms are fully managed by
stable, increased or decreased in frequency of occurrence
psychotropic drugs, restraints, or a behaviour-
or alterability as compared to 3 months ago (or since last
management programme. For example: A “wandering”
assessment if less than 3 months ago). Consider changes
resident who did not wander in the last 7 days because
in any area, including (but not limited to) wandering,
he was restricted to a chair would be coded “0” –
symptoms of verbal or physical abuse or aggressiveness,
Behavioural symptom not exhibited in last 7 days. The
socially inappropriate behaviour or resistance to care. If
questionable clinical practice of restricting wandering by
the resident is a new admission to the home, this item
placing a person in a chair to restrict movement would
includes changes during the period prior to admission.
then be evaluated using the Physical Restraints RAP.
Definition
 Chapter 3: The Item-by-Item Guide to the MDS Full Assessment Form: Section E

Figure 3.1.

Examples for wandering (A) (B)

Ms. T has dementia and is severely impaired in making decisions Frequency Alterability
about daily life. She is dependent on others to guide her through
each day. When she is not involved in some type of activity (leisure,
eating, ADLs, etc.) she wanders about the home. Despite the 3 0
repetitive, daily nature of her wandering, this behaviour is easily
channelled into other activities when staff redirect Ms. T by inviting
her to activities. Ms. T is easily engaged and is content to stay
and participate in whatever is going on.
Mr. W has dementia and is severely impaired in making daily decisions.
He wanders all around the home throughout each day. He is extremely
hard of hearing and refuses to wear his hearing aid. He is easily
frightened by others and cannot stay still for activitiy programmes. 3 1
Numerous attempts to redirect his wandering have been met with
Mr. W hitting and pushing staff. Over time, staff have found him to
be most content while he is wandering within a structured setting.

Change in behavioural symptoms – refers to the status Code “2” (Deteriorated) if the behavioural symptoms
(new onset, improvement, worsening) of any of the became more frequent or more intense or were
symptoms described in item E4 (Behavioural symptoms). complicated by the onset of additional behavioural
Such changes include: symptoms as compared to 3 months ago.

■ increased or decreased numbers of behavioural Examples of change in behavioural symptoms

symptoms
■ increased or decreased frequency of behavioural
symptoms occurrence
■ increased or decreased intensity of behavioural
symptoms
■ increased or decreased alterability of behavioural
symptoms
Process
Review resident’s records, including the transfer records
of newly admitted residents. Observe the resident.
Consult with care staff across all shifts, if possible, and
the resident’s family to clarify your observations.
Coding
Code “0” if no change has occurred in behavioural
symptoms. This code should also be used for the resident
who has no behavioural symptoms currently or 3 months
ago.
Code “1” (Improved) if the behavioural symptoms
became fewer, less frequent, less intense, and were not
complicated by the onset of additional behavioural
symptoms as compared to 3 months ago.
During the 7-day assessment period, Mrs. D had a
difficult time with bowel regularity. She had a history of
constipation that became worse during an episode of
pneumonia and poor fluid intake that resulted in
dehydration. During this time Mrs. D was more confused
and subdued. She was found on several occasions during
the assessment period disimpacting herself and smearing
faeces (Socially inappropriate/ disruptive behaviour).
Upon examination Mrs. D was found to have a faecal
impaction. She received treatment and was placed on a
bowel management programme. The programme was
successful in eliminating the socially inappropriate
behavioural symptoms that was induced by discomfort.
However, once Mrs. D started to feel better and was
more alert, she resumed her former daily wandering (of 4
months ago), pushing others and rummaging through
their dresser drawers. Code “0” for No change since last
assessment.
Mrs. F has always been a quiet passive woman who has
never exhibited any behavioural symptoms since her
admission to the home. During the assessment following
Mrs. F’s stroke, no problematic behavioural symptoms
were noted. Code “0” for No change since last
 Chapter 3: The Item-by-Item Guide to the MDS Full Assessment Form: Section E

assessment.
Mr. C wanders in and out of other residents’ rooms and
rummages through their belongings at least once a day
and sometimes more often. Despite this behaviour,
during the last few weeks, he has been easier to work
with now that he is more familiar with staff. Although
wandering and rummaging continue, he no longer
screams, curses, and shoves residents and staff who try to
stop this behaviour as he did 3 months ago. Code “1” for
Improved.
Three months ago Mrs. R banged her walking stick loudly
and repetitively on the dining room table about once a
week. In the past week, staff have noticed that this
socially inappropriate behavioural symptom (disruptive
sounds) now occurs multiple times daily. Code “2” for
Deteriorated.
 Section E. Mood and Behaviour Patterns

1 Indicators of depres- (Code for indicators observed in last month, irrespective of the assumed cause)

sion, 0. Indicator not exhibited in last month

7,8,17
1. Indicator of this type exhibited up to five days a week
anxiety, sad mood 7,8,17
2. Indicator of this type exhibited daily or almost daily (6,7 days a week)

Verbal expressions of distress

a. Resident made negative statements - eg. “Nothing matters; Would rather be dead;
8
What’s the use; Regrets having lived so long; Let me die”
8
b. Repetitive questions - eg. “Where do I go; What do I do?”

8
c. Repetitive verbalisations - eg. calling out for help (“God help me”)

d. Persistent anger with self or others - eg. easily annoyed, anger at placement in a
8
home; anger at care received
8
e. Self deprecation - eg. “I am nothing; I am of no use to anyone”

f. Expressions of what appear to be unrealistic fears - eg. fear of being abandoned, left
8
alone, being with others

g. Recurrent statements that something terrible is about to happen - eg. believes he or

8
she is about to die, have a heart attack

h. Repetitive health complaints - eg. persistently seeks medical attention, obsessive

8
concern with body functions

i Repetitive anxious complaints/concerns (non-health related) eg. persistently seeks

attention/reassurance regarding schedules, meals, laundry, clothing, relationship issues
8

Sleep-cycle issues
j. Unpleasant mood in the morning
8

k. Insomnia/change in usual sleep pattern

8

Sad, apathetic, anxious appearance

l. Sad, pained, worried facial expressions - eg. furrowed brows
8

m. Crying tearfulness
8

n. Repetitive physical movements - eg. pacing, hand wringing, restlessness,

fidgeting, picking
8,17

Loss of interest
o. Withdrawal from activities of interest - eg. no interest in long standing activities or
being with family/friends
7,8

p. Reduced social interaction

8
 Section E. Mood and Behaviour Patterns Continued

2 Mood persistence One or more indicators of depressed, sad or anxious mood were not easily altered by
attempts to “cheer up”, console, or reassure the resident over last 7 days
0. No mood indicators
8
1. Indicators present, easily altered
8
2. Indicators present, not easily altered

3 Change in mood Resident’s mood status has changed as compared to status of 3 months ago (or since last
assessment if less than 3 months)
0. No change
1. Improved
1,17
2. Deteriorated

4 Behavioural (A) Behavioural symptoms frequency in last 7 days

symptoms 0. Behaviour not exhibited in last 7 days

9,11
1. Behaviour of this type occurred 1 to 3 days in last 7 days
9,11
2. Behaviour of this type occurred 4 to 6 days but less than daily
9,11
3. Behaviour of this type occurred daily
(B) Behavioural symptoms alterability in last 7 days
0. Behaviour not present OR behaviour was easily altered
1. Behaviour was not easily altered
A B
a. Wandering (moved with no rational purpose, seemingly oblivious to
9,11
needs or safety)
b. Verbally abusive behavioural symptoms (others were threatened,
9
screamed at, cursed at)
c. Physically abusive behavioural symptoms (others were hit, shoved,
9
scratched, sexually abused)
d. Socially inappropriate/disruptive behavioural symptoms (made
disruptive sounds, noisiness, screaming, self-abusive acts, sexual behaviour
or disrobing in public, smeared/threw food/faeces, hoarding, rummaged
9
through others’ belongings)
e. Resists care (resisted taking medications/injections, ADL assistance,
9
or eating)

5 Change in Resident’s behaviour status has changed as compared to status of 3 months ago (or since
last assessment if less than 3 months)
behavioural
0. No change
symptoms 1. Improved
9

1,17
2. Deteriorated
 Section E: Mood and Behaviour Patterns
Triggers for Resident Assessment Protocols

Question MDS Item Code RAPs

Number

8
E1a to E1p Indicators of depression, anxiety, 1, 2 Mood State
sad mood

17
E1n Repetitive movement 1, 2 Psychotropic Drug Use

7
E1o Withdrawal from activities 1, 2 Psychosocial Well-being

8
E2 Mood persistence 1, 2 Mood State

1
E3 Change in mood 2 Acute Confusional State
17
Psychotropic Drug Use

11
E4aA Wandering 1, 2, 3 Falls

9
E4aA - E4eA Behavioural symptoms 1, 2, 3 Behavioural Symptoms

9
E5 Change in behavioural symptoms 1 Behavioural Symptoms

1
E5 Change in behavioural symptoms 2 Acute Confusional State
17
Psychotropic Drug Use
 Chapter 3: The Item-by-Item Guide to the MDS
Section F: Psychosocial Well-Being
The purpose of this section is to determine the resident’s
emotional adjustment to the home, including his or her
general attitude, adaptation to surroundings and change in
relationship patterns.
1. Sense of initiative/involvement
Purpose
To assess the degree to which the resident is involved in
the life of the home and takes initiative in participating in
various social and recreational programmes, including
solitary pursuits.
Definitions
At ease interacting with others – Consider how the resident
behaves during the time you are together, as well as
reports of how the resident behaves with other residents,
staff and visitors. A resident who tries to shield himself or
herself from being with others, spends most time alone, or
becomes agitated when visited, is not “at ease interacting
with others”.
At ease doing planned or structured activities – Consider
how the resident responds to organised social or
recreational activities. A resident who feels comfortable
with the structure or not restricted by it is “at ease doing
planned or structured activities”. A resident who is unable
to sit still in organised group activities and either acts
disruptively or makes attempts to leave, or refuses to
attend any such activities, is not “at ease doing planned or
structured activities”.
At ease doing self-initiated activities – These include leisure
activities (e.g. gardening, watching TV, talking with
friends), and work activities (e.g. folding personal laundry,
organising belongings). A resident who spends most of his
or her time alone and unoccupied, or who is always
looking for someone to find something for him or her to
do, is not “at ease doing self-initiated activities”.
Establishes own goals – Consider statements the resident
makes, such as “I hope I am able to walk again”, or “I
would like to get up early and visit my family”. Goals can
be as traditional as wanting to learn how to walk again
following a hip replacement, or wanting to live to say
goodbye to a loved one. However, some goals may not
actually be verbalised by the resident, but inferred in that
the resident is observed to have an individual way of living
at the home (e.g. organising own activities or setting own
pace).
Pursues involvement in life of home – In general, consider
Full Assessment Form: Section F
whether resident partakes of home events, socialises with
peers and discusses activities as if he or she are part of
things. A resident who conveys a sense of belonging to the
community represented by the home is “involved in the
life of the home”.
Accepts invitations into most group activities – A resident
who is willing to try group activities even if later deciding
the activity is not suitable and leaving, or who does not
regularly refuse to attend group programmes, “accepts
invitations into most group activities”.
Process
Selected responses should be confirmed by objective
observation of the resident’s behaviour (either verbal or
nonverbal) in a variety of settings (e.g. in own room, in
dining room, in day room) and situations (e.g. alone, in
one-to-one situations, in groups) over the past 7 days. The
primary source of information is the resident. Talk with the
resident and ask about his or her perception (how he or
she feels), how he or she likes to do things, and how he or
she responds to specific situations. Then talk with staff
members who have regular contact with the resident (e.g.
carers, volunteers, social work staff, or therapists if the
person receives active rehabilitation). Remember, it is
possible for discrepancies to exist between how the
resident sees himself or herself and how he or she actually
behaves. Use your best judgment as a basis for planning
care.
Coding
Tick all that apply. None of the choices are to be construed
as negative or positive. Each is simply a statement to be
ticked if it applies and not ticked if it does not apply. If you
do not tick any items in Section F1, tick NONE OF
ABOVE. For individualised care-planning purposes,
remember that information conveyed by unticked items is
no less important than information conveyed by ticked
items.
2. Unsettled relationships
Purpose
To indicate the quality and nature of the resident’s
interpersonal contacts (i.e. how the resident interacts with
staff members, family and other residents).
Definition
Covert/open conflict with or repeated criticism of staff –
The resident frequently complains about some staff
members to other staff members, verbally criticises staff
 Chapter 3: The Item-by-Item Guide to the MDS
members in group situations causing disruption within the
group, or constantly disagrees with routines of daily life in
the home. Ticking this item does not require any
assumption about why the problem exists or how it might
be remedied.
Unhappy with roommate – Unhappiness may include
frequent requests for room changes, or grumbling about
roommate spending too long in the bathroom, complaints
about roommate rummaging in one’s belongings, or
complaints about physical, mental or behavioural status of
roommate. Other examples of roommate compatibility
issues include early bedtime vs. staying up and watching
TV, neat vs. sloppy maintenance of personal area,
roommate spending too much time on the telephone, or
snoring, or odours from incontinence or poor hygiene.
Unhappy with residents other than roommate – May be
manifested by chronic complaints about the behaviours of
others, poor quality of interaction with other residents, or
lack of peers for socialisation. This definition refers to
conflict or disagreement outside of the range of normal
criticisms or requests (i.e. repetitive, ongoing complaints
beyond a reasonable level).
Openly expresses conflict/anger with family/friends –
Includes expressions of feelings of abandonment,
ungratefulness on part of family, lack of understanding by
close friends, or hostility regarding relationships with family
or friends.
Absence of personal contact with family/friends – Absence
of visitors or telephone calls from significant others in the
last 7 days.
Recent loss of close family member/friend – Includes
relocation of family member/friend to a more distant
location, even temporarily (e.g. for the winter months),
incapacitation or death of a significant other, or a
significant relationship that recently ceased (e.g. a favourite
member of staff who has left to work elsewhere).
Does not adjust easily to change in routines – Signs of
anger, prolonged confusion, or agitation when changes in
usual routines occur (e.g. staff turnover or reassignment;
new treatment or medication routines; changes in activity
or meal programmes; new roommate).
Example
For the past 6 months Mrs. G has been receiving 2 white
pills, 1 blue pill, 1 yellow pill and 2 puffs of medication
from an orange hand-held aerosol inhaler. The drug
Full Assessment Form: Section F
company that makes the inhaler recently changed its
packaging. When Mrs. G is given the new blue inhaler to
use and is told that it is the same drug with a different
colour holder, she becomes very agitated and upset. It
takes a lot of patience and reassurance by the carer before
Mrs. G uses the new inhaler. This happened for several
days during the past week.
Process
Ask the resident for his or her point of view. Is he or she
generally content in relationships with staff and family, or
are there feelings of unhappiness? If the resident is
unhappy, what specifically is he or she unhappy about?
It is also important to talk with family members who visit
or have frequent telephone contact with the resident. How
have relationships with the resident been in the last 7
days?
During routine care activities, observe how the resident
interacts with staff members and other residents. Do you
see signs of conflict? Talk with staff and ask for their
observations of behaviour that indicate either conflicted or
harmonious interpersonal relationships. Consider the
possibility that some staff members describing these
relationships may be biased. As the evaluator, you are
seeking to gain an overall picture, a consensus view.
Coding
Tick all that apply over the last 7 days. If none apply, tick
NONE OF ABOVE.
3. Past roles
Purpose
To document the resident’s recognition or acceptance of
feelings regarding previous roles or status now that he or
she is living in a home.
Definition
Strong identification with past roles and status – This may
be indicated, for example, when the resident enjoys telling
stories about his or her past, or takes pride in past
accomplishments or family life, or continues to be
connected with prior lifestyle (e.g. celebrating family
events, carrying on life-long traditions).
Expresses sadness/anger/empty feeling over lost roles/status
– Resident expresses feelings such as “I’m not the man I
used to be” or “I wish I had been a better mother to my
children” or “It’s no use, I’m not capable of doing things I
like to do anymore”. Resident cries when reminiscing
about past failures, accomplishments, memories.
 Chapter 3: The Item-by-Item Guide to the MDS
Resident perceives that daily routine (customary routine,
activities) is very different from prior pattern in the
community – In general, the resident’s pattern of routines
is perceived by the resident not to be comparable with his
or her previous lifestyle.
Examples
In the home, resident takes a shower 2 mornings a week
vs. taking a daily bath before going to bed as she did at
home.
The resident now retires at 7 pm whereas at home he
stayed up to watch the 10 pm news.
In the community Mrs. L enjoyed multiple daily telephone
conversations with her 5 daughters. In the nursing home
there is only one public telephone that seems to be in
constant use by residents and staff. Mrs. L now speaks with
Full Assessment Form: Section F
each daughter only once a week.
Process
Initiate a conversation with the resident about life prior to
home admission. It is often helpful to use environmental
cues to prompt discussions (e.g. family photos,
grandchildren’s letters or art work). This information may
emerge from discussions around other MDS topics (e.g.
Daily Routine, Activity Pursuits, ADLs). Care staff and
family visitors may also have useful insights.
Coding
Tick item if it applies over the last 7 days. If none apply,
tick NONE OF ABOVE.
 Section F. Psychosocial Well-Being

1 Sense of initiative/ ■ a. At ease interacting with others

involvement ■ b. At ease doing planned or structured activities

■ c. At ease doing self-initiated activities

7
■ d. Establishes own goals

■ e. Pursues involvement in life of home (eg. makes/keeps friends; involved in group

activities; reponds positively to new activities; assists in religious services)

■ f. Accepts invitations into most group acitvities

■ g. NONE OF ABOVE

2 Unsettled ■ a. Covert/open conflict with or repeated criticism of staff

7

relationships ■ b. Unhappy with roommate

7

7
■ c. Unhappy with residents other than roommate
7
■ d. Openly expresses conflict/anger with family/friends

■ e. Absence of personal contact with family/friends

■ f. Recent loss of close family member/friend

■ g. Does not adjust easily to change in routines

■ h. NONE OF ABOVE

3 Past roles ■ a. Strong identification with past roles eg. occupation, head of family
7

7
■ b. Express sadness/anger/empty feeling over lost roles/status

■ c. Resident perceives that daily routine is very different from prior pattern in the
7
community

■ d. NONE OF ABOVE

Section F: Psychosocial Well-Being

Triggers for Resident Assessment Protocols

Question MDS Item Code RAPs

Number

7
F1d Establishes own goals ✓ Psychosocial Well-being

7
F2a to F2d Unsettled relationships ✓ Psychosocial Well-being

7
F3a Strong id, past roles ✓ Psychosocial Well-being

7
F3b Lost roles ✓ Psychosocial Well-being

7
F3c Daily routine different ✓ Psychosocial Well-being
 Chapter 3: The Item-by-Item Guide to the MDS
Section G: Mobility and Activities of Daily Living
Most care home residents are at risk of physical decline.
Many residents will also have multiple chronic illnesses
and are subject to a variety of other factors that can
severely affect independence. For example, cognitive
deficits can limit ability or willingness to initiate or
participate in self-care or constrict understanding of the
tasks required to complete Activities of Daily Living
(ADLs). A wide range of physical and neurological
illnesses can adversely affect physical factors important to
self-care such as stamina, muscle tone, balance, and
bone strength. Side effects of medications and other
treatments can also contribute to needless loss of
independence.
Due to these many, possibly adverse influences, a
resident’s potential for maximum function is often greatly
underestimated by family, staff and the resident him or
herself. Thus, all residents are candidates for
rehabilitative care that focuses on maintaining and
expanding self-involvement in ADLs. Individualised plans
of care can be successfully developed only when the
resident’s self-performance has been accurately assessed
and the amount and type of support being provided to
the resident by others has been evaluated.
1. (A) Activities of Daily Living (ADL)
self-performance
Purpose
To record the resident’s self-care performance in activities
of daily living (i.e. what the resident actually did for
himself or herself and/or how much help was required
from staff members e.g. washes hands/face, required
assistance with total body wash) during the last 7 days.
Definition
ADL self-performance – Measures what the resident
actually did (not what he or she might be capable of
doing) within each ADL category over the last 7 days
according to a performance-based scale.
Bed mobility – How the resident moves to and from a
lying position, turns side to side, and positions body
while in bed.
Transfer – How the resident moves between surfaces –
i.e. to/from bed, chair, wheelchair, standing position.
Exclude from this definition movement to/from bath or
toilet, which is covered under Toilet Use and Bathing.
Walk in room – How resident walks between locations in
his/her room.
Full Assessment Form: Section G
Walk in corridor – How resident walks in corridor in
home.
Mobility around immediate space – How the resident
moves between locations in his or her room and adjacent
corridor on the same floor. If the resident is in a
wheelchair, mobility is defined as self-sufficiency once in
the chair.
Mobility around home – How the resident moves to and
returns from off unit locations (e.g. areas set aside for
dining, activities, or treatments). If the home has only
one floor, locomotion off the unit is defined as how the
resident moves to and from distant areas on the floor. If
in wheelchair, self-sufficiency once in chair.
Dressing – How the resident puts on, fastens, and takes
off all items of day clothing, including donning/removing
a prosthesis e.g. artificial limb.
Eating – How the resident eats and drinks, regardless of
skill. Includes, intake of food by other means (e.g. tube
feeding).
Toilet use – How the resident uses the toilet, commode,
bedpan, or urinal, transfers on/off toilet, cleans self,
changes pad, manages colostomy/urostomy or catheter,
and adjusts clothes.
Personal hygiene – How the resident maintains personal
hygiene, including combing hair, brushing teeth,
showering, applying makeup, and washing/drying face,
hands, and post toilet use. Exclude from this definition
personal hygiene in baths and showers, which is covered
under bathing.
Bathing – How the resident takes a full-body
bath/shower, sponge bath, and transfers in/out of
bath/shower. Exclude washing of back and hair.
Process
In order to be able to promote the highest level of
functioning among residents, staff must first identify what
the resident actually does for himself or herself, noting
when assistance is received and clarifying the types of
assistance provided (verbal cueing, physical support, etc.)
A resident’s ADL self-performance may vary from day to
day, shift to shift, or within shifts. There are many
possible reasons for these variations, including mood,
medical condition, relationship issues (e.g. willing to
perform for a carer he or she likes), and medications.
The responsibility of the assessor, therefore, is to capture
 Chapter 3: The Item-by-Item Guide to the MDS
the total picture of the resident’s ADL self-performance
over the 7-day period, 24 hours a day – i.e. not only
how the assessor sees the resident, but how the resident
performs on other shifts as well.
In order to accomplish this, it is necessary to gather
information from multiple sources – i.e.
interviews/discussion with the resident and care staff on
all shifts, including weekends, and review of
documentation used to communicate with staff across
shifts. Ask questions pertaining to all aspects of the ADL
activity definitions. For example, when discussing bed
mobility, be sure to inquire specifically how the resident
moves to and from a lying position, how the resident
turns from side to side, and how the resident positions
himself or herself while in bed. A resident can be
independent in one aspect of bed mobility yet require
extensive assistance in another aspect. Since accurate
coding is important as a basis for making decisions on
the type and amount of care to be provided, be sure to
consider each activity definition fully.
The wording used in each coding option is intended to
reflect real-world situations in care homes, where slight
variations are common. Where variations occur, the
coding ensures that the resident is not assigned to an
excessively independent or dependent category. For
example, by definition, codes 0, 1, 2, and 3
(Independent, Supervision, Limited Assistance and
Extensive Assistance) permit one or two exceptions for
the provision of heavier care. This is clinically useful and
increases the likelihood that staff will code ADL self-
performance items consistently and accurately.
Because this section involves a two-part evaluation (Item
G1A. ADL self-performance and Item G1B, ADL
support), each using its own scale, it is recommended
that you complete the self-performance evaluation for all
ADL self-performance activities before beginning the
ADL support evaluation.
To evaluate a resident’s ADL self-performance, begin by
reviewing the documentation in the resident record. Talk
with staff from each shift to ascertain what the resident
does for himself or herself in each ADL activity as well as
the type and level of staff assistance being provided. As
previously noted, be alert to differences in resident
performance from shift to shift and apply the ADL codes
that capture these differences. For example, a resident
may be independent in toilet use during daylight hours
Full Assessment Form: Section G
but receive non-weight-bearing physical assistance every
evening. In this case, the resident would be coded as “2”
(Limited Assistance) in toilet use.
The following box provides general guidelines for
recording accurate ADL self-performance and ADL
support assessments.
Guidelines for assessing ADL self-performance and
ADL support
■ The scales in Items G1A and G1B are used to record
respectively the resident’s actual level of involvement
in self-care and the type and amount of support
actually received during the last 7 days.
■ Do not record your assessment of the resident’s
capacity for involvement in self-care – i.e. what you
believe the resident might be able to do for himself or
herself based on demonstrated skills or physical
attributes. An assessment of potential capability is
covered in Item G8 (“ADL Potential for
Rehabilitation”).
■ Do not record the type and level of assistance that the
resident “should” be receiving according to the written
plan of care. The type and level of assistance actually
provided may be quite different from what is
indicated in the plan. Record what is actually
happening.
■ Engage care staff from all shifts who have cared for
the resident over the last 7 days in discussions
regarding the resident’s ADL functional performance.
Remind staff that the focus is on the last 7 days only.
To clarify your own understanding and observations
about each ADL activity (bed mobility, transfer, etc.),
ask probing questions, beginning with the general and
proceeding to the more specific.
Coding
For each ADL category, code the appropriate response
for the resident’s actual performance during the past 7
days. Enter the code in column (A).
In your evaluations, you will also need to consider the
type of assistance known as “initial help” (e.g. comb,
brush, toothbrush, toothpaste have been laid out at the
bathroom sink by the carer). Initial help is recorded
under ADL Support Provided (Item G1B). But in
evaluating the resident’s ADL self-performance, include
initial help within the context of the “0” (Independent)
 Chapter 3: The Item-by-Item Guide to the MDS Full Assessment Form: Section G

code. For example: If a resident grooms independently However, do not confuse a resident who is totally
once grooming items are set up for him, code “0” dependent in an ADL activity (code 4 – Total
(Independent) in personal hygiene. Dependence) with the activity itself not occurring.
0. Independent – No help or staff oversight. Or, staff Each of these ADL self-performance codes is exclusive;
help/oversight provided only one or two times during the there is no overlap between categories. Changing from
last 7 days. one self-performance category to another demands an
1. Supervision – Oversight, encouragement, or cueing increase or decrease in the number of times that help is
provided three or more times during last 7 days. Or provided. Thus, to move from Independent to
supervision (3 or more times) plus physical assistance Supervision to Limited Assistance, non weight-bearing
provided only one or two times during last 7 days. supervision or physical assistance must increase from one
or two times up to three or more times during the last 7
2. Limited assistance – Resident highly involved in
days.
activity, received physical help in guided manoeuvring of
limbs or other non-weight-bearing assistance on three or Where, as is commonly the case, there is variability in
more occasions. Or, limited assistance (3 or more times) degrees of assistance/independence during the 7-day
plus more help provided only one or two times during period, Figure 3.2 Scoring ADL Self Performance may
last 7 days. help you code this item.
3. Extensive assistance – While the resident performed
part of activity over last 7 days, help of following type(s)
was provided three or more times:
■ Weight-bearing support provided three or more times
■ Full staff performance of activity (3 or more times)
during part (but not all) of last 7 days
4. Total dependence – Full staff performance of the
activity during entire 7-day period. Complete non-
participation by the resident in all aspects of the ADL
definition.
For example: For a resident to be coded as totally
dependent in eating, he or she would be fed all food and
liquids at all meals and snacks (including tube feeding
delivered totally by staff), and never initiate any subtask
of eating (e.g. picking up finger foods, giving self tube
feeding or assisting with procedure) at any meal.
8. Activity did not occur during the entire 7-day period –
Over the last 7 days, the ADL activity was not performed
by the resident or staff. In other words, the particular
activity did not occur at all.
For example: The definition of dressing specifies the
wearing of day clothes. During the 7-day period, if the
resident did not wear day clothing, a code of “8” would
1. (B) ADL support provided
apply (i.e. the activity did not occur during the entire
seven day period). Likewise, a resident who was Purpose
restricted to bed for the entire 7-day period and was To record the type and highest level of support the
never transferred from bed would receive a code of “8” resident received in each ADL activity over the last 7
for transfer. days.
 Figure 3.2: Scoring ADL Self-Performance
START

Frequency 8
0 Does on own OR Activity never performed Activity did
Independent of Help or
aided 1 or 2 times only (a) By resident or other not occur
Supervision

3o
rm
ore
tim
es

Key
a. Can include one or two events where
Weight Bearing 4
received supervision, non-weight bearing Assistance or Full Full staff performance
s Total
help, or weight bearing help. ime Staff Performance every time over 7-day
,2,t dependence
0,1 Supervision period
b. Can include one or two episodes of
weight bearing help e.g. two events with
non-weight bearing plus two of weight 3o
rm
bearing would be coded as a “2”. Non-Weight ore
tim es
Bearing Physical

3
c. Can include one or two episodes where Assistance (b)

or
physical help received e.g. two episodes of
supervision, one of weight bearing, and one mo
re
3
t
i

of non-weight bearing would be coded as Extensive

me
s

“1”. assistance
(b
)

times
0,1,2,
2
Supervision Limited
(c) assistance
im es (oversight, cueing)
o re t
rm
3o

1
Supervision
 Chapter 3: The Item-by-Item Guide to the MDS
Definition
ADL support provided – Measures the highest level of
support provided by staff over the last 7 days, even if
that level of support only occurred once. This is a
different scale, and is entirely separate from the ADL self-
performance assessment.
Initial help –The type of help characterised by providing
the resident with articles, devices or preparation
necessary for greater resident self-performance in an
activity. This can include giving or holding out an item
that the resident takes from the caregiver.
Examples of initial help
For bed mobility – handing the resident the monkey pole
to assist with bed movement.
For transfer – giving the resident a transfer board or
locking the wheels on a wheelchair for safe transfer.
For mobility
■ Walking – handing the resident a walking stick or
frame.
■ Wheeling – unlocking the brakes on the wheelchair or
adjusting foot rests to facilitate foot motion while
wheeling.
For dressing – retrieving clothes from wardrobe and
laying out on the resident’s bed; handing the resident an
item of clothing.
For eating – cutting meat and opening containers at
meals.
For toilet use – handing the resident a bedpan or placing
articles necessary for changing colostomy appliance
within reach.
For personal hygiene – providing a wash basin and
grooming articles.
For bathing – placing bathing articles at side of bath
within the resident’s reach; handing the resident a towel
upon completion of bath.
Process
For each ADL category, code the maximum amount of
support the resident received over the last 7 days
irrespective of frequency, and enter in the “SUPPORT”
column. Be sure your evaluation considers all shifts, 24
hours per day, including weekends. Code independently
of the resident’s self-performance evaluation. For
Full Assessment Form: Section G
example, a resident could have been Independent in
ADL self-performance in transfer but received a one-
person physical assistance one or two times during the 7-
day period. Therefore, the ADL self-performance coding
for transfer would be “0” (Independent), and the ADL
support coding “2” (One person physical assistance).
Coding
Note: The highest code of physical assistance in this
category (other than the “8” code) is a code of “3” not
“4” as in self-performance.
0. No initial or physical help from staff
1. Initial help only – The resident is provided with
materials or devices necessary to perform the activity of
daily living independently.
2. One person physical assistance
3. Two+ persons physical assistance
8. ADL activity itself did not occur during the entire 7
days – When an “8” code is entered for an ADL Support
provided category, enter an “8” code for ADL self-
performance in the same category.
For example, if a resident never left their room during the
assessment period, code “8” for mobility around home.
The activity did not occur, there was no help provided.
Examples of resident descriptions together with the
appropriate self performance and support codings are
given in Appendix C. Staff can use these to test their
ability to code these correctly.
2. Bathing
Bathing is the only ADL activity for which the ADL self-
performance codes in item G1A do not apply. A unique
set of self-performance codes, to be used only in the
Bathing assessment, are described below. The self-
performance codes for the other ADL items would not be
applicable for bathing given the normal frequency with
which the bathing activity is carried out during a one-
week period. Assuming that the average frequency of
bathing during a 7-day period would be one or two
baths, the coding for the other ADL self-performance
items, which permits one or two exceptions of heavier
care, would result in the inaccurate classification of
almost all residents as “Independent” for bathing.
The ADL support provided codes given in item G1B,
however, continue to apply to the bathing activity.
 Chapter 3: The Item-by-Item Guide to the MDS
Purpose
To record the resident’s self-performance and
support provided in bathing, including how the
resident transfers into and out of the bath or
shower.
Definition
Bathing – How the resident takes a full bath,
shower or sponge bath, including transfers in and
out of the bath or shower. The definition does
not, however, include the washing of back or hair.
Coding
A. Bathing self-performance codes
Record the resident’s self-performance in bathing
according to the codes listed below. When
coding,
apply the code number that reflects the maximum
amount of assistance the resident received during
bathing episodes.
0. Independent – No help provided.
1. Supervision – Oversight help only.
2. Physical help limited to transfer only
3. Physical help in part of bathing activity
4. Total dependence
8. Activity itself did not occur during entire 7 days
B. Support
Next, score the maximum amount of support provided in
bathing activities using the ADL Support Scale (Item
G1B).
3. Test for balance
Purpose
To record the resident’s capacity of a) balance while
standing (not walking) without an assistive device or
assistance of a person, and b) balance while sitting
without using the back or arms of the chair for support.
Full Assessment Form: Section G
Examples: ADL self-performance and support self-perf. support
Bathing
Resident received verbal cueing and 1 0
encouragement to take twice-weekly showers.
Once staff walked resident to bathroom, he
bathed himself with periodic oversight.
On Monday, one staff member helped transfer 3 2
resident to bath and washed his legs. On
Thursday, resident had physical help of one
person to get into bath but washed himself
completely.
Resident afraid of mechanical lift. Given full 3 2
sponge or bed bath by carer twice weekly.
Actively involved in this activity.
For one bath, resident received light guidance 4 2
of one person to position self in bath. However,
due to her fluctuating moods, she received total
help for her other bath. Rationale: The coding
directions for bathing state, “code for most
dependent in self performance and support”.
Residents with impaired balance in standing and sitting
are at greater risk of falling. It is important to assess an
individual’s balance abilities so that interventions can be
implemented to prevent injuries (e.g. strength training
exercises; safety awareness).
Process
a. Balance while standing
Preparation:
■ Obtain a watch with a second hand to time the test.
■ Pick a time to test the resident when he or she is likely
to be at his or her best. If the resident refuses,
negotiate a better time and try again later.
■ Place a chair directly behind the resident in case the
resident needs to sit down.
■ Stand close to the resident while testing balance in
order to catch or balance the resident, if necessary.
■ If the resident is heavy or tall or seems frail, ask
another staff person to stand by with you in case the
resident needs assistance.
■ Test balance without assistive devices. For residents
who use a zimmer frame, make sure this is placed
 Chapter 3: The Item-by-Item Guide to the MDS
directly in front of the resident within easy reach in
case it is needed for rebalancing.
Conducting the tests:
■ DO each of the following tests (10 seconds each) on
residents who are able to stand without physical help.
■ DO NOT attempt to test residents who cannot stand
by themselves. Code these residents as “3”, Not able
to attempt test without physical help.
■ For persons with visual impairment who may not be
able to see your demonstrations of feet placement,
provide rich verbal descriptions.
Position 1 –
“I would like you to stand with your feet together, side-
by-side, like this (demonstrate as illustrated). [Note, in
this and all tests, both feet should be firmly on the floor
for support.]
“Do not move your feet until I say stop. Ready, OK,
begin.” If the resident is ABLE to maintain this position
for 10 seconds, proceed to test resident in Position 2. If
the resident is NOT ABLE to maintain this position for 10
seconds, stop testing here. Do not proceed with Position
2 for balance testing.
Position 2 –
“Now I would like you to stand with one foot halfway in
front of the other like this (demonstrate as illustrated).
“You may use either foot, whichever is more comfortable
for you. Ready, OK, begin.” If the resident is ABLE to
maintain this position for 10 seconds, proceed to test
resident in Position 3. If the resident is NOT ABLE to do
this, stop testing here.
Full Assessment Form: Section G
Position 3 –
“Now I would like you to stand with the heel of one foot in
front of you touching the toes of the other foot like this
(demonstrate as illustrated). You may use either foot,
whichever is more comfortable for you. Ready, OK, begin.”
Coding
0. Maintained position as required in test – Resident was
able to maintain all 3 standing positions for 10 seconds
and without moving feet out of position.
1. Unsteady, but able to rebalance self without physical
support – Resident was unable to maintain one or more
standing positions for 10 seconds each without moving
feet out of position. Resident was unsteady but was able
to rebalance self without physical support from others or
from an assistive device in at least the first position.
2. Partial physical support during test, or stands but does
not follow directions for test – While the resident
performed part of the activity, resident was unable to
maintain one or more standing positions without physical
support from other(s) or from an assistive device. This
category also includes residents who can stand but are
unable or refuse to follow your directions to perform a
test of balance.
3. Not able to attempt test without physical help -
Resident is not able to stand without physical help from
another person or an assistive device.
Examples of balance testing
Mrs. R. usually walks with a zimmer frame. After
completing the test preparation steps for safety, which
include placing Mrs. R’s zimmer frame directly infront of
her in case she needs it during the test, you briefly
explain to Mrs. R what you are going to ask her to do.
You also demonstrate the actions. Once Mrs. R is
standing, start to test her in Position 1 by giving her the
brief directions and your demonstration of the position.
You start timing her once you say, “Ready, OK, begin”.
Results: During the 10-second test, Mrs. R. moves her
 Chapter 3: The Item-by-Item Guide to the MDS
feet out of position to rebalance herself.
How to proceed: Tell Mrs. R, “That was a good try.”
STOP the test because the next 2 positions are harder to
perform. If Mrs. R. cannot maintain Position 1, it is
unlikely she will be able to maintain Positions 2 or 3.
Coding:”1”, Unsteady, but able to rebalance self without
physical support.
Rationale: Mrs. R. moved her feet out of position but did
not need to hold her zimmer frame, or lean against the
chair behind her, or receive assistance from you during
the 10 seconds.
Mr. C has cognitive and hearing impairment and
restlessness. He usually walks independently (wandering)
and occasionally stands at the door of the home’s office
to be with the secretary. Therefore, you know he can
stand, but you do not know if he would be able to
maintain his balance if he were asked to “hold” specific
standing positions for 10 seconds each. After completing
the test preparation, and steps for safety, you give Mr. C
the brief directions and demonstration for testing position
1.
Results: During your interaction with Mr. C he becomes
agitated, says “No, no” and walks away.
How to proceed: STOP the test.
Coding:”2”, Partial physical support during test or stands
but does not follow directions for test. Rationale: This is
the best you can do under the circumstances. Although
Mr. C did not need physical help to balance, you really
do not know what his true balance capacity is. All you
know is that he is able to stand, but you can’t test his
balance capacity because he refuses and is unable to
follow directions.
Ms. M has multiple sclerosis and has been confined to
her bed and reclining chair for the last 2 years.
How to proceed: DO NOT perform any standing balance
tests. Ms. M cannot stand.
Coding:”3”, Not able to attempt test without physical
help.
Process
b. Balance while sitting – position, trunk control
Preparation:
■ Obtain a watch with a second hand to time the test.
Full Assessment Form: Section G
■ Do not conduct sitting balance in wheelchair. Find a
chair with a firm, solid seat to conduct the test.
■ The height of the chair seat should be low enough to
allow the bottom of the resident’s feet to rest on the
floor for support.
■ It is safer to use a chair with arms in case the resident
needs physical support during the test.
■ Stand close to the resident while testing sitting balance
in order to catch or balance the resident, if necessary.
■ If the resident is heavy or tall or seems frail, ask
another staff person to stand by with you in case the
resident needs assistance.
Conducting the test:
DO NOT attempt to test residents who are clearly unable
to sit without physical help. Code these residents as “3”,
Not able to attempt test without physical help.
Instruct the resident to sit in a chair with arms folded
across his or her chest without using the back or arms of
the chair for support. Make sure the resident’s feet are
both flat on the floor for support. Demonstrate the action
to the resident. Observe balance for 10 seconds, then ask
resident to stop.
Coding
0. Maintained position as required in test – Resident was
able to sit for 10 seconds without touching the back or
sides of the chair for support.
1. Unsteady, but able to rebalance self without physical
support – Resident was unable to maintain sitting
balance for 10 seconds without touching the back or
sides of the chair for support. Resident was unsteady but
was able to rebalance self.
2. Partial physical support by others during test or sits but
does not follow directions for test – While resident
performed part of activity, resident was unable to
maintain sitting balance without physical support from
other(s) or from touching the backs or sides of the chair
for support. This category also includes residents who
can sit but are unable or refuse to follow your directions
to perform this test of sitting balance.
3. Not able to attempt test without physical help –
Resident is not able to sit without physical help from
another, or an assistive/adaptive device, or chair
back/arms for support.
 Chapter 3: The Item-by-Item Guide to the MDS
Examples of sitting balance
Ms. Z spends a lot of time sitting in a wheelchair on a
cushion for pressure relief. She has a left-sided below-the-
knee amputation. She does not have a leg prosthesis.
She also has a left-sided hemiparesis from a CVA one
year ago. You complete the test preparation activities for
safety, assist Ms. Z to transfer into a chair with a firm
seat, and ask her to place her right foot firmly on the
floor. You instruct her to cross her arms over her chest.
She cannot lift her left arm across her chest but is able to
hold it across her abdomen. You instruct her to “sit up in
the chair without leaning on the chair back or arms for
support”. You demonstrate this activity from another
chair. Once the resident begins, you time for 10 seconds.
Results: Ms. Z maintained the position for the full 10
seconds without touching the chair back/arms for
support.
How to proceed: Tell Ms. Z, “You did an excellent job.
That’s all we have to do.” STOP testing. The test is
complete.
Coding:“0”, Maintained position as required in test.
4. Functional limitation in range of motion
Purpose
To record the presence of (A) functional limitation in
range of joint motion or (B) loss of voluntary movement.
(A) Limitation in range of motion
Definition
Limitation that interferes with daily functioning
(particularly with activities of daily living), or places the
resident at risk of injury.
Process
Assessing for functional limitations:
■ Do each of the following tests on all residents unless
contraindicated (e.g. recent fracture or joint
replacement).
■ Perform each test on both sides of the resident’s body.
■ If the resident has difficulty following verbal directions
demonstrate each movement (e.g. Ask the resident to
do what you’re doing).
■ If resident is still unable to perform the activity after
your demonstration, move the resident’s joints
through slow, active assisted range of motion to assess
for limitations. In active assistive range of motion
Full Assessment Form: Section G
exercises, the health professional provides support
and direction with the resident performing some of
the activity.
■ STOP if a resident experiences pain.
Neck – With resident seated in a chair, ask him or her to
turn the head slowly, looking side to side. Then ask the
resident to return head to centre and then try to reach
the right ear towards the right shoulder, then left ear
towards left shoulder.
Arm – including shoulder or elbow – With resident seated
in a chair instruct him or her to reach with both hands
and touch palms to back of the head (mimics the action
needed to comb hair). Then ask the resident to touch
each shoulder with the opposite hand. Alternatively,
observe the resident donning or removing a shirt over
the head.
Hand – including wrist or fingers – For each hand,
instruct the resident to make a fist, then open the hand
(useful actions for grasping utensils, letting go).
Leg – including hip or knee – While resident is lying
supine in a flat bed, instruct the resident to lift his or her
leg (one at a time), bending it at the knee. [The knee will
be at a right angle (90 degrees).] Then ask the resident to
slowly lower his or her leg, and extend it flat on the
mattress.
Foot – including ankle or toes – While supine in bed,
instruct the resident to flex (pull toes up towards head)
and extend (push toes down away from head) each foot.
Other limitation or loss – Decreased mobility in spine,
jaw, or other joints that are not listed.
Coding
For each body part, code the appropriate response for
the resident’s active (or assisted passive) range of motion
function during the past 7 days. Enter the code in the
column labeled (A). If the resident has an amputation on
one side of the body, use code “1”, Limitation on one
side of the body. If there are bilateral amputations, use
code “2”, Limitation on both sides of the body.
0. No limitation – Resident has full function range of
motion on the right and left side.
1. Limitation on one side of the body (either right or left
side).
2. Limitation on both sides of the body.
 Chapter 3: The Item-by-Item Guide to the MDS Full Assessment Form: Section G

Example of coding for (A) limitation in range of motion 2. Full loss of voluntary movement – Resident is not able
Mr. O was admitted to the home for rehabilitation to initiate the required task. There is no voluntary
following right knee surgery. His right leg is in a plaster. movement on either side.
With the exception of his right leg, Mr. O has full active Example of function limitation
range of motion in all other areas.
Mrs. X is a diabetic who sustained a CVA 2 months ago.
Coding (A) She can only turn her head slightly from side to side and
Neck 0 tip her head towards each shoulder (limited neck range
of motion). She can perform all arm, hand, leg, and foot
Arm 0
movements on the right side, with smooth coordinated
Hand 0
movements. She is unable to move her left side (limited
Leg 1 arm, hand, leg and foot motion) as she has a flaccid left
Foot 0 hemiparesis. She is able to extend her legs flat on the
Other 0 bed. She has no other limitations.
Coding Limitation in Limitation in
(B) Loss of voluntary movement
range of motion voluntary movement
Definition
Loss of voluntary movement – Impairment in purposeful Neck 1 0
(intentional) functional movement. This category refers to Arm 1 1
a range of impairments exhibited when a resident tries to Hand 1 1
perform a task and includes deficits such as Leg 1 1
incoordination, tremors, spasms, muscular rigidity, Foot 1 1
“freezing”, choreiform movements (jerking) as well as Other 0 0
lack of initiation of movement. Impairments in voluntary
5. Modes of locomotion
movement are often due to injury or disease of muscles,
bones, nerves, spinal cord or the brain and can place a Purpose
resident at risk for functional disability and injury. To record the type(s) of appliances, devices, or personal
assistance the resident used for locomotion (in and out of
Process
the home).
While performing the assessment of range of motion in
item G4(A) above, observe the resident for impairment(s) Definition
in purposeful movement on each side of the resident’s Stick/zimmer/crutches/tripod – Also tick this item in those
body. instances where the resident walks by pushing a
wheelchair for support.
Coding
For each body part, code the appropriate response for Wheeled self – Includes using a hand-propelled or
the resident’s function during the past 7 days. Enter the motorised wheelchair, as long as the resident takes
code in the column labelled (B). If the body part is responsibility for self-mobility, even for part of the time.
missing on one side (e.g. left above knee amputation), Other person wheeled – Another person pushed the
code “1”, Partial loss of voluntary movement. If missing resident in a wheelchair.
bilaterally, code “2”, Full loss of voluntary movement.
Wheelchair primary mode of locomotion – Even if
0. No loss of voluntary movement – Resident moves resident walks some of the time, he or she is primarily
body part to complete the required task. Movements are dependent on a wheelchair to get around. The
smooth and coordinated. wheelchair may be motorised, self-propelled, or pushed
1. Partial loss of voluntary movement – Resident is able by another person.
to initiate and complete the required task but movements Coding
are slow, spastic, uncoordinated, rigid, choreiform frozen, Tick all that apply during the last 7 days. If no appliances
etc. on one or both sides. or assistive devices were used, tick NONE OF ABOVE.
 Chapter 3: The Item-by-Item Guide to the MDS
6. Modes of transfer
Purpose
To record the type(s) of appliances or assistive devices
the resident used for transferring in and out of bed or
chair and for bed mobility.
Definition
Bedfast all or most of the time – Resident is in bed or in
an armchair in own room for 22 hours or more per day.
For care planning purposes this information is useful for
identifying residents who are at risk of developing
physical and functional problems associated with
restricted mobility, as well as cognitive, mood, and
behaviour impairment related to social isolation. Code
this item when it was true on at least 4 of the last 7 days.
Lifted manually – The resident was completely lifted by
one or more persons.
Lifted mechanically – The resident was lifted by a
mechanical device. Does not include a bath lift.
Transfer aid – Includes devices such as slide boards,
sticks, zimmer frames and other assistive devices.
Coding
Tick all that apply. If none of these items apply, tick
NONE OF ABOVE.
7. Task segmentation
Purpose
To identify residents who are more involved and
independent in personal care tasks (such as eating,
bathing, grooming, dressing) because they have received
help in breaking tasks down into smaller steps. Some
residents become overwhelmed and anxious when there
are expectations for greater independence and they are
no longer able to perform the steps necessary to
complete an ADL activity. Such residents are at great risk
of becoming dependent on others unless activities are
made easier for them to manage by task segmentation.
These residents usually have some deficits in memory,
thinking, or paying attention to the task consequent to
problems such as dementia, head injury, stroke or
depression. Other residents receive task segmentation
care because of body-control problems, poor stamina or
other physical difficulties that limit self-performance.
Definition
Task segmentation provides the resident with directions –
such as verbal cues, physical cues, or verbal and physical
Full Assessment Form: Section G
cues – for performing each constituent step in an ADL
activity.
Verbal cueing involves giving a verbal direction to
complete the first step in a task, and once the step is
accomplished, giving another verbal direction to
complete the next step. Verbal encouragement, praise,
and feedback for the resident’s successful completion of
the steps are usually given by care staff prior to providing
the next verbal cue. For example, “That looks good. Now
put on this skirt”.
Physical cueing involves giving the resident an object
as a reminder of what needs to be done – e.g. handing
the resident some toilet paper as a cue to wipe self,
or placing an item from a food tray in front of the
resident and handing him or her a fork as a cue to eat
the item.
Physical and verbal cueing involves use of objects and
words to stimulate action – e.g. giving the resident one
item of clothing at a time and saying “Put this shirt on,”
which is less confusing to a cognitively impaired resident
than putting all clothing items before him or her and
saying “Get dressed”.
Examples
Task segmentation
■ When handed a soapy face cloth and asked, “Would
you please wash your face?” the resident washes her
face.
■ When a carer sets a mirror in front of the resident,
and hands him a brush, the resident brushes his hair.
■ When the carer hands the resident a sock and says
“Put this sock on this foot” and upon completion of
the step hands the resident another sock and says
“Put this sock on this foot,” the resident dons his
socks.
■ When single food items and only one utensil are
presented to the resident in succession, the resident
eats independently.
■ When a carer gives verbal directions for each step in
transferring from a wheelchair (e.g. “Lock the
brakes... Hold onto the arms of the chair and push
yourself up... Hold onto your frame with both hands
like this [demonstrates]”), the resident succeeds in
transferring himself from a seated to a standing
 Chapter 3: The Item-by-Item Guide to the MDS
position.
For all above examples, Code “1” for Yes.
No task segmentation
■ When a wash basin, a face cloth, a towel, and various
grooming supplies are placed before the resident, the
resident becomes overwhelmed.
■ When a carer places the resident’s clothes for the day
on the bed and says, “Get dressed,” the resident
becomes confused and is unable to dress self.
■ When a tray containing an entire meal and several
different utensils are placed before the resident on a
table, the resident becomes confused and is unable to
eat by herself.
■ When a carer lifts a resident from a sitting to a
standing position and does not involve the resident in
the process of self-care in the activity, the resident
becomes more physically dependent on the carer.
For all above examples, Code “0” for No.
Process
Ask the carer to think about how the resident completes
activities of daily living, or ways in which the resident
completed an activity of daily living over the last 7 days.
Specifically: Did the carer break the ADL activity into
subtasks (smaller steps) so that the resident could
perform them? Did this occur in the last 7 days?
Coding
Code “0” if task segmentation was not done. Code “1” if
ADLs were broken into a series of subtasks so that the
resident could perform them.
8. Potential for rehabilitation
Purpose
To describe beliefs and characteristics related to the
resident’s functional ability that may indicate he or she
has the capacity for greater independence and
involvement in self-care in at least some ADL areas. Even
if highly independent in an activity, the resident may
believe he or she can do better (e.g. walk longer
distances, shower independently).
Process
Ask if the resident thinks he or she could be more self-
sufficient given more time. Listen to and record what the
resident believes, even if it appears unrealistic. Also, as a
clue to whether the resident might do better all the time,
ask if his or her ability to perform ADLs varies from time
Full Assessment Form: Section G
to time, or if ADL function or range of motion of joints
has declined or improved in the last three months.
Ask care staff (on all shifts) who routinely care for the
resident if they think he or she is capable of greater
independence, or if the resident’s performance in ADLs
varies from time to time. Ask if ADL function or range of
motion of joints declined or improved in the last three
months. You may need to prompt staff to consider such
factors as:
■ Has self-performance in any ADL varied over the last
week (e.g. the resident usually requires two-person
assistance but on one day transferred out of bed with
assistance of one person)?
■ Has resident’s performance varied during the day
(e.g. more involved and independent in the afternoon
than in the morning)?
■ Was the resident so slow in performing some activities
that staff members intervened and performed the task
or activity? Is the resident capable of increased self-
performance when given more time? - OR - Is the
resident capable of increased self-performance when
tasks are broken into manageable steps?
■ Does the resident tire noticeably during most days?
■ Does the resident avoid an ADL activity even though
physically or cognitively capable (e.g. refuses to walk
alone for fear of falling, demands that others attend to
personal care because they do it better)?
■ Has the resident’s performance in any ADL
improved?
Coding
Tick all that apply. If none of these items apply tick NONE OF
ABOVE.
Examples
Mr. N, who is cognitively impaired, receives limited
physical assistance in walking for safety purposes.
However, he believes he is capable of walking alone and
often gets up and walks by himself when staff aren’t
looking. Tick “a” (Resident believes he/she capable of
increased independence).
The carer who feeds Mrs. W has noticed in the past week
that Mrs. W has made several attempts to pick up finger
foods. She believes Mrs. W could become more
independent in eating if she received close supervision
 Chapter 3: The Item-by-Item Guide to the MDS
(cueing). Tick “b” (Care staff believes resident is capable
of increased independence).
Mrs. Y has demonstrated the ability to get dressed, but
has missed breakfast on several occasions because she
was slow getting organised. Therefore, every morning
care staff physically helped her to dress so that she would
be ready for breakfast. Tick “c” (Resident able to perform
task but is very slow).
Mrs. F remained continent during day shifts while
receiving supervision in toileting. During the evening and
night shifts she was incontinent because she was not
helped out of bed to the toilet room. After incontinence
episodes, care staff provided total help in hygiene. Tick
“d” (Difference in ADL self-performance or ADL support,
comparing mornings to evenings).
Mr. K has hemiplegia secondary to a stroke. He receives
extensive assistance in bed mobility transfer, dressing,
toilet use, personal hygiene and eating. He is totally
dependent in locomotion (wheelchair). Whenever he has
tried to do more for himself he has experienced chest
pain and shortness of breath. Both Mr. K and care staff
believe that he is involved in self-care as much as he is
physically able. Tick “e” (NONE OF ABOVE).
9. Change in ADL function
Purpose
To document any changes occurring in the resident’s
overall ADL self-performance, as compared to status of 3
months ago (or since last assessment if less than 3
months ago). These include, but are not limited to,
changes in the resident’s level of involvement in ADL
activities as well as the amount and the type of support
received from staff.
Process
Review the record for indications of a change. Consult
with the resident and care staff. If applicable, review
Section G from the last assessment and compare these
findings with current findings. For new residents, consult
with the primary family caregiver.
Coding
Code “0” if there has been no change. Code “1” if the
resident’s ADL function has improved. Code “2” if the
resident’s function has deteriorated. You may find that
some ADLs have improved, some deteriorated and
others remain unchanged. You must weigh all of the
information and make an overall clinical judgment (e.g.
Full Assessment Form: Section G
in general, the resident’s ADL function has.…)
Examples
Mr. B had been highly involved in self-care in most ADL
activities. Seven weeks ago he slipped, fell and bruised
his right wrist. For several weeks he received more
extensive assistance with dressing, grooming and eating.
However, in the last 3 weeks he is functioning at the
same level of involvement in ADLs as before the fall.
Code “0” for No change.
With lots of encouragement and supervision from home
staff, Mrs A has progressed from requiring extensive
assistance to feeding herself under staff supervision. Her
performance in other ADLs remains unchanged. Code
“1” for Improved.
Since fracturing her left hip 3 weeks ago, Mrs. Z receives
more weight-bearing help with transfers, locomotion,
dressing, toileting, personal hygiene and bathing.
However, she has made strides in occupational therapy
and physiotherapy. Her improvement in self-care has
been steady although she still has a long way to go to
reach her Self-Performance level of 3 months ago. Code
“2” for Deteriorated.
Mr. L’s favourite carer (Miss McC) transferred to another
part of the home a month ago. Although he says he’s
happy for her, he has become more passive and
withdrawn. He no longer dresses himself in a suit and tie.
His personal hygiene habits have deteriorated and he
now must be frequently coaxed to shave and wash
himself and comb his hair. Because he now wears
stained clothing, staff have started to select and set out
his clothes each day. Despite these losses, Mr. L is now
somewhat more self-sufficient in locomotion, making
twice-a-week trips to see Miss McC. Code “2” for
Deteriorated. The rationale for the coding decision is that
although some improvement is noted in one ADL activity
(locomotion) it only occurs twice weekly. In general, Mr.
L has deteriorated in his self-care performance in two
ADL activities (dressing and personal hygiene) that
require multiple daily tasks.
Chapter 3: The Item-by-Item Guide to the MDS Full Assessment Form: Section G
 Section G. Mobility and Activities of Daily Living

1 A. Activities of Daily Living (ADL) Self Performance

Ability to perform eg. eating/drinking/mobility/dressing
(Code for resident’s performance over all shifts during last 7 days)

0. Independent - No help or oversight - or - Help/oversight provided only 1 or 2 times dur-

ing last 7 days
1. Supervision - Oversight, encouragement or cueing provided 3 or more times during last 7
days - or- Supervision (3 or more times) plus physical assistance provided only 1 or 2 times
5
during last 7 days.
2. Limited assistance - Resident highly involved in activity; received physical help in guided
manoeuvering of limbs or other nonweight bearing assistance 3 or more times -
5,16
or - More help provided only 1 or 2 times during last 7 days.
3. Extensive assistance - While resident performed part of activity, over last 7 day period,
help of following type(s) provided 3 or more times:
• Weight bearing support
5,16
• Full staff performance during part (but not all) of last 7 days
4. Total dependence - Full staff performance of activity during entire 7 days 5,16

16
8. Activity did not occur during entire 7 days

B. ADL Support provided

Code for most support provided over all shifts during last 7 days; code regardless of
resident’s self performance classification
0. No initial or physical help from staff
1. Initial help only
2. One person physical assistance
3. Two+ persons physical assistance
4. ADL activity itself did not occur during entire 7 days

a Bed mobility
A B
How resident moves to and from lying position, turns side to side,
5,16
and positions body while in bed

b Transfer
A B
How resident moves between surfaces - to/from: bed, chair, wheelchair,
5
standing position. (Exclude to/from bath/toilet)

c Walk in room
A B
How resident walks between locations in his/her room 5

d Walk in corridor
A B
5
How resident walks in corridor in home
 Section G. Mobility and Activities of Daily Living Continued

e Mobility around immediate space

A B
How resident moves between locations in his/her room and adjacent
5
corridor on same floor. If in wheelchair, self-sufficiency once in chair

f Mobility around home

A B How resident moves to and returns from off unit locations (eg. areas set
aside for dining, activities, or treatments). If home has only one floor, how
resident moves to and from distant areas on the floor. If in wheelchair, self-
5
sufficiency once in chair

g Dressing
A B
How resident puts on, fastens, and takes off all items of day clothing,
5
including donning/removing prosthesis

h Eating
A B
How resident eats and drinks (regardless of skill), includes intake of
5
nourishment by other means (eg. tube feeding)

i Toilet use
A B
How resident uses the toilet (or commode, bedpan, urinal); transfers on/off
toilet, cleanses, changes pad, manages ostomy or catheter;
5
adjusts clothes

j Personal hygiene
A B How resident maintains personal hygiene, including combing hair, brushing
teeth, shaving, applying make-up, washing/drying face, hands, and post
5
toilet use. (Exclude baths and showers)

2 Bathing How resident takes full-body bath/shower, sponge bath, and transfers in/out of bath/shower
(Exclude washing of back and hair).
Code for most dependent in self-performance and support
A. Bathing self-performance codes appear below
0. Independent - No help provided
5
A B 1. Supervision - Oversight help only
5
2. Physical help limited to transfer only
5
3. Physical help in part of bathing activity
5
4. Total dependence
8. Activity itself did not occur during entire 7 days
B. Bathing support codes are as defined in item 1
 Section G. Mobility and Activities of Daily Living Continued

3 Test for balance Code for ability during the last 7 days

(see manual) 0. Maintained position for 10 seconds

17
1. Unsteady, but able to rebalance self without physical support
2. Partial physical support during test; or stands (sits) but does not follow
17
directions for test
17
3. Not able to attempt test without physical help
a. Balance while standing

17
b. Balance while sitting - position, trunk control

4 Functional Consider limitations during last 7 days that interfered with daily functions or placed resident at
risk of injury
limitation in range
Code A range of motion
of motion
0. No limitation
(see manual)
1. Limitation on one side
2. Limitation on both sides
Code B voluntary movement
17
0. No loss
1. Partial loss
2. Full loss
A B

a. Neck

b. Arm - including shoulder or elbow

c. Hand - including wrist or fingers

d. Leg - including hip or knee

e. Foot - including ankle or toes

f. Other limitation or loss

5 Modes of Tick all that apply during last 7 days

locomotion ■ a. Stick/zimmer frame/crutches/tripod

■ b. Wheeled self

■ c. Other person wheeled

■ d. Wheelchair primary mode of locomotion

■ e. NONE OF ABOVE

6 Modes of Tick all that apply during last 7 days

16
transfer ■ a. Bedfast all or most of time

■ b. Bed rails used for bed mobility or transfer

■ c. Lifted manually
 Section G. Mobility and Activities of Daily Living Continued

6 Modes of ■ d. Lifted mechanically

transfer cont… ■ e. Transfer aid (eg. slide board/stick/zimmer frame)

■ f. NONE OF ABOVE

7 Task segmentation Some or all of ADL activities were broken into subtasks during last 7 days so that
resident could perform them. eg preparing clothes, cutting food.

0. No

1. Yes

8 Potential for ■ a. Resident believes he/she is capable of increased independence in at least some
5
rehabilitation ADLs - ask resident

■ b. Care staff believe resident is capable of increased independence in at least some

5
ADLs

■ c. Resident able to perform tasks/activity but is very slow

■ d. Difference in ADL Self Performance or ADL Support, comparing mornings

to evenings
Specify:

■ e. NONE OF ABOVE

9 Change in ADL Resident’s ADL self-performance status has changed as compared to status of 3 months

function ago (or last assessment if less than 3 months)

0. No change

1. Improved

2. Deteriorated
 Section G:
Mobility and Activities of Daily Living
Triggers for Resident Assessment Protocols

Question MDS Item Code RAPs

Number

5
G1aA - G1jA ADL self-performance 1, 2, 3, 4 ADL - Rehabilitation Trigger A

16
G1aA Bed mobility 2, 3, 4, 8 Pressure Sores

5
G2A Bathing 1, 2, 3, 4 ADL - Rehabilitation Trigger A

17
G3b Balance while sitting 1, 2, 3 Psychotropic Drug Use

16
G6a Bedfast ✓ Pressure Sores

5
G8a, b Resident/staff believe capable ✓ ADL - Rehabilitation Trigger A
of increased independence
 Chapter 3: The Item-by-Item Guide to the MDS
Section H: Continence in Last 14 Days
1. Continence self-control categories
This section differs from the other ADL assessment items
in that the time period for review has been extended to
14 days. Research has shown that 14 days are the
minimum required to obtain an accurate picture of bowel
continence patterns. For the sake of consistency, both
bowel continence and bladder continence are evaluated
over 14 days.
Purpose
The purpose of this section is to determine and record
the resident’s pattern of bladder and bowel continence
(control) over the last 14 days.
Definition
Bladder and bowel continence – Refers to control of
urinary bladder function and/or bowel movement. This
item describes the resident’s bowel and bladder
continence pattern even with scheduled toileting plans,
continence training programmes or appliances. It does
not refer to the resident’s ability to toilet self – e.g. a
resident can receive extensive assistance in toileting and
yet be continent, perhaps as a result of staff help. The
resident’s self-performance in toilet use is recorded in
Item G1iA.
Process
Review the resident’s record and any urinary or bowel
elimination record sheets (if available). Validate the
accuracy of written records with the resident. Make sure
that your discussions are held in private. Control of
bladder and bowel function are sensitive subjects,
particularly for residents who are struggling to maintain
control. Many people with poor control will try to hide
their problems out of embarrassment or fear of
retribution. Others will not report problems to staff
because they mistakenly believe that incontinence is a
natural part of ageing and that nothing can be done to
reverse the problem. Despite these common reactions to
incontinence, many elderly people are relieved when a
health care professional shows enough concern to ask
about the nature of the problem in a sensitive,
straightforward manner.
■ Validate continence patterns with people who know
the resident well (e.g. primary caregiver of newly
admitted resident; care staff).
■ Remember to consider continence patterns over the
last 14-day period, 24 hours a day, including
Full Assessment Form: Section H
weekends. If staff allocation change frequently,
consider initiating and maintaining a bladder and
bowel elimination flow chart in order to gather more
accurate information as a basis for coding decisions
and, ultimately, care planning.
A five-point coding scale is used to describe continence
patterns. Notice that in each category, different
frequencies of incontinent episodes are specified for
bladder and bowel. The reason for these differences is
that there are more episodes of urination per day and
week, whereas bowel movements typically occur less
often.
0. Continent – Complete control (including control
achieved by care that involves prompting, habit training,
reminders, etc.).
1. Usually Continent – Bladder, incontinent episodes
occur once a week or less; Bowel incontinent episodes
occur less than once a week.
2. Occasionally Incontinent – Bladder incontinent
episodes occur two or more times a week but not daily;
Bowel incontinent episodes occur once a week.
3. Frequently Incontinent – Bladder incontinent episodes
tend to occur daily, but some control is present (e.g. on
day shift); Bowel incontinent episodes occur two to three
times per week.
4. Incontinent – Has inadequate control. Bladder
incontinent episodes occur multiple times daily; Bowel
incontinent is all (or almost all) of the time.
Coding
Choose one response to code level of bladder continence
and one response to code level of bowel continence for
the resident over the last 14 days.
Code for the resident’s actual bladder and bowel
continence pattern – i.e. the frequency with which the
resident is wet and dry during the 14-day assessment
period. Do not record the level of control that the
resident might have achieved under optimal
circumstances.
For bladder incontinence, the difference between a code
of “3” (Frequently Incontinent) and “4” (Incontinent) is
determined by the presence (“3”) or absence (“4”) of
any bladder control.
 Chapter 3: The Item-by-Item Guide to the MDS
Examples of bladder continence coding
Mr. Q was taken to the toilet after every meal, before
bed, and once during the night. He was never found wet
and is considered continent. Code “0” for “Continent” –
Bladder.
Mr. R had an indwelling catheter in place during the
entire 14-day assessment period. He was never found
wet and is considered continent. Code “0” for
“Continent” – Bladder.
Although she is generally continent of urine, every once
in a while (about once in 2 weeks) Mrs. T doesn’t make it
to the bathroom to urinate in time after receiving her
daily diuretic pill. Code “1” for “Usually Continent” –
Bladder.
Mrs. A has less than daily episodes of urinary
incontinence, particularly late in the day when she is
tired. Code “2” for “Occasionally Incontinent” – Bladder.
Mr. S is comatose. He wears an external (condom)
catheter to protect his skin from contact with urine. This
catheter has been difficult for staff to manage as it keeps
slipping off. They have tried several different brands
without success. During the last 14 days Mr. S has been
found wet at least twice daily on the day shift. Code “3”
for “Frequently Incontinent” – Bladder.
Mrs. U is terminally ill with end-stage Alzheimer’s disease.
She is very frail and has stiff, painful contractures of all
limbs. She is primarily bedfast on a special water
mattress, and is turned and re-positioned hourly for
comfort. She is not toileted and is incontinent of urine for
all episodes. Code “4” for “Incontinent” – Bladder.
2. Bowel elimination pattern
Purpose
To record the effectiveness of resident’s bowel function.
Definition
Bowel elimination pattern regular – Resident has at least
one movement every three days.
Constipation – Resident passes two or less bowel
movements per week, or strains more than one out of
four times when having a bowel movement.
Diarrhoea – Frequent elimination of watery stools from
any cause (e.g. diet, viral or bacterial infection).
Faecal impaction – The presence of hard stool upon
digital rectal exam. Faecal impaction may also be present
Full Assessment Form: Section H
if stool is seen on abdominal x-ray in the sigmoid colon
or higher, even with a negative digital exam or
documentation in the record of daily bowel movement.
Process
Ask the resident. Review the records, particularly any
documentation flow sheets of bowel elimination patterns.
Ask care staff (from all shifts).
Coding
Tick all that apply in the last 14 days. If no items apply,
tick NONE OF ABOVE.
3. Appliances and programmes
Definition
Any scheduled toileting plan – A plan whereby staff
members at scheduled times each day either take the
resident to the toilet room, or give the resident a urinal,
or remind the resident to go to the toilet. Includes habit
training and/or prompted toilet use.
Bladder retraining programme – A retraining programme
where the resident is taught to consciously delay
urinating (voiding) or resist the urgency to void.
Residents are encouraged to void on a schedule rather
than according to their urge to void. This form of training
is used to manage urinary incontinence due to bladder
instability.
External (condom) catheter – A urinary collection
appliance worn over the penis.
Indwelling catheter – A catheter that is maintained within
the bladder for the purpose of continuous drainage of
urine. Includes catheters inserted through the urethra or
by supra-pubic incision.
Intermittent catheter – A catheter that is used period-ically
for draining urine from the bladder. This type of catheter
is usually removed immediately after the bladder has
been emptied. Includes intermittent catheterization
whether performed by a professional or by the resident.
Catheterization may occur as a one-time event (e.g. to
obtain a sterile specimen) or as part of a bladder
emptying programme (e.g. every shift in a resident with
an underactive or acontractile bladder muscle).
Did not use toilet room/commode/urinal – Resident never
used any of these items during the last 14 days, nor used
a bed pan.
Pads/briefs used – Any type of absorbent, disposable or
 Chapter 3: The Item-by-Item Guide to the MDS
reusable undergarment or item, whether worn by the
resident or placed on the bed or chair for protection from
incontinence. Does not include the routine use of pads
on beds when a resident is never or rarely incontinent.
Enemas/irrigation – Any type of enema or bowel
irrigation, including ostomy irrigations.
Ostomy present – Any type of ostomy of the
gastrointestinal or genitourinary tract. (e.g. colostomy,
urostomy)
Process
Consult with carers and the resident. Be sure to ask
about any items that are usually hidden from view
because they are worn under daytime clothing (e.g. pads
or briefs).
Coding
Tick all that apply. If none of the items apply, tick NONE
OF ABOVE.
4. Change in urinary continence
Purpose
To document changes in the resident’s urinary
continence as compared to 3 months ago (or since last
assessment if less than 3 months ago), including any
changes in self-control categories, appliances, or
programmes.
Process
Review the resident’s record and bladder continence
patterns as recorded in the last assessment (if available).
Validate findings with the resident and care staff on all
shifts. For new residents, consult with the resident’s family.
Coding
Code “0” for No change, “1” for Improved, or “2” for
Deteriorated. A resident who was incontinent 3 months
Full Assessment Form: Section H
ago who is now continent by virtue of a catheter should
be coded as “1”, Improved.
Examples of change in urinary continence
During an outbreak of gastroenteritis at the home six
weeks ago, Mrs. L, who is usually continent, became
totally incontinent of bladder and bowel. This problem
lasted only two weeks and she has been continent for the
last month. Code “0” for No change.
Mr. R had prostate surgery three months ago. Prior to
surgery, he was frequently incontinent. Upon returning
from the hospital, his indwelling catheter was
discontinued. Although he initially experienced
incontinence, he now remains dry with only occasional
incontinence. He sings the praises of surgery to his peers.
Code “1” for Improved.
Mrs. B is a new admission. Both she and her daughter
report that she has never been incontinent of urine. By
her third day of residency, her urinary incontinence
became evident, especially at night. Code “2” for
Deteriorated.
Prior to a hospital admission, Mr. K was totally
incontinent of urine. Following the admission, he is now
continent with an indwelling catheter in place. Code “1”
for Improved. Rationale: Although one could perceive
that Mr. K had “deteriorated” because he now has a
catheter for bladder control, remember that the MDS
definition for bladder continence states “Control of
bladder function with appliances (e.g. foley) or
continence programmes, if employed”.
 Section H. Continence in Last 14 Days

1 Continence categories (Code for resident’s performance over all shifts)

0. Continent - Complete control (includes use of indwelling urinary catheter or ostomy
device that does not leak urine or stool)
1. Usually continent - bladder, incontinent episodes once a week or less;
16
bowel, Less than weekly
2. Occasionally incontinent - bladder, 2 or more times a week but not daily;
6,16
bowel, once a week
3. Frequent incontinent - bladder, tended to be incontinent daily, but some control present
6,16
(eg. on day shift); bowel, 2-3 times a week
4. Incontinent - had inadequate control bladder, multiple daily episodes; bowel, all (or
6,16
almost all) of the time

a. Bowel continence Control of bowel movement, by self, appliance or bowel continence

16
programmes if used.

b. Bladder continence Control of urinary bladder function (if dribbles, volume insufficient to soak through
6
underpants), with appliances (eg catheter) or continence programmes if used

2 Bowel elimination ■ a. Bowel elimination pattern regular - at least one movement every three days
pattern ■ b. Constipation
17

■ c. Diarrhoea
17
■ d. Faecal impaction

■ e. NONE OF ABOVE
Specify normal pattern:

3 Appliances and pro- ■ a. Any scheduled toileting plan

grammes ■ b. Bladder retraining programme
6
■ c. External catheter
6
■ d. Indwelling catheter
6
■ e. Intermittent catheter

■ f. Did not use toilet room/commode/urinal

6
■ g. Pads/briefs used

■ h. Enemas/irrigation

■ i. Ostomy present

■ j. NONE OF ABOVE

4 Change in urinary Resident’s urinary continence has changed as compared to status of 3 months ago (or since

continence last assessment if less than 3 months)

0. No change
1. Improved
2. Deteriorated
 Section H: Continence in Last 14 Days
Triggers for Resident Assessment Protocols

Question MDS Item Code RAPs

Number

16
H1a Bowel incontinence 1, 2, 3, 4 Pressure Sores

H1b Bladder incontinence 2, 3, 4 Urinary Incontinence and

6
Indwelling Catheter

17
H2b Constipation ✓ Psychotropic Drug Use

17
H2d Faecal impaction ✓ Psychotropic Drug Use

H3c,d,e Catheter use ✓ Urinary Incontinence and

6
Indwelling Catheter

H3g Use of pads/briefs ✓ Urinary Incontinence and

6
Indwelling Catheter
 Chapter 3: The Item-by-Item Guide to the MDS
Section I: Disease Diagnoses
The involvement of a doctor or qualified nurse, in this
part of the assessment process is crucial.
The purpose of this section is to document the presence
of diseases that have a relationship to the resident’s
current ADL status, cognitive status, mood or behaviour
status, medical treatments, nursing monitoring or risk of
death. In general, these are conditions that drive the
current care plan. Do not include conditions that have
been resolved or no longer affect the resident’s
functioning or care plan. In many homes, nursing and
medical staff neglect to update the list of resident’s
“active” diagnoses. There may also be a tendency to
continue old diagnoses that are either resolved or no
longer relevant to the resident’s plan of care. One of the
important functions of the MDS assessment is to generate
an updated, accurate picture of the resident’s health
status.
Definition
Nursing monitoring – Includes clinical monitoring by a
registered nurse (e.g. blood pressure monitoring,
medication management, etc.)
1. Diseases
Definition
Diabetes mellitus – Includes insulin-dependent diabetes
mellitus and diet-controlled diabetes mellitus (Non insulin
dependent diabetes).
Cardiac dysrhythmias – Disorder of heart rate or heart
rhythm.
Peripheral vascular disease – Vascular disease of the
lower extremites that can be of venous and/or arterial
origin.
Arthritis – Includes degenerative joint disease,
osteoarthritis, and rheumatoid arthritis. Record more
specific forms of arthritis (e.g. Sjögren’s syndrome; gouty
arthritis) in Question 3 in this section.
Hip fracture – Includes any hip fracture that occurred at
any time that continues to have a relationship to current
status, treatments, monitoring, etc. Hip fracture diagnoses
also include femoral neck fractures, fractures of the
trochanter and subcapital fractures.
Missing limb (e.g. amputation) – Includes loss of any part
of any upper or lower extremity.
Pathological bone fracture (eg Paget’s disease) – Fracture
Full Assessment Form: Section I
of any bone due to weakening of the bone, usually as a
result of a cancerous process.
Aphasia – A speech or language disorder caused by
disease or injury to the brain resulting in difficulty
expressing thoughts (i.e. speaking, writing), or
understanding spoken or written language.
Cerebral palsy – Paralysis related to developmental brain
defects or birth trauma.
Cerebrovascular accident (CVA/stroke) – A vascular insult
to the brain that may be caused by intracranial bleeding,
cerebral thromboses, infarcts or emboli.
Dementia other than Alzheimer’s disease – Includes
diagnoses of organic brain syndrome or chronic brain
syndrome, senile dementia, multi-infarct dementia and
dementia related to neurologic diseases other than
Alzheimer’s (e.g. Picks, Creutzfeldt-Jakob disease,
Huntington’s disease, etc.).
Hemiplegia/hemiparesis – Paralysis/partial paralysis
(temporary or permanent impairment of sensation,
function, motion) of both limbs on one side of the body.
Usually caused by cerebral haemorrhage, thrombosis,
embolism, or tumour. There must be a diagnosis of
hemiplegia or hemiparesis in the resident’s record.
Paraplegia – Paralysis (temporary or permanent
impairment of sensation, function, motion) of the lower
part of the body, including both legs. Usually caused by
cerebral haemorrhage, thrombosis, embolism, tumour, or
spinal cord injury. There must be a diagnosis of
paraplegia in the resident’s record.
Quadriplegia – Paralysis (temporary or permanent
impairment of sensation, function, motion) of all four
limbs. Usually caused by cerebral haemorrhage,
thrombosis, embolism, tumour, or spinal cord injury.
There must be a diagnosis of quadriplegia in the
resident’s record.
Transient ischaemic attack – A sudden, temporary,
inadequate supply of blood to a localised area of the
brain. Often recurrent.
Traumatic brain injury – Damage to the brain as a result
of physical injury to the head.
Manic depressive (bipolar disease) – Includes
documentation of clinical diagnoses of either manic
depression or bipolar disorder.
 Chapter 3: The Item-by-Item Guide to the MDS
Emphysema/COPD – Includes COPD (chronic
obstructive pulmonary disease) or asbestosis or chronic
bronchitis.
Allergies – Any hypersensitivity caused by exposure to a
particular allergen. Includes agents (natural and artificial)
to which the resident is susceptible for an allergic
reaction, not only those to which he or she currently
reacted to in the last 7 days. This item includes allergies
to drugs (e.g. aspirin, antibiotics), foods (e.g. nuts eggs,
wheat, strawberries, shellfish, milk), environmental
substances (e.g. dust, pollen), animals (e.g. dogs, birds,
cats), and cleaning products (e.g. soap, laundry
detergent), etc. Hypersensitivity reactions include but are
not limited to, itchy eyes, runny nose, sneezing, contact
dermatitis, etc.
Anaemia – Includes anaemia of any cause.
Process
Consult transfer documentation and resident’s record
(including current medical treatments and nursing care
plans). If the resident was admitted from hospital, the
discharge forms often list diagnoses that were current
during the hospital stay. If these diagnoses are still active,
record them on the MDS form. Also, accept statements
by the resident that seem to have clinical validity. Consult
with doctor for confirmation.
The doctor should be asked to review the items in
Section I at the time of visit closest to the MDS
assessment. Use this visit as an opportunity to ensure that
active diagnoses are noted and “inactive” diagnoses are
designated as resolved. This is also an important
opportunity to share the entire MDS assessment with the
doctor. It is the responsibility of home staff to ensure
doctor involvement. Inaccurate or missed diagnoses can
be a serious impediment to care planning. Thus, you
should share this section of the MDS with the doctor and
ask for his or her input. A doctor completing a portion of
the MDS assessment should sign in Item R2 (Signatures
of Those Completing the Assessment).
Full doctor review of the most recent MDS assessment or
ongoing input into the assessment currently being
completed can be very useful. For the doctor, the MDS
assessment completed by home staff can provide insights
that would have otherwise not been possible. For staff,
the informed comments of the doctor may suggest new
avenues of inquiry, or help to confirm existing
observations, or suggest the need for additional follow-
Full Assessment Form: Section I
up.
Tick a disease item only if the disease has a relationship
to current ADL status, cognitive status, behaviour status,
medical treatment, nursing monitoring, or risk of death.
For example, it is not necessary to tick “high blood
pressure” if one episode occurred several years ago
unless the high blood pressure is either currently being
controlled with medications, diet, biofeedback, etc. or is
being regularly monitored to prevent a recurrence.
Coding
Do not record any conditions that have been resolved
and no longer affect the resident’s functional status or
care plan.
Tick all that apply. If none of the conditions apply, tick
NONE OF ABOVE.
If you have more detailed information available in the
medical record for a more definitive diagnosis than is
provided in the list in question I1, tick the more general
diagnosis in I1 and then enter the more detailed
diagnosis under question I3. For example, if the record
reveals that the resident has osteoarthritis tick item I1l
(arthritis) and record osteoarthritis in question I3.
There will be times when a particular diagnosis will not
be documented in the record. If that is the case, as
indicated above, accept statements by the resident that
seem to have clinical validity, consult with the doctor for
confirmation.
For example: If a new resident says he or she had a
severe depression and was seeing a psychiatrist in the
community, this information may have been missed if the
information was not carried forward in records
accompanying the resident from an acute care hospital to
the home.
2. Infections
Definition
Antibiotic resistant infection – An infection in which
bacteria have developed a resistance to the effective
actions of an antibiotic. Tick this item only if there is
supporting documentation in the clinical record
(including transfer records of new admissions and recent
transfers from other institutions).
Clostridium difficile (C.diff) – Diarrhoea caused by the
Clostridium difficile bacteria. Tick this item only if there is
supporting documentation in the clinical record of new
 Chapter 3: The Item-by-Item Guide to the MDS
admissions and recent transfers (e.g. hospital referral or
discharge summary, laboratory report).
Conjunctivitis – Inflammation of the mucous membranes
lining the eyelids. May be of bacterial, viral, allergic or
traumatic origin.
HIV infection – Tick this item only if there is supporting
documentation or the resident’s family informs you of the
presence of a positive blood test result for the Human
Immunodeficiency Virus or diagnosis of AIDS.
Pneumonia – Inflammation of the lungs; most commonly
of bacterial or viral origin.
Respiratory infection – Any upper or lower (e.g.
bronchitis) respiratory infection other than pneumonia.
Septicaemia – Morbid condition associated with bacterial
growth in the blood.
Sexually transmitted diseases – Tick this item only if there
is supporting documentation of a current diagnosis of
gonorrhoea, or syphilis. DO NOT include HIV in this
category.
Tuberculosis – Includes residents with active tuberculosis
or those who have converted to PPD positive tuberculin
status and are currently receiving drug treatment for
tuberculosis.
Urinary tract infection – Includes chronic and acute
symptomatic infection(s) in the last month. Tick this item
only if there is current supporting documentation and
significant laboratory findings in the clinical record.
Full Assessment Form: Section I
Viral hepatitis – Inflammation of the liver of viral origin.
This category includes diagnoses of hepatitis A, hepatitis
B, hepatitis non-A non-B, and hepatitis C.
Wound infection – Infection of any type of wound (e.g.
surgical; traumatic; pressure) on any part of the body.
Process
Consult transfer documentation and the resident’s clinical
record (including current treatment and nursing care
plans). Accept statements by the resident that seem to
have clinical validity. Consult with doctor for
confirmation.
Coding
Tick an item only if the infection has a relationship to
current ADL status, cognitive status, mood and
behaviour status, medical treatment, nursing monitoring
or risk of death. Do not record any conditions that have
been resolved and no longer affect the resident’s
functional status or care plan. For example, do not tick
“tuberculosis” if the resident had TB several years ago
unless the TB is either currently being controlled with
medications or is being regularly monitored to detect a
recurrence.
Tick all that apply. If none of the conditions apply, tick
NONE OF ABOVE. If you have more detailed
information available in the clinical record for a more
definitive diagnosis than is provided in the list in question
I2 in this section tick the appropriate box and enter the
more detailed information under question I3.
 Section I. Disease Diagnoses

Tick only those diseases that have a relationship to current ADL status, cognitive status, mood and behaviour status, medical
treatments, nursing monitoring, or risk of death.

1 Diseases If none apply, tick the none of above box

Endocrine/metabolic/nutritional
■ a. Diabetes mellitus
■ b. Hyperthyroidism
■ c. Hypothyroidism

Heart/circulation
■ d. Arteriosclerotic heart disease
■ e. Cardiac dysrhythmias
■ f. Congestive heart failure
■ g. Deep vein thrombosis
■ h. High blood pressure
17
■ i. Low blood pressure
Refer to appropriate professional eg GP/District Nurse or notes

16
■ j. Peripheral vascular disease
■ k. Other cardiovascular disease

Musculoskeletal
■ l. Arthritis
■ m. Hip fracture
■ n. Missing limb (eg. amputation)
■ o. Osteoporosis
■ p. Pathological bone fracture (eg. Paget’s disease)

Neurological
■ q. Alzheimer’s disease
■ r. Aphasia
■ s. Cerebral palsy
■ t. Cerebrovascular accident (CVA/stroke)
■ u. Dementia other than Alzheimer’s disease
■ v. Hemiplegia/hemiparesis
■ w. Multiple sclerosis
■ x. Paraplegia
■ y. Parkinson’s disease
■ z. Quadriplegia
■ aa. Seizure disorder (epilepsy)
■ bb. Transient ischaemic attack (TIA)
■ cc. Traumatic brain injury

Psychiatric/mood
■ dd. Anxiety disorder
17
■ ee. Depression
■ ff. Manic depression (bipolar disease)
■ gg. Schizophrenia
 Section I. Disease Diagnoses Continued

1 Diseases cont… Pulmonary

■ hh. Asthma
■ ii. Emphysema/COPD

Sensory
3
■ jj. Cataracts
■ kk. Diabetic retinopathy
3
■ ll. Glaucoma
■ mm. Macular degeneration

Other
■ nn. Allergies
■ oo. Anaemia
■ pp. Cancer
■ qq. Renal failure
■ rr. NONE OF ABOVE

2 Infections If none apply tick the none of above box

■ a. Antibiotic resistant infection

■ b. Clostridium difficile (C. diff)
Refer to appropriate professional

■ c. Conjunctivitis
eg GP/District Nurse or notes

■ d. HIV infection
■ e. Pneumonia
■ f. Respiratory infection
■ g. Septicaemia
■ h. Sexually transmitted diseases
■ i. Tuberculosis
14
■ j. Urinary tract infection in last month
■ k. Viral hepatitis
■ l. Wound infection
■ m. NONE OF ABOVE

3 Other current
a
diagnoses
b

14
If dehydration is currently diagnosed above this triggers
 Section I: Disease Diagnoses
Triggers for Resident Assessment Protocols

Question MDS Item Code RAPs

Number

17
I1i Low blood pressure ✓ Psychotropic Drug Use

16
I1j Peripheral vascular disease ✓ Pressure Sores

17
I1ee Depression ✓ Psychotropic Drug Use

3
I1jj Cataracts ✓ Visual Function

3
I1II Glaucoma ✓ Visual Function

14
I2j UTI ✓ Dehydration/Fluid Maintenance

I3 Dehydration noted Dehydration/Fluid Maintenance 14

 Chapter 3: The Item-by-Item Guide to the MDS
Section J: Health Conditions
1. Problem conditions
Purpose
To record specific problems or symptoms that affect or
could affect the resident’s health or functional status and to
identify risk factors for illness, accident and functional
decline.
Definition
Indicators of fluid status
It is often difficult to recognise when a frail, chronically ill
older person is experiencing fluid overload that could
precipitate congestive heart failure, or alternatively
dehydration. Ways to monitor the problem, particularly in
residents who are unable to recognise or report the
common symptoms of fluid variation, are as follows:
Weight gain or loss of 3 or more pounds (1.4 kgs) within a
7-day period – This can only be determined in residents
who are weighed in the same manner at least weekly.
However, the majority of residents will not require weekly
or more frequent weights, and for these residents you will
be unable to determine whether there has been a 3 or
more pound gain or loss (1.4 kgs). When this is the case,
leave this item blank.
Inability to lie flat due to shortness of breath – resident is
uncomfortable lying flat. Resident requires more than one
pillow or having the head of the bed mechanically raised in
order to get enough air. This symptom often occurs with
fluid overload. If the resident has shortness of breath when
not lying flat, also Tick item J1l “Shortness of breath”. If the
resident does not have shortness of breath when upright
(e.g. O.K. when using two pillows or sitting up) do not Tick
item J1l.
Dehydrated; output exceeds intake – Tick this item if the
resident has 2 or more of the following indicators.
■ Resident usually takes in less than the recommended
2500 ml of fluids daily (water or liquids in beverages
and water in food).
■ Resident has clinical signs of dehydration (e.g. dry skin,
tongue, confusion, decline in passing urine).
■ Resident’s fluid loss exceeds the amount of fluids he or
she takes in (e.g. loss from vomiting, fever, diarrhoea
that exceeds fluid replacement).
Insufficient fluid; did NOT consume all/almost all liquids
provided during last 3 days – Liquids can include water,
juices, tea, coffee, and soups.
Full Assessment Form: Section J
Other
Delusions – Fixed, false beliefs not shared by others that
the resident holds even when there is obvious proof or
evidence to the contrary (e.g. belief he or she is terminally
ill; belief that spouse is having an affair; belief that food
served is poisoned).
Dizziness/vertigo – The resident experiences the sensation
of unsteadiness, that he or she is turning, or that the
surroundings are whirling around.
Oedema – Excessive accumulation of fluid in tissues, either
localised or systemic (generalised). Includes all types of
oedema (e.g. dependent, pulmonary, pitting).
Fever – Rectal temperatures above 100° Fahrenheit (38°
Celsius) are considered significant in a care home
population. Many frail older people have normally low
rectal baseline temperatures (e.g. 96° to 99°F). A fever is
present when the resident’s temperature (°F) is 2.4 degrees
greater than the baseline temperature.
Hallucinations – False perceptions that occur in the
absence of any real stimuli. A hallucination may be
auditory (e.g. hearing voices), visual (e.g. seeing people,
animals), tactile (e.g. feeling bugs crawling over skin),
olfactory (e.g. smelling poisonous fumes), or gustatory (e.g.
having strange tastes).
Internal bleeding – Bleeding may be frank (such as bright
red blood) or occult (hidden blood in stools). Clinical
indicators include black, tarry stools, vomiting “coffee
grounds” (dark coloured matter), haematuria (blood in
urine), haemoptysis (coughing up blood), and severe
epistaxis (nosebleed).
Recurrent lung aspirations in last 3 months – Note the
extended time frame. Often occurs in residents with
swallowing difficulties or who receive tube feedings (i.e.
oesophageal reflux of stomach contents). Clinical indicators
include productive cough, shortness of breath, wheezing. It
is not necessary that there be X-ray evidence of lung
aspiration for this item to be ticked.
Shortness of breath – Difficulty breathing (dyspnoea)
occurring at rest, with activity, or in response to illness or
anxiety. If the resident has shortness of breath while lying
flat, also tick item J1b (Inability to lie flat due to shortness
of breath).
Fainting – Transient loss of consciousness, characterised by
unresponsiveness and loss of postural tone (falling) with
 Chapter 3: The Item-by-Item Guide to the MDS
spontaneous recovery.
Unsteady gait – A gait (manner of walking) that places the
resident at risk of falling. Unsteady gaits take many forms.
The resident may appear unbalanced or walk with a sway.
Other gaits may have uncoordinated or jerking movements.
Examples of unsteady gaits may include fast gaits with
large, careless movements; abnormally slow gaits with small
shuffling steps; or wide-based gaits with halting, tentative
steps.
Vomiting – Regurgitation of stomach contents; may be
caused by any number of things (e.g. drug toxicity;
influenza; psychological causes).
Process
Ask the resident if he or she has experienced any of the
listed symptoms in the last 7 days. Review the residents
records (including current care plan) and consult with staff
members and the resident’s family if the resident is unable
to respond. A resident may not complain to staff members
or others, attributing such symptoms to “old age”.
Therefore, it is important to ask and observe the resident,
directly if possible, since the health problems being
experienced by the resident can often be remedied.
Coding
Tick all conditions that occurred within the past 7 days
unless otherwise indicated (i.e. lung aspirations in the last 3
months). If no conditions apply, Tick NONE OF ABOVE.
2. Pain symptoms
Purpose
To record the frequency and intensity of signs and
symptoms of pain. For care planning purposes this item can
be used to identify indicators of pain as well as to monitor
the resident’s response to pain management interventions.
Definition
Pain – For MDS assessment purposes, pain refers to any
type of physical pain or discomfort in any part of the body.
Pain may be localised to one area, or may be more
generalised. It may be acute or chronic, continuous or
intermittent (comes and goes), or occur at rest or with
movement. The pain experience is very subjective; pain is
whatever the resident says it is.
Shows evidence of pain – depends on the observation of
others (i.e. cues), either because the resident does not
verbally complain or is unable to verbalise.
Process
Full Assessment Form: Section J
Ask the resident if he or she has experienced any pain in
the last 7 days. Ask him/her to describe the pain. If the
resident states he or she has pain, take his or her word for
it. Pain is a subjective experience. Also observe the resident
for indicators of pain. Indicators include moaning, crying,
and other vocalisations; wincing or frowning and other
facial expressions; or body posture such as
guarding/protecting an area of the body, or lying very still;
or decrease in usual activities.
In some residents, the pain experience can be very hard to
discern. For example, in residents who have dementia and
cannot say that they are feeling pain, symptoms of pain can
be manifested by particular behaviours such as calling out
for help, pained facial expressions, refusing to eat, or
striking out at a person who tries to move them or touch a
body part. Although such behaviours may not be solely
indicative of pain, but rather may be indicative of multiple
problems, code for the frequency and intensity of
symptoms if in your clinical judgement it is possible that the
behaviour could be caused by the resident experiencing
pain.
Ask carers and therapists who work with the resident if the
resident had complaints or indicators of pain during the last
week.
Coding
Code for the highest level of pain present in the last 7 days.
If the resident has no pain, code “0”, (No pain) and then
Skip to item J4.
a. Frequency
How often the resident complains or shows evidence of
pain.
0. No pain (Skip to item J4)
1. Pain less than daily
2. Pain daily
b. Intensity
The severity of pain as described or visible in the resident.
1. Mild pain – Although the resident experiences some (“a
little”) pain he or she is usually able to carry on with daily
routines, socialization or sleep.
2. Moderate pain – Resident experiences “a medium”
amount of pain.
3. Times when pain is horrible or excruciating – Worst
possible pain. Pain of this type usually interferes with daily
 Chapter 3: The Item-by-Item Guide to the MDS Full Assessment Form: Section J

routines, socialization and sleep. or rubbing the head) of headache.

Use your best judgement when coding. If you have Hip pain – Pain localised to the hip area. May occur at
difficulty determining the exact frequency or intensity of rest or with physical movement.
pain, code for the more severe level of pain. Rationale:
Incisional pain (e.g. recent operation) – The resident
Residents having pain will usually require further evaluation
complains or shows evidence of pain at the site of a
to determine the cause and to find interventions that
recent surgical incision/operation.
promote comfort. You never want to miss an opportunity to
relieve pain. Pain control often enables rehabilitation, Joint pain (other than hip) – The resident complains or
greater socialization and activity involvement. shows evidence of discomfort in one or more joints either
at rest or with physical movement.
3. Pain site
Soft tissue pain – Superficial or deep pain in any muscle
Purpose
or non-bony tissue. Examples include abdominal
To record the location of physical pain as described by the
cramping, rectal discomfort, calf or wound pain.
resident, or gained from objective physical tests. Sometimes
is difficult to pinpoint the exact site of
pain, particularly if the resident is unable Examples Pain Pain
Frequency Intensity
to describe the quality and location of
pain in detail. Likewise, it will be difficult Mrs. G, a resident with poor short-and-long 2 1
to pinpoint the exact site if the resident term memory and moderately impaired
has not had physical or laboratory tests to cognitive function asked for “a pill to make
evaluate the pain. In order to begin to my aches and pains go away” once a day
develop a responsive care plan for during the last 7 days. The medication record
promoting comfort, the intent of this item shows that she received paracetamol every
is to help residents and caregivers begin a evening. The record states that Mrs. G usually
pain evaluation by attempting to target rubs her left hip when she asks for a pill.
the site of pain. However, when you ask her about pain,
Mrs. G tells you that she is fine and never has
Definition pain. Rationale for coding: It appears that
Back pain – Localised or generalised Mrs. G has forgotten that she has reported
pain in any part of the neck or back. having pain during the last 7 days. Best clinical
Bone pain – Commonly occurs in judgement calls for coding that reflects that
metastatic disease (cancer). Pain is Mrs. G has mild, daily pain.
usually worse during movement but can
Mr. T is up and about and involved in self-care, 2 3
be present at rest. May be localised and
social and recreational activities. During the
tender but may also be quite vague.
last week he has been cheerful, engaging and
Chest pain while doing usual activities – active. When checked by staff at night, he
The resident experiences any type of appears to be sleeping. However, when you
pain in the chest area, which may be ask him how he’s doing, he tells you that he
described as burning, pressure, stabbing, has been having horrible cramps in his legs
vague discomfort, etc. “Usual activities” every night. He’s only been resting, but feels
are those that the resident engages in tired upon rising. Rationale for coding: Although
normally. For example, the resident’s Mr. T may look comfortable to staff, he reports
usual activities may be limited to minor to you that he has terrible cramps. Best clinical
participation in dressing and grooming, judgement for coding this “screening” item for
short walks from chair to toilet. pain would be to record codes that reflect what
Headache – The resident regularly Mr. T tells you. It is highly likely that Mr. T
complains or shows evidence (clutching warrants a further evaluation.
 Chapter 3: The Item-by-Item Guide to the MDS
Stomach pain – The resident complains or shows
evidence of pain or discomfort in the left upper quadrant
of the abdomen.
Other – Includes either localised or diffuse pain of any
other part of the body. Examples include general “aches
and pains”, etc.
Process
Ask the resident and observe for signs of pain. Consult
staff members. Review the record. Use your best clinical
judgement or refer to appropriate professional for review.
Coding
Tick all that apply during the last 7 days. If the resident has
mouth pain tick item K1c in Section K, “Oral/Nutritional
Status”.
4. Accidents
Purpose
To determine the resident’s risk of future falls or injuries.
Falls are a common cause of ilness/injury and death
amongst the elderly. Residents who have sustained at least
one fall are at risk of future falls.
Definition
Fell – Note time (past month and past 1 to 6 months).
Hip fracture in last 6 months – Note time (last 6 months).
Other fracture in last 6 months – Any fracture other than a
hip fracture. Note time (last 6 months).
Process
New admissions – Consult with the resident and the
resident’s family. Review transfer documentation.
Current residents – Review the resident’s records
(including incident reports, current care plan). Consult with
the resident. Sometimes, a resident will fall, and believing
that he or she “just tripped”, will get up and not report the
event to anyone. Therefore, do not rely solely on the
records but also ask the resident directly if he or she has
fallen during the indicated time frame.
Coding
Tick all conditions that apply. If no conditions apply, tick
NONE OF ABOVE.
5. Stability of conditions
Purpose
To determine if the resident’s disease or health conditions
present over the last 7 days are acute, unstable or
Full Assessment Form: Section J
deteriorating.
Definition
Fluctuating, precarious, deteriorating – Denotes the
changing and variable nature of the resident’s condition.
For example, a resident may experience a variable response
to the intensity of pain and the effect of pain medications.
On “good days” over the last 7 days, he or she will
participate in ADLs, be in a good mood, and enjoy
preferred leisure activities. On “bad days”, he or she will be
dependent on others for care, be agitated, cry, etc.
Likewise, this category reflects the degree of difficulty in
achieving a balance between treatments for multiple
conditions.
Acute episode – Resident is symptomatic for an acute
health condition (e.g. new myocardial infarction; adverse
drug reaction; influenza), a recurrent (acute) condition (e.g.
aspiration pneumonia; urinary tract infection) or an acute
phase of a chronic disease (e.g. shortness of breath,
oedema, and confusion in a resident with congestive heart
disease; acute joint pain and swelling in a resident who has
had arthritis for many years). An acute episode is usually of
sudden onset, has a time-limited course, requires review by
a doctor and a significant increase in monitoring by home
staff or community nurses.
End-stage disease – In one’s best judgement, the resident
with any end-stage disease has only 6 or fewer months to
live. This judgement should be substantiated by a well
documented disease diagnosis and deteriorating clinical
course.
Process
Observe the resident. Consult staff members and the
resident’s doctors. Review the resident’s record.
Coding
Tick all that apply during last 7 days. If none apply, tick
NONE OF ABOVE.
Examples
Mrs. M is diabetic. She requires daily or more frequent
blood sugar tests in conjunction with administering sliding-
scale medication. She has been confused on one occasion
in the past week when she was hypoglycaemic. Tick “a” for
unstable – fluctuating, precarious, or deteriorating.
If Mrs. M (above) were also to have pneumonia and fever
during her assessment period, Tick “a” for unstable and “b”
for acute.
 Chapter 3: The Item-by-Item Guide to the MDS Full Assessment Form: Section J

Ms. F had been doing well and was ready for discharge to congestive heart failure. Her heart has become significantly
her warden controlled flat until she came down with the flu.
Currently she has a low grade fever, general aches and weaker despite maximum treatment with medications and
pains and respiratory symptoms of productive cough and
nasal congestion. Although she has taken to bed for a few oxygen. Her doctor has discussed her deteriorating
days she has had no change in ADL function, mood, etc.
and is looking forward to discharge in a few days. Tick “b” condition with her and her family and has documented that
for acute.

Mrs. T was admitted to the home with a diagnosis of her prognosis for survival in the next couple of months is
chronic congestive heart failure. During the past few
months she has had 3 hospital admissions for acute poor. Tick “c” for end-stage disease.
 Section J. Health Conditions

1 Problem Tick all problems present in last 7 days unless other timeframe is indicated

conditions Indicators of fluid status

14
■ a. Weight gain or loss of 3 or more pounds within a 7-day period
■ b. Inability to lie flat due to shortness of breath
14
■ c. Dehydrated; output exceeds input
14
■ d. Insufficient fluid; did not consume all/almost all liquids provided during last 3 days
Other
■ e. Delusions
11,17
■ f. Dizziness/vertigo
■ g. Oedema
14
■ h. Fever
17
■ i. Hallucinations
14
■ j. Internal bleeding
17
■ k. Recurrent lung aspirations in last 3 months
■ l. Shortness of breath
17
■ m. Fainting
17
■ n. Unsteady gait
■ o. Vomiting
■ p. NONE OF ABOVE

2 Pain symptoms Code the highest level of pain present in the last 7 days

A. Frequency with which resident complains or shows evidence of pain

0. No pain (Skip to J4)
1. Pain less than daily
2. Pain daily

B. Intensity of pain
1. Mild pain
2. Moderate pain
3. Times when pain is horrible or excruciating

3 Pain site If pain present, tick all sites that apply in last 7 days

■ a. Back pain
■ b. Bone pain
■ c. Chest pain while doing usual activities
■ d. Headache
■ e. Hip pain
■ f. Incisional pain (eg. recent operation)
■ g. Joint pain (other than hip)
■ h. Soft tissue pain (eg. lesion, muscle)
■ i. Stomach pain
■ j. Other/specify location
 Section J. Health Conditions Continued

4 Accidents Tick all that apply

11,17
■ a. Fell in past month
11,17
■ b. Fell in past 1-6 months
17
■ c. Hip fracture in last 6 months
■ d. Other fracture in last 6 months
■ e. NONE OF ABOVE

5 Stability of ■ a. Conditions/diseases make resident’s cognitive, ADL, mood or behaviour pattern

conditions unstable - (fluctuating, precarious, or deteriorating)
■ b. Resident experiencing an acute episode of a flare-up of a recurrent or chronic prob-
lem
■ c. End-stage disease, 6 or fewer months to live
■ d. NONE OF ABOVE
 Section J: Health Conditions
Triggers for Resident Assessment Protocols

Question MDS Item Code RAPs

Number

14
J1a Weight fluctuation ✓ Dehydration/Fluid Maintenance

14
J1c Dehydrated ✓ Dehydration/Fluid Maintenance

14
J1d Insufficient fluid ✓ Dehydration/Fluid Maintenance

11
J1f Dizziness ✓ Falls
17
Psychotropic Drug Use

14
J1h Fever ✓ Dehydration/Fluid Maintenance

17
J1iHallucinations ✓ Psychotropic Drug Use

14
J1jInternal bleeding ✓ Dehydration/Fluid Maintenance

17
J1k Lung aspirations ✓ Psychotropic Drug Use

17
J1m Fainting ✓ Psychotropic Drug Use

17
J1n Unsteady gait ✓ Psychotropic Drug Use

11
J4a,b Fell ✓ Falls
17
Psychotropic Drug Use

17
J4c Hip fracture ✓ Psychotropic Drug Use
 Chapter 3: The Item-by-Item Guide to the MDS
Section K: Oral/Nutritional Status
1. Oral problems
Purpose
To record any oral problems present in the last 7 days.
Definition
Chewing problem – Inability to chew food easily and
without pain or difficulties, regardless of cause (e.g. resident
uses ill-fitting dentures, or has a neurologically impaired
chewing mechanism, or has jaw pain, or a painful tooth).
Swallowing problem – Dysphagia. Evidence of this include
frequent choking and coughing when eating or drinking,
holding food in mouth for prolonged periods of time, or
excessive drooling.
Mouth pain – Any pain or discomfort associated with any
part of the mouth, regardless of cause. Clinical
manifestations include favouring one side of the mouth
while eating, refusing to eat, refusing food or fluids of
certain temperatures (hot or cold).
Process
Ask the resident about difficulties in these areas. Observe
the resident during meals. Inspect the mouth for
abnormalities that could contribute to chewing or
swallowing problems or mouth pain.
Coding
Tick all that apply. If none apply, tick NONE OF ABOVE.
2. Height and weight
Purpose
To record a current height and weight in order to monitor
nutrition and hydration status over time; also, to provide a
mechanism for monitoring stability of weight over time. For
example, a resident who has had oedema can have an
intended and expected weight loss as a result of taking a
diuretic (water tablet). Or weight loss could be the result of
poor intake, or adequate intake accompanied by recent
participation in a fitness programme.
a. Height
Process
New admissions – Measure height in cms or inches.
Current resident – Check the records. If the last height
recorded was more than one year ago, measure the
resident’s height again.
Coding
Round height upward to nearest whole cm or inch.
Measure height consistently over time in accord with
Full Assessment Form: Section K
standard practice (shoes off, etc.).
b. Weight
Process
Check the resident records. If the last recorded weight was
taken more than one month ago or weight is not available,
weigh the resident again. If the resident’s weight was taken
more than once during the preceding month, record the
most recent weight.
Coding
Round weight upward to the nearest whole kilo or pound.
Measure weight consistently over time in accord with
standard practice (after voiding, before meal, etc.).
3. Weight change
Purpose
To record variations in the resident’s weight over time.
a. Weight loss
Definition
Weight loss in percentages (e.g. 5% or more in last month,
or 10% or more in last 6 months).
Process
New admissions – Ask the resident or family about weight
changes over the last month and 6 months. Consult doctor,
review transfer documentation and compare with
admission weight. Calculate weight loss in percentages
during the specified time periods.
Current resident – Review the records and compare current
weight with weights of one month and 6 months ago.
Calculate weight loss in percentages during the specified
time periods.
Coding
Code “0” for No or “1” for Yes. If there is no weight to
compare to, enter NA.
b. Weight gain
Definition
Weight gain in percentages (i.e. 5% or more in last month,
or 10% or more in last 6 months).
Process
New admission – Ask the resident or family about weight
changes over the last month and 6 months. Consult doctor,
review transfer documentation and compare with
admission weight. Calculate weight gain during the
specified time periods.
Current resident – Review the resident records and
 Chapter 3: The Item-by-Item Guide to the MDS
compare current weight with weights of one month and 6
months ago. Calculate weight gain during the specified time
periods.
Coding
Code “0” for No or “1” for Yes. If there is no weight to
compare to, enter NA.
4. Nutritional problems
Purpose
To identify specific problems, conditions, and risk factors for
functional decline present in the last 7 days that affect or
could affect the resident’s health or functional status. Such
problems can often be reversed and the resident can
improve.
Definition
Complains about the taste of many foods – The sense of
taste can change as a result of health conditions or
medications. Also, complaints can be culturally based – e.g.
someone used to eating spicy foods may find home meals
bland.
Regular or repetitive complaints of hunger – On most days
(at least 2 out of 3), resident asks for more food or
repetitively complains of feeling hungry (even after eating a
meal).
Leaves 25% or more of food uneaten at most meals – Eats
less than 75% of food (even when substitutes are offered)
at least 2 out of 3 meals a day.
Process
Consult resident’s records (including current care plan),
dietary/fluid intake records, dietary progress
notes/assessments. Consult with care staff and dietician. Ask
the resident if he or she experienced any of these
symptoms in the last 7 days. Sometimes a resident will not
complain to staff members because he or she attributes
symptoms to “old age”. Therefore, it is important to ask the
resident directly. Observe the resident while eating. If he or
she leaves food or picks at it, ask “Why are you not
eating?” Note if resident winces or makes faces while
eating.
Coding
Tick all conditions that apply. If no conditions apply, tick
NONE OF ABOVE.
5. Nutritional approaches
Definition
Parenteral/IV – Intravenous (IV) fluids given continuously or
Full Assessment Form: Section K
intermittently. This category also includes administration of
fluids via IV lines. This category does not include
administration of IV medications. If the resident receives IV
medications, tick item P1c in “Special Treatments and
Procedures”.
Feeding tube – Presence of any type of tube that can
deliver food/nutritional substances/fluids/medications
directly into the gastrointestinal system. Examples include,
but are not limited to nasogastric and gastrostomy tubes.
Mechanically altered diet – A diet specifically prepared to
alter the consistency of food in order to facilitate oral
intake. Examples include soft solids, pureed foods, minced
meat. Diets for residents who can only take liquids that
have been thickened to prevent choking are also included
in this definition.
Syringe (oral feeding) – Use of syringe to deliver liquid or
pureed nourishment directly into the mouth.
Therapeutic diet – A diet ordered to manage problematic
health conditions. Examples include calorie-specific, low-
salt, low-fat, no added sugar, and supplements during
meals.
Dietary supplement between meals – Any type of dietary
supplement provided between scheduled meals (e.g. high
protein/calorie shake, or 3 pm. snack for resident who is
diabetic). Do not include snacks that everyone receives as
part of daily routine.
Plate guard, adapted cutlery, etc. – Any type of specialised,
altered, or adaptive equipment to facilitate the resident’s
involvement in self-performance of eating.
On planned weight change programme – Resident is
receiving a programme of which the documented purpose
and goal are to facilitate weight gain or loss (e.g. double
portions; high calorie supplements; reduced calories; 10
grams fat).
Coding
Tick all that apply. If none apply, tick NONE OF ABOVE.
6. Parenteral or enteral intake – skip to Section L if neither
item K5a nor K5b is ticked.
Purpose
To record the proportion of calories received, and the
average fluid intake, through parenteral or tube feeding in
the last 7 days.
A. Calorie intake
 Chapter 3: The Item-by-Item Guide to the MDS Full Assessment Form: Section K

Definition received by tube.

Proportion of total calories received – the proportion of all
Step 4: Code “4” for 76% to 100%
calories during the last 7 days ingested that the resident
actually received (not ordered) by parenteral or tube B. Average fluid intake
feedings. Determined by calorie count. Definition
Process Average fluid intake per day by IV or tube feeding in last 7
Review intake record. If the resident took no food or fluids days refers to the actual amount of fluid the resident
by mouth, or took just sips of fluid, stop here and code “4” received by these modes (not the amount ordered).
(76%-100%). If the resident had more substantial oral Process
intake than this, consult with the dietician who can derive a Review the intake and output record from the last 7 days.
calorie count received from parenteral or tube feedings. Add up the total amount of fluid received each day by IV
Coding and/or tube feedings only. Divide the week’s total fluid
Code for the best response. intake by 7. This will give you the average of fluid intake
per day.
0. None
Coding
1. 1% to 25%
Code for the average number of mls of fluid the resident
2. 26% to 50% received per day by IV or tube feeding.
3. 51% to 75%
0. None
4. 76% to 100%
1. 1 to 500 ml/day
Example of calculation for proportion of total calories
2. 501 to 1000 ml/day
from IV or tube feeding
Mr. H has had a feeding tube since his surgery. He is 3. 1001 to 1500 ml/day
currently more alert, and feeling much better. He is very 4. 1501 to 2000 ml/day
motivated to have the tube removed. He has been taking
soft solids by mouth, but only in small to medium amounts. 5. 2001 or more ml/day
For the past week he has been receiving tube feedings for Example of calculation for average daily fluid intake
nutritional supplementation. As his oral intake improves, Ms. A has swallowing difficulties secondary to Huntington’s
the amount received by tube will decrease. The dietician disease. She is able to take oral fluids by mouth with
has totalled his calories per day as follows: supervision, but not enough to maintain hydration. She
Step 1: Oral Tube received the following daily fluid totals by supplemental
Sun. 500 + 2000 tube feedings (including water, prepared nutritional
Mon. 250 + 2250 supplements, juices) during the last 7 days.
Tues. 250 + 2250 Step 1:
Wed. 350 + 2250 Sun. 1250
Thurs. 500 + 2000 Mon. 775 ml
Fri. 800 + 1800 Tues. 925 ml
Sat. 800 + 1800 Wed. 1200 ml
TOTAL 3450 + 14350 Thurs. 1200 ml
Fri. 1200 ml
Step 2: Total calories = 3450 + 14350 = 17800 Kcal
Sat. 1000 ml
Step 3: Calculate percentage of total calories by tube TOTAL 7550 ml
feeding.
Step 2: 7550 divided 7 = 1078.6 ml
14350 x 100 [multiply total tube amount by 100
17800 then divide by total calories] Step 3: Code “3” for 1001 to 1500 ml/day

1435000 divided by 17800 = 80.6% of total calories

 Section K. Oral/Nutritional Status

1 Oral problems ■ a. Chewing problem

17
■ b. Swallowing problem
15
■ c. Mouth pain
■ d. NONE OF ABOVE

2 Height and weight Record (A) height in cms or inches and (B) weight in kilos or pounds. Base weight on most
recent measures in last month; measure weight consistently in accord with standard facility
practice eg. in am after voiding, before meal, with shoes off, and in nightclothes.

Height in cms or inches

Weight in kilos or pounds

3 Weight change a. Weight loss - 5% or more in last month; or 10% or more in last 6 months

0. No
12
1. Yes

b. Weight gain - 5% or more in last month; or 10% or more in last 6 months

0. No
1. Yes

4 Nutritional ■ a. Complains about the taste of many foods

12

problems ■ b. Regular or repetitive complaints about hunger

12
■ c. Leaves 25% or more food uneaten at most meals
■ d. Does not eat at every mealtime
■ e. NONE OF ABOVE

5 Nutritional Tick all that apply in last 7 days

12,14
approaches ■ a. Parenteral/IV
13,14
■ b. Feeding tube
12
■ c. Mechanically altered diet
12
■ d. Syringe (oral feeding)
12
■ e. Therapeutic diet
Specify
■ f. Dietary supplement between meals
Specify
■ g. Plate guard, adapted cutlery
Specify
■ h. On a planned weight change programme
■ i. NONE OF ABOVE

6 Parenteral or enteral Skip to section L if neither 5a nor 5b is ticked

intake A. Code the proportion of total calories the B. Code the average fluid intake per day by
resident received through parenteral or tube IV or tube in last 7 days
feeding in the last 7 days
Refer to appro-
priate profes-
sional eg
Dietician

0. None 0. None
1. 1% to 25% 1. 1 to 500ml/day
2. 26% to 50% 2. 501 to 1000ml/day
3. 51% to 75% 3. 1001 to 1500 ml/day
4. 76% to 100% 4. 1501 to 2000 ml/day
5. 2001 to more ml/day
 Section K: Oral/Nutritional Status
Triggers for Resident Assessment Protocols

Question MDS Item Code RAPs

Number

17
K1b Swallowing problem ✓ Psychotropic Drug Use

15
K1c Mouth pain ✓ Dental Care

12
K3a Weight loss 1 Nutritional Status

12
K4a Taste alteration ✓ Nutritional Status

12
K4c Leave 25% food ✓ Nutritional Status

12
K5a Parenteral/IV feeding ✓ Nutritional Status
14
Dehydration/Fluid Maintenance

13
K5b Feeding tube ✓ Feeding Tubes
14
Dehydration/Fluid Maintenance

12
K5c Mechanically altered diet ✓ Nutritional Status

12
K5d Syringe feeding ✓ Nutritional Status

12
K5e Therapeutic diet ✓ Nutritional Status
 Chapter 3: The Item-by-Item Guide to the MDS Full Assessment Form: Section L

Section L: Oral/Dental Status

1. Oral status and disease prevention Process

Purpose Ask the resident, and examine the resident’s mouth. Ask
To document the resident’s oral and dental status as well care staff if they have noticed any problems. Review the
as any problematic conditions. resident record.

Definition Coding
Carious – Pertains to tooth decay and disintegration Tick all that apply. If none apply, tick NONE OF ABOVE.
(cavities).
 Section L. Oral/Dental Status

1 Oral status and ■ a. Debris (soft, easily movable substances) present in mouth prior to going to
disease prevention bed at night
15

■ b. Has dentures or removable bridge

■ c. Some/all natural teeth lost - does not have or does not use dentures
15
(or partial plates)
15
■ d. Broken, loose, or carious teeth
15
■ e. Inflamed gums (gingiva); swollen or bleeding gums; oral abcesses; ulcers or rashes

■ f. Daily cleaning of teeth/dentures or daily mouth care - by resident or staff

15
( if not ticked)

■ g. NONE OF ABOVE

Section L: Oral/Dental Status

Triggers for Resident Assessment Protocols

Question MDS Item Code RAPs

Number

15
L1a,c,d,e Dental ✓ Dental Care

L1f Daily cleaning teeth Not ✓ Dental Care

15
 Chapter 3: The Item-by-Item Guide to the MDS
Section M: Skin Condition
On completion of this section if any problems are
identified it is important to involve a registered nurse or
doctor.
The purpose of this section is to determine the condition
of the resident’s skin, identify the presence, stage, type,
and number of ulcers, and document other problematic
skin conditions. Additionally, it documents any skin
treatments for active conditions as well as any protective
or preventive skin or foot care treatments the resident has
received in the last 7 days.
1. Ulcer (due to any cause)
Purpose
To record the number of ulcers, of any type at each ulcer
stage, on any part of the body.
Definition
Stage 1. A persistent area of skin redness (without a
break in the skin) that does not disappear when pressure
is relieved.
Stage 2. A partial thickness loss of skin layers that
presents clinically as an abrasion, blister, or shallow
crater.
Stage 3. A full thickness of skin is lost, exposing the
subcutaneous tissues. Presents as a deep crater with or
without undermining adjacent tissue.
Stage 4. A full thickness of skin and subcutaneous tissue
is lost, exposing muscle or bone.
Process
Review the resident’s record and consult with carers
about the presence of an ulcer. Examine the resident and
determine the stage and number of any ulcers present.
Without a full body check an ulcer can be missed.
Assessing a Stage 1 ulcer requires a specially focused
assessment for residents with darker skin tones to take
into account variations in black skins. To recognise Stage
1 ulcers in black complexions, look for: (1) any change in
the feel of the tissue in a high-risk area; (2) any change in
the appearance of the skin in high-risk areas, such as the
“orange-peel” look; (3) a subtle purplish hue; and (4)
extremely dry, crust-like areas that, upon closer
examination, are found to cover a tissue break.
Coding
Record the number of ulcers at each stage on the
resident’s body, in the last 7 days, regardless of the ulcer
cause. If necrotic eschar (black dead skin) is present,
Full Assessment Form: Section M
prohibiting accurate staging, code the ulcer as Stage “4”
until the eschar has been debrided (surgically or
mechanically removed) to allow staging. If there are no
ulcers at a particular stage, record “0” (zero) in the box
provided. If there are more than 9 ulcers at any one
stage, enter “9” in the appropriate box.
Example
Mrs. L has end-stage metastatic cancer and weighs 5 1/ 2
stones. She has a Stage 3 ulcer over her sacrum and two
Stage 1 ulcers over her heels.
Stage Code
1 2
2 0
3 1
4 0
2. Type of ulcer
Purpose
To record the highest stage for two types of ulcers,
pressure and stasis, that were present in the last 7 days.
Definition
Pressure sore – Any lesion caused by pressure resulting in
damage of underlying tissues. Other terms used to
indicate this condition include bed sores and decubitus
ulcers.
Stasis ulcer – An open lesion, usually in the lower
extremities, caused by decreased blood flow from chronic
venous insufficiency; also referred to as a venous ulcer or
ulcer related to peripheral vascular disease.
Process
Review the resident’s record. Consult with the doctor
regarding the cause of the ulcer(s).
Coding
Using the ulcer staging scale in item M1 record the
highest ulcer stage for pressure and stasis ulcers present
in the last 7 days. Remember that there are other types of
ulcers than the two listed in this item (e.g. ischaemic
ulcers). An ulcer recorded in item M1 may not necessarily
be recorded in item M2. (See last example below).
Examples
Mr. C has diabetes and poor circulation to his lower
limbs. Last month Mr. C spent 2 weeks in hospital where
he had a left below the knee amputation for treatment of
 Chapter 3: The Item-by-Item Guide to the MDS
a gangrenous foot. His hospital course was complicated
by an acute confusional state and he spent most of his
time on bed rest. Nurses remarked that he would only
stay lying on his back. He was readmitted to the nursing
home 3 days ago with a Stage 2 pressure sore over his
sacrum and a Stage I pressure sore over his right heel
and both elbows. No other ulcers were present.
Type of ulcer Code (highest stage)
a. Pressure sore 2 viruses, contact with irritating substances such as urine or
b. Stasis ulcer 0 (dermatitis) within skin folds.
Rationale for coding: Mr. C has 4 pressure sores, the
highest stage of which is Stage 2.
Mrs. B has a blockage in the arteries of her right leg
causing impaired arterial circulation to her right foot
(ischaemia). She has only 1 ulcer, a Stage 3 ulcer on the
dorsal surface (top) of her right foot.
Type of ulcer Code (highest stage)
a. Pressure sore 0 peripheral vascular disease and neurological disorders. In
b. Stasis ulcer 0 sensation can be tested in the following way by a
Rationale for coding: Mrs. B’s ulcer is an ischaemic ulcer
rather than caused by pressure or venous stasis.
3. History of resolved/cured ulcers
Purpose
To determine if the resident previously had an ulcer that
was resolved or cured during the past 3 months.
Identification of this condition is important because it is a
risk factor for development of subsequent ulcers.
Process
Review records
Coding
Code “0” for No or “1” for Yes.
4. Other skin problems or lesions present
(The following tests should only be undertaken by a
qualified health care professional.)
Purpose
To document the presence of skin problems other than
ulcers and conditions that are risk factors for more
serious problems.
Definition
Abrasions, bruises – Includes skin scrapes, bruises,
localised areas of swelling, tenderness and discoloration.
Full Assessment Form: Section M
Burns (second or third degree) – Includes burns from any
cause (e.g. heat, chemicals) in any stage of healing. This
category does not include first degree burns (changes in
skin colour only).
Rashes – Includes inflammation or eruption of the skin
that may include change in colour, spotting, blistering,
etc. and symptoms such as itching, burning, or pain.
Record rashes from any cause (e.g. heat, drugs, bacteria,
detergents, allergies, etc.). Intertrigo refers to rashes
Skin desensitised to pain or pressure – The resident is
unable to perceive sensations of pain or pressure.
Review the resident’s record for documentation of
impairment of this type. An obvious example of a
resident with this problem is someone who is comatose.
Other residents at high risk include those with
quadriplegia, paraplegia, hemiplegia or hemiparesis,
the absence of documentation in the resident record,
qualified health professional:
■ To test for pain, use a new, disposable safety pin or
wooden “orange stick” (usually used for nail care).
Always dispose of the pin or stick after each use to
prevent contamination.
■ Ask the resident to close his or her eyes. If the resident
cannot keep his or her eyes closed or cannot follow
directions to close eyes, block what you are doing (in
local areas of legs and feet) from view with a cupped
hand or towel.
■ Lightly press the pointed end of the pin or stick
against the resident’s skin. Do not press hard enough
to cause pain, injury, or break in the skin. Use the
pointed and blunt ends of the pin or stick alternately
to test sensations on the resident’s arms, trunk, and
legs. Ask the resident to report if the sensation is
“sharp” or “dull”.
■ Compare the sensations in symmetrical areas on both
sides of the body.
■ If the resident is unable to feel the sensation, or
cannot differentiate sharp from dull, the area is
considered desensitised to pain sensation.
■ For residents who are unable to make themselves
 Chapter 3: The Item-by-Item Guide to the MDS
understood or who have difficulty understanding your
directions, rely on their facial expressions (e.g.
wincing, grimacing, surprise), body motions (e.g.
pulling the limb away, pushing the examiner) or
sounds.
■ Do not use pins with agitated or restless residents.
Abrupt movements can cause injury.
Skin tears or cuts (other than surgery) – Any traumatic
break in the skin penetrating to subcutaneous tissue.
Examples include skin tears, lacerations, etc.
Surgical wounds – Includes healing and non-healing,
open or closed surgical incisions, skin grafts or drainage
sites on any part of the body. This category does not
include healed surgical sites or stomas.
Process
Ask the resident if he or she has any problem areas.
Examine the resident. Ask care staff. Review the
resident’s record.
Coding
Tick all that apply. If there is no evidence of such
problems in the last 7 days, tick NONE OF ABOVE.
5. Skin treatments
Purpose
To document any specific or generic skin treatments the
resident has received in the past 7 days.
Definition
Pressure relieving device(s) for chair – Includes gel, air or
other cushioning placed on a chair or wheelchair.
Pressure relieving device(s) for bed – Includes air
fluidised, low airloss therapy beds, flotation, water, or
bubble mattress or pad placed on the bed.
Turning/repositioning programme – Includes a
continuous, consistent programme for changing the
resident’s position and realigning the body.
Nutrition or hydration intervention to manage skin
problems – Dietary measures received by the resident for
the purpose of preventing or treating specific skin
conditions – e.g. wheat-free diet to prevent allergic
dermatitis, high calorie diet with added supplements to
prevent skin breakdown, high protein supplements for
wound healing.
Ulcer care – Includes any intervention for treating an
ulcer at any ulcer stage. Examples include use of
Full Assessment Form: Section M
dressings, chemical or surgical debridement, wound
irrigations, and hydrotherapy.
Surgical wound care – Includes any intervention for
treating or protecting any type of surgical wound.
Examples of care include topical cleansing, wound
irrigation, application of anti-microbial ointments,
dressings of any type, suture removal, and warm soaks or
heat application.
Application of dressings (with or without topical
medications) other than to feet – Includes dry gauze
dressings, dressings moistened with saline or other
solutions, transparent dressings, hydrogel dressings, and
dressings with hydrocolloid or hydroactive particles.
Application of ointments/medications (other than to feet)
– Includes ointments or medications used to treat a skin
condition (e.g. cortisone, anti-fungal preparations,
chemotherapeutic agents, etc.). This definition does not
include ointments used to treat non-skin conditions (e.g.
transdermal glyceryl trinitrate for chest pain).
Other preventative or protective skin care (other than to
feet) – Includes application of creams or bath soaks to
prevent dryness, scaling; application of protective elbow
pads (e.g. down, sheepskin, padded, quilted).
Process
Review the resident’s records. Ask the resident and carer.
Coding
Tick all that apply. If none apply in the past 7 days, tick
NONE OF ABOVE.
6. Foot problems and care
Purpose
To document the presence of foot problems and care to
the feet during the last 7 days.
Definition
Open lesions on the foot – Includes cuts, ulcers, fissures.
Nails or calluses trimmed during the last 3 months –
Pertains to care of the feet. Includes trimming by nurse or
any health professional, including a chiropodist.
Received preventative or protective foot care – Includes
any care given for the purpose of preventing skin
problems on the feet, such as diabetic foot care, foot
soaks, protective footwear (e.g. down, sheepskin,
padded, quilted), special shoes, orthotics, application of
toe pads, toe separators, etc.
 Chapter 3: The Item-by-Item Guide to the MDS Full Assessment Form: Section M

Application of dressings with or without topical Tick all that apply. If none apply in the past 7 days, tick
medications – Includes dry gauze dressings, dressings
moistened with saline or other solutions, transparent
dressings, hydrogel dressings, and dressings with
hydrocolloid or hydroactive particles.
Process
Ask the resident and staff. Inspect the resident’s feet.
Review the resident’s clinical records.
Coding NONE OF ABOVE.
 Section M. Skin Condition

1 Ulcers Record the number of ulcers at each ulcer stage - regardless of cause. If none present at a

(Due to any cause) stage, record “0” (zero). Code all that apply during last 7 days. (Requires full body
examination)
Stage 1. A persistent area of skin redness (without a break in the skin) that does
professional for advice
eg District Nurse, GP
Refer to appropriate
not disappear when pressure is relieved
Stage 2. A partial thickness loss of skin layers that presents clinically as an
abrasion, blister, or shallow crater
Stage 3. A full thickness of skin is lost, exposing the subcutaneous tissues -
presents as a deep crater with or without undermining adjacent tissue
Stage 4. A full thickness of skin and subcutaneous tissue is lost exposing muscle
or bone

2 Type of ulcer For each type of ulcer, code the highest stage in the last 7 days as given in previous question.
a. Pressure sore - any lesion caused by pressure resulting in damage of
underlying tissue
16
If stage 1 coded
12,16
If stage 2 - 4 coded

b. Stasis ulcer - open lesion caused by poor circulation in the lower limb

3 History of resolved Resident had an ulcer that was resolved or cured in last 3 months

ulcers 0. No.
16
1. Yes

4 Other skin Tick all that apply in last 7 days

problems or ■ a. Abrasions, bruises

lesions present ■ b. Burns (second or third degree)

■ c. Open lesions other than ulcers, rashes cuts (eg. cancer lesions)
■ d. Rashes - eg intertrigo, eczema, drug rash, heat rash, herpes zoster
16
■ e. Skin desensitised to pain or pressure
■ f. Skin tears or cuts (other than surgery)
■ g. Surgical wounds
■ h. NONE OF ABOVE

5 Skin treatments Tick all that apply during last 7 days

■ a. Pressure relieving device(s) for chair

■ b. Pressure relieving device(s) for bed
■ c. Turning/repositioning programme
■ d. Nutrition or hydration intervention to manage skin problems
■ e. Ulcer care
■ f. Surgical wound care
■ g. Application of dressings (with or without topical medications) other than to feet
■ h. Application of ointments/medications (other than to feet)
■ i. Other preventative or protective skin care (other than to feet)
■ j. NONE OF ABOVE
 Section M. Skin Condition Continued

6 Foot problems Tick all that apply in last 7 days

and care ■ a. Resident has one or more foot problems - eg. corns, callouses, bunions, hammer
toes, overlapping toes, pain, structural problems

■ b. Infection of the foot - eg. cellulitis, purulent discharge

■ c. Open lesions on the foot

■ d. Nails/calluses trimmed during last 3 months
■ e. Received preventative or protective footcare (eg. used special shoes, inserts, pads,
toe separators
■ f. Application of dressings (with or without topical medications)
■ g. NONE OF ABOVE

Section M: Skin Condition

Triggers for Resident Assessment Protocols

Question MDS Item Code RAPs

Number

16
M2a Pressure sore 1,2,3,4 Pressure sores

12
M2a Pressure sore 2,3,4 Nutritional status

16
M3 Previous pressure sore 1 Pressure sores

16
M4e Impaired tactile sensation ✓ Pressure sores
 Chapter 3: The Item-by-Item Guide to the MDS
Section N: Activity Pursuit Patterns
The purpose of this section is to record the amount
and types of interests and activities that the resident
currently pursues, as well as activities the resident
would like to pursue that are not currently available.
Activity pursuits are any activity other than ADLs that a
resident pursues in order to enhance a sense of well-
being. These include activities that provide increased
self-esteem, pleasure, comfort, education, creativity,
success and financial or emotional independence.
1. Time awake
Purpose
To identify those periods of a typical day (over the last
7 days) when the resident was awake all or most of the
time (i.e. no more than one hour nap during any such
period). For care planning purposes this information
can be used in at least two ways:
■ The resident who is awake most of the time could
be encouraged to become more mentally, physically
and/or socially involved in activities (solitary or
group).
■ The resident who naps a lot may be bored or
depressed and could possibly benefit from greater
activity involvement.
Process
Consult with care staff, the resident and the resident’s
family.
Coding
Tick all periods when resident was awake all or most of
the time. Morning is from 7 am (or when resident
wakes up, if earlier or later than 7 am) until noon.
Afternoon is from noon to 5 pm. Evening is from 5 pm
to 10 pm (or bedtime, if earlier). Specify where
resident spends most of waking day, bed or chair. If
equal time tick ‘bed’. If resident is comatose, this is the
only section N item to code, skip all other section N
items and go to section O.
2. Average time involved in activities
Purpose
To determine the proportion of available time that the
resident was actually involved in activity pursuits as an
indication of his or her overall activity-involvement
pattern. Available time refers to free time when the
resident was awake and was not involved in care,
treatments or engaged in ADL activities and could have
Full Assessment Form: Section N
been involved in activity pursuits and organised
recreation.
Process
Consult with care staff, the resident and the resident’s
family. Ask about time involved in different activity
pursuits.
Coding
In coding this item, exclude time spent in receiving
treatments (e.g. medications, heat treatments, dressing
changes, rehabilitation therapies, or ADLs). Include
time spent in pursuing independent activities (e.g.
watering plants, reading, letter-writing); social contacts
(e.g. visits, phone calls) with family, other residents,
staff, and volunteers; recreational pursuits in a group,
one-to-one or an individual basis; and involvement in
organised recreation.
3. Preferred activity settings
Purpose
To determine activity circumstances/settings that the
resident prefers, including (though not limited to)
circumstances in which the resident is at ease.
Process
Ask the resident, family and care staff about the
resident’s preferences. Staff knowledge of observed
behaviour can be helpful, but only provides part of the
answer. Do not limit preference list to areas to which
the resident now has access, but try to expand the
range of possibilities for the resident.
Example
Ask the resident, “Do you like to go outdoors? Outside
the home (to the shops)? To events outside?” Ask staff
members to identify settings that resident frequents or
where he or she appears to be most at ease.
Coding
Tick all responses that apply. If the resident does not
wish to be in any of these settings, Tick NONE OF
ABOVE.
4. General activity preferences (adapted to resident’s
current abilities)
Purpose
Determine which activities of those listed the resident
would prefer to participate in (independently or with
others). Choice should not be limited by whether or not
 Chapter 3: The Item-by-Item Guide to the MDS
the activity is currently available to the resident, or
whether the resident currently engages in the activity.
Definition
Exercise/sports – Includes any type of physical activity
such as dancing, yoga, walking, sports (e.g. bowling,
croquet, golf, or watching sports).
Music – Includes listening to music or being involved in
making music (singing, playing piano, etc.).
Reading/writing – Reading can be independent or done
in a group setting where a leader reads aloud to the
group or the group listens to “talking books”. Writing can
be solitary (e.g. letter-writing or poetry writing) or done
as part of a group programme (e.g. recording oral
histories).
Spiritual/religious activities – Includes participating in
religious services as well as watching them on television
or listening to them on the radio.
Gardening or plants – Includes tending one’s own or
other plants, participating in garden club activities,
regularly watching a television programme or video
about gardening.
Talking or conversing – Includes talking and listening to
social conversations and discussions with family, friends,
other residents or staff. May occur individually, in groups,
or on the telephone; may occur informally or in
structured situations.
Helping others – Includes helping other residents or staff,
being a good listener, assisting with home routines, etc.
Process
Consult with the resident, the resident’s family and staff
members. Explain to the resident that you are interested
in hearing about what he or she likes to do or would be
interested in trying. Remind the resident that a discussion
of his or her likes and dislikes should not be limited by
perception of current abilities or disabilities. Explain that
many activity pursuits are adaptable to the resident’s
capabilities. For example, if a resident says that he used
to love to read and misses it now that he is unable to see
small print, explain about the availability of taped books
or large print editions.
For residents with dementia or aphasia, ask family
members about resident’s former interests. A former
love of music can be incorporated into the care plan
(e.g. bedside audiotapes, sing-alongs). Also observe
Full Assessment Form: Section N
the resident in current activities. If the resident appears
content during an activity (e.g. smiling, clapping during
a music programme) tick the item on the form.
Coding
Tick each activity preferred. If none are preferred, tick
NONE OF ABOVE.
5. Prefers change in daily routine
Purpose
To determine if the resident has an interest in pursuing
activities not offered or not made available to the
resident. This includes situations in which an activity is
provided but the resident would like to have other
choices in carrying out the activity (e.g. the resident
would like to watch the news on TV rather than the
game shows and soap operas preferred by the majority
of residents). Residents who resist
attendance/involvement in activities offered are also
included in this category in order to determine possible
reasons for their lack of involvement.
Process
Review how the resident spends the day. Ask the resident
if there are things he or she would enjoy doing (or used
to enjoy doing) that are not currently available or, if
available, are not “right” for him or her in their current
format. If the resident is unable to answer, ask the same
question of a close family member or friend. Would the
resident prefer slight or major changes in daily routines,
or is everything OK?
Coding
For each of the items, code for the resident’s preferences
in daily routines using the codes provided.
0. No change – Resident is content with current activity
routines.
1. Slight change – Resident is content overall but would
prefer minor changes in routine (e.g. a new activity,
modification of a current activity).
2. Major change – Resident feels bored, restless, isolated,
or discontent with daily activities or resident feels too
involved in certain activities, and would prefer a
significant change in routine.
Example
Mrs. B is regularly involved in several small group
 Chapter 3: The Item-by-Item Guide to the MDS Full Assessment Form: Section N

activities. She also has expressed a preference for music. a. Type of activities in which 1 (Slight change)
However, she has consistently refused to go resident is currently involved
to group sing-alongs. She says she doesn’t like big
b. Extent of resident involvement 1 (Slight change)
groups and prefers to relax and listen to classical
in activities
music in her room. She wishes she had a radio
or tape player to do this.
Code
 Section N. Activity Pursuit Patterns

1 Time awake Tick appropriate time period over last 7 days

Resident awake all or most of the time (ie. naps no more than one hour per time period) in
the:
10 (with N2=0)
■ a. Morning
■ b. Afternoon
■ c. Evening
Specify: In bed In chair

■ d. NONE OF ABOVE

If resident is unconscious skip to section O

2 Average time
involved in activities
When awake and not receiving treatment or ADL care
10 (with N1a = ticked)
0. Most - more than 2/3 of time
1. Some - from 1/3 to 2/3 of time
10
2. Little - less than 1/3 of time
10
3. None

3 Preferred activity Tick all settings in which activities are preferred

settings ■ a. Own room

■ b. Day/activity room
■ c. Inside home
■ d. Outside home
■ e. NONE OF ABOVE

4 General activity Tick all preferences whether or not activity is currently available to resident

preferences ■ a. Cards/other games

(adapted to resident’s ■ b. Crafts/arts

current abilities) ■ c. Exercise/sport
■ d. Music
■ e. Reading/writing
■ f. Spiritual/religious activities
■ g. Trips/shopping
■ h. Walking/wheeling outdoors
■ i. Watching TV
■ j. Gardening or plants
■ k. Talking or conversing
■ l. Helping others
■ m. NONE OF ABOVE
Specify

5 Prefers change in Code for resident preferences in daily routine

daily routine 0. No change

10
1. Slight change
2. Major change 10

10
a. Type of activities in which resident is currently involved

10
b. Extent of resident involvement in activities
 Section N: Activity Pursuit Patterns
Triggers for Resident Assessment Protocols

Question MDS Item Code RAPs

Number

10
N1a Awake morning ✓* Activities Trigger B

10
N2 Involved in activities 0* Activities Trigger B

N2 Involved in activities 2, 3 Activities Trigger A 10

N5a,b Prefers change in daily routine 1, 2 Activities Trigger A 10

*Both of these questions need to be answered in this way to trigger RAP Activities Trigger B, one answer only is not sufficient.
 Chapter 3: The Item-by-Item Guide to the MDS
Section O: Medications
Doctor involvement in this part of the assessment process
is crucial. The doctor should be asked to review the items
in Section O at the time of visit closest to the MDS
assessment.
1. Number of medications
Purpose
To determine the number of different medications (over-
the-counter and prescription drugs) the resident has
received in the past 7 days.
Process
Count the number of different medications (not the
number of doses or different dosages) administered by
any route (e.g. oral, IV, injections, patch) at any time
during the last 7 days. Include any routine, as required
and one-off doses given. “Medications” can also include
topical preparations, ointments, creams used in wound
care, eye drops, vitamins and suppositories. Include any
medication that the resident administers to self, if known.
If the resident takes both the generic and brand name of
a single drug, count as only one medication. If the
resident received a long-acting antipsychotic medication
prior to the assessment period (e.g. if a Fluphenazine or
Haloperidol is given once a month) count as one drug.
Coding
Write the appropriate number in the answer box. Count
only those medications actually administered and
received by the resident over the last 7 days. Do not
count medications ordered but not given.
Example
Resident was given Digoxin 0.25 mg by mouth on
Tuesday and Thursday and Digoxin 0.125 mg by mouth
on Monday, Wednesday, and Friday. Although the
dosage is different for different days of the week, the
medication is the same. Code “1” (one medication
received).
2. New medications
Purpose
To record whether the resident is currently receiving
medications that were initiated in the last 3 months.
Coding
Code “1” if the resident received (and continues to
receive) new medications in the last 3 months. Code “0”
if the resident did not receive any new medications in the
past 3 months. If the resident received new medication(s)
Full Assessment Form: Section O
in the last 3 months but they were discontinued prior to
this assessment period, code “0” (no new medication).
3. Injections received
Purpose
To determine the number of days during the past 7 days
that the resident received any type of medication, antigen
or vaccine, by injection. Although antigens and vaccines
are considered “biologicals” and not medication per se, it
is important to track when they are given to monitor for
localised or systemic reactions. This category does not
include intravenous (IV) fluids or medications. If the
resident received IV fluids, record in Item K5a,
Parenteral/IV. If IV medications were given, record in Item
P1c.
Coding
Record the number of DAYS in the answer box.
Example
During the last 7 days, Mr. T received a flu injection on
Monday, a Vitamin B12 injection on Wednesday. Code
“2” for Resident received injections on two days during
the last 7 days.
4. Days received the following medication
Purpose
To record the number of days that the resident received
each type of medication listed (antipsychotics, anxiolytic,
antidepressants, hypnotics, diuretics) in the past 7 days.
Includes any of these medications given to the resident
by any route (e.g. by mouth, injection or IV) in any
setting (e.g. at the home, in a clinic).
Process
Review the resident’s record for documentation that a
medication was received by the resident during the past 7
days. In the case of a new admission, review any transfer
records.
Coding
Enter the number of days each of the listed types of
medications was received by the resident during the past
7 days. In the case of a new admission, if it is clearly
documented that the resident received any type of
medication (listed in this item) prior to admission, record
the number of days each listed medication was received
during the past 7 days. If transfer records are not clear or
do not reference that the resident received one of these
medications, record “0” (not used) in the corresponding
 Chapter 3: The Item-by-Item Guide to the MDS Full Assessment Form: Section O

box. If the resident did not use any medications from a Example 2
drug category, enter “0”. If the resident uses long-lasting Mr. S was admitted to the home on 12th September
drugs that are taken less often than weekly (e.g. 1994 (Date of Entry) from an acute hospital. The home
Modecate (Fluphenazine) given every few weeks or
staff established that 16th September 1994 would be the
monthly) enter “1”.
MDS assessment reference date (last day of MDS
Example 1 observation period). By establishing 16th September
Medication record for Mrs. P 1994 as the reference date, the observation period of 7
days extended back to 10th September 1994 when Mr. S
Haloperidol 0.5 mg by mouth p.r.n.: Received once a
day on Monday, Wednesday, and Thursday [Note: was still in the hospital. His hospital discharge summary
Haloperidol = Antipsychotic drug] mentioned that Mr. S was started on a daily dose of
Prozac (an antidepressant) on 20th August 1994. The
Lorazepam 2 mg by mouth: Received every day [Note:
hospital discharge summary was too sketchy to
Lorazepam = Anxiolytic drug]
accurately determine if Mr. S received other medications
Mrs. P became severely short of breath in the middle of during his hospital stay. Since admission to the nursing
the night during the last 7 days. She was transferred (but home Mr. S continues to receive the same dose of
not admitted) to A&E Dept at the local hospital. Upon Prozac.
her return to the home the A&E transfer record stated
Coding
that she had received 1 dose of IV Frusemide [Note:
Medication No. of days received
Frusemide = Diuretic].
a. Antipsychotic “0” (days)
Coding b. Anxiolytic “0” (days)
Medication No. of days received c. Antidepressant “7” (days)
a. Antipsychotic “3” (days) d. Hypnotic “0” (days)
b. Anxiolytic “7” (days) e. Diuretic “0” (days)
c. Antidepressant “0” (days)
d. Hypnotic “0” (days)
e. Diuretic “1” (days)
 Section O. Medications

1 Number of Record the number of different medications used in the last 7 days; enter “0” if none
used.
medications

2 New medications Resident currently receiving medication that was initiated during the last 3 months

0. No

1. Yes

3 Injections received Record the number of days injections of any type received during the last 7 days;
enter “0” if none used

4 Days received Record the number of days during last 7 days; enter “0” if not used. Note - enter “1” for
long-acting medications used less than weekly
the following
medication a. Antipsychotic 17

11,17
b. Anxiolytic
Refer to appropriate pro-

11,17
fessional eg GP

c. Antidepressant

d. Hypnotic

14
e. Diuretic

Note: 17 to trigger this RAP requires a, b, or c = 1 to 7 plus one other of triggers

for RAP 17 found elsewhere on the form. (listed in RAP 17, Chapter 4)
 Section O: Medications
Triggers for Resident Assessment Protocols

Question MDS Item Code RAPs

Number

17
04a Antipsychotics* 1-7 Psychotropic Drug Use

17
04b Anxiolytic* 1-7 Psychotropic Drug Use
11

17
04c Antidepressants* 1-7 Psychotropic Drug Use
11

14
04e Diuretic 1-7 Dehydration/Fluid Maintenance

*One of these three plus at least one of the other items on the MDS form which trigger RAP 17 are required to trigger
the Psychotropic Drug Use RAP
 Chapter 3: The Item-by-Item Guide to the MDS
Section P: Special Treatments and Procedures
If any problems are identified in reviewing this section,
the involvement of a registered nurse or doctor is crucial.
1. Special treatments, procedures and
programmes
Purpose
To identify any special treatments, therapies or
programmes that the resident received in the specified
time period.
A. Special care – treatments
The following treatments may be received by a resident
either at the home, as a hospital out-patient, or in-patient
basis, etc. Tick the appropriate MDS item regardless of
where the resident received the treatment.
Definition
Chemotherapy – Includes any type of chemotherapy
(drug therapy e.g. anti-cancer drugs) given by any route.
Dialysis – Includes peritoneal or renal dialysis.
IV Medication – Includes any drug given by intravenous
pump or drip. Does not include a saline or heparin flush
to keep a heparin lock patent, or IV fluids without
medication.
Intake/output monitoring – The measurement and
evaluation of all fluids the resident received and/or
excreted for at least three consecutive shifts (i.e. 24
hours).
Monitoring acute medical condition – Includes
observation by a registered nurse for ANY acute physical
or psychiatric illness.
Ostomy care – This item refers only to care that requires
assistance. Do not include tracheostomy care. Code
tracheostomy care by ticking item P1j.
Oxygen therapy – Includes continuous or intermittent
oxygen via mask, nasal cannula, etc.
Radiation – Includes radiation therapy or having a
radiation implant.
Suctioning – Includes nasopharyngeal or tracheal
aspiration.
Tracheostomy care – Includes cleansing of tracheostomy
and cannula.
Transfusions – Includes transfusions of blood or any
blood products (e.g. platelets).
Ventilator or respirator – Assures adequate ventilation in
Full Assessment Form: Section P
residents who are, or who may become, unable to
support their own respiration. Includes any type of
electrically or pneumatically powered closed system
mechanical ventilatory support devices. Any resident who
was in the process of being weaned off the ventilator or
respirator in the last 14 days should be coded under this
definition.
A. Special care – programmes
Definition
Alcohol/drug treatment programme – A comprehensive
interdisciplinary programme within the home where
interventions are designed specifically for the treatment of
alcohol or drug addictions.
Alzheimer’s/dementia special care unit – Any identifiable
part of the home, such as an entire floor where staffing
patterns and resident care interventions are designed
specifically for cognitively impaired residents who may or
may not have a specific diagnosis of Alzheimer’s disease.
Hospice care – The resident is identified as requiring care
for terminally ill persons where services are necessary for
the management of terminal illness and related
conditions.
Respite care – Resident’s care involves a short-term stay
in the home for the purpose of providing relief to carers.
Following this planned short stay, it is anticipated that the
resident will return to his or her home in the community.
Training in skills required to return to the community –
Resident is regularly involved in individual or group
activities with a professional (e.g. occupational therapist,
physiotherapist) to attain goals necessary for community
living (e.g. medication management, meal preparation,
shopping, using transportation, activities of daily living).
Process
Review the resident’s record.
Coding
Tick all treatments and procedures that were received
during the last 14 days. If no items apply in the last 14
days, tick NONE OF ABOVE.
B. Therapies
Therapies that occurred after admission to the home,
were agreed by interdisciplinary assessment, and were
performed by a qualified therapist.
The therapy treatment may occur either inside or outside
 Chapter 3: The Item-by-Item Guide to the MDS
the home. Includes only therapies based on a therapist’s
assessment and treatment documented in the resident’s
record.
Purpose
To record the (A) number of days and (B) total number
of minutes each of the following therapies was
administered (for at least 15 minutes a day) in the last 7
days.
Definition
Speech therapy, audiology services – Services that are
provided by a qualified speech therapist or audiologist.
Occupational therapy – Therapy services that are
provided or directly supervised by a qualified
occupational therapist. A qualified occupational therapy
assistant may provide therapy but not supervise others
(aides or volunteers) giving therapy.
Physiotherapy – Therapy services that are provided or
directly supervised by a qualified physiotherapist. A
qualified physiotherapy assistant may provide therapy
but not supervise others (aides or volunteers) giving
therapy.
Respiratory therapy – Included are coughing, deep
breathing, heated nebulizers and mechanical ventilation,
etc., which must be provided by a qualified professional
(i.e. trained nurse, physiotherapist). Does not include
hand held medication dispensers. Count only the time
that the qualified professional spends with the resident.
Psychological therapy – Therapy given by any registered
mental health professional, such as a psychiatrist,
psychologist, psychiatric nurse or psychiatric social
worker.
Process
Review the resident’s record and consult with each of the
qualified therapists.
Coding
Box A
In the first column, enter the number of days the therapy
was administered for 15 minutes or more in the last 7
calendar days. Enter “0” if none.
Box B
In the second column, enter the total number of minutes
the particular therapy was provided in the last 7 days
even if you entered “0” in Box A (e.g. less than 15
minutes of therapy provided). The time should include
Full Assessment Form: Section P
only the actual treatment time (not time waiting or
writing reports). Enter”0” if none.
Example
Following a stroke Mrs. F was admitted to the home in
a stable condition for rehabilitation therapies. Since
admission she has been receiving speech therapy twice
weekly for 30 minute sessions, occupational therapy
twice weekly for 30 minute sessions, and physiotherapy
twice a day (30 minute sessions) for 5 days and
respiratory therapy for 10 minutes per day on each of
the last 7 days. During the last 7 days Mrs. F has
participated in all of her scheduled sessions.
Coding A B
a. Speech-therapy, audiology 2 60
services
b. Occupational therapy 2 60
c. Physiotherapy 5 300
d. Respiratory therapy 0 70
e. Psychological therapy 0 0
2. Intervention programmes for mood,
behaviour, cognitive loss
Definition
Special behaviour symptom evaluation programme – A
programme of ongoing, comprehensive, interdisciplinary
evaluation of behavioural symptoms (such as the
symptoms described in item E4). The purpose of such a
programme is to attempt to understand the “meaning”
behind the resident’s behavioural symptoms in relation to
the resident’s health and functional status, and social and
physical environment. The ultimate goal of the
evaluation is to develop and implement a plan of care
that serves to reduce distressing symptoms.
Evaluation by a registered mental health specialist in the
last 3 months – An assessment of a mood, behaviour
disorder, or other mental health problem by a qualified
clinical professional such as a psychiatrist, psychologist,
psychiatric nurse, or psychiatric social worker. Do not tick
this item for routine visits by the social worker.
Evaluation may take place at the home, clinic, health
centre, etc.
Group therapy – Resident regularly attends sessions at
least weekly. Therapy is aimed at helping to reduce
loneliness, isolation, and the sense that one’s problems
are unique and difficult to solve. The session may take
 Chapter 3: The Item-by-Item Guide to the MDS
place either at the home (e.g. support group run by a
social worker) or outside the home (e.g. group
programme at health centre, Alcoholics Anonymous
meeting, Parkinson’s disease support group). This item
does not include group recreational or leisure activities.
Resident-specific deliberate changes in the environment
to address mood/behaviour/cognitive patterns –
Adaptation of the environment focused on the resident’s
individual mood/behaviour/cognitive pattern. Examples
include placing a banner labelled “wet paint” across a
closet door to keep the resident from repetitively
emptying all the clothes out of the closet, or placing a
bureau of old clothes in an alcove along a corridor to
provide diversionary “props” for a resident who
frequently stops wandering to rummage. The latter
diverts the resident from rummaging through belongings
in other residents’ rooms along the way.
Reorientation – Individual or group sessions that aim to
reduce disorientation in confused residents. Includes
environmental cueing in which all staff involved with the
resident provide orienting information and reminders.
Process
Review the resident’s record for documentation of
intervention programmes. These interventions should
also be documented in the care plan.
Coding
Tick all that apply. If none apply, tick NONE OF ABOVE.
3. Nursing rehabilitation/restorative care
Purpose
To determine the extent to which the resident receives
rehabilitation or restorative services from other than
specialised therapy staff (e.g. occupational therapist,
physiotherapist, etc.). Rehabilitative or restorative care
refers to interventions that promote the resident’s ability
to adapt and adjust to living as independently and safely
as is possible. This concept actively focuses on achieving
and maintaining optimal physical, mental and
psychosocial functioning.
Skill practice in such activities as walking and mobility,
dressing and grooming, eating and swallowing,
transferring, amputation care, and communication can
improve or maintain function in physical abilities and
ADLs and prevent further impairment.
Definition
Full Assessment Form: Section P
Rehabilitation/restorative care – Included are nursing
interventions that assist or promote the resident’s ability
to attain his or her maximum functional potential. This
item does not include procedures or techniques carried
out by or under the direction of qualified therapists, as
identified in item P1B. In addition, to be included in this
section, a rehabilitation or restorative practice must meet
all of the following additional criteria:
■ Measurable objectives and interventions must be
documented in the care plan and in the resident’s
record.
■ Evidence of periodic evaluation must be present in
the resident’s record.
■ Carers must be trained in the techniques that promote
resident involvement in the activity.
■ These activities are carried out or supervised by
qualified members of the nursing team. Other staff
and volunteers may be assigned to work with specific
residents under nursing supervision.
■ This category does not include exercise groups with
more than four residents per supervising helper or
caregiver.
Range of motion – The extent to which, or the limits
between which, a part of the body can be moved around
a fixed point, or joint. Range of motion exercise is a
programme of passive or active movements to maintain
flexibility and useful motion in the joints of the body.
Active range of motion – Exercises performed by a
resident, with cueing or supervision by staff, that are
planned, scheduled, and documented in the resident’s
record.
Splint or brace assistance – Assistance can be of 2 types:
1) where staff provide verbal and physical guidance and
direction that teaches the resident how to apply,
manipulate, and care for a brace or splint, or 2) where
staff have a scheduled programme of applying and
removing a splint or brace, assess the resident’s skin and
circulation under the device, and reposition the limb in
correct alignment. These sessions are planned,
scheduled, and documented in the record.
Training and skill practice – Activities including repetition,
physical or verbal cueing, and task segmentation
provided by any staff member or volunteer.
Bed mobility – Activities used to improve or maintain the
 Chapter 3: The Item-by-Item Guide to the MDS
resident’s self-performance in moving to and from a lying
position, turning side to side, and positioning him or
herself in bed.
Transfer – Activities used to improve or maintain the
resident’s self-performance in moving between surfaces
either with or without assistive devices.
Walking – Activities used to improve or maintain the
resident’s self-performance in walking, with or without
assistive devices.
Dressing or grooming – Activities used to improve or
maintain the resident’s self-performance in dressing and
undressing, bathing and washing, and performing other
personal hygiene tasks.
Eating or swallowing – Activities used to improve or
maintain the resident’s self-performance in feeding him
or herself food and fluids, or activities used to improve or
maintain the resident’s ability to ingest nutrition and
hydration by mouth.
Amputation/prosthesis care – Activities used to improve
or maintain the resident’s self-performance in putting on
and removing a prosthesis, caring for the prosthesis, and
providing appropriate hygiene at the site where the
prosthesis attaches to the body (e.g. leg stump or eye
socket).
Communication – Activities used to improve or maintain
the resident’s self-performance in using newly acquired
functional communication skills or assisting the resident
in using residual communication skills and adaptive
devices.
Other – Any other activities used to improve or maintain
the resident’s self-performance in functioning. This
includes, but is not limited to, teaching self-care for
diabetic management, self-administration of medications
and ostomy care.
Process
Review the resident’s record and the current care plan.
Consult with staff. Look for rehabilitation and restorative
care activities in the resident’s record sheet.
Coding
For the last 7 days, enter the number of days on which
the technique, procedure, or activity was practiced for a
total of at least 15 minutes during the 24-hour period.
The 15 minutes does not have to occur all at once.
Remember that persons with dementia learn skills best
Full Assessment Form: Section P
through repetition that occurs multiple times per day.
Review for each activity throughout the 24-hour period.
Enter zero “0” if none.
Examples of rehabilitation/restoration
Mr. V has lost range of motion (ROM) in his right arm,
wrist and hand due to a stroke experienced several years
ago. He has moderate to severe loss of cognitive
decision-making skills and memory. To avoid further
ROM loss and contractures to his right arm, the
occupational therapist fabricated a right resting
handsplint and instructions for its application and
removal. Nursing staff developed instructions for
providing passive range of motion exercises to his right
arm, wrist and hand 3 times per day. The carer and Mr.
V’s wife have been instructed on how and when to apply
and remove the handsplint and how to do the passive
ROM exercises. These plans are documented on Mr. V’s
care plan. The total amount of time involved each day in
removing and applying the handsplint and completing
the ROM exercises is 30 minutes. The home staff report
that there is less resistance in Mr. V’s affected extremity
when bathing and dressing him. For both Splint or Brace
assistance and Range of Motion (passive), enter “7” as
the number of days these nursing rehabilitative
techniques were provided.
Mrs. K was admitted to the home 7 days ago following
repair to a fractured hip. Physiotherapy was delayed due
to complications and a weakened condition. Upon
admission, she had difficulty moving herself in bed and
required total assistance for transfers. To prevent further
deterioration and increase her independence, the home
staff implemented a plan on the second day following
admission to teach her how to move herself in bed and
transfer from bed to chair using a zimmer frame, the
bedrails, and a transfer board. The plan was documented
in Mrs. K’s record and communicated to all staff at the
change of shift. It was documented in the care plan that
in the five days Mrs. K has been receiving training and
skill practice for bed mobility and transferring, her
endurance and strength are improving, and she requires
only extensive assistance for transferring. Each day the
amount of time to provide this rehabilitation intervention
has been decreasing so that for the past five days, the
average time is 45 minutes. Enter “5” as the number of
days training and skill practice for bed mobility and
transfer was provided.
 Chapter 3: The Item-by-Item Guide to the MDS
Mrs. J had a stroke less than a year ago resulting in left-
sided hemiplegia. Mrs. J has a strong desire to participate
in her own care. Although she cannot dress herself
independently, she is capable of participating in this
activity of daily living. Mrs. J’s overall care plan goal is to
maximise her independence in ADLs. A plan,
documented on the care plan, has been developed to
teach Mrs. J how to put on and take off her blouse with
no physical assistance from the staff. All of her blouses
have been adapted for front closure with velcro. The care
assistants have been instructed in how to verbally guide
Mrs. J as she puts on and takes off her blouse. It takes
approximately 20 minutes per day for Mrs. J to complete
this task (dressing and undressing). Enter “7” as the
number of days training and skill practice for dressing
and grooming was provided.
Using a stick and a short leg brace, Mrs. D is receiving
training and skill practice in walking. Together, Mrs. D
and the nursing staff have set progressive walking
distance goals. The nursing staff have received instruction
on how to provide Mrs. D with the instruction and
guidance she needs to achieve the goals. She has three
scheduled times each day where she learns how to apply
her short leg brace followed by walking. Each teaching
and practice episode for brace application and walking,
supervised by home staff, takes approximately 15
minutes. Enter “7” as the number of days for splint and
brace assistance and training and skill practice in walking
were provided.
Mr. W’s cognitive status has been deteriorating
progressively over the past several months. Despite
deliberate attempts to promote his independence in
feeding himself, he will not eat unless he is fed. Because
Mr. W did not receive nursing rehabilitation/restoration
for eating in the last 7 days, enter “0” as the number of
days training and skill practice for eating was provided.
4. Devices and restraints
Purpose
To record the frequency, over the last 7 days, with which
the resident was restrained by any of the devices listed
below at any time during the day or night.
Definition
This category includes restraint by any device (e.g.
physical or mechanical device, material, or equipment
attached or adjacent to the resident’s body) that the
resident cannot easily remove and that restricts freedom
Full Assessment Form: Section P
of movement or normal access to his or her body.
Full bed rails – Full rails may be one or more rails along
both sides of the resident’s bed that block three-quarters
to the whole length of the mattress from top to bottom.
This definition also includes beds with one side placed
against the wall (prohibiting the resident from entering
and exiting on that side) and the other side blocked by a
full rail (one or more rails).
Other types of bed rails used – (e.g. one-side half rail,
one-side full rail, two-sided half rails).
Trunk restraint – Includes any device or equipment or
material that the resident cannot easily remove.
Limb restraint – Includes any device or equipment or
material that the resident cannot easily remove, that
restricts movement of any part of an upper extremity (i.e.
hand, arm) or lower extremity (i.e. foot, leg).
Chair prevents rising – Any type of chair with locked lap
board or chair that places resident in a recumbent
position that restricts rising or a chair that is soft and low
to the floor (e.g. bean bag chair). Includes “comfort
cushions”.
Process
Check the resident’s records. Consult home staff.
Observe the resident.
Coding
For each restraint type, enter:
0. Not used in last 7 days
1. Used, but used less than daily in last 7 days
2. Used on a daily basis in last 7 days
5. Hospital stay(s)
Purpose
To record how many times the resident was admitted to
the hospital with an overnight stay in the last 3 months
or since the last assessment if less than 3 months.
Definition
The resident was formally admitted as an in-patient with
the expectation that he or she will stay overnight. It does
not include day surgery, out-patient clinic, etc.
Process
Review the resident’s record. If the resident is a new
admission, ask the resident and resident’s family.
Coding
Enter the number of hospital admissions in the box.
 Chapter 3: The Item-by-Item Guide to the MDS
Enter “0” if no hospital admissions.
6. Accident & emergency department visits
Purpose
To record if during the last 3 months the resident visited a
hospital A&E department (e.g. for treatment or
evaluation) but was not admitted to the hospital for an
overnight stay at that time.
Definition
Accident & emergency department visit – A visit to
hospital not accompanied by an overnight hospital stay.
Exclude prior scheduled visits for outpatients,
transfusions, chemotherapy, etc
Process
Review the resident’s record. For new admissions, ask the
resident and the resident’s family and, if available, review
the transfer record.
Coding
Enter the number of A&E visits in the last 3 months (or
since last assessment if less than 3 months). Enter “0” if
no A&E visits.
Examples
One evening, Mr. X complained of chest pain and
shortness of breath. He was transferred to the local
hospital A&E department. By the time he was stabilised,
it was late in the evening and he was admitted to hospital
for observation. He was transferred back to the home the
next afternoon. Code “0” for No A&E visits. The
rationale for this coding is that although Mr. X was
transferred to the A&E department, he was admitted to
the hospital overnight. An overnight stay is not part of
the definition of this item.
During the night shift, Mrs. F slipped and fell on her way
to the bathroom. She complained of pain in her right hip
and was transferred to the local hospital for x-rays. The
x-rays were negative for a fracture and Mrs. F was
transferred back to the home within several hours. Code
“1” for 1 A&E visit.
7. Doctor visits
Purpose
To record the number of days during the last 14-day
period a physician has examined the resident (or since
admission if less than 14 days ago). Examination can
occur in the home or in the doctor’s surgery. In some
cases the frequency of doctor’s visits is indicative of
Full Assessment Form: Section P
clinical complexity.
Definition
Doctor – Includes GP or consultant
Doctor examination – May be a partial or full exam at the
home or in the doctor’s surgery. This does not include
exams conducted in an A&E. If the resident was
examined by a doctor during an unscheduled A&E visit,
record the number of times this happened in the last 3
months in Item P6, A&E visits.
Coding
Enter the number of days the doctor examined the
resident. If none, enter “0”.
8. Doctor prescriptions/instructions
Purpose
To record the number of days during the last 14-day
period (or since admission, if less than 14 days ago) in
which a doctor has changed the resident’s treatment. In
some cases the frequency of treatment changes is
indicative of clinical complexity.
Definition
Doctor – Includes GP or Consultant.
Doctor prescription/instruction – Includes written or
consultation changes for new or altered treatment. Does
NOT include request for admission to hospital.
Coding
Enter the number of days on which doctor’s treatment
plans were changed. Do not include prescription
renewals without change. If no prescription/instruction
changes, enter “0”.
9. Abnormal blood tests or other laboratory
investigations
Purpose
To document whether the resident had any abnormal
laboratory values during the last 3 months. This item
refers only to laboratory tests performed after admission
to the home. “Abnormal” refers to laboratory values that
are abnormal when compared to standard values, not
abnormal for the particular resident.
Example
An elevated prothrombin time in a resident receiving
anticoagulant therapy is coded “1” for Yes (Abnormal)
even though this may be the desired effect.
 Chapter 3: The Item-by-Item Guide to the MDS Full Assessment Form: Section P

Process
Check records, discuss with GP.

Coding
Enter “0” if no abnormal value was noted in the record,
and “1” if the resident has had at least one abnormal
laboratory value.
 Section P. Special Treatments and Procedures

1 Special treatments A. Special care Tick treatments or programmes received during last 14 days

procedures and pro- Treatments

grammes ■ a Chemotherapy
■ b. Dialysis
■ c. IV medication
■ d. Intake/output monitoring
■ e. Monitoring acute medical condition
■ f. Ostomy care
Refer to appropriate professional

■ g. Oxygen therapy
■ h. Radiation
eg GP/District Nurse

■ i. Suctioning
■ j. Tracheostomy care
■ k. Transfusions
■ l. Ventilator

Programmes
■ m. Alcohol/drug treatment programme
■ n. Alzheimer’s/dementia special care unit
■ o. Hospice care
■ p. Respite care
■ q. Training in skills required to return to the community ( eg. taking medications, house-
work, shopping, transportation, ADLs)
■ r. NONE OF ABOVE

B. Therapies Record the number of days and total minutes each of the following
therapies was administered (for at least 15 minutes a day) in the last week (Enter “0” if
none or less than 15 min. daily) Note - count only post admission therapies.

A = number of days administered for 15 minutes or more

B = total number of minutes provided in last 7 days

Days Min
A B

a. Speech therapy and audiology services

b. Occupational therapy

c. Physiotherapy

d. Respiratory therapy

e. Psychological therapy (by a mental health team

professional)
 Section P. Special Treatments and Procedures Continued

2 Intervention Tick all interventions or strategies used in last 7 days - no matter where received

programmes for ■ a Special behaviour symptom evaluation programme

mood, behaviour, ■ b. Evaluation by a registered mental health specialist in last 3 months

■ c. Group therapy
cognitive loss ■ d. Resident-specific deliberate changes in the environment to address mood/
behaviour patterns - eg. providing cupboard in which to rummage, sensory room
■ e. Reorientation - eg. cueing
■ f. NONE OF ABOVE

3 Nursing Record the number of days each of the following rehabilitation or restorative techniques or
practices was provided to the resident for more than or equal to 15 minutes per day in the
rehabilitation/
last 7 days (Enter 0 if none or less than 15 min. daily)
restorative care
a. Range of motion (passive)

b. Range of motion (active)

c. Splint or brace assistance

Training and skill practice in:

d. Bed mobility

e. Transfer

f. Walking

g. Dressing or grooming

h. Eating or swallowing

i. Amputation/prosthesis care

j. Communication

k. Other

4 Devices and Use the following codes for last 7 days

11,18 11,16,18
restraints 0. Not used 1. Used less than daily 2. Used daily

a. Full bed rails on all open sides of bed

b. Other types of bed rails used (eg. half rail, one side)

11,16,18
c. Trunk restraint eg. wheelchair safety strap

18
d. Limb restraint

18
e. Chair prevents rising
 Section P. Special Treatments and Procedures Continued

5 Hospital stay(s) Record number of times resident was admitted to hospital with an overnight stay in last 3
months (or since last assessment if less than 3 months)
Enter 0 if no hospital admissions

6 A&E visits Record number of times resident visited A&E without an overnight stay in last 3 months (or
since last assessment if less than 3 months)
Enter 0 if no A&E visits

7 Doctor visits In the last 14 days (or since admission if less than 14 days in home) how many days has the
doctor examined the resident?
Enter 0 if none

8 Doctor In the last 14 days (or since admission if less than 14 days in home) for how many days has
the doctor changed the resident’s treatment?
prescriptions/
Enter 0 if none
instructions

9 Abnormal blood Has the resident had any abnormal lab values during the last 3 months (or since admission)?

tests or other 0. No

laboratory
1. Yes
investigations

Section P: Special Treatments and Procedures

Triggers for Resident Assessment Protocols

Question MDS Item Code RAPs

Number
11
P4c Trunk restraint 1, 2 Falls
18
Physical Restraints

16
P4c Trunk restraint 2 Pressure Sores

18
P4d Limb restraint 1, 2 Physical Restraints

18
P4e Chair prevents rising 1, 2 Physical Restraints
 Chapter 3: The Item-by-Item Guide to the MDS Full Assessment Form: Section Q

Section Q: Discharge Potential and Overall Status

1. Discharge potential
Purpose
To identify residents who are potential candidates for
discharge within the next 3 months. Some residents will
meet the “potential discharge” profile at admission;
others will move into this status as they continue to
improve during the first few months of residency.
Definition
Discharge – Can be to their own home, another
community setting, another care home, or a residential
setting. A prognosis of death should not be considered as
an expected discharge.
into the new lifestyle at the home. Creating unrealistic
expectations for a resident can be cruel. Use careful
judgement. Listen to what the resident brings up (e.g.
Calls out, “I want to go home”). Ask indirect questions
that will give you a better feel for the resident’s
preferences. For example, say, “It’s been about one year
that we’ve known each other. How are things going for
you here at (this home)”.
Consult with primary care and social services staff, the
resident’s family and significant others. Review resident
records. Discharge plans are often recorded in social
services or nursing notes.

Support person – Can be a spouse, family member or Coding

significant other.
Process
For new and recent admissions, ask the resident directly.
The longer the resident lives at the home, the tougher it
is to ask about preferences to return to the community.
After one year of residency, many persons feel settled
a. Resident expresses/indicates preference to return to the
community. Enter “0” for No or “1” for Yes.
b. Resident has a support person who is positive towards
discharge. Enter “0” for No or “1” for Yes.
c. Stay projected to be of a short duration – Discharge
projected within 3 months (do not include expected

Examples
Mrs. F is a 65 year old married woman who had a stroke 2 months ago. She was admitted to the home one week ago
from a rehabilitation centre for further rehab, particularly for transfer, balance and wheelchair mobility. Mrs. F is
extremely motivated to return home. Her husband is supportive and has been busy making their home “user friendly”
to promote her independence. Their goal is to be ready for discharge within 2 months.

Discharge potential Coding

a. Resident expresses/indicates preference to return to the community. 1 (Yes)
b. Resident has a support person who is positive towards discharge. 1 (Yes)
c. Stay projected to be of a short duration – discharge projected within 3 months 2 (Within 1 to 3 months)
(do not include expected discharge due to death).

Mrs. D is a 67 year old widow with end-stage metastatic cancer to bone with pathological fractures. Currently her
major problems are pain control and confusion secondary to narcotics. Mrs. D periodically calls out for someone to
take her home to her own bed. Her daughter is unwilling and unable to manage her hospice care at home. Because of
the fractures, Mrs. D is totally dependent in all ADLs except eating (she can hold a straw).

Discharge potential Coding

a. Resident expresses/indicates preference to return to the community 1 (Yes)
b. Resident has a support person who is positive towards discharge 0 (No)
c. Stay projected to be of short duration – discharge projected within 3 months 0 (No)
(do not include expected discharge due to death).
Rationale for coding: Although Mrs. D is near death, you should apply a code of “0” (No). Rationale: This MDS
item instructs you “do not include expected discharge due to death”.
 Chapter 3: The Item-by-Item Guide to the MDS Full Assessment Form: Section Q

Mr. S is a 70 year old married gentleman who was admitted to the home 2 weeks ago from the hospital following
surgical repair of a left hip fracture. Mr. S has a long history of alcoholism and cirrhosis of the liver. His daughter
reports that when he is drinking he is abusive towards his wife of 40 years. Though he has a strong wish to return
home, his wife states she can’t take it anymore and doesn’t want him to return home. He has basically worn out all his
family options. Other social support options are being explored. At this time plans for discharge remain uncertain.

Discharge potential Coding

a. Resident expresses/indicates preference to return to the community. 1 (Yes)
b. Resident has a support person who is positive towards discharge. 0 (No)
c. Stay projected to be of a short duration – discharge projected within 3 months 3 (Uncertain)
(do not include expected discharge due to death).

discharge due to death). Enter “0” for No, “1” for within
1 months, “2” for within 1 to 3 months or “3” for
discharge status uncertain.
2. Overall change in care needs
Purpose
To monitor the resident’s overall progress at the home
over time. Document changes as compared to his or her
status of 3 months ago. If the resident is a new admission
to the home, this item should consider changes during
the period prior to admission.
Definition
Overall self sufficiency – Includes self care performance
and support, continence patterns, involvement patterns,
use of treatments, etc.
Process
Review resident’s record, admission records (if new
admission or readmission), previous MDS assessments
and care plan. Discuss with caregivers.
Coding
Record the number corresponding to the most correct
response. Enter “0” for No change, “1” for Improved
(receives fewer supports, needs less restrictive level of
care), or “2” for Deteriorated (receives more support).
Examples
Mr. R is a 90 year old comatose gentleman admitted to
the home from a 6 months stay at another nursing home
to be closer to his wife’s residence. His condition has
remained unchanged for approximately 6 months. Code
“0” for No change.
Mrs. T has suffered from Alzheimer’s disease for several
years. In the past 4 months her overall condition has
generally improved. Although her cognitive function has
remained unchanged, her mood is improved. She seems
happier, less agitated, sleeps more soundly at night, and
is more socially involved in daily activity programmes.
Code “1” for Improved.
Mr. D has also suffered from Alzheimer’s disease for sev-
eral years. Although for the past year he was quite
dependent on others in most areas, he was able to eat
and walk with supervision until recently. In the past 3
months he has become more dependent. He no longer
feeds himself. Additionally, he fell 2 weeks ago and has
been unable to learn how to use a zimmer frame. He
requires 2 person assistance for walking even short
distances. Code “2” for Deteriorated.
 Section Q. Discharge Potential and Overall Status

1 Discharge a. Resident expresses/indicates preference to return home

potential 0. No
1. Yes

b. Resident has a support person who is positive towards discharge

0. No
1. Yes

c. Stay projected to be of a short duration - discharge projected within

3 months (do not include expected discharge due to death)

0. No
1. Within 1 month
2. Within 1-3 months
3. Discharge status uncertain - not planned

2 Overall change in Resident’s overall self sufficiency has changed significantly as compared to status of
3 months ago (or since last assessment if less than 3 months)
care needs
0. No change
1. Improved - receives fewer supports, needs less restrictive level of care
2. Deteriorated - receives more support
 Chapter 3: The Item-by-Item Guide to the MDS
Section R: Assessment Information
1. Participation in assessment
Purpose
To record the participation of the resident, family and/or
significant others in the assessment, and to indicate
reason if the resident’s assessment is incomplete.
Definition
Family – A spousal, kin (e.g. sibling, child, nephew), or
in-law relationship.
Significant other – May include close friend, partner, legal
guardian or lawyer. Significant other does not, however,
include staff at the home.
Process
Preparing residents and family members to participate in
the care-planning process begins with assessment. When
staff members explain the assessment process to a
resident, they should also explain that the outcome of
assessment is care delivery guided by a care plan. Every
assessment team member can establish an expectation of
resident participation by asking for and respecting the
resident’s perspective during assessment.
Asking family members about their expectations of the
home and their concerns during the assessment process
can prove beneficial. Relatives may need to talk to a staff
member or they may need information. Some family
concerns and expectations may be appropriately
addressed at a care-planning conference. Discussing
these matters with the family during the assessment
process can assist in maintaining a focus on the resident
during a care-planning conference.
Staff should consider some organisational aspects of
resident and/or family participation in assessment and
care planning. Attention to seating arrangements that will
facilitate communication is necessary for several reasons:
■ To keep the resident from feeling intimidated and/or
powerless in front of professionals.
■ To accommodate any communication impairments.
■ To minimise any tendencies for family members to
dominate the resident in the conference yet encourage
them to support the resident if that is needed.
■ To facilitate non-verbal support of the resident by staff
with whom the resident is close.
Verbal communication should be directed to the resident,
even when the resident is cognitively impaired. The terms
used should be tailored to facilitate understanding by the
Full Assessment Form: Section R
resident. The resident’s opinions, questions, and
responses to the developing care plan should be solicited
if they are not forthcoming.
Coding
a) Resident – Enter zero ”0” for No or “1” for Yes to
indicate whether the resident participated in the
assessment. This item should be completed last.
b) Family – Enter zero “0” for No or “1” for Yes to
indicate whether the family participated; enter “2” for No
family.
c) Significant other – Enter “0” for No or “1” for Yes to
indicate whether a significant other participated; enter
“2” for None if there is no significant other.
2. Signatures of person(s) completing the assessment
Purpose
Accurate recording of resident information should be
adhered to through the use of local and professional
guidance.
Process
Each staff member who completes any portion of the
MDS must sign and date the MDS and indicate beside
their signature which portions they completed. Two or
more staff members can complete items within the same
section of the MDS.
a. Signature of assessment coordinator
Coding
The person who acted as the assessment coordinator for
sections A to R of the MDS should enter his or her
signature on the day the MDS assessment form was
completed.
b. Date assessment coordinator signed as
complete
Coding
Enter date the form was signed.
c. Other signatures
Coding
All persons completing part of this assessment, must sign
their names in the appropriate locations. To the right of
the name, enter title and the letters that correspond to
sections of the MDS for which the assessor was
responsible, and also enter the date on which the form is
signed.
 Section R. Assessment Information

1 Participation in a. Resident

assessment 0. No
1. Yes

b. Family

0. No
1. Yes

2. No family

c. Significant other

0. No
1. Yes
2. None
If yes, specify relationship eg. friend

2 Signatures of a. Signature of Assessment Coordinator

person(s)
completing the b. Date Assessment Coordinator signed as complete
assessment
Day Month Year

c. Other signatures Title Sections Date

 Chapter 3: The Item-by-Item Guide to the MDS Discharge Tracking Form: Sections AA, AB, R

This form includes Section AA (Identification Purpose

Information) Items 1-10, but only the 3 discharge codes
from item 7, Reason for assessment. It also contains
Section AB 1-2 and Section R 3-4. This form must be
completed whenever a resident is discharged from the
home for reasons other than a temporary visit to their
own home.
Section AA: Identification Information
To document the reason for completing the discharge
tracking form.
Definitions
Discharged – return not anticipated – Use this code when
a resident is permanently discharged from the home.
Discharged – return anticipated – Use this code when a
resident is temporarily discharged to a hospital.

The purpose of this section is to provide key information Discharged prior to completing intial assessment – Use
necessary to identify and track residents in homes. this code when a resident is discharged during their first
14 days AND the MDS assessment remains incomplete.
1. Resident name
Coding
Definition
Choose the number that applies to the appropriate
Legal name in record
category.
Coding
8. Name of home
Use printed letters. If the resident goes by his or her
middle name, enter the full middle name. If the resident Coding
has no middle initial, leave item (b) blank. Enter the name of the home.

2. Gender 9. Home identifier

Coding Coding
Enter “1” for Male or “2” for Female. Enter the appropriate home number.

3. Date of birth 10. Signatures of persons completing form

Coding Coding
For example: 2 January, 1925 should be entered as: Staff who completed parts of Section AA: Identification
information must enter their signatures, titles, and date
they completed the section.
0 2 0 1 1 9 2 5
1. Date of entry
Day
4. Race/ethnicity Month Year
Purpose
Process This should only be completed for individuals who
Enter the race or ethnic category the resident uses to
Section AB: Demographic Information
identify him or herself. Consult the resident, as necessary.
stayed for less than 14 days and for whom the full MDS
Coding
assessment was not completed. The purpose is to identify
Choose only one answer.
the date of admission. Given this definition, enter the
5. National Health Service number date the person first became a resident in your home.
Coding Definition
Enter the resident’s National Health Service number. Date the stay began – The date the resident was most
6. National Insurance number recently admitted to your home. For example: if the
resident was officially discharged in the past without the
Coding
expectation of return (e.g. discharged home or to another
Enter the resident’s National Insurance number.
care home), enter the most recent admission date.

Process
7. Reason for completing form
Review the records.
 Chapter 3: The Item-by-Item Guide to the MDS Discharge Tracking Form: Sections AA, AB, R

Coding Review resident’s records. Consult the resident and the

Use all boxes. For a one-digit month or day, place a zero resident’s family.
in the first box. For example: 3 February, 1999, should
Coding
be entered as:
Choose only one answer.

Example
Mr. F, who had been living in his own home with his
wife, was admitted to hospital with a stroke. From the
Example hospital, Mr. F was transferred to this nursing home for
Mrs. Z, was admitted to the home on 10/12/98 suffering rehabilitation. Because Mr. F was admitted to your home
from confusion and 0breathing difficulties. Evaluation by a from the acute care hospital, “7” is the appropriate code.
0 3 2 1 9 9 9
general practitioner indicated that Mrs. Z. was suffering 3. Discharge status
Day Month Year
from a chest infection and arranged for her admission to
Coding
hospital on 13/12/98 from whence it was expected she
would return to her own home. No full MDS assessment Enter the number which best describes the resident’s
could be made. discharge location.

4. Discharge date

Section R: Assessment/Discharge Information

2. Admitted from (at entry) Coding
Purpose Enter the date of discharge or death eg Resident
To record discharged on 16.11.98.
1 0place from
1 which
2 the resident
1 9 9 had
8 been
admitted when discharged in less than 14 days.
Day Month Year
Definition
Private home or flat – Any house, or flat in the
community whether owned by the resident or another
person. Also included in this category are retirement
communities, and independent housing for the elderly.
Sheltered housing – Warden controlled home. 1 6 1 1 1 9 9 8

Other – e.g. hospice Day Month Year

Process
 UK Minimum Data Set (MDS)
For Home Resident Assessment and Care Screening
Discharge Tracking Form (Do not use for temporary visits home)

Section AA. Identification Information

1 Resident name a. (First name)

b. (Middle initial)

c. (Last name)

d. (Title)

2 Gender 1. Male

2. Female

3 Date of birth
Day Month Year

4 Race 1. European-Caucasian 7. Chinese

2. African-Caribbean 8. Other Asian
3. African
9. Other ethnic minority
4. Pakistani
5. Bangladeshi (specify)
6. Indian 10. Not known

5 N.H.S. number

6 N.I. number

7 Reason for (Note - Other codes do not apply to this form)

completing form Primary reason for assessment:

6. Discharged - return not anticipated
7. Discharged - return anticipated
8. Discharged prior to completing initial assessment

8 Name of home

9 Home identifier

10 Signatures Signatures Title Date

of persons
completing form
 Section AB. Demographic Information
(complete only for stays less than 14 days) (AA7 = code 8)

1 Date of entry Date the stay began. Note - Does not include readmission if record was closed at time of
temporary discharge to hospital, etc. In such cases, use prior admission date.

Day Month Year

2 Admitted from 1. Private home/flat with no health/personal social services

2. Private home/flat with health/personal social services
(at entry)
3. Sheltered housing
4. Board and care/assisted living/group home
5. Residential home
6. Nursing home
7. Acute care hospital
8. Psychiatric hospital
9. Rehabilitation hospital
10. Other

Section R Assessment/Discharge Information

3 Discharge status Code for resident location upon discharge
1. Private home/flat with no health/personal social services
2. Private home/flat with health/personal social services
3. Sheltered housing
4. Board and care/assisted living/group home
5. Residential home
6. Nursing home
7. Acute care hospital
8. Psychiatric hospital
9. Rehabilitation hospital
10. Deceased
11. Other

4 Discharge date Date of death or discharge

Day Month Year

 Chapter 3: The Item-by-Item Guide to the MDS Re-entry Tracking Form: Section AA, A

This form includes Section AA Items 1 - 10 but only one Definitions

code designating re-entry from Item 7, Reason for Re-entry – Use this code when a resident is readmitted
completing form. It also contains Items A4a and b. This from a temporary discharge to a hospital.
form is completed whenever a resident re-enters the home
Coding
following temporary admission to hospital or other health
Choose the number that applies to the appropriate
care setting.
category.
Section AA: Identification Information 8. Name of home

The purpose of this section is to provide key information Coding

necessary to identify and track residents in homes. Enter the name of the home.

1. Resident name 9. Home identifier

Definition Coding
Legal name in record Enter the appropriate home number.

Coding 10. Signatures of persons completing forms

Use printed letters. If the resident goes by his or her Coding
middle name, enter the full middle name. If the resident Staff who completed parts of Section AA: Identification
has no middle initial, leave item (b) blank. information must enter their signatures, titles, and date
they completed the section.
2. Gender
Coding 4a. Date of re-entry
Enter “1” for Male or “2” for Female.
Section A: Identification and Background Information
3. Date of birth
Purpose
Coding
To track the date of the resident’s readmission to the
For example: 2 January, 1925 should be entered as:
home following a temporary discharge to a hospital.
0 2 0 1 1 9 2 5
Definition
Date Month Year The date the resident was most recently readmitted to
4. Race/ethnicity your home after being temporarily discharged for
hospital stay in last 3 months (or since last assessment if
Process
less than 3 months).
Enter the race or ethnic category the resident uses to
identify him or herself. Consult the resident, as necessary. Process
Review the records.
Coding
Choose only one answer. Coding
5. National Health Service number If the resident has not been hospitalised in the last 3
months, leave blank. Otherwise, use all boxes. For a one-
Coding
digit month or day, place a zero in the first box. For
Enter the resident’s National Health Service number.
example: February 3, 1998, should be entered as:
6. National Insurance number
Coding
Enter the resident’s National Insurance number
0 3 0 2 1 9 9 8
7. Reason for completing form
Date Month Year
Purpose
To document the reason for completing the re-entry
tracking form. 4b. Admitted from (at re-entry)
 Chapter 3: The Item-by-Item Guide to the MDS Re-entry Tracking Form: Section AA, A

Purpose Sheltered housing – Warden controlled home.

To record place from which the resident has been
Other – e.g. hospice
admitted.
Process
Definition
Review resident’s records. Consult the resident and the
Private home or flat – Any house, or flat in the
resident’s family.
community whether owned by the resident or another
person. Also included in this category are retirement Coding
communities, and independent housing for the elderly. Choose only one answer.
 UK Minimum Data Set (MDS)
For Home Resident Assessment and Care Screening
Re-entry Tracking Form

Section AA. Identification Information

1 Resident name a. (First name)

b. (Middle initial)

c. (Last name)

d. (Title)

2 Gender 1. Male

2. Female

3 Date of birth
Day Month Year

4 Race 1. European-Caucasian 7. Chinese

2. African-Caribbean 8. Other Asian
3. African
9. Other ethnic minority
4. Pakistani
5. Bangladeshi (specify)
6. Indian 10. Not known

5 N.H.S. number

6 N.I. number

7 Reason for (Note - Other codes do not apply to this form)

completing form Primary reason for assessment:

9. Re-entry

8 Name of home

9 Home identifier

10 Signatures Signatures Title Date

of persons
completing form
 Section A. Identification and Background Information

4a Date of re-entry Date of re-entry

Day Month Year

4b Admitted from 1. Private home/flat with no health/personal social services

2. Private home/flat with health/personal social services
(at re-entry)
3. Sheltered housing
4. Board and care/assisted living/group home
5. Residential home
6. Nursing home
7. Acute care hospital
8. Psychiatric hospital
9. Rehabilitation hospital
10. Other
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
The care process in a home is central to successful
resident care outcomes. It is guided by both professional
standards of practice and regulatory requirements.
Assessment and care planning shape the care process in
the home. The Resident Assessment Instrument (RAI) is
an integral part of this care process which ensures that
staff collect minimum, necessary, standardised
assessment information for each resident at regular
intervals. This allows an individual care plan to be
developed based on the identified needs, strengths and
preferences of the resident. Documentation of this
process is necessary to ensure consistency and continuity
of care.
This chapter gives instructions on using the Resident
Assessment Protocols (RAPs). These are identified by the
Minimum Data Set (MDS) assessment triggering
mechanism. The goal of the RAPs is to guide the
interdisciplinary team through a structured
comprehensive assessment of a resident’s needs and
strengths. Going through the full assessment process will
help staff set resident-specific objectives in order to meet
the physical, mental and psychosocial needs of residents
through a structured care planning process.
WHAT ARE THE RESIDENT ASSESSMENT
PROTOCOLS (RAPS)?
The MDS alone does not provide a comprehensive
assessment of the resident. Rather, the MDS is used for
systematic screening to identify potential resident
problems, strengths and preferences. The RAPs are
problem-oriented frameworks for additional assessment.
They form a critical link to decisions about care planning.
The RAP guidelines provide guidance on how to use the
assessment information so as to help staff evaluate
“triggered” conditions.
It is helpful to think of the RAI as a package. The MDS
identifies actual or potential problem areas. The RAPs
provide further assessment of the “triggered” areas; they
help to look for causes or complicating factors which may
be reversed. Use the RAPs to analyse assessment findings
and then “chart your thinking”. It is important to
document the causes or unique risk factors for decline or
lack of improvement. The plan of care then addresses
these factors with the goal of promoting the resident’s
highest practicable level of functioning.
RAPs function as decision facilitators, which means they
lead to a more thorough understanding of possible
problems by providing understanding and structure to the
assessment process. The RAPs will give the
interdisciplinary team a sound basis for the development
of the resident’s care plan. After the comprehensive
assessment process is completed, the interdisciplinary
team will be able to decide if:
■ The resident has a condition that warrants
intervention, and addressing this problem is necessary
for other functional problems to be successfully
addressed;
■ Improvement of the resident’s functioning in one or
more areas is possible;
■ Improvement is not likely, but the present level of
functioning should be preserved as long as possible,
with rates of decline minimised over time;
■ The resident is at risk of decline and efforts should
emphasise slowing or minimising decline, and
avoiding functional complications (e.g. contractures,
pain); or
■ The central issues of care revolve around symptom
relief and other palliative measures during the last
months of life.
It is important that the appropriate and relevant
professionals are involved in reviewing the RAPs. These
could include the specialist nurse, general practitioner,
social worker, chiropodist or therapists.
HOW ARE THE RAPS ORGANISED?
There are 18 RAPs in the Resident Assessment
Instrument which cover the majority of areas likely to be
addressed in a resident’s care plan.
Acute confusional state 1
Cognitive loss/dementia 2
Visual function 3
Communication 4
ADL function/rehabilitation potential 5
Urinary incontinence and indwelling catheter 6
Psychosocial well-being 7
Mood state 8
Behavioural symptoms 9
Activities 10
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
Falls 11
Nutritional status 12
Feeding tubes 13
Dehydration/fluid maintenance 14
Dental care 15
Pressure sores 16
Psychotropic drug use 17
Physical restraints 18
There are four parts to each RAP:
The problem
This gives general information about how a condition
affects the person. The problem statement often describes
the focus or objectives of the protocol. It is important
when reviewing a “triggered” RAP not to overlook
information in the problem section, as this provides
relevant background information.
The triggers
These identify one or a combination of MDS item
responses that alert the assessor to the resident’s possible
problems, needs or strengths. The specific MDS response
indicates that factors are present that may or may not
represent a condition that should be addressed in the
care plan. Triggers merely “flag” conditions that should
be considered by the interdisciplinary team members in
making care planning decisions.
When the resident’s status on a particular MDS item(s)
matches one of the “triggers” for a RAP, the RAP is
“triggered” and a review (with the possibility of
additional information gathering and assessment) is
required using the RAP Guidelines. Triggers are shown
on the MDS assessment form as a hand followed by the
number of the RAP triggered e.g. 4 would refer to
RAP number 4, Communication. They are also shown in
the tables at the end of each section in the item-by-item
guide in Chapter 3, and in the trigger legend at the end
of this chapter.
The guidelines
The guidelines present information for evaluating factors
that may cause, contribute to, or exacerbate the triggered
areas. The guidelines help staff decide if a triggered
condition actually does limit the resident’s functional
status or if the resident is at particular risk of developing
the condition.
If the condition is found to be a problem for the resident,
the guidelines will assist the interdisciplinary team in
determining if the problem can be eliminated or reversed,
or if special care must be taken to maintain a resident at
his or her current level of functioning.
In addition to identifying causes or risk factors that
contribute to the resident’s problem, the guidelines may
assist you to:
■ Find associated causes and effects. Sometimes a
problem condition (e.g. falls) is associated with just
one specific cause (e.g. a new drug that caused
dizziness). More often, a problem (e.g. falls) stems
from a combination of multiple factors (e.g. a new
drug; resident forgot zimmer frame; bed too high,
etc.).
■ Determine if multiple triggered conditions are related
(e.g. Falls & Vision).
■ Suggest a need to get more information about a
resident’s condition from the resident, resident’s
family, responsible party, doctor, care staff, diagnostic
tests, psychiatrist, community care staff etc.
■ Determine if a resident is a good candidate for
rehabilitation.
■ Identify the need for a referral to an expert in an area
of resident need. (e.g. community psychiatric nurse).
■ Begin to formulate care plan goals and approaches.
The RAP overview
This section summarises the information in the guidelines
and should be used for reference.
WHAT DOES THE RAP PROCESS INVOLVE?
There are various models for completing the RAP in-
depth assessment process for a resident with a particular
problem. You may also establish procedures locally
where certain RAPs are always reviewed by a particular
discipline (e.g. the District Nurse, completes the
skincare/footcare section and RAP, if triggered). The
interdisciplinary team may also review RAP guidelines in
a joint manner and have the assessment process flow
seamlessly into care planning. Homes can be creative
and experiment with the way RAPs are used until they
find “what works” most efficiently and effectively for
them in achieving the desired outcome (i.e. a sound and
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
comprehensive assessment that is used to develop an
individualised plan of care for each resident).
The RAP process involves five steps as described below:
1. Staff use the RAI triggering mechanism to determine
which RAP problem areas require review and additional
assessment.
2. Staff use the RAPs to further assess the resident in the
areas that have been triggered to determine the nature of
the problem.
3. Staff document key findings regarding the resident’s status
based on the RAP review.
4. Based on the review of assessment information, the
interdisciplinary team decides whether or not the
triggered condition affects the resident’s functional ability
or well-being and warrants a care plan intervention.
5. The interdisciplinary team, reflecting the wishes of the
resident and resident’s family develop, revise or continue
the care plan based on this comprehensive assessment.
These 5 steps are described in more detail in the following
sections:
Step 1: Identifying need for further resident assessment by
triggering RAP conditions
A RAP may have several MDS assessment areas that are
defined as triggers. Only one of the triggers need be
present for a RAP to be triggered, although for many
RAPs, each of the specific trigger items that are present
must be investigated (e.g. address each of the potential
side effects for the Psychotropic Drug Use RAP).
To identify the triggered RAPs from the MDS schedule:
1. Scan the MDS Assessment form. Note the items coded
against which a is marked and the RAP number.
2. Check the code required to trigger that particular RAP
by looking on the RAP Trigger Legend. How to use this is
described in the box below:
To identify the triggered RAPs using the Trigger Legend
a. Compare the completed MDS with the Trigger Legend
to determine which RAPs are “triggered” for review.
Begin by looking at the KEY in the upper left corner
of the Trigger Legend. Note that there are four
possible ways for a RAP to trigger:
● = the predominant method and requires only one
MDS item to trigger a RAP.
❷ = requires two MDS items to trigger a RAP.
✳ = requires one of three types of psychotropic
medications (antipsychotic, anxiolytic or
antidepressant), and one other item in the
Psychotropic Drug Use column indicated by ●
@ = This is a special ADL trigger that will focus the
RAP review on rehabilitation or on the maintenance
of current function. If there are solid circles in both
ADL columns, the ADL Maintenance column will take
precedence.
b. Examine the two left columns of the Trigger Legend
listing the letter and number codes as well as the name
of the MDS items to be considered. The third column
lists the specific resident codes that will trigger a RAP.
The remaining columns list the individual RAP titles.
To identify a triggered RAP, match the resident’s MDS
assessment item responses with the “Code” column. If
there is a “match”, follow horizontally to the right until
a trigger is indicated by one of the key symbols. If, for
example, there is a solid circle in the column, the RAP
titled at the top of that column is “triggered”. This
means that further assessment using the RAP guideline
is required for that particular condition.
c. Note which RAPs are triggered by particular MDS
assessment items.
d. Continue down the left column of the Trigger Legend
matching recorded MDS item responses with trigger
definitions until all triggered RAPs have been
identified.
e. When the Trigger Legend review is completed,
document on the RAP Summary Form which RAPs
are triggered by ticking the boxes in the column
entitled “tick if triggered”.
3. Document on the RAP Summary Form which RAPs
are triggered by ticking the boxes in the column
entitled ‘tick if triggered’.
Example 1
When Mrs. D. returns to her room after eating breakfast,
she cannot recall eating breakfast, and always asks the
nurse when breakfast will be served. MDS item Short
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
Term Memory, B2a, has been coded 1 (Memory Problem)
RAP triggered
Cognitive loss/Dementia RAP is triggered for further
assessment. 2 good communication to all persons involved in the
Example 2
Mr. P. is receiving an antipsychotic medication two times
per day. He has fallen within the last month. The MDS
item Antipsychotics, O4a, is coded 7 (Received 7 days a
week). The MDS item Falls (in past month), J4a, is ticked.
RAP triggered
The Psychotropic Drug Use RAP 17 is triggered for
further assessment. (Note: Because J4a is ticked, the Falls
RAP will also be triggered.)
Step 2: Assessment of the resident whose
condition triggered RAPs
“Reviewing” a triggered RAP means doing an in-depth
assessment of a particular problem for a resident, in terms
of the potential need for care plan interventions. The RAP
is used to organise or guide the assessment process so
that information needed to fully understand the resident’s
condition is not overlooked.
The triggered RAPs are used to glean information that
pertains to the resident’s condition. While reviewing the
RAP, staff consider what MDS items caused the RAP to
trigger and what type of trigger it is. This focuses the
review on information that will be helpful in deciding if a
care plan intervention is necessary, and what type of
intervention is appropriate.
The information in the RAP is used to supplement
judgment and stimulate creative thinking when attempting
to understand or resolve difficult or confusing symptoms
and their causes. The guidelines are an aide, a tool, and a
starting point. It is the understanding and insight of
members of the interdisciplinary team that will help
integrate these factors into a meaningful resident
assessment and care plan.
Steps 3 and 4: Decision-making and documentation of
the RAP findings
It is recommended that staff who have participated in the
assessment and who have documented information about
the resident for triggered RAPs be a part of the
interdisciplinary team that develops the resident’s care
plan. The team, including the resident, family or resident
representative, makes the final decision to proceed to
address the “triggered” condition on the care plan.
In order to provide continuity of care for the resident and
resident’s care, it is important that information from the
assessment that led the team to their care planning
decision, be clearly documented.
RAP assessment documentation should generally
describe:
■ Nature and impact of the condition (may include
presence or lack of objective information and
subjective complaints).
■ Reasons for proceeding to care plan including risk
factors, potential improvement and minimising decline.
■ Reasons for not proceeding to care plan including
intervention not appropriate or condition not a
problem for resident.
■ Need for referrals to or further evaluation by
appropriate health professionals.
Written documentation of the RAP findings and decision-
making process may appear anywhere in the resident’s
record.
No matter where the information is recorded, use the
“Location and Date of RAP Assessment Documentation”
column in the RAP Summary form to note where the
RAP review and decision making documentation can be
found in the resident’s record. Also indicate in the column
“Care Plan Decision” if the triggered problem is addressed
in the care plan.
Step 5: Development or revision of the care plan
Following the decision to address a “triggered” condition
on the care plan, staff should:
■ Review the current care plan if the problem is already
addressed and make changes, as needed, to reflect the
new assessment; and
■ Develop new care plan problems, goals and
approaches as needed.
Staff may choose to combine related “triggered”
conditions into a single care plan problem that will
address the initial set of causal problems and related
outcomes identified in the RAP review.
Chapter 5 addresses the development of resident care
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
plans in more detail.
DIFFERENT TYPES OF TRIGGERS
Different types of triggers can change the focus of the
RAP review. There are four types of triggers:
1. Potential problems
Those factors that suggest the presence of a problem that
warrants additional assessment and consideration in the
care plan. For example the presence of a pressure sore
which indicates the need for further review to determine
what type of intervention is appropriate.
2. Broad screening triggers
These are factors that assist to identify hard to diagnose
problems. Because some problems are often difficult to
assess in the older person, certain triggers have been
“broadly” defined and consequently may have a fair
number of “false positives” (i.e. the resident may trigger a
RAP which is not automatically representative of a
problem for the resident). Examples include factors
related to acute confusional state or dehydration. At the
same time, experience of the use of the MDS in US
nursing homes has shown that many residents who have
these problems were not identified prior to having
triggered for review. Thus careful consideration of these
triggered conditions is warranted.
3. Prevention of problems
Factors that assist staff to identify residents at risk of
developing particular problems. Examples include risk
factors for falling or developing a pressure sore.
4. Rehabilitation potential
Those factors that are aimed at identifying residents with
rehabilitation potential. Not all triggers identify deficits or
problems. Some triggers indicate areas of resident
strengths. In general, these factors suggest consideration
to improve a resident’s functioning or minimise decline.
For example, MDS item responses indicating “Resident
believes he or she is capable of increased independence
in at least some ADLs” (G8a) may focus the assessment
and care plan on functional areas most important to the
resident or on the area with the highest potential for
improvement.
Staff assessing a resident whose condition “triggers” a
RAP should know what item responses on the MDS
assessment triggered that RAP. This step is often missed,
especially if someone other than the person(s) who
completed the MDS assessment reviews the Trigger
Legend or the triggering is automated by a software
package. Referring to the Triggers section of the RAP to
identify relevant triggers can help to “steer” the
assessment to factors particular to the individual resident.
For example, if a staff member assigned to assess a
resident who has fallen or is at risk for falls, knows that
the Falls RAP was triggered because the resident had
been dizzy during the MDS assessment period (MDS item
Dizziness (J1f) was ticked), the RAP review would include
a focus on causal factors and interventions for dizziness.
While reviewing the RAP, other factors may come to light
regarding the resident’s risk for falls, but knowing the
trigger condition clarifies or possibly rules out certain
avenues of approach to the resident’s problem.
At the same time, there can also be a tendency to believe
that the RAP review is limited to only those MDS
assessment items that triggered the RAP. Such a view is
false and can lead to key causal factors being unnoticed
and a less than appropriate plan of care being initiated.
Many of the trigger conditions serve to initiate a more
comprehensive review process including specific causal
factors that should be considered relative to the resident’s
status.
WHAT TO DO IF A RESIDENT ALWAYS
TRIGGERS THE SAME RAP?
If a resident always triggers the same RAP in the same
way it is not necessary to always review and document
RAP findings on subsequent assessments the way you
would on the initial assessment. Triggers identify areas
warranting further assessment. The RAP guides this
assessment.
Example
Mrs S always triggers for the Nutritional Status RAP
because she often leaves 25% of her food uneaten at
most meals. She is not a big eater and prefers to snack
throughout the day. In this example, further assessment
may reveal a swallowing problem, chewing problem,
acute confusional state, activity endurance problem, or a
healthy life time pattern. If Mrs S chooses to eat frequent
snacks, and still is consuming a nutritionally adequate
diet, then there is no reason to complete the RAP in its
entirety at each full assessment. In this example, clearly
document the initial nutritional assessment including:
preferences, information that confirms her diet is
sufficient, any supporting weights or any lab results that
give insight into nutrition. If she continues to trigger this
RAP for the same reasons, make a one line entry
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)

referring to the original nutritional assessment and status assessment is not necessary if no deficits were
indicate that the resident’s status has not changed. On
noted using the MDS assessment. Using multiple
subsequent assessments, it is always necessary to assess
the resident to validate that his or her status has not assessment tools that basically measure the same thing is
changed as compared to the original RAP assessment
and documentation. often a poor use of resources. All members of the team

WHEN IS THE RESIDENT ASSESSMENT INSTRU- should be trained in assessment and capable of
MENT NOT ENOUGH?
determining what is necessary and appropriate for a
The MDS assessment is a screening instrument and does
not include detailed descriptions of all factors necessary particular resident. Elaborate assessment systems should
for care planning and evaluation. When completing the
not necessarily replace the judgment of the team
MDS assessment, the assessor simply indicates whether
or not a factor is present. For certain situations, if the members.
MDS assessment indicates the presence of a potential
resident problem, need, or strength, the assessor may INTRODUCTION TO THE RAPS
need to investigate and document the resident’s
condition in more detail. For example, if a resident is The remainder of this chapter consists of the 18 RAPs.
noted as having a contracture on the MDS assessment,
additional documentation in the record may include the This is followed by the Trigger Legend and the RAP
number of contractures present, sites, and degree of summary sheet. These RAPs were originally written for
restriction in each affected joint. RAPs also assist in
gathering additional information for some conditions. use in nursing homes in the USA where levels of

In addition, completion of the MDS and RAPs may not qualified nursing staff tend to be higher than in the UK.
be sufficient in itself. Staff have a responsibility to assess
areas that are relevant to individual residents regardless When adapting them for use in the UK we have taken
of whether or not the appropriate areas are included in this into account. However, there remain areas where
the MDS/RAI. For example, the MDS assessment includes
a listing of those diagnoses that affect the resident’s clarification by a qualified nurse or doctor is likely to be
functioning or needs in the past 7 days. While the MDS
important and these have been indicated in the text. The
assessment may indicate the presence of medical
problems, such as unstable diabetes, there should be RAPs cover these problems in some detail and
evidence of additional assessment of these factors if
relevant to the development of the care plan for an unqualified staff may find it most useful to start by
individual resident. However, additional assessment
reading the initial problem section and the overview at
should only be carried out when relevant for an
individual resident. For example, an extensive cognitive the end of each RAP.
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
RAP 1: Acute Confusional State
This protocol should be reviewed with a registered nurse
or the resident’s general practitioner
PROBLEM
Acute confusional state is a common indicator or non-
specific symptom of a variety of acute, treatable illnesses.
It is a serious problem, with high rates of morbidity
(disease) and mortality (death), unless it is recognised
and treated appropriately. Acute confusional state is
never a part of normal ageing and is a treatable
condition. Some of the classic signs of acute confusional
state may be difficult to recognise and may be mistaken
for the natural progression of dementia, particularly in
the late stages of dementia when acute confusional state
has high mortality. Thus careful observation of the
resident and review of potential causes is essential.
Acute confusional state is characterised by fluctuating
states of consciousness, disorientation, decreased
environmental awareness, and behavioural changes. The
onset of acute confusional state may vary, depending on
severity of the cause(s) and the resident’s health status;
however, it usually develops rapidly, over a few days or
even hours. Even with successful treatment of cause(s)
and associated symptoms, it may take several weeks
before cognitive (mental awareness) abilities return to
their previous state.
In residents suffering from dementia acute confusional
state can account for a rapid deterioration in the
resident’s cognitive function. To prevent this it is
important that it is identified and treated in this group of
residents.
Successful management depends on accurate
identification of the clinical condition, correct diagnosis of
specific cause(s) and prompt nursing and medical
intervention. Acute confusional state is often caused and
aggravated by multiple factors. Thus, if one cause is
identified and addressed, but the acute confusional state
continues, other major causes should be reviewed and
treated.
TRIGGERS
Acute confusional state problem suggested if one or more
of following present:
■ Easily distracted✳ [B5a = 2]
■ Periods of altered perception or awareness of
surroundings✳ [B5b = 2]
RAP 1
■ Episodes of disorganised speech✳ [B5c = 2]
■ Periods of restlessness✳ [B5d = 2]
■ Periods of lethargy✳ [B5e = 2]
■ Mental function varies over the course of the day✳
[B5f = 2]
■ Cognitive decline✳ [B6 = 2]
■ Mood decline✳ [E3 = 2]
■ Behaviour decline✳ [E5 = 2]
✳Note: All of these items also trigger the Psychotropic Drug Use RAP
(when psychotropic drug use present).
GUIDELINES
Detecting signs and symptoms of acute confusional state
requires careful observation. Knowledge of a person’s
baseline cognitive abilities helps in evaluation. Staff
should become familiar with resident’s cognitive function
by regularly observing the resident in a variety of
situations so that even subtle but important changes can
be recognised. Family and friends can also help to detect
any changes from the resident’s normal state. When
observed in this manner, the presence of any trigger
signs/symptoms may be seen as a potential indicator of
acute, treatable illness.
Precipitating factors
By correctly identifying the underlying cause(s) of acute
confusional state, you may prevent a cycle of worsening
symptoms arising from an infection-fever-dehydration-
confusion syndrome, or provision of inappropriate
medication. The most common causes of acute
confusional state are associated with circulatory,
respiratory, infectious and metabolic disorders. Other
factors which affect the body’s ability to maintain fluid
balance may also be associated with the development of
acute confusional state. In the elderly the presence of
acute confusional state may be the only outward sign of
an infection. Often the condition may arise from more
than one factor.
Medications
Many medications given alone or in combination can
cause acute confusional state.
■ Ensure correct drugs given as medication error can cause
problem.
■ Review the resident’s medications with the GP.
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
Number of medications
The greater the number, the greater the possibility of
adverse drug reaction/toxicity and interaction.
■ Review medication to determine need and benefit
(ask if resident is receiving more than one type of
drug to treat a condition).
■ Check to determine whether an alternative to drug
therapy has been considered (e.g. a behaviour
management programme rather than antipsychotics to
address the needs of a resident who has physically or
verbally abusive behavioural symptoms).
New medications
■ Review to determine whether there is a relationship
between onset or worsening of acute confusional state
and start of new medication.
There are many drugs that cause acute confusional state
and systematic review with the doctor is critical to the
effective management of acute confusional state.
Psychosocial
After serious illness and drug toxicity are ruled out as
causes of acute confusion, consider the possibility that the
resident could be experiencing psychosocial (emotional)
distress that may produce signs of acute confusional state.
These could include:
Isolation
■ Has the resident been away from people and
situations?
■ Is the resident confused about time, place and
meaning?
■ Has the resident been in bed or in an isolated area
while recuperating from an illness or receiving a
treatment?
Recent loss of family/friend
Loss of someone close can precipitate a grief reaction that
presents as acute confusion, especially if the person
provided safety and structure for a resident with a
diagnosis of dementia.
■ Review the MDS to determine whether the resident has
experienced a recent loss of a close family
member/friend.
Depression/sad or anxious mood
Mood states can lead to confusional states that resolve with
RAP 1
appropriate treatment.
■ Review the MDS to determine whether the resident
exhibits any signs or symptoms of sad or anxious mood
or has a diagnosis of a psychiatric illness.
Restraints
Restraints often aggravate the conditions staff are trying to
treat (e.g. confusion, agitation, wandering). They should
not be used for management of this condition.
Recent relocation
■ Has the resident recently been admitted to a new
environment (new room, unit, home)?
■ Was there an orientation programme that provided a
calm, gentle approach with reminders and structure to
help the new resident settle into the environment?
Sensory losses
Sensory impairments often produce signs of confusion
and disorientation, as well as behaviour changes. This is
especially true of residents with early signs of dementia.
They can also aggravate a confusional state by impairing
the resident’s ability to accurately perceive or cope with
environmental stimuli (e.g. loud noises; onset of
evening). This can lead to the resident experiencing
hallucinations/delusions and misinterpreting noises and
images.
Hearing
■ Is hearing problem related to easily remedied situations
- impacted ear wax or hearing aid dysfunction?
■ Has hearing impairment led to confusion?
■ Has a doctor seen the resident to review any ear
problems?
Vision
■ Has vision loss created confusion?
■ Have major changes occurred in visual function without
the resident being referred to a doctor?
Clarifying information
■ Does the resident have a recent sleep disturbance?
■ Does the resident have Alzheimer’s disease or other
dementia?
■ Has the time of onset of the resident’s cognitive and
behavioural function been within the last few hours to
days?
 Chapter 4: Completing the Resident Assessment Protocols (RAPs) RAP 1

Environment Anxiolytic medications

■ Is the resident’s environment conducive to reducing Hypnotics
symptoms (e.g. quiet, well-lit, calm, familiar objects Analgesics (pain medications)
present)? Cardiac medications
■ Is the resident’s daily routine broken down into smaller Gastro-intestinal medications
tasks (task segmentation) to help him/her cope? Anti-inflammatory medications
OVERVIEW OF ACUTE CONFUSIONAL STATE RAP Anticholinergics
GUIDELINES
Psychosocial
Factors which may be associated with signs & symptoms
of acute confusional state. Sad or anxious mood
Isolation
Precipitating factors
Recent loss
Diabetes
Depression
Hyperthyroidism/hypothyroidism
Restraints
Cardiac dysrhythmias
Congestive heart failure Recent relocation
Stroke/Transient Ischaemic Attacks (TIA)
Sensory impairment
Asthma
Emphysema/Chronic Obstructive Pulmonary Disease Hearing/vision impairment
Anaemia
Clarifying information to be considered in
Cancer
Dehydration or fever establishing a diagnosis
Heart attack Sleep disturbance
Infection Alzheimer’s disease
Head injury Other dementia
Hypothermia
Time of symptom onset (recent onset i.e. within hours to
Hypoglycaemia
days)
Medications
Environment conducive to reducing symptoms
Number of medications
New medications Quiet, well-lit, calm, familiar objects
Antipsychotics Task segmentation
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
RAP 2: Cognitive Loss/Dementia
The resident’s general practitioner or a community
psychiatric nurse should participate in the review of the
protocol if triggered.
PROBLEM
For most residents, the syndrome of cognitive loss
(decreased mental awareness) or dementia is chronic and
progressive and appropriate care should focus on
enhancing quality of life, sustaining functional capacities,
minimising decline and preserving dignity. Studies in the
UK have shown that between 40 and 60% of residents in
residential homes and over three-quarters of residents in
nursing homes are very confused.
Confusion and/or behavioural disturbances present care
staff with challenges. Identifying and treating acute
confusion and behaviour problems can facilitate
assessment of how chronic cognitive deficits affect the life
of the resident (e.g. Alzheimer’s disease).
For residents with chronic cognitive deficits, a therapeutic
environment is supportive rather than specific/curative
and is an environment in which care staff are encouraged
(and trained) to comprehend a resident’s experience of
cognitive loss. With this insight, staff can develop care
plans focused on three main goals: (1) to provide positive
experiences for the resident (e.g. enjoyable activities) that
do not involve overly demanding tasks and stress; (2) to
define appropriate support roles for each staff member
involved in a resident’s care; and (3) to lay the
foundation for reasonable staff and family expectations
concerning a resident’s capacities and needs.
In recent years there has been a move towards a
recognition of the personhood of people suffering from
dementia, that is, their unique identity as individuals. The
ability to engage and communicate effectively with others
in a major component of what has been called
personhood. Therefore, the provision of sustained
positive interaction, together with an emphasis on
person-centred care, should be central to the care of
older people with dementia.
TRIGGERS
A cognitive loss/dementia problem suggested if one or
more of following are present:
■ Short-term memory problem [B2a = 1]
■ Long-term memory problem [B2b =1]
■ Impaired decision-making(a) [B4 = 1, 2, 3]
RAP 2
■ Problem understanding others(b) [C6 = 1, 2, or 3]
(a) Note: Code 3 also triggers on the ADL (Maintenance) RAP.
(b) Note: These codes also trigger on the Communication RAP.
GUIDELINES
Review the following MDS items to investigate possible
links between these factors and the resident’s cognitive
loss and quality of life. The four triggers identify residents
with differing levels of cognitive loss. Even for those who
are most highly impaired, the RAP seeks to help identify
areas in which staff intervention might be beneficial.
Neurological
Fluctuating cognitive signs and symptoms/
neurological status
Presence of both acute confusional state and progressive
cognitive (awareness) loss can result in erroneous
impressions concerning the nature of the resident’s
chronic limitations. Only when acute confusion and
behavioural disturbances are treated, or when the
treatment is judged to be as effective as possible, can a
true measure of chronic cognitive deficits be obtained.
Recent changes in the signs/symptoms of the dementia
process
Identifying these changes can heighten staff awareness of
the nature of the resident’s cognitive and functional
limitations. This knowledge can assist staff in developing
reasonable expectations of the resident’s capabilities and
in focusing care to enhance the resident’s quality of life.
This knowledge can also challenge staff to identify
potentially reversible causes for recent losses in cognitive
status.
Alzheimer’s disease, and other dementias
The most common diagnoses for cognitively impaired
residents are Alzheimer’s disease and vascular dementia.
There are also some residents in care homes with
learning disabilities and many adults suffering from
Down’s syndrome appear to develop dementia as they
age. The distinctions among these groups can be useful
in reminding staff of the types of long-term intellectual
reserves that are available to these residents.
Mood/behaviour
Specific treatments for behavioural distress as well as
treatments for acute confusion, can lessen and even cure
the behavioural problem. At the same time, however,
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
some behaviour problems will not be reversible, and staff
should be prepared (and encouraged) to learn to live
with them. In some situations where problem/distressed
behaviour continues, staff may feel that the behaviour
poses no threat to the resident’s safety, health, or activity
pattern and is not disruptive to other residents. For the
resident with declining cognitive functions and a
behavioural problem, you may wish to consider the
following issues:
■ Have cognitive skills declined subsequent to initiation
of a behaviour control programme?
■ Is decline due to the treatment programme (e.g. drug
toxicity)?
■ Have cognitive skills improved subsequent to initiation
of a behaviour control programme?
■ Has staff assistance enhanced resident self-
performance patterns?
Concurrent medical problems
Identifying and treating health problems can positively
affect cognitive functioning and the resident’s quality of
life. Effective therapy for congestive heart failure, chronic
obstructive pulmonary disease (chronic chest conditions)
and constipation can lead, for example, to functional and
cognitive improvement. Comfort (pain avoidance) is a
paramount goal in controlling both acute and chronic
conditions for cognitively impaired residents. Verbal
reports from residents should be one (but not the only)
source of information. Some residents will be unable to
communicate sufficiently to pinpoint their pain.
Failure to thrive
Cognitively impaired residents can reach the point where
their accumulated health/neurological problems place
them at risk of complications (e.g. pressure sores) and
death. As this level of disability approaches, staff can
review the following:
■ Do emotional, social and/or environmental factors
play a key role?
■ If a resident is not eating, is this due to a reversible
mood problem, a basic personality problem, a
negative reaction to the physical environment in
which eating activity occurs (e.g. anti-social habits of
others); or a neurological problem such as deficiency
in swallowing or loss of hand coordination?
RAP 2
■ Could an identified problem be remedied through
improved staff education so that other therapies are
considered e.g. antidepressants or referral to
occupational therapy?
■ What interventions are or could be in place to
decrease complications?
Functional limitations
Functional changes are often the first concrete indicators
of cognitive decline and suggest the need to identify
reversible causes. You may find it helpful to determine
the following:
■ To what extent is resident dependent for mobility,
dressing and eating?
■ Could the resident be more independent?
■ Is resident going downhill (e.g. experiencing declines
in bladder continence, mobility, dressing, vision, time
involved in activities)?
Sensory impairments
Perceptual difficulties
Many cognitively impaired residents have difficulty
identifying small objects, positioning a plate to eat, or
positioning themselves in a chair. Such difficulties can
cause a resident to become cautious and ultimately cease
to carry out everyday activities. If problems are vision-
based, corrective intervention may be effective (e.g.
prescription glasses). Unfortunately, many residents have
difficulty indicating that the source of their problem is
visual. Thus, cognitively impaired residents can often
benefit if tested for possible visual deficits.
Ability to communicate
Many individuals suffering from cognitive deficits seem
incapable of meaningful communication. However, many
of the seemingly incomprehensible behaviours (e.g.
screaming, aggressive behaviour) in which these
individuals engage may constitute their only form of
communication. By observing the behaviour and the
pattern of its occurrence, one can frequently come to
some understanding of the needs of individuals with
dementia. For example, residents may become noisy due
to bladder or bowel urgency. There is also potential for
behaviours to be influenced by the interaction skills of
care staff.
■ Is resident willing/able to engage in meaningful
communication?
 Chapter 4: Completing the Resident Assessment Protocols (RAPs) RAP 2

■ Do staff use non-verbal communication techniques ■ Are special environmental stimuli present (e.g.
(e.g. touch, gesture) to encourage resident to directional markers, special lighting)?
respond?
■ Do staff regularly assist residents in ways that permit
Medications them to maintain or attain their highest predictable
Psychotropic medication (medication affecting the mind) level of functioning (e.g. verbal reminders, physical
and other medications can be a factor in cognitive cues and supervision regularly provided to aid in
decline. If necessary, review Psychotropic Drug Use RAP. carrying out ADLs; ADL tasks presented in segments
to give residents enough time to respond to cues;
Involvement factors pleasant, supportive interaction)?
Opportunities for independent activity ■ Has the resident experienced a recent loss of someone
Staff can encourage residents to participate in the many close (e.g. death of spouse, change in key care staff,
available activities, and staff can guard against assuming recent move to the home, decreased visiting by family
an overly protective attitude toward residents. Decline in and friends)?
one functional area does not indicate the need for staff to
OVERVIEW OF COGNITIVE LOSS/DEMENTIA RAP
assume full responsibility in that area nor should it be
GUIDELINES
interpreted as an indication of inevitable decline in other
areas. Review information in the MDS when considering Factors to review for relationship to cognitive loss
the following issues: Acute confusional state
Cognitive decline Alzheimer’s/other dementia
■ Are there factors that suggest that the resident can be
Learning disability
more involved in his/her care (e.g. instances of greater
self-performance; desire to do more independently; Confounding problems that may require resolution or
retained ability to learn; retained control over trunk, suggest reversible causes
limbs and/or hands)?
Mood/behaviour
■ Can resident participate more extensively in decisions Depression
about daily life? Anxiety
■ Does resident retain any cognitive ability that permits Sad mood or mood decline
some decision-making? Behavioural symptoms or behavioural decline
Manic depression
■ Is resident passive? Other psychiatric disorders
■ Does resident resist care? Medical problems
■ Are activities broken into manageable subtasks? Constipation
Diarrhoea
Extent of involvement in activities of daily life (ADL) Faecal impaction
Programmes focused on physical aspects of the resident’s Diabetes
life can lessen the disruptive symptoms of cognitive Hypothyroidism
decline for some residents. Consider the following: Congestive heart failure
Asthma
■ Are residents with some cognitive skills and without
Emphysema/Chronic Obstructive Pulmonary Disease
major behavioural problems involved in the life of the
Cancer
home and the world around them?
Infection
■ Can modifying task demands, or the environmental Pain
circumstances under which tasks are carried out, be
Failure to thrive
beneficial (e.g. eating in own room or change of
Weight loss
seating arrangements)?
Terminal prognosis
■ Are small group programmes encouraged? Low weight for height
 Chapter 4: Completing the Resident Assessment Protocols (RAPs) RAP 2

Deterioration since last assessment Anxiolytics

Functional limitations
ADL impairment Antidepressants
Decline in ADL
Decline in continence Diuretics

Sensory impairment
Hearing problems Involvement factors
Speech unclear
Rarely/never understands New admission
Visual problems
Skin desensitised to pain Withdrawal from activities
Medications
Antipsychotics Resident/staff believe can do more.
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
RAP 3: Visual Function
It may be necessary for the resident’s general practioner
to participate in the review of this protocol if physical
examination is required.
PROBLEM
The ageing process leads to a gradual decline in visual
acuity (sharpness): a decreased ability to focus on close
objects or to see small print, a reduced capacity to adjust
to changes in light and dark, and diminished ability to
discriminate colour. The aged eye requires about 3-4 times
more light in order to see as the young eye. Studies in the
UK have shown that 14% of residents in nursing homes
have visual impairment.
The leading causes of visual impairment in the elderly are
macular degeneration (deterioration in the area of greatest
visual sharpness in the retina), cataracts, glaucoma, and
diabetic retinopathy. In addition, visual perceptual deficits
(impaired perceptions of the relationship of objects in the
environment) are common in this population. Such deficits
are common consequences of cerebrovascular events
(such as stroke) and are often seen in the late stages of
Alzheimer’s disease and other dementias. The incidence of
all these problems increases with age. A significant number
of residents in any home may be expected to have
difficulty performing tasks dependent on vision as well as
problems adjusting to vision loss.
The consequences of vision loss are wide-ranging and can
seriously affect physical safety, self-image and participation
in social, personal, self-care, and rehabilitation activities.
This RAP is primarily concerned with identifying two types
of residents: 1) those who have treatable conditions that
place them at risk of permanent blindness (e.g. glaucoma,
diabetes, retinal hemorrhage); and 2) those who have
impaired vision whose quality of life could be improved
through use of appropriate visual appliances. It also
suggests new acute conditions which will need further
investigation (e.g. sudden loss of vision; recent red eye;
shingles; etc.).
TRIGGERS
An acute, reversible [R] visual function problem or the
potential for visual improvement [I] suggested if one or
more of following present:
■ Side vision problem [R] [D2a = ticked]
■ Cataracts [R] [I1jj = ticked]
■ Glaucoma [R] [I1ll = ticked]
RAP 3
■ Vision impaired [I] [D1 =1,2,3]
GUIDELINES
Visual impairment may be related to many causes. One
purpose of this section is to screen for the presence of
major risk factors and to review the resident’s recent
treatment history. This section also considers items which
can lead to improvement in a resident’s visual function.
Eye medications
It is important that eye medications are administered in the
correct way. Details can be found in nursing procedural texts
such as the Royal Marsden NHS Trust Manual of Clinical
Nursing Procedures (1996). Eye drop instillers are available
which can help the resident administer their own medication
and maintain independence.
Glaucoma, which is an increase of pressure within the
eyeball is a common cause of blindness in older people.
The medication for glaucoma is particularly important.
Staff should be aware that some medications, eg cold or
allergy medications, that can be obtained over the counter,
can make the condition worse. These medications should
not be taken without consulting a qualified nurse or doctor.
■ Is the resident receiving his/her eye medication as
prescribed?
■ Does the resident experience any side effects eg red
eyes? Is the eye condition responding to treatment or
getting worse?
Diabetes, cataracts, glaucoma, or macular degeneration
Diabetes may affect the eye by causing blood vessels in
the retina to haemorrhage (retinopathy). All these
conditions are associated with decreased visual sharpness
and visual field deficits. If the resident is able to cooperate
it is possible for an opthalmologist or optician to test for
glaucoma and retinal problems.
Examination by ophthalmologist or optician/optometrist
since problem noted
■ Has the resident been seen by a opthalmologist or
optician/optometrist?
■ Have the recommendations been followed (e.g.
medications, new glasses, surgery)?
■ Is the recommendation compatible with the resident’s
wishes?
If neurological diagnosis or dementia is present has doctor
reviewed vision since problem noted?
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
Check the resident record to see if a doctor has examined
the resident for visual/perceptual difficulties. Some
residents with diseases such as myasthenia gravis, stroke
and dementia will have such difficulties associated with the
central nervous system in the absence of diseases of the
eye.
Sad or anxious mood
Some residents, especially those in a new environment,
will complain of visual difficulties. Visual disorganisation
may improve with treatment of the sad or anxious mood.
Appropriate use of visual appliances
Residents may have more severe visual impairment when
they do not wear their glasses appropriately. Residents
who wear reading glasses when walking, for example, may
misperceive their environment and bump into objects or
fall.
■ Are glasses labelled or colour coded in a fashion that
enables the resident/staff to determine when they
should be used?
■ Are the lenses of glasses clean and free of scratches?
■ Were glasses recently lost? Were they recently being
used, and now they are missing?
Functional need for eye exam/new glasses
Many residents with limited vision will be able to use the
environment with little or no difficulty, and neither the
resident nor staff will perceive the need for new visual
appliances. In other circumstances, needs will be identified,
and for residents who are capable of participating in a
visual examination, new appliances, surgery to remove
cataracts, etc., can be considered.
■ Does resident have peripheral vision or other visual
problems that impede his/her ability to eat food, walk in
the home, or interact with others?
■ Is resident’s ability to recognise staff limited by a visual
problem?
■ If resident is having difficulty negotiating his/her
environment or participating in self-care activities
because of visual impairment has he/she been referred
for eye examination?
■ Does resident report difficulty seeing TV/reading
material of interest?
■ Does resident express interest in improved vision?
RAP 3
■ Has resident refused to have eyes examined? How long
ago did this occur? Has it occurred more than once?
Environmental modifications
Residents whose vision cannot be improved by use of
glasses or medical and/or surgical intervention may benefit
from environmental modifications.
■ Does the resident’s environment enable maximum
visual function (e.g. low-glare floors and table surfaces,
night lights)?
■ Has the environment been adapted to resident’s
individual needs (e.g. large print signs marking rooms,
colour coded tape on dresser drawers, large numbers
on telephone, reading lamp with high watt bulb,
provision of talking books)? Could the resident be more
independent with different visual cues (e.g. labelling
items, task segmentation) or other sensory cues (e.g.
walking stick for recognising there are objects in path)?
Acute problems that may have been missed
Eye pain, blurry vision, double vision, sudden loss of
vision are symptoms usually associated with acute eye
problems.
■ Has resident been seen by GP or ophthalmologist?
OVERVIEW OF VISUAL FUNCTION RAP
GUIDELINES
Issues and problems to be reviewed that may suggest need
for intervention
Eye medication
Diabetes
Cataracts
Glaucoma
Macular degeneration
Examination by ophthalmologist since problem noted
Neurological disorder/dementia
Depression/anxiety/sad mood
Appropriate use of glasses
Need for eye test/new glasses
Environmental changes e.g. better lighting
Other acute problems: eye pain, blurry vision, double
vision, sudden loss of vision
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
RAP 4: Communication
PROBLEM
Good communication enables residents to express
emotion, listen to others, and share information. It also
eases adjustment to a strange environment and lessens
social isolation and depression.
EXPRESSIVE communication problems include
changes/difficulties in: speech and voice production,
finding appropriate words, expressing coherent
statements, describing objects and events, using nonverbal
communication (e.g. facial expression) and writing.
RECEPTIVE communication problems include
changes/difficulties in: hearing, speech discrimination in
quiet and noisy situations, vocabulary comprehension,
vision, reading and interpreting facial expressions. Hearing
loss may accompany the ageing process leading to
inability to hear high frequency sounds.
When communication is limited assessment should focus
on reviewing several factors: underlying causes of the
problem, the success of attempts to remedy these, the
resident’s ability to compensate with nonverbal strategies
(e.g. ability to see nonverbal signs and signals) and the
willingness and ability of staff to engage with residents to
ensure effective communication takes place. As language
use recedes with dementia, both the staff and the resident
must expand their nonverbal communication skills - one
of the most basic and automatic of human abilities.
Touch, facial expression, eye contact, tone of voice and
posture are all powerful means of communicating with a
resident with dementia and recognising and using all
practical means is the key to effective communication.
TRIGGERS
Potential for improved communication suggested if one or
more of following present:
■ Hearing problem [C1 = 1, 2, 3]
■ Problem making self understood [C4 = 1, 2, 3]
■ Problem understanding others✳ [C6 = 1, 2, 3]
✳Note: These codes also trigger on the Cognitive Loss/Dementia RAP.
GUIDELINES
The communication trigger suggests residents for whom
development of a care plan may be beneficial, such as
those residents with potentially correctable problems. An
effective review requires a special effort by staff to
overcome any preconceived notions or fixed perceptions
they may have about the resident’s probable
RAP 4
responsiveness to treatment. These perceptions may be
based on the failure of prior treatment, as well as on
assumptions that may not have been recently tested about
the resident’s unwillingness to participate.
Review items listed on the RAP OVERVIEW as follows:
Confounding problems
As these confounding problems lessen or further decline is
prevented, the resident’s communication abilities should
be reviewed.
Components of communication
Treatment should focus on the residents’ strengths and
weaknesses in understanding, hearing and expression.
Residents who report problems with their hearing may
require an audiology referral.
Factors to be reviewed for possible relationship to
communication problems
■ For chronic conditions that are unlikely to improve,
consider communication treatments or interventions
that might compensate for losses (e.g. for moderately
impaired residents with Alzheimer’s disease, the use of
short, direct phrases and touch can be effective;
effective position of speaker to facilitate lip reading).
■ Are there acute or temporary conditions which if
successfully resolved may result in improved ability to
communicate? (e.g. the presence of ear wax may
require a GP referral for treatment)
■ Are medications in use that could cause or complicate
communication deficits, where dose changes or
substitution may result in improved ability to
communicate?
■ Are opportunities to communicate limited in ways that
could be remedied - e.g. availability of someone to
communicate with?
■ Are there environmental factors which impede
communication? (e.g. background noise such as radio
or television)
Clarifying issues
Treatment/evaluation history
■ Has resident received an evaluation by an audiologist
(hearing technician) or speech therapist? How
recently?
■ Has the resident’s condition deteriorated since the
most recent evaluation?
 Chapter 4: Completing the Resident Assessment Protocols (RAPs) RAP 4

■ If such an evaluation resulted in a plan of care, has it Parkinson’s disease

been followed as specified? Psychiatric disorder
OVERVIEW OF COMMUNICATION RAP Asthma
GUIDELINES
Cancer
Confounding problems which may require Chronic Obstructive Pulmonary disease
resolution
Emphysema
Decline in cognitive status
Increased mood problems Transitory conditions
Decline in ADL status
Acute confusional state
Components of communication to be considered
Infections
Hearing
Communication devices/modes of expression Medications
Decline in communication/hearing Psychotropics
Ear problems needing medical review e.g. ear discharge,
ear wax, hearing changes Narcotics
Vision Medication for Parkinson’s disease

Factors to be reviewed for possible relationship to com- Clarifying issues to be considered

munication problems
Memory
Chronic conditions
Recent hearing/language assessments
Alzheimer’s disease/dementia
Aphasia (inability to express speech) Deterioration in resident’s condition
Stroke Quality/quantity of communication
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
RAP 5: Activities of Daily Living - Function/Rehabilitation Potential
PROBLEM
Personal mastery of ADL (Activities of Daily Living) and
mobility are as crucial to human existence in the care
home setting as they are in the community. In care homes
most residents require help with self-care functions. A UK
study has shown that 23% of older people in residential
and nursing homes require help with feeding themselves,
52% need help transferring between bed and chair, 72%
require assistance with dressing and 90% need help to
bath themselves. ADL dependence can lead to intense
personal distress - isolation, diminished self-worth and a
loss of control over one’s destiny. As inactivity increases,
complications such as pressure sores, falls, contractures
and muscle wasting can be expected.
The Activities of Daily Living RAP assists staff in setting
positive and realistic goals for rehabilitation.
Rehabilitation has traditionally focussed on the acute
phase of illness and does not often include the potential
of those suffering from chronic conditions. These should
not be excluded when considering the needs of each
resident. The World Health Organisation has described
rehabilitation as an active process by which those disabled
by injury or disease achieve full recovery, or if full
recovery is not possible, realise their optimal physical,
mental and social potential and are integrated into the
most appropriate environment.
During assessment staff need to weigh the advantages of
independence against risks to safety and self-identity. In
promoting independence staff must be willing to accept a
reasonable degree of risk and active resident participation
in setting treatment objectives.
Rehabilitative goals of several types can be considered:
■ To restore function to maximum self-sufficiency in one
or more areas;
■ To replace hands-on assistance with a programme of
breaking down tasks and verbal cueing;
■ To restore abilities to a level that allows the resident to
function with fewer supports;
■ To shorten the time required for providing assistance;
■ To expand the amount of space in which self-
sufficiency can be practiced;
■ To avoid or delay additional loss of independence; and
■ To support the resident who is certain to decline in
order to lessen the likelihood of complications (e.g.
RAP 5
pressure sores and contractures).
TRIGGERS
There are two MDS trigger categories. Trigger A for
rehabiliation and Trigger B for maintenance. Residents
may have either the need and potential to improve
(rehabilitation) or the need for services to prevent decline
(maintenance).
ADL Trigger A (Rehabilitation)
Rehabilitation/restorative plans suggested if one or more
of following present:
■ Bed mobility – not independent [G1aA = 1-4](a)
■ Transfer – not independent [G1bA = 1-4]
■ Walk in room – not independent [G1cA = 1-4]
■ Walk in corridor – not independent [G1dA = 1-4]
■ Mobility around immediate space – not independent
[G1eA = 1-4]
■ Mobility around home – not independent [G1fA = 1-4]
■ Dressing – not independent [G1gA = 1-4]
■ Eating – not independent [G1hA = 1-4]
■ Toilet use – not independent [G1iA = 1-4]
■ Personal hygiene – not independent [G1jA = 1-4]
■ Bathing – not independent [G2A = 1-4]
■ Resident believes he/she capable of increased
independence in at least some ADLs [G8a = ticked]
■ Staff believe resident capable of increased inde-
pendence in at least some ADLs [G8b = ticked]
ADL Trigger B (Maintenance)
Maintenance/complication avoidance plan suggested if:
[Note: when both triggers present (A & B), B takes
precedence in the RAP Review]
■ No ability to make decisions [B4 = 3](b)
(a) Note: Codes 2,3, and 4 also trigger on the Pressure Sore RAP
(b) Note: This code also triggers on the Cognitive Loss/Dementia RAP
GUIDELINES
Base an approach to a resident’s ADL difficulty on clinical
knowledge of the causes of dependence; the expected
course of the problem(s); and which types of help work or
do not work.
The MDS goal is to assist in identifying residents for
 Chapter 4: Completing the Resident Assessment Protocols (RAPs) RAP 5

whom rehabilitative/restorative goals can be reasonably ■ Is mobility severely impaired?

established. Many ADL-restricted residents can regain
partial ability for self-care. Certain types of disease- ■ Is trunk, leg, arm and/or hand use severely impaired?
generated losses will respond to therapy. In addition, the
removal of inappropriate restraints and the close ■ Are there distinct behavioural problems?
monitoring of potentially toxic medications can often
■ Are there distinct mood problems?
result in increased functioning.
Use the items in the ADL RAP OVERVIEW to consider ■ Is the resident motivated to work at a rehabilitative
the resident’s risk of decline and potential for
programme?
rehabilitation. The first thing that needs to be considered
is the possible presence of confounding problems that
Where rehabilitation goals are envisaged use of the ADL
may require resolution before rehabilitation goals can be
reasonably attempted. The second task is to clarify the Supplement will help care planners to focus on those
resident’s potential for improved functioning. Staff may
areas that might be improved and to choose from among
find the following sequence of questions useful in
initiating a review. a number of basic tasks in designated areas. Part 1 of the

■ Does the resident have the ability to learn? To what Supplement can assist in the evaluation of all residents
extent can the resident call on past memory to assist in
triggered into the RAP. Part 2 of the Supplement can be
current problem-solving situations?
helpful for residents with rehabilitation potential (ADL
■ What is the resident’s general functional ability? How
disabled is the resident and does ability vary? Trigger A), to help plan a treatment programme.
 ADL Supplement (Attaining maximum possible independence)

Part 1: ADL Problem Evaluation Dressing Bathing Toileting Mobility Transfer Eating
INSTRUCTIONS:
For those triggered –
Where help is provided,
indicate reason(s) for this help

Mental limitations
Sequencing problems, incomplete
performance, anxiety limitations, etc

Physical Limitations
Weakness, limited range of motion,
poor coordination, visual
impairment, pain etc.

Home conditions
Policies, rules, physical layout, etc

Part 2: Possible ADL Goals

If wheelchair tick: ■
INSTRUCTIONS: Locates/ Goes to Goes to toilet Walks in Positions self in Opens/pours/
selects/ bath/shower (include room/nearby preparation unwraps/cuts
For those considered for
obtains commode/ etc
rehabilitation or maintenance treat-
ment – indicate specific type of ADL
clothes urinal at night) ■
activity that might require: Grasps/puts Turns on Removes/ Walks in Approaches Graps utensils
1. Maintenance to prevent decline on upper/ water/adjusts opens unit chair/bed and cups
lower body temperature clothes in
2. Treatment to achieve preparation ■
highest practical self
sufficiency (selecting ADL Manages Washes Transfers/ Walks Prepares Scoops/spears
abilities that are just above those the buttons body (except positions self throughout chair/bed food (uses
resident can now perform or partici- zip etc back) building (uses (locks pad, fingers when
pate in) lift) ■ moves covers) necessary)

Enter 1 or 2 in the appropriate Puts on in Rinses body Eliminates Walks Transfers Chews, drinks,
cell(s). If Other please specify. correct into toilet outdoors (stands/sits/ swallows
order lifts/turns)
■
Grasps, Dries with Tears/uses Walks Repositions/ Repeats
removes each towel paper to clean on uneven arranges self until food
item self surfaces consumed
■
Replaces Other Flushes Other Uses napkins.
clothes
Other ■ cleans self
properly

Other Adjusts Other

clothes,
washes hands
 Chapter 4: Completing the Resident Assessment Protocols (RAPs) RAP 5

OVERVIEW OF ADL RAP GUIDELINES Clarifying issues to be considered:

Confounding problems that may require Ability to make decisions
Communication problems
resolution:
Vision
Acute confusional state Balance problems
Mood problems
Complete ADL supplement Part 1 for triggered
Behavioural problems
residents
Acute health problem
Medication Complete ADL supplement Part 2 for a resident with
Deterioration rehabilitation potential
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
RAP 6: Urinary Incontinence and Indwelling Catheter
A registered nurse and/or the resident’s general
practitioner should review this protocol.
PROBLEM
Urinary incontinence is the inability to control bladder
function in a socially appropriate manner. Studies in the
UK have shown that around 27% of residents in
residential homes and 43% of residents in nursing homes
are incontinent. Incontinence causes many problems,
including skin rashes, isolation and pressure sores.
Unsurprisingly, continence is a key goal for many
residents because incontinence affects psychological well-
being and social interactions. Urinary incontinence is
curable in many older people but not all will realistically
benefit from a full investigation of its cause. Indwelling
urinary catheters are a common response to managing
incontinence but increase the risk of life-threatening
infections, bladder stones and cancer. The use of
catheters also contributes to resident discomfort and the
needless use of toxic medications often required to treat
the associated bladder spasms. For many (but not all)
residents, urinary incontinence is curable, and safer and
more comfortable approaches are often practical for
residents with indwelling catheters.
Even if a resident is not believed to be a candidate for
bladder re-training, a full assessment should still be done
since other treatable conditions may be found, the
treatment of which will both improve incontinence and
the overall quality of life for the resident. Interestingly,
mobility rather than cognitive impairment has been
demonstrated to be the crucial predictor for continence
amongst nursing home residents.
The goal of this RAP is to detect reversible causes of
incontinence, such as infections and medications, and
institutionally induced incontinence, and to consider the
appropriateness of indwelling catheter use.
Continence depends on the following factors: a bladder
that can store and expel urine and a urethra (the canal
through which urine is expelled) that can close and open
appropriately. Other factors include the resident’s ability
(with or without staff assistance) to reach the toilet on
time (mobility), his/her ability to adjust clothing
(dexterity), cognitive function and social awareness (e.g.
recognising the need to void in time and in an
appropriate place), and the resident’s motivation. Fluid
balance and the integrity of the spinal cord and
peripheral nerves also have an effect on continence.
RAP 6
Change in any one of these factors can result in
incontinence, although there may be alterations in
several factors before incontinence develops.
TRIGGERS
A care plan is suggested if one or more of the following
are present:
■ Incontinent 2+ times a week [H1b = 2, 3 or 4]
■ Use of external (condom) catheter [H3c = ticked]
■ Use of indwelling catheter [H3d = ticked]
■ Use of intermittent catheter [H3e = ticked]
■ Use of pads/briefs [H3g = ticked]
GUIDELINES
For residents with incontinence (including those with
condom catheters), the MDS items described in section A
should be reviewed. If incontinence persists review
section B, and if necessary section C.
A. Items necessary to evaluate incontinence or need for
an indwelling catheter
Review the reversible problems listed on the RAP
OVERVIEW section. Most are easily diagnosed, and their
treatment will improve not only incontinence but
functional status as well. A registered nurse can identify
many of these factors, but some will need a medical
assessment.
Urinary tract infection (UTI)
Urinary tract infections are a common cause of
incontinence, especially new incontinence. Therefore,
they should be looked for in all residents who present
with this problem. A qualified nurse may suggest a
specimen of urine is sent for analysis and culture to
detect whether an infection is present and treatment may
then be required.
Faecal impaction
Faecal impaction is very common in older people and
can cause urinary incontinence by preventing the bladder
from emptying completely. It is important therefore to
check for impaction in all residents who are incontinent.
Faecal impaction may present as diarrhoea where the
rectum is full and overflow occurs.
■ The registered nurse or doctor should undertake a
rectal examination.
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
■ The finding of no stool or small amount of soft stool
indicates that impaction is unlikely to be the cause of
incontinence. A record demonstrating that the resident
has recently passed stool is not sufficient to rule out
faecal impaction.
Acute confusion
If present, this problem requires immediate attention.
Often when acute confusion is treated, incontinence will
resolve. In the meantime, regular toileting will help.
Lack of toilet access
The use of restraints prevents residents from getting to
the toilet. The toilet may be too far away for a resident
who does not get much warning of the need to pass
urine (e.g. there may not be a toilet near the day room).
Environmental modifications such as clear sign posting,
extra rails, raised toilet seats, good lighting and the
provision of a bedside commode or urinal can be useful.
To remain continent, residents may also require staff
support and prompt responses to requests for assistance.
Those from different cultural backgrounds may need
special toilet facilities e.g. Muslims may wish to wash the
vulval, perineal and anal areas after using the toilet and
therefore need washing facilities and some means of
pouring water directly onto themselves.
Immobility
Immobility is a common cause of incontinence.
Improving the resident’s ability in transferring, mobility
and dexterity will often reduce incontinence, as will
providing prompt staff assistance when needed. An
occupational therapist may be able to help the resident to
manage his/her clothing.
Depression
Severe depression can result in loss of the motivation to
stay continent. Prompted toileting is often helpful as a
means of positive reinforcement.
Congestive cardiac failure (CCF)
Congestive cardiac failure is often associated with
oedema (swelling of the legs) and shortness of breath
which reduces mobility. Treatment of these conditions is
vital and will improve both incontinence and functional
ability.
Recent stroke
Once the resident is stable, any acute confusion has
cleared, and mobility has improved, continue with
RAP 6
investigations if incontinence persists.
Diabetes mellitus
Poorly controlled diabetes, which results in persistently
high blood sugar levels, causes fluid loss that can cause
or worsen incontinence. Treatment of the diabetes will
improve continence and functional status.
Medications
Many medications can affect the bladder or urethra and
result in incontinence. Diuretics cause the most obvious
problems. For example loop diuretics such as frusemide
cause the bladder to fill rapidly giving the person little
time to respond. Night sedation dulls the senses, which
may result in night-time incontinence. Some anti-
depressants have an effect on the smooth muscle of the
bladder wall and may cause difficulty in micturition.
Analgesics particularly codeine and opiates often cause
constipation. Doctors may discontinue the offending
medication(s) after weighing up the risks and benefits of
doing so.
■ A review of all medications including regularly
prescribed, occasional or “PRN” (as required), and
any non-prescribed (“over-the-counter”) medications
should be undertaken by the doctor.
A number of types of drugs may affect continence. These
include diuretics and sedatives and systematic review
with the doctor is critical to the effective management of
continence problems.
B. Other potential causes or factors contributing to incon-
tinence or use of catheters
Much of the information asked for above will appear in a
completed MDS. However, other items of information
should be obtained and reviewed if incontinence persists.
Pain
Pain in the bladder, related to emptying the bladder, is a
rare and abnormal symptom, and often indicates another
pathological (disease) process, which may be treatable.
Review by the doctor is important.
Excessive or inadequate urine output
If daily urine output is less than 1 litre, incontinence may
worsen because strong, concentrated urine can irritate
the bladder. A daily output over 1.5 litres can overwhelm
the bladder. If present, the identification of the underlying
cause of the high urine output (e.g. diabetes, high
calcium, or excessive fluid intake) is required before
 Chapter 4: Completing the Resident Assessment Protocols (RAPs) RAP 6

restricting fluids. a closed system. Residents should be monitored for signs

■ The amount of urine excreted should be measured for of a urinary tract infection such as a high temperature,
1 to 2 days. cloudy urine or signs of acute confusional state.

Atrophic vaginitis OVERVIEW OF URINARY INCONTINENCE RAP

Atrophic vaginitis is caused by reduced amount of the GUIDELINES
female hormone oestrogen, this condition causes or
Possible reversible problems to be reviewed in evaluating
contributes to incontinence in many women.
incontinence and need for catheter
■ Vaginal examination by a doctor for evidence of
Acute confusion
oestrogen deficiency.
Faecal impaction
■ Pain or irritation during the insertion of a catheter is
Depression
another useful sign of the condition (catheterisation
Oedema
may be uncomfortable, but should not be painful).
Mobility
■ Atrophic vaginitis can be treated with a low dose of Lack of access to toilet
oral oestrogens. Contraindications to oestrogen
Restraints
therapy include a history of breast or endometrial
Diabetes
cancer.
Congestive heart failure
Enlarged prostate Stroke
The most common reason for outflow obstruction in men Parkinson’s disease
is an enlarged prostate gland. This is common in elderly Medications
men. Symptoms include urinary frequency, urinary
retention, nocturia, haematuria (blood in the urine), poor Other potential factors contributing to incontinence or
stream of urine and dribbling urine. use of catheter

C. Evaluation if incontinence persists Pain

Atrophic vaginitis
If incontinence persists an evaluation by a continence
Bladder cancer
advisor or a specialist physician is required.
Prostate cancer
D. Residents with an indwelling catheter
Final evaluation if incontinence persists
An indwelling catheter should only be used as a last
resort or where there is obvious benefit to the residents. Refer to general practitioner/continence advisor
Residents with an indwelling catheter are at a high risk of
Residents with an indwelling catheter
developing a urinary tract infection. To help prevent this
strict asceptic techniques should be followed during Monitor signs of urinary tract infection
catheterisation, the drainage system should be kept Use aseptic technique
below the level of the resident’s bladder so that there is Keep drainage system closed
no backflow of urine and the drainage system should be Avoid backflow
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
RAP 7: Psychosocial Well-Being
PROBLEM
Well-being refers to feelings about self and social
relationships. For many new residents in homes there
may be considerable difficulty in adapting to new
routines, environments or people. As a consequence
their self image and social relationships may appear
negative. Positive attributes include initiative and
involvement in life; negative attributes include
distressing relationships and concern about loss of
status. Residents with negative attributes often have
serious behavioural and/or mood problems. With such
residents initial treatment is often focused on mood and
behaviour manifestations and the success of treatment
for psychosocial distress is dependent on how the
resident responds to the primary mood/behaviour
intervention programme.
Care staff can make a positive contribution to a
resident’s psychosocial well-being by offering residents
choices in everyday activities, ensuring they are always
treated with dignity and respect, and that issues such as
privacy are addressed. Life review so as to learn about
a resident’s past can help staff to see them as a unique
individual with their own values, preferences and
experiences. This can help to prevent negative elements
of communication, such as staff conversations in the
presence of residents which exclude them.
TRIGGERS
Well-being problem (P) or need to maintain psychosocial
strengths (S) suggested if one or more of following
present:
■ Withdrawal from care/activities [P]✳ [E1o = 1,2]
■ Conflict with staff [P] [F2a = ticked]
■ Unhappy with roommate [P] [F2b = ticked]
■ Unhappy with other resident [P] [F2c = ticked]
■ Conflict with family/friends [P] [F2d = ticked]
■ Grief over lost status/roles [P] [F3b = ticked]
■ Daily routine is very different from prior pattern in the
community [P] [F3c = ticked]
■ Establishes own goals [S] [F1d = ticked]
■ Strong identification with past [S] [F3a = ticked]
✳ Note: This item also triggers on the Mood State RAP.
GUIDELINES
RAP 7
Sequentially review the items found on the RAP
OVERVIEW
Confounding problems
Treatment for mood/behaviour problems is often
immediately beneficial to well-being.
■ Does the resident have an increasing or persistently
sad mood?
■ Does the resident have increasing frequency of
disturbed behaviour?
■ Did the mood/behaviour problems appear before the
reduced sense of well-being?
■ Has the resident’s condition deteriorated since last
assessment?
■ Have ongoing treatment programmes been effective?
Environmental factors that may impede ability to
interact with others
■ Environmental problems are often amenable to staff
intervention without the burden of staff having to
“change the resident”.
■ Have key social relationships been altered/terminated
(e.g. loss of family member, friend or staff)?
■ Have changes in the resident’s environment altered
access to others or to routine activities - for example,
room change?
■ Do staff regularly interact positively with the resident?
Resident characteristics that may hinder ability to interact
with others
These focus on areas where the resident may lack the
ability to enter freely into satisfying social relationships.
They represent substantial impediments to easy
interaction with others and highlight areas where staff
intervention may be crucial.
■ Do cognitive/communication deficits or a lack of
interest in activities impede interactions with others?
■ Does resident indicate unease in social relationships?
Lifestyle issues
Residents can withdraw or become distressed because
they feel life lacks meaning. It is important to understand
their previous interests, values and preferences so that
activities contribute meaningfully to the residents’
experience.
 Chapter 4: Completing the Resident Assessment Protocols (RAPs) RAP 7

■ Was life more satisfactory prior to entering the home? Loss of family/friend/member of staff
■ Is resident preoccupied with the past, unwilling to Physical restraint use
respond to the needs of the present? New admission
■ Has the home focused on a daily routine that Change in room allocation/dining location
resembles the resident’s prior lifestyle?
Resident characteristics that may impede ability to inter-
■ Is there inappropriate pressure to participate in
act with others
activities uncongenial to the resident?
Acute confusional state/cognition decline
Additional information to clarify the nature of the prob-
Communication problem
lem
Not at ease interacting with others
Supplementary problem clarification issues in the RAP
Mobility deficit
OVERVIEW can be used to specify the nature of the
well-being problem for residents for whom it is Dementia
anticipated that this will be included in the care plan. Depression
These represent topics around which questions can be Aphasia
phrased. Each item includes the positive and negative
end of a continuum, representing the possible range that Lifestyle issues
staff can use in thinking about these issues. For those Major change of lifestyle
items selected, the following issues should be considered:
Strong identification with past roles
■ How do staff/resident perceive the severity of the
problem? Supplemental problem clarification issues (from

■ Has the resident ever demonstrated (while in the resident/family if necessary)

home) strengths in the area under review? Ability to relate to others
■ Are corrective strategies now being used? Have they Skill/unease in dealing with others
been used in the past? To what effect? Reaches out/distances self
■ Is this an area that might be improved? Friendly/unapproachable

OVERVIEW OF PSYCHOSOCIAL WELL-BEING RAP Flexible/ridiculed by others

GUIDELINES Relationships resident could draw on
Confounding problems Supported/isolated
Increasing/persistent sad mood
Many friends/friendless
Disturbing behaviour
Deterioration of condition Dealing with grief
Situational factors that may impede ability to interact Moving through grief/bitter and inconsolable
with others Religious faith/feels punished
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
RAP 8: Mood State
This protocol should be reviewed with the resident’s
general practitoner or community psychiatric nurse.
PROBLEM
Feelings of depression can manifest themselves in many
ways. Such signs are often expressed as sad mood,
feelings of emptiness, anxiety or unease. They are also
manifested in a wide range of bodily complaints and
dysfunctions, such as loss of weight, tearfulness, sleep
changes, agitation, constipation, aches and pains.
Studies in the UK have shown that about 45% of
residents in nursing and residential homes are classified
as depressed.
TRIGGERS
A mood problem suggested if one or more of following
present:
■ Resident made negative statements [E1a = 1,2]
■ Repetitive questions [E1b = 1,2]
■ Repetitive verbalisations [E1c = 1,2]
■ Persistent anger with self or others [E1d = 1,2]
■ Self deprecation [E1e = 1,2]
■ Expressions of what appear to be unrealistic fears [E1f
= 1,2]
■ Recurrent statements that something terrible is about
to happen [E1g = 1,2]
■ Repetitive health complaints [E1h = 1,2]
■ Repetitive anxious complaints/concerns [E1i = 1,2]
■ Unpleasant mood in morning [E1j = 1,2]
■ Insomnia/change in usual sleep pattern [E1k = 1,2]
■ Sad, pained, worried facial expressions [E1l = 1,2]
■ Crying, tearfulness [E1m = 1,2]
■ Repetitive physical movements(a) [E1n = 1,2]
■ Withdrawal from activities of interest(b) [E1o = 1,2]
■ Reduced social interaction [E1p = 1,2]
■ Mood persistence [E2 = 1,2]
(a) Note: This item also triggers on the Psychotropic Drug Use RAP
when psychotropic drug use present
(b) Note: This item also triggers on the Psychosocial Well-Being RAP.
GUIDELINES
Specific conditions described below suggest the need for
RAP 8
an altered/new care strategy. They are not exhaustive;
other situations may arise in which staff decide that an
altered care plan is necessary. The most obvious are
instances of drug-induced side effects (addressed in
Psychotropic Drug Use RAP). Residents whose mood
problems do not call for care plan alterations are those
with stable behaviour and no unusual confounding
problems.
Many of the questions and issues that follow relate to the
MDS items listed on the Mood State RAP OVERVIEW.
An altered care strategy is suggested when specified
conditions are met.
Indicators of the need to consider a new/altered care
strategy:
Has mood recently declined or problems
intensified?
■ Were mood problems present 6 months ago?
■ Does resident have a cyclic history of decline and
improvement in mood state?
■ Has loss of appetite with accompanying weight loss
occurred?
■ Has interest in activities declined, even though
resident remains physically capable?
Mood unimproved and potentially reversible causes pres-
ent
Resolution of acute confusional state, behavioural,
relationship and/or communication problems often affect
a resident’s mood state. Only when these conditions
have been addressed can the nature of a mood problem
be fully understood.
Also, consider the possible presence of other complicating
factors, such as:
■ Review recent changes in the life of the resident (e.g.
death of a child, transfer to new environment,
separation from loved ones, loss of functional abilities
or change in body image, loss of autonomy),
■ Review nature and intensity of relationship and/or
behaviour problems.
Activities of Daily Living (ADL) decline can be both a
cause and a consequence of distressed mood. Reviewing
the sequence of ADL and mood decline may be
informative. In any case, where mood seems to impair
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
ADL functioning (e.g. depression and self care), useful
strategies include modifying the physical environment,
separating the resident’s performance of ADL activities
into a series of small tasks, and using verbal reminders
and cues.
■ Review assessment to determine whether there has
been a sudden onset or worsening of cognitive
symptoms or communication skills following initiation
of treatment (e.g. medications)
■ Review of drug therapies by doctor to determine
whether the resident is using any medications known
to cause mood shifts, such as psychotropics,
antihypertensives, cytoxic agents,
immunosuppressants, sedatives, steroids or stimulants.
Mood unimproved and other factors to consider
The passive resident with distressed mood may be
overlooked. Such a resident may be erroneously
assumed to have no mood state problem.
■ Does the resident show little/no initiative?
■ Does he/she remain uninvolved in activities (alone or
with others)?
■ Is the sad mood persistent?
■ Is the resident’s expression unresponsive and lacking
in emotion?
Does sad mood appear to respond to treatment (e.g.
drug regime)?
■ Has the mood problem remained relatively
unchanged for the last 3 months, or has it improved
with the current treatment programme?
■ Have there been cycles of decline and improvement?
■ Is resident receiving antidepressant medications
and/or psychosocial therapy?
Confounding issues
Some conditions may affect mood problems.
RAP 8
These conditions include: Alzheimer’s disease, chronic
respiratory disorders, cancer, cardiac disease, metabolic
(chemical) and endocrine disorders (e.g. hypercalcaemia,
Cushing’s disease, Addison’s disease, hypoglycaemia,
hypokalaemia, porphyria), Parkinson’s disease, stroke, or
other neurological disease and thyroid disease. Are there
indicators of a new problem appearing or an existing
problem getting worse associated with any of these
conditions?
OVERVIEW OF MOOD STATE RAP GUIDELINES
Indicators of the need to consider a new/altered care
strategy
Mood decline
Mood unimproved and potentially reversible causes pres-
ent
Recent move into/within the home
Acute confusional state
Cognitive decline
Delusions
Hallucinations
Communication decline
Grief
ADL decline
Use of medications known to cause mood shifts.
Communication skills
Mood unimproved and other factors to consider
Little or no initiative shown
Little or no involvement in activities
Review current treatment programme
Confounding issues to be considered
Diseases e.g. Thyroid disease, chronic respiratory
disorders, cardiac disease, neurological disorder, anxiety,
depression, schizophrenia, cancer, hypercalceamia,
Cushing’s disease, Addison’s disease, hypoglycaemia,
hypokalaemia, porphyria.
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
RAP 9: Behavioural Symptoms
This RAP should be reviewed with the resident’s general
practioner and/or community psychiatric nurse.
PROBLEM
Residents with behavioural symptoms also frequently
have other related problems. These can include
cognitive, mood and/or relationship problems.
Behavioural symptoms are often seen as a source of
danger and distress to the residents themselves and
sometimes to other residents and staff. Homes often find
such residents difficult to cope with, and staff often seem
unaware of the wide range of available treatment and
management options. As a result, overuse of restraints
(e.g. baffle locks on doors, bed rails) or psychotropic
drugs is not uncommon. These interventions, however,
have potentially serious negative side-effects and as a
result, there is an increasing trend toward using other
interventions and treatments in addressing behavioural
symptoms.
TRIGGERS
The MDS trigger items identify two types of residents for
whom further review is suggested. The first type of
residents include those who exhibit the behavioural
symptoms of wandering, being verbally abusive, being
physically aggressive and/or exhibiting socially
inappropriate behavioural symptoms [P]. The second
type of residents are those whose behavoural symptoms
appear to have improved but this may be due to current
treatments or intervention masking their symptoms. (e.g.
decreased wandering because of sedating effects of
medication) [I].
Review of behaviour status suggested if one or more of
following present:
■ Wandering [P]✳ [E4aA = 1,2,3]
■ Verbally abusive [P] [E4bA = 1,2,3]
■ Physically abusive [P] [E4cA = 1,2,3]
■ Socially inappropriate [P] [E4dA = 1,2,3]
■ Resists care [P] [E4eA = 1,2,3]
■ Behaviour improved [I] [E5 = 1]
✳Note – This Item also triggers on the Falls RAP
GUIDELINES
The items in the first part of this RAP (and in the RAP
OVERVIEW) help to draw the distinction between serious
RAP 9
behavioural problems and others which can be more
easily accommodated. This is followed by a section on
potential causes or factors involved in the manifestation
of problem behaviours, resolution of which might reduce
or eliminate the behaviour.
Evaluating the seriousness of behavioural
symptoms
The first group of triggers [P] identify residents who
currently exhibit some type of behavioural symptoms for
which additional or new treatment programmes may be
considered, although not all behaviours need extensive
intervention. Some behaviours neither endanger nor
distress the resident or others. For example, some
hallucinations and delusions (when not a sign of
psychosis or an acute condition, such as acute
confusional state) may be harmless. Residents with such
behavioural manifestations may be accommodated (e.g.
tolerated, behaviour re-channelled or redirected) within
the environment of the home. Thus, determining whether
a particular behavioural manifestation is a problem is an
important step and involves determining the nature and
severity of the behaviour(s) in question, the effects of the
behaviour(s) and for whom the behaviour is most
problematic.
Observing specific behavioural manifestations in the most
recent 7-day period
Recording the pattern of occurrence of the behaviour
over a period of time can aid understanding.
■ Review to determine the intensity, duration and
frequency of behaviour problems over the last 7-day
and 14-day periods. Did these changes vary over
time?
■ Is there a pattern to the behaviour based on
observations over a 7-14 day time period? (Consider
such factors as time of day, nature of the
environment, what the resident and others were doing
at the time the problem behaviour was manifested.)
Identifying stability/change in the nature of behavioural
problems
Identifying patterns of behaviours over time may help
you clarify the underlying causes of problem behaviours.
For example, such a review may reveal a pattern in
which a resident’s reactions typically occur only in the
presence of a particular combination of stressors (e.g. a
person who can tolerate large groups for singing but not
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
for meals). Similarly, observing a resident over time may
reveal that a resident’s seemingly random behaviours are
associated with particular events (e.g. yelling/screaming
associated with objecting to someone changing the
channel during a favoured television programme;
wandering associated with the need to toilet). Addressing
the causes of such patterns may reduce or eliminate the
behaviour. Family members and an understanding of the
resident’s personal history may assist in making better
sense of the behaviour.
■ How did the behaviour develop over time? Were
problem signs evident earlier in the resident’s stay or
even earlier in the resident’s life?
■ Has resident experienced recent changes (e.g.
movement to a new home, assignment of new care
staff to the home, change in medication, withdrawal
from a treatment programme, decline in cognitive
status)?
Determine the ways in which behaviour
problems impinge on other functioning
Understanding that a behavioural problem can, but does
not always, interfere with a resident’s self-performance
and treatment is useful in considering the need for
interventions. This view can also help to ensure that
aggressive treatments or interventions (e.g. physical
restraints or antipsychotics) are not introduced simply to
keep the resident “looking normal”.
■ Does the behaviour endanger the resident? Others? If
so, in what ways does it endanger the resident or
others? What sort of risk is acceptable?
■ Are behaviour problems related to daily variations in
functional performance? If so, how?
■ Does behaviour problem lead to resistance to care?
■ Does it lead to difficulties dealing with people and
coping in the home?
Review of potential causes of behavioural
symptoms
Many behaviours, however, are problematic for the
resident or others. Many are directly associated with
acute health conditions, neurological diseases, or
psychiatric conditions. Still others originate in the
resident’s reaction to external factors, such as
psychotropic medications, the use of physical restraints,
and stressors in the environment (e.g. loud noises,
RAP 9
changes in familiar routines). Identifying the various
factors involved in the presentation of behavioural
symptoms is critical. Such a process may reveal
conditions that can be resolved, thus eliminating or
reducing the behavioural symptoms. Further, distin-
guishing among potential causes or inter-relationships is
essential to developing an appropriate care plan.
Consideration of the items in the Behavioural Symptoms
RAP OVERVIEW (as well as in related RAPs as
indicated) should facilitate this process.
Cognitive status problem interactions
Decision-making ability is a key indicator of effective
cognitive skills. Resolving acute confusion, a potentially
reversible problem, can be critical to behaviour
management. (See Acute Confusional State RAP if a
diagnosis or signs and symptoms of acute confusional
state are present.)
For many residents with chronic progressive dementia,
certain behaviours may continue in spite of remedial
treatments or interventions. In some instances, the
behaviours will be distressing; however, in many
instances behaviours can be accommodated. For
example, many residents who wander can be accommo-
dated in a hazard-free environment. Similarly, the needs
and behaviour patterns of demanding residents can often
be anticipated and the most disrupting reactions to the
distress alleviated. The Cognitive Loss/Dementia RAP
refers to several issues that can be considered for such
residents. Thus, that RAP should be completed prior to
this RAP on behaviours for residents who have cognitive
problems.
Presence of mood and/or relationship problem
interactions
Mood and relationship problems often produce disturbed
behavioural symptoms. If the underlying problems are
resolved, the behaviour may lessen or stop.
■ Does the resident have an unresolved mood state or
relationship problem that may lead to behavioural
symptoms (e.g. anxiety disorder and agitation;
depression or isolation and verbally abusive
behaviour)? Refer to the Psychosocial Well-Being RAP
and to the Mood State RAP.
■ Is there an association between mood state,
relationship and behavioural symptoms?
■ Can a cause and effect relationship be determined?
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
■ Does the resident experience a sense of frustration
because of rejection by family? If so, does this
frustration result in the resident verbally abusing staff
or other residents?
Relationship difficulties that may affect
behaviour
■ Does the presence or absence of other persons
precipitate an event?
■ Was an aggressive act prompted by paranoid
delusions about another’s motives or actions?
■ Did recent loss of loved one, change in staff, a move,
or placement with a roommate with whom the
resident cannot communicate lead to disruptive
behavioural symptoms?
Environmental conditions
A review of the resident’s behaviours over time may, as
noted earlier, reveal patterns of behaviour that helps
identify the causes of the behaviours. Because
environmental conditions often have a profound effect
on a resident’s behaviours, these factors should be given
special consideration.
■ Are staff sufficiently responsive? Do they recognise
stressors for the resident and early warning signs of
problem behaviour?
■ Do staff follow the resident’s familiar routines?
■ Do noise, crowding or dimly lit areas affect resident’s
behaviour?
■ Are other residents physically aggressive?
Illness/conditions
Sometimes, the onset of acute illnesses and/or the
worsening of a chronic illness produces disturbed
behaviours. Often identification and treatment of the
illness will resolve the problem behaviour. In addition, a
resident with certain chronic conditions, particularly
difficulties in making his/her needs understood or in
understanding others may also exhibit problem
behaviours that can be eliminated or reduced if more
effective methods of communication are adopted by staff
and families. Sensory impairments (vision, hearing) may
also produce disruptive behaviours that would lessen or
disappear if the underlying condition were addressed.
■ Can physical health factors close in time to the
disturbed behaviour be identified (e.g. pain or
RAP 9
discomfort from physical conditions such as arthritis,
constipation, or headache)?
■ Can the observed behaviour be associated with an
acute illness (e.g. urinary tract infection, other
infections, fever, hallucinations/delusions, sleep
deprivation, fall with physical trauma, nutritional
deficiencies, weight loss, dehydration/insufficient
fluids, blood chemistry disorder, or low blood
pressure)?
■ Can the behaviour be associated with the worsening
of a chronic illness (e.g. congestive heart failure,
psychoses, Alzheimer’s disease or other dementia,
stroke or hypoglycaemia for a diabetic)?
■ What was the role of impaired hearing, vision, or
ability to communicate or understand others?
Current treatment/management procedures: positive and
negative consequences
A number of treatment or management interventions may
affect a resident’s behaviour. Some may have had a
positive effect, while others may exacerbate existing
behavioural symptoms - or produce new problems. Both
are important to consider in reaching a decision about
whether to proceed with a care plan intervention. For
example, review the resident’s interest in, use of, or
participation in psychological treatment programme(s).
This review will be especially important for residents who
have recently experienced improved behaviour. For some
residents and some management programmes,
continuation of treatments may be central to maintaining
their new-found control. In other cases, either the
interventions can be reduced (at least on a trial basis), or
the side effects of the intervention may be so severe that
alterations in the treatment plan should be considered. For
example, a drug programme may result in increased
confusion and agitation, reduced ADL self-performance, a
decline in mood, or a general decrease in the quality of
life for the resident. On the other hand, breaking tasks of
daily life down into smaller steps that the resident can
comprehend and perform may reduce stress and prevent
problem behaviour.
■ Has the resident been seen by a psychiatrist,
community psychiatric nurse, psychologist, etc.?
When?
■ Are there indicators that treatments have helped
resident gain increased control over life? What were
 Chapter 4: Completing the Resident Assessment Protocols (RAPs) RAP 9

they? Cognitive factors

■ Can improvement be attributed to an identifiable Acute confusional state

treatment? Alzheimer’s disease

■ If behavioural symptoms have decreased, can Other dementia

medication or behaviour management programmes Stroke
be withdrawn?
Mood or relationship problems
■ Is the onset or change of behaviours associated with Unsettled relationships
the start of (or change in prescription of) a Sad or anxious mood
medication(s)?
Psychiatric disorder
■ Is the behaviour associated with the use of a physical Recent loss
restraint, such as a bed rail, (e.g. increased agitation
and anger)? Environmental factors
Presence of stressful condition of an aggressive resident
■ Are there special staff training/support programmes
Change of routine
that focus on managing behavioural symptoms?
Staff responses
■ What disciplines are involved? How
frequent/consistent is the training? Illness/conditions
Onset of acute illness
■ Has task segmentation been used to maximise
resident involvement? Worsening of condition
Diabetes
OVERVIEW OF BEHAVIOURAL SYMPTOMS RAP
Congestive heart failure
GUIDELINES
Infection
Review and describe behavioural symptoms
Pneumonia
Evaluating the seriousness and stability/change of behav- Constipation
ioural symptoms Urinary tract infection
Duration Septicaemia
Intensity
Fever
Frequency
Pattern of behaviour Hallucinations
Development over time and effect on the resident and Delusions
others Pain
Change or start of new medication Fall with head trauma
Review of potential causes that could be addressed or Hearing/visual problem
resolved Making self understood/understanding others
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
RAP 10: Activities
PROBLEM
The Activities RAP targets residents whose inactivity may
be problematic and for whom a revised activity care plan
may be required. Resident capabilities may not be fully
recognised because the resident may have recently
moved into the home or the focus of care has been on
the resident’s daily living needs.
Resident involvement in passive activities, such as
watching television, can be as important as more active
pursuits in both the care home and the community. The
capabilities of the average resident have obviously been
altered as abilities and expectations change, disease may
occur, opportunities may become less frequent, and
extended social relationships less common. There is great
variability within the resident population. Although many
will have Activities of Daily Living (ADL) deficits, few will
be totally dependent. Many will have impaired cognition
but will still have the ability to apply old skills and learn
new ones. Sensory impairment may be common, but
some type of two-way communication is almost always
possible. Staff should remember that all residents are
individuals and should avoid stereotyping older people in
terms of amount and types of activities deemed suitable.
Activity planning is an important part of home life. The
types of cases that will be triggered are:
1. Residents who have indicated a desire for additional
activity choices.
2. Cognitively intact, distressed residents who may
benefit from an enriched activity programme.
3. Cognitively impaired, distressed residents whose
activity levels should be evaluated.
4. Highly involved residents whose health may be in
jeopardy because of their failure to “slow down.”
In evaluating triggered cases, staff should consider the
following questions:
■ Is inactivity disproportionate to the resident’s
physical/cognitive abilities or limitations? i.e. could the
resident be more actively involved in social or hobby
activities.
■ Have decreased demands of home life removed the
need to make decisions, to set schedules, to meet
challenges? Have these changes contributed to
resident apathy?
RAP 10
■ What is the nature of the naturally occurring physical
and mental challenges the resident experiences in
everyday life?
■ In what activities is the resident involved? Is he/she
normally an active participant in the life of the home?
Is the resident reserved, but actively aware of what is
going on around him/her? Or is he/she unaware of
surroundings and activities that take place?
■ Consider the extent to which the resident is fully and
happily participating in the activity?
■ Are there proven ways to extend the resident’s
inquisitive/active engagement in activities?
■ Might simple staff actions improve resident
involvement in activities? For example: Can
equipment be modified to permit greater resident
access? Can the resident’s location or position be
changed to permit greater access to people, views, or
programmes? Can time and/or distance limitations for
activities be made less demanding without destroying
the challenge? Can staff modes of interacting with the
resident be more accommodating, possibly less
threatening, to resident deficits?
TRIGGERS
Activities trigger A (revise)
Consider revising activity plan if one or more of
following present:
■ Involved in activities little or none of time [N2 = 2, 3]
■ Prefers change in daily routine [N5a = 1,2] [N5b =
1,2]
Activities trigger B (review)
Review of activity plan suggested if both of following
present:
■ Awake all or most of time in morning [N1a = ticked]
■ Involved in activities most of time [N2 = 0]
GUIDELINES
This section addresses factors that may impede resident
involvement in activities. Although many factors can play
a role, age as a valid impediment to participation can
normally be ruled out. If age continues to be linked as a
major cause of lack of participation, a staff education
programme may prove effective in remedying what may
be overprotective staff behaviour.
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
Issues to be considered as activity plan is
developed
Is resident suitably challenged/overstimulated?
To some extent, competence depends on environmental
demands. When the challenge is not sufficiently
demanding, a resident can become bored, perhaps
withdrawn, may resort to fault-finding and perhaps
display behaviour which is anti-social to relieve the
boredom. Eventually, such a resident may become less
competent because of the lack of challenge. In contrast,
when the resident lacks the competence to meet
challenges presented by the surroundings, he or she may
react with anger and aggressiveness.
■ Do available activities correspond to resident lifetime
values, attitudes, and expectations?
■ Does resident consider “leisure activities” a waste of
time - he/she never really learned to play, or to do
things just for enjoyment?
■ Have the resident’s wishes and prior activity interests
been considered by staff?
■ Have staff considered how activities requiring lower
energy levels may be of interest to the resident - e.g.
reading a book, talking with family and friends,
watching the world go by, knitting?
■ Does the resident have cognitive/functional deficits
that either reduce options or preclude involvement in
all/most activities that would otherwise have been of
interest to him/her?
Confounding problems to be considered
Health-related factors may affect participation in activities
Cardiac problems, an acute illness, reduced energy
reserves and breathing problems are some of the many
reasons that activity levels may decline. Most of these
conditions need not necessarily incapacitate the resident.
All too often, disease-induced reduction of activity may
lead to progressive decline through disuse, and further
decrease in activity levels. However, this pattern can be
broken: many activities can be continued if they are
adapted to require less exertion or if the resident is
helped, for example in adapting to a lost limb, decreased
communication skills, new appliances, and so forth.
■ Is resident suffering from an acute health problem?
■ Is resident hindered because of embarrassment/
RAP 10
unease due to presence of health-related equipment
(tubes, oxygen cylinder, colostomy bag, wheelchair)?
■ Has the resident recovered from an illness? Is the
capacity for participation in activities greater?
■ Has an illness left the resident with some disability
(e.g. slurred speech, necessity for use of stick/zimmer
frame/wheelchair, limited use of hands)?
■ Does resident’s treatment allow little time or energy
for participation in preferred activities?
Other issues to be considered
Recent decline in resident status – cognition,
communication, function, mood, or behaviour
When pathological changes occur in any aspect of the
resident’s competence, the pleasurable challenge of
activities may narrow. Of special interest are problematic
changes that may be related to the use of some
medications e.g. antidepressants, sedatives etc.
Compensatory strategies may be helpful, for example
task segmentation, or reserving energy for pleasurable
activities or those activities that have personal
significance.
■ Have staff or the resident been overprotective? Or
have they misread the seriousness of resident
cognitive/functional decline? In what ways?
■ Has the resident retained skills, or the capacity to
learn new skills, sufficient to permit greater activity
involvement?
■ Do staff know what the resident was like prior to the
most recent decline? Has the doctor/other staff offered
a prognosis for the resident’s future recovery, or
continued decline?
■ Is there any substantial reason to believe that the
resident cannot tolerate or would be harmed by
increased activity levels? What reasons support a
counter opinion?
■ Does resident retain any desire to learn or master a
specific new activity? Is this realistic?
■ Has there been a lack of participation in the majority
of activities which he/she stated a preference for, even
though these types of activities are provided?
Environmental factors
Environmental factors include recent changes in resident
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
location, home rules, season of the year, and physical
space limitations that hinder effective resident
involvement.
■ Does the interplay of personal, social, and physical
aspects of the home environment hamper
involvement in activities? How might this be
addressed?
■ Are current activity levels affected by the season of the
year or the nature of the weather?
■ Can the resident choose to participate in or to create
an activity?
■ Does resident prefer to be with others, but the
physical layout of the home gets in the way? Do other
features frustrate the resident’s desire to be involved in
the life of the home? What corrective actions are
possible? Have any been taken?
Changes in availability of family/friends/staff support
Many residents will experience not only a change in
residence but also a loss of relationships. When this
occurs, staff may wish to consider ways for a resident to
develop supportive relationships with other residents,
staff members or volunteers that may increase the desire
to socialise with others and/or to participate in activities
with new friends.
■ Has a staff member who has been instrumental in
involving a resident in activities left the home?
■ Is a new member in a group activity viewed by a
resident as taking over?
■ Has another resident who was a leader in the home,
died or left the home?
■ Is resident shy, unable to make new friends?
■ Does resident’s expression of dissatisfaction with
RAP 10
fellow residents indicate he/she does not want to be a
part of an activities group?
Possible confounding problems to be considered for
those now actively involved in activities
Of special interest are cardiac and other diseases that
might suggest a need to slow down.
OVERVIEW OF ACTIVITIES RAP GUIDELINES
Issues to be considered as activity plan is
developed
Expectations and wishes of resident
Resident’s normal routine
Boredom
Cognitive status
Walking/mobility
Medication (psychotropic)
Confounding problems to be considered
Unstable acute/chronic conditions
Performs tasks slowly and at different levels (reduced
energy reserves)
Cardiac dysrhythmias (heart beat irregularities)
High blood pressure
Stroke
Respiratory diseases
Pain
Other issues to be considered
Recent decline in mood or behaviour
Task segmentation
Reserving energy for pleasurable activities
Routine very different prior to entry to home
Recent loss of family/friends/member of staff
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
RAP 11: Falls
This protocol should be reviewed with a registered nurse
or the resident’s general practitoner
PROBLEM
Falls are a common source of serious injury and death
among the elderly. Moreover, most older people are
afraid of falling, and this fear can limit their activities. In a
study undertaken in the UK 15% of residents in
residential homes and 35% in nursing homes were
identified as being at severe risk of falling. Risk factors
that are internal to the resident include the resident’s
physical health and functional ability. External risk factors
include side effects of medication, the use of appliances
and restraints, and environmental conditions e.g. objects
left on the floor, loose rugs. Identification and assessment
of those who have fallen and those who are at high risk
of falling are the goals of this RAP.
Although it is obviously desirable to avoid serious injury
a low incidence of falls may not necessarily indicate good
care. Where residents are not allowed to take any risks,
rehabilitation and individual rights can be undermined.
TRIGGERS
Potential for additional falls [A] or risk of initial fall [R]
suggested if one or more of following present:
■ Fell in past month [A](c) [J4a = ticked]
■ Fell in past 1 to 6 months [A](c) [J4b = ticked]
■ Wandering [R](a) [E4aA = 1,2,3]
■ Dizziness/vertigo [R](c) [J1f = ticked]
■ Use of trunk restraint [R](b) [P4c = 1,2]
■ Use of anxiolytic drugs [R](d) [O4b = 1-7]
■ Use of antidepressant drugs [R](d) [O4c = 1-7]
(a) Note: This item also triggers on the Behavioural Symptoms RAP.
(b) Note: Code 2 also triggers on the Pressure Sore RAP. Both codes
trigger on the Physical Restraints RAP.
(c) Note: This item also triggers on the Psychotropic Drug Use RAP
(when psychotropic drugs present).
(d)
Note: When present with specific conditions, this item is part of
trigger on Psychotropic Drug Use RAP.
GUIDELINES
To reach a decision on a care plan, begin by reviewing
whether one or more of the major risk factors listed on
the RAP OVERVIEW are present. Clarifying information
RAP 11
on the nature of the risk or type of issue to be considered
follows.
Multiple falls
Is there a previous history of falls, or was the fall an
isolated event? Refer to the previous MDS assessment (if
available), reports of the family and incident/accident
reports.
Internal risk factors
Review to determine whether the items listed in the RAP
OVERVIEW under the following headings are present.
Each of these represents an underlying health problem or
condition that can cause falls and may be addressed so
as to prevent falls in the future.
■ Cardiovascular (heart conditions)
■ Neuromuscular/functional (e.g. mobility, Parkinson’s
disease)
■ Orthopaedic (e.g. osteoarthritis of hip/knee joint)
■ Perceptual (e.g. stroke, vision problems)
■ Psychiatric or cognitive (e.g. dementia)
External risk factors
These risk factors can often be modified to reduce the
resident’s risk of falls.
Medications
Certain drugs can produce falls by causing related
problems (low blood pressure, muscle rigidity, impaired
balance, other extrapyramidal side effects [e.g. tremors],
and decreased alertness). These drugs include:
antipsychotics, anxiolytics/hypnotics, antidepressants,
cardiovascular medications and diuretics.
■ Were these medications administered prior to or after
the fall?
■ If prior to the fall, how close to it were they first
administered?
Appliances and devices
■ If the resident who falls (or is at risk of falling) uses a
walking aid observe his/her use of the appliance for
possible problems, such as an incorrectly sized
appliance.
■ Review the previous MDS assessment and the
resident’s notes to determine whether restraints were
used prior to the fall and might have contributed to
the fall (e.g. by causing an increase in agitation).
 Chapter 4: Completing the Resident Assessment Protocols (RAPs) RAP 11

Environmental hazards modifications are needed

Many easily modifiable hazards (e.g. poor lighting, ■ Observe resident’s usual pattern of interaction with
patterned carpeting, poorly arranged furniture or slippery his/her environment - the way he/she gets out of bed,
floors) in the environment may cause falls both in walks, turns, gets in and out of chairs, uses the
relatively healthy and in frail elderly residents. bathroom. Observations may reveal environmental
For those who have fallen previously, review the solutions to prevent falls.
circumstances under which the fall occurred ■ Hip pads may be useful in reducing injury from falls.
Attempt to gather information on most recent fall. OVERVIEW OF FALLS RAP GUIDELINES
Useful information includes:
Consider risk factors:
■ Time of day, time since last meal.
Multiple falls
■ Was resident doing usual or unusual activity?
Internal risk factors
■ Was he/she standing still or walking? Reaching up or
Cardiovascular
down? Not reaching?
Cardiac dysrhythmia (irregular heart beat)
■ Was resident in a crowd of people? Responding to
bladder/bowel urgency? Functional
Loss of arm or leg movement
■ Was there glare or liquid on floors? Foreign objects in Decline in functional status
the way? New furniture placement or other changes in Incontinence
environment? Low blood pressure
■ Is there a pattern of falls in any of the above Stroke
circumstances? Hemiplegia/Hemiparesis
Parkinson’s disease
■ If you know what the resident was doing during the
Epilepsy
fall, have her/him perform that activity and observe
Fainting
(protect resident to ensure that a fall does not occur
Unsteady gait
during this test).
Orthopaedic
■ Did the resident’s clothing, such as ill fitting shoes,
Joint pain
contribute to the fall?
Arthritis
■ Was the resident trying to hurry to the toilet due to a Hip fracture
bladder problem? Osteoporosis
Amputation
Take necessary vital signs
■ At time of fall, obtain lying and standing blood Perceptual
pressure and heart rate (if registered practitioner Hearing loss
available) and if the resident does not have a serious Visual problems
injury such as a fracture of the hip or lower extremity. Dizziness/vertigo

■ When reproducing circumstances of a fall (e.g. if the Psychiatric

resident fell 10 minutes after eating a large meal, take Acute confusional state
vital signs 10 minutes after the resident eats). Cognitive decline
Alzheimer’s disease
■ Measure blood pressure and heart rate when the
Other dementia
resident is lying down and 1 and 3 minutes after
Manic depression
standing; note temperature and respiratory rate.
External risk factors
For residents at risk of future falls, review
environmental/situational factors to determine whether Medications
 Chapter 4: Completing the Resident Assessment Protocols (RAPs) RAP 11

Appliances Proximity to aggressive resident

Walking aid
Time of day
Review environmental/situational hazards and, if rele- Time since meal
vant, circumstances of recent fall(s)
Type of activities
Slippery floors
Uneven surface Standing still/walking in crowded area
Patterned carpets Reaching/not reaching
Poor lighting
Responding to bladder/bowel urgency
New arrangement of furniture
Recent move into/within the home Use of hip pads to reduce injury from falls
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
RAP 12: Nutritional Status
This protocol should be reviewed with a dietician,
registered nurse or the resident’s general practitioner.
PROBLEM
Eating and drinking are central to life, not only from the
perspective of maintaining health and well-being but also
as a means of socialising and for cultural and religious
reasons. It is therefore important that food is appetising,
nutritionally appropriate, and served attractively in
convivial surroundings with appropriate utensils and
equipment and tables and chairs of a correct height.
There may be age-related changes which decrease the
ability to taste food which may lead to poor nutrition.
The impact of nutrition on health and functioning is
profound. The ability to defend the body against disease,
think clearly and possess the energy and desire to engage
in social activity is determined to a large extent by
nutritional status. It is desirable to provide all the
elements for adequate nutrition in a balanced diet that
includes fibre, suitable carbohydrates, good quality
protein, vitamins and trace elements, fruit and
vegetables, adequate calcium and an avoidance of excess
fat.
Malnutrition is not a normal response to ageing, it has
many causes and is unlikely to result from an isolated or
single factor. Its presence may signal the worsening of a
life-threatening illness, and it should always be seen as a
dramatic indicator of decline. Severe malnutrition is,
however, relatively rare, and this RAP focuses on signs
and symptoms which suggest that the resident may be at
risk of becoming malnourished. For many residents who
are triggered by the RAP, there will be no obvious,
outward signs of malnutrition. Prevention is the goal, and
early detection is the key.
Recognising the problem early can help to ensure
appropriate nutritional intervention. Assessment and
documentation of nutritional status is vital. For many
residents, simple adjustments in feeding may be
sufficient. For others, food supplements may be required.
Adequate nutrition is best accomplished by eating regular
well-balanced meals. Tube feeding should be limited to
residents who are unable to consume sufficient food
orally to prevent major malnutrition or weight loss or
who are at risk of choking because of swallowing
difficulties. Parenteral (e.g. through a vein) feeding is
normally limited to life-saving situations where both oral
RAP 12
and tube feeding are contraindicated or inadequate to
meet nutritional needs. Depending on the nature of the
problem, residents can be encouraged to use finger
foods, to take small bites, to use the tongue to move food
in the mouth from side to side, to chew and swallow
each bite, to avoid food that causes mouth pain, etc.
Adapted utensils may be required to compensate for
problems in sucking, closing lips, or grasping utensils.
Residents with dementia may require prompting.
TRIGGERS
A malnutrition problem is suggested if one or more of
following are observed:
■ Weight loss [K3a = 1]
■ Taste alterations [K4a = ticked]
■ Leaves 25% or more food uneaten at most meals
[K4c = ticked]
■ Parenteral/IV feeding(a) [K5a = ticked]
■ Mechanically altered diet [K5c = ticked]
■ Syringe (oral feeding) [K5d = ticked]
■ Therapeutic diet [K5e = ticked]
■ Pressure sores(b) [M2a = 2, 3, or 4]
(a) Note: These items also trigger on the Dehydration/Fluid
Maintenance RAP.
(b) Note: These items also trigger on the Pressure Sores RAP
GUIDELINES
Resident factors that may impede ability to
consume/absorb food
Reduced ability to feed self
A resident’s ability to feed him/herself can be due to
arthritis, contractures, partial or total loss of voluntary
arm movement, hemiplegia (paralysis of one side of the
body) or quadriplegia (paralysis of all four limbs), vision
problems, inability to perform activities of daily living
without significant assistance, and coma.
Chewing problems
Residents with oral abscesses, ill-fitting dentures, teeth
that are broken, decayed, loose or missing, frequently
cannot eat enough food to meet their calorie and other
nutritional needs. Significant weight loss can, in turn,
result in poorly fitting dentures and infections that can
lead to more weight loss. Good oral care and referral for
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
regular dental checks are important.
Swallowing problems
Swallowing problems are associated with: the long-term
results of chemotherapy, radiation therapy, or surgery for
malignancy (including head and neck cancer); fear of
swallowing because of chronic chest problems (e.g.
COPD/emphysema/asthma); stroke; neurological deficits
such as hemiplegia or quadriplegia; Alzheimer’s disease
or other dementias. Particular skills are needed to feed
residents with swallowing problems and advice should be
sought from both a speech therapist and a dietician.
Losses from diarrhoea or an ostomy (e.g. ileostomy)
Possible medical causes
Numerous conditions and diseases affect nutritional
requirements (calories, protein, vitamins, minerals, water,
and fibre) or nutritional intake for residents.
Malignancy and nutritional consequences of chemothera-
py, radiation therapy/surgery
If a resident is undergoing therapy for a malignancy
which is aimed at remission or cure, aggressive nutritional
support is crucial. If, however, a resident has an
incurable malignancy and is undergoing palliative
therapy or is not responding to curative therapy, different
forms of nutritional support may be more appropriate.
Anaemia (iron deficiency)
Anaemia is a reduction in the haemoglobin concentration
in the blood that reduces its oxygen carrying capacity.
■ Are shortness of breath, weakness, paleness of
mucous membranes and nailbeds, and brittle spoon-
shaped nails present which may indicate anaemia?
Chronic Obstructive Pulmonary Disease (COPD)
This increases calorie needs and can be complicated by a
fear of choking when eating or drinking.
Shortness of breath
Frequently seen with congestive heart failure, high blood
pressure, oedema, and COPD/emphysema/asthma. This
may also cause a fear of eating and drinking, with a
consequent reduction in food intake.
Constipation/intestinal obstruction/pain
This can inhibit appetite.
Drug-induced anorexia
RAP 12
This often causes decreased or altered ability to taste and
smell foods.
Acute confusional state
Pain
Nausea and vomiting
Problems to be reviewed for possible
relationship to nutritional status
Eating environment
For most residents, enjoying food and mealtimes affects
quality of life.
■ Does the area in which meals are served lend itself to
socialisation among residents? Can conversation
easily take place?
■ Are there adequate staff and/or adequate time to
assist residents to eat at mealtimes?
■ Are residents positioned appropriately for eating?
■ Has the need for adapted utensils to promote
independence been recognised and is there
appropriate equipment such as non-slip mats and
adapted cutlery available for residents?
■ Are religious and cultural food practices and
preferences observed?
■ Is the resident capable of telling staff that he/she has a
problem with the food being served e.g. finds it to be
unappetising or unattractively presented?
Inability to communicate
Inability to make food and mealtime choices known can
result in a resident eating poorly, losing weight, and being
unhappy. Malnutrition due to poor communication
usually indicates substandard care. Early correction of
communication problems, where possible, can prevent
malnutrition.
Mental health problems
Various mental health problems can lead to anorexia,
resulting in significant amounts of uneaten food and
subsequent weight loss. These include: learning
disabilities, Alzheimer’s disease and other dementias,
depression, paranoid fears that food is poisoned,
delusions, hallucinations and obsessive compulsive
disorder.
Behaviour patterns and problems
 Chapter 4: Completing the Resident Assessment Protocols (RAPs) RAP 12

Residents who are fearful, who pace or wander, withdraw Problems to be considered which may influence nutri-
from activities, cannot communicate, or refuse to tional status
communicate, often refuse to eat or will eat only a
limited variety and amount of foods. Left untreated, Eating environment
behaviour problems that result in refusal to eat can cause
significant weight loss and subsequent Mental health problems
malnutrition. Learning disabilities
■ Does the resident use food to gain staff attention? Alzheimer’s disease

■ Is the resident able to understand the importance of Other dementia

eating? Depression

OVERVIEW OF NUTRITIONAL STATUS RAP Fear that food is poisoned

GUIDELINES Anxiety disorders
Factors which may affect ability to consume/absorb food
Behavioural problems
Unable to feed self
Wandering
Chewing problems
Swallowing problems Pacing
Ostomy losses Throwing food
Possible medical causes Slowness of eating
Diarrhoea Withdrawal
Cancer
Anaemia Communication
Pneumonia Comatose
Fever
Unable to express food and mealtime preferences
Shortness of breath
Nutrient/medications interactions Difficulty understanding others/being understood
Chemotherapy Aphasia
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
RAP 13: Feeding Tubes
This protocol should be reviewed by a registered nurse or
the resident’s general practitioner
PROBLEM
The complications and problems of feeding tubes are
known to be high and the benefits difficult to determine.
As a long-term treatment for individuals the effectiveness
of tube feeds requires careful evaluation.
Where residents have difficulty eating and staff have
limited time to assist them, insertion of feeding tubes for
the convenience of care staff is an unacceptable rationale
for use. The only rationale for such feedings is
demonstrated medical need to prevent malnutrition or
dehydration. Even here, all possible alternatives should
be explored prior to using such an approach for long-
term feeding, and restoration to normal feeding should
remain the goal throughout the treatment programme.
As a general rule, residents who are unable to swallow or
eat food and unlikely to eat within a few days, for
example after a stroke, should be assessed regarding the
need for a nasogastric tube or an alternative feeding
method.
In addition, a nasogastric tube may be necessary if
normal calorific intake is substantially impaired due to an
endotracheal tube or a tracheostomy.
This RAP and your goals for care should focus on
reviewing the status of the resident using tubes. The
Nutritional Status and Dehydration/Fluid Maintenance
RAPs focus on resident needs that may warrant the use
of tubes. To help clarify the latter issue, the following
guidelines indicate the type of review process required to
ensure that tubes are used in only the exceptional and
acceptable situation.
1. Assess causes of poor nutritional status that may be
identified and corrected as a first step in determining
whether a nasogastric tube is necessary (see
Nutritional Status RAP).
2. Determine the need for such a tube. Alternatives to
nasogastric tubes should always be considered. This
should be discussed with the resident’s GP.
3. Where possible, informed consent should be obtained
before inserting a nasogastric tube. Potential
advantages, disadvantages, and complications need
to be discussed. Resident preference is normally given
the greatest weight in decisions regarding tube
feeding. Where the resident is not competent the
RAP 13
doctor may have the responsibility for making a
decision regarding the use of tube feeding. In some
cases, when illness is terminal and/or irreversible,
technical means of providing fluids and nutrition can
represent extraordinary rather than ordinary means of
prolonging life.
4. Monitor for complications and correct/change
procedures and feedings when necessary. Periodic
changing of the nasogastric tube is necessary,
although the appropriate interval for changing tubes is
not clear. Assessment and determination of continued
need should be undertaken by a doctor before a tube
is reinserted.
TRIGGER
Consider efficacy and need for feeding tubes if:
■ Feeding tube present✳ [K5b = ticked]
✳Note: This item also triggers on the Dehydration/Fluid Maintenance
RAP
GUIDELINES
For residents on long term tube feeding a review of
nutritional status by a dietitian should always be
undertaken.
Complications of tube feeding
Serious potential negative consequences include
agitation, depression, mood disorders, self-extubation
(removal of the tube by the resident), infections,
aspirations, misplacement of tube in trachea or lungs,
pain, and tube dysfunction.
Infection in the trachea or lungs
Gastric organisms grow as a result of alkalising (raising)
the gastric pH. Gastric colonisation results in transmission
of gastric organisms to the trachea and the development
of nosocomial pneumonia. Symptoms of respiratory
infections to be monitored include coughing, shortness of
breath, fever, chest pain, respiratory arrest, acute
confusional state, confusion and seizures.
Aspiration of gastric organisms into the trachea and the
lungs
The incidence is difficult to determine, but most studies
suggest it is relatively high.
Inadvertent respiratory placement of the tube
Respiratory placement can occur in any patient, but is
most likely in those who are neurologically depressed,
 Chapter 4: Completing the Resident Assessment Protocols (RAPs) RAP 13

heavily sedated, unable to gag, or have an endotracheal
tube. Detecting such placement is difficult; the following
comments address this issue:
■ Radiology detection is the most definitive means to
detect tube displacement.
■ pH testing of gastric aspirates to determine whether a
tube is in the gastric, intestine, or the respiratory area
is a promising method for testing feeding tube
placement. However, parameters for various
secretions from the three areas have not yet been
clinically defined.
Complications for the cardiovascular systems
Symptoms of cardiac distress or arrest to be monitored
include chest pain, loss of heart beat, loss of
consciousness, and loss of breathing.
Other complications
Other complications include pain, nose bleeds,
pneumothorax, hydrothorax (fluid in the pleural cavity),
nasopharyngitis, oesophagitis, infection of the eustachian
tubes, oesophageal strictures, airway obstruction,
pharyngeal and oesophageal perforations. Symptoms of
respiratory infections should be reviewed.

■ Aspiration of visually recognisable gastrointestinal OVERVIEW OF FEEDING TUBES RAP

secretions, although a frequently used method of GUIDELINES
determining placement of tubes, is of questionable
Factors which may necessitate continued use of a feeding
value as the visual characteristics of secretions can be
tube
similar to those from the respiratory tract.
Stroke
■ Ausculatory method: although “shooshing” or Chewing/swallowing problems
gurgling sounds can indicate placement in the Mouth pain
stomach, the same sounds can occur when feeding (See Nutritional Status RAP 12 for further information on
tubes are inadvertently placed in the pharynx, conditions which may necessitate tube feeding)
oesophagus and respiratory tract. Although small-bore
tubes make the ausculatory method more difficult to Potential complications of tube feeding
use, large-bore nasogastric tubes may also be placed Agitation
inadvertently in the respiratory tract producing false Anxiety
gurgling. Depression
Recurrent lung aspirations
Prior to administering a tube feed it is vital to check that
Removal of tube by resident
the feeding tube is positioned correctly in the stomach.
Chest infections
This check should be carried out on each occasion food
Fever
is to be inserted.
Shortness of breath
Complications of gastric tract infections and Displacement of tube into lung
gastric problems Constipation
Symptoms include abdominal pain, abdominal Diarrhoea
distention, stress ulcers, and gastric hemorrhage. There is Faecal impaction
also a need to monitor for complications including Abdominal pain
diarrhoea, nausea and abdominal distension. Such Dehydration
complications signal the need for a change in the type of Respiratory problems
formula or diagnostic work for other conditions. Cardiac problems e.g. cardiac arrest
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
RAP 14: Dehydration/Fluid Maintenance
This protocol should be reviewed with a registered nurse
or the resident’s general practitioner
PROBLEM
On average, a person can live only four days without
water. Water is necessary for the distribution of nutrients
to cells, elimination of wastes, regulation of body
temperature, and countless other complex processes.
Dehydration is a condition in which water or fluid loss
(output) far exceeds fluid intake. The body becomes less
able to maintain adequate blood pressure, deliver
sufficient oxygen and nutrients to the cells, and rid itself of
wastes. Many distressing symptoms can originate from
these conditions, including:
■ Dizziness on sitting/standing (blood pressure insufficient
to supply oxygen and glucose to brain);
■ Confusion or change in mental status (decreased
oxygen and glucose to brain);
■ Decreased urine output (kidneys conserve water);
■ Decreased skin turgor, dry mucous membranes
(symptoms of dryness);
■ Constipation (water insufficient to rid body of wastes);
and
■ Fever (water insufficient to maintain normal
temperature)
Other possible consequences of dehydration include:
decreased functional ability, predisposition to falls
(because of postural hypotension), faecal impaction,
predisposition to infection, fluid and electrolyte
disturbances, and ultimately death.
Residents in care homes are particularly vulnerable to
dehydration. Often homes are overheated which can
exacerbate the problem. It is often difficult or impossible
to access fluids independently; the perception of thirst can
be muted; the aged kidney can have a decreased ability
to concentrate urine; and acute and chronic illness can
alter fluid and electrolyte balance.
Unfortunately, many symptoms of this condition do not
appear until significant fluid has been lost. Early signs and
symptoms tend to be unreliable and nonspecific; staff will
often disagree about the clinical indicators of dehydration
for specific cases; and the identification of the most crucial
symptoms of the condition are most difficult to identify
among the aged. Early identification of dehydration is
RAP 14
thus problematic, and the goal of this RAP is to identify
any and all possible high risk cases, permitting the
introduction of programmes to prevent the condition from
occurring.
When dehydration is in fact observed, your care plan
objectives should focus on restoring normal fluid volume,
preferably orally. If the resident cannot drink between 2.5
to 3 litres every 24 hours, water and electrolyte deficits
can be made up via other routes. Fluids can be
administered intravenously, subcutaneously, or by tube
until resident is adequately hydrated and can take and
retain sufficient fluids orally.
TRIGGERS
Dehydration suggested if one or more of following
present:
■ Dehydration [J1c = ticked]
■ Insufficient fluid/did not consume all liquids provided
[J1d = ticked]
■ UTI [I2j = ticked]
■ Dehydration diagnosis [I3 = noted]
■ Weight fluctuation of 3+ pounds [J1a = ticked]
■ Fever [J1h = ticked]
■ Internal bleeding [J1j = ticked]
■ Parenteral/IV(a) [K5a = ticked]
■ Feeding tube(b) [K5b = ticked]
■ Taking diuretic [O4e = 1-7]
(a) Note: This item also triggers on the Nutritional Status RAP
(b) Note: This item also triggers on the Feeding Tube RAP
GUIDELINES
Resident factors that may impede ability to
maintain fluid balance
Moderate/severely impaired decision-making ability
■ Has there been a recent unexplainable change in
mental status?
■ Does resident seem unusually agitated or disoriented?
■ Is resident confused?
■ Is resident comatose?
Comprehension/communication problems
■ Does dementia, aphasia or other condition seriously
 Chapter 4: Completing the Resident Assessment Protocols (RAPs) RAP 14

limit resident’s understanding of others, or how well
others can understand the resident?
Body control problems
■ Does resident require extensive assistance to transfer?
■ Does resident freely move in the home?
Frequent use of laxatives, enemas, diuretics
Excessive urine output (polyuria)
Excessive urine output (polyuria) may be due to:
■ Drugs (e.g. overuse of diuretics, lithium, phenytoin),
alcohol abuse

■ Has there been recent ADL decline? ■ Disease (e.g. diabetes mellitus, diabetes insipidus)

Hand dexterity problem Other test results

■ Can resident grasp cup? Relevant test result to be considered:

Bowel problems ■ Does systolic/diastolic blood pressure drop 20 points

■ Does the resident have constipation or a faecal on sitting/standing?
impaction that may be interfering with fluid intake? ■ On inspection, do oral mucous membranes appear
dry?
Swallowing problems
■ Does resident have mouth sore(s)/ulcer(s)? ■ Does urine appear more concentrated and/or
decreased in volume?
■ Does resident refuse food, meals or medication?
■ Can resident drink from a cup or suck through a Home environment
straw? ■ Is the resident able to reach drinks?

■ Is the resident able to choose drinks he or she prefers?

Use of parenteral/IV
■ Are feeding tubes in use? OVERVIEW OF DEHYDRATION/FLUID MAINTENANCE
RAP GUIDELINES
Resident dehydration risk factors
Dehydration risk factors can be categorised in terms of Review the following as possible factors that impede fluid
whether they decrease fluid intake or increase fluid loss. maintenance
The higher the number of factors, the greater the risk of Indicators of acute confusional state
dehydration. Ongoing fluid loss through the lungs and Moderate/severely impaired decision making ability
skin occurs at a normal rate of approximately 500 mls/day Comprehension/communication problems
and increases with rapid respiratory rate and sweating. Body control problems
Therefore, decreased fluid intake for any reason can lead Hand dexterity problems
to dehydration. Constipation
Purposeful restriction of fluid intake Faecal impaction
■ Has there been a decrease in thirst perception? Swallowing problems
Recent (within last 7 days) deterioration of Activities of
■ Is resident unaware of the need to intake sufficient Daily Living (ADL) function
fluids?
Dehydration risk factors
■ Has resident or staff restricted intake to avoid urinary
Purposeful restriction of fluids
incontinence?
Diarrhoea
■ Are fluids restricted because of diagnostic procedure or Infection
other health reason? Fever
■ Does sad mood, grief, or depression cause resident to Nausea/vomiting
refuse foods/liquids? Excessive sweating
Excessive urine output
Presence of infection, fever, vomiting/diarrhoea/ Frequent laxative, enema, diuretic medication
nausea, excessive sweating (e.g. a heat wave) Environment/resident preferences
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
RAP 15: Dental Care
PROBLEM
Having teeth/dentures that function properly is an
important requisite for maintaining adequate food intake.
Having teeth/dentures that are clean and attractive can
promote a resident’s positive self-image as well as
personal appearance thereby enhancing social interactions
among residents, residents and staff, and residents and
visitors. Good oral health can decrease a resident’s risk of
oral discomfort and in some instances, systemic illness
from oral infections/cancer. Residents at greatest risk due
to impaired abilities are primarily those with multiple
medical conditions and medications, functional limitations
in self-care, and communication deficits. Also at risk are
more self-sufficient residents who lack motivation or have
no consistent history of performing oral health functions.
Residents with a history of alcohol and/or tobacco use
have a greater risk of developing chronic oral lesions.
TRIGGERS
Dental care or oral health problem suggested if:
■ Mouth debris (dental care) [L1a = ticked]
■ Less than daily cleaning of teeth/dentures (dental care)
[L1f = not ticked]
■ Mouth pain (oral health) [K1c = ticked]
■ Some/all natural teeth lost and does not have or does
not use dentures (oral health) [L1c = ticked]
■ Broken, loose or carious teeth (oral health) [L1d =
ticked]
■ Inflamed gums, oral abscesses, swollen/bleeding gums,
ulcers, rashes (oral health) [L1e = ticked]
GUIDELINES
Confounding problems
Debris on teeth, gums, and oral tissues may consist of
food and bacteria-laden plaque that can begin to decay
teeth or cause bad breath if not removed at least once
daily. The purpose of this section is to examine
confounding problems which may make it difficult for
residents to clean their teeth properly.
Impaired cognitive skills
■ Does the resident need reminders to clean his/her
teeth/dentures?
■ Does he/she remember the steps necessary to
complete oral hygiene?
RAP 15
■ Would he/she benefit from task segmentation or
supervision?
Impaired ability to understand
■ Can the resident follow verbal directions or
demonstrations for mouth care?
■ If the resident has language difficulties, does he/she
know what to do when handed a
toothbrush/toothpaste and placed at the bathroom
sink?
Impaired vision
■ Is resident’s vision adequate for performing mouth
care or checking its adequacy?
Impaired personal hygiene
■ Did the resident receive supervision or assistance with
oral/dental care during the last 7 days?
■ Has he/she been assessed to see if he/she could do it
independently?
■ Does the resident have partial/total loss of voluntary
arm movement or impaired hand dexterity that
interferes with self-care?
■ What would the resident need to be more
independent?
Resists ADL assistance
Does the resident resist mouth care? If so, why (e.g. would
rather do own care, painful mouth, apathy related to
depression, not motivated - never cared for teeth/mouth,
approach of staff, fear, agitation secondary to dementia)?
Resident who is independent in oral/dental care but still has
debris or performs care less than daily
■ Is he/she brushing adequately?
■ Does he/she know that it is most important to brush
near the gum line?
■ Does he/she need to be shown how or be given
reinforcement for maintaining good hygiene?
Adaptive equipment for oral hygiene
■ Has the resident tried or would he/she benefit from
using a built-up, long-handled, or electric toothbrush
for cleaning teeth?
■ If resident has dentures, does he/she have denture
cleaning devices (e.g. denture brush, soaking bath)?
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
Dry mouth from dehydration or medications
■ Dry mouth can contribute to the formation of debris.
Are the resident’s lips, tongue, or mouth dry, sticky, or
coated with film?
■ Is the resident taking enough fluids? Is lip balm being
applied to resident who has painful, cracking or
bleeding lips?
■ Is he/she taking any medications that can cause dry
mouth (e.g. decongestants, antihistamines, diuretics,
antihypertensives, antidepressants, antipsychotics)?
■ If these medications are necessary, has the resident
tried mouth wash, sugar free mints and sweets?
Treatment history and other relevant factors
Mouth pain or sensitivity can be related to either minor
and easily treatable (e.g. gum irritation from ill-fitting
dentures, localised periodontal problem) or more serious
problems (e.g. oral abscess, cancer, advanced tooth decay
or periodontal disease). The presence of pain may
prevent the resident from eating adequately.
Residents with cognitive impairment and/or those who
have difficulty making their needs known are difficult to
assess. They may not complain specifically of mouth pain
but may instead have decreased food intake or changes
in behaviour.
The presence of lesions, ulcers, inflammation, bleeding,
swelling, or rashes may be representative of a minor
problem (e.g. irritation from wearing dentures for 24
hours/day), which resolves when the cause is alleviated
(e.g. combination of mouth care and leaving dentures
out). However, these signs may also indicate more serious
problems, even dental emergencies (e.g. infection). A
dental consultation should be considered if these signs are
accompanied by pain, fever or swollen glands and/or
signs of local infection, chewing or swallowing problems,
or changes in mental status or behaviour OR if the
problem does not resolve with specific local treatment
after a couple of days.
Review mouth for thrush (white areas that appear to be
removable anywhere in mouth, mostly on tongue) for
lethargic residents who have one or more of following
diagnoses: stroke, Alzheimer’s disease, Parkinson’s
disease, anxiety disorder, depression, diabetes,
osteoporosis, or septicaemia, or are receiving antibiotic
treatment.
RAP 15
Broken, loose, or carious teeth may progress to more
severe problems (e.g. dislodging a decayed tooth and
swallowing or aspirating it). Therefore a dental
consultation should be considered.
If a resident has lost some or all of his/her natural teeth
and does not have dentures (or partial plates) staff should
consider if the resident has the cognitive ability and
motivation to wear dentures.
■ Has a dentist reviewed the resident for dentures?
■ Why doesn’t resident use his/her dentures (or partial
plates)?
■ Are teeth in good repair?
■ Do they fit well?
■ Are they comfortable to wear when eating or talking?
■ Does the resident like the way he/she looks when
wearing them?
■ Has a dental hygienist reviewed and made
recommendations regarding oral hygiene care?
Examination by dentist since problem noted
When evaluating a resident with mouth pain or the
presence of any of the other trigger signs, check the
record to see if a dentist has examined the resident since
the problem was first noted.
■ Was the current problem addressed?
■ What were the recommendations?
OVERVIEW OF DENTAL CARE RAP GUIDELINES
Confounding problems which make it difficult for resi-
dents to clean their teeth properly
Impaired cognitive skills
Impaired ability to understand
Impaired vision
Impaired personal hygiene
Resists ADL assistance
No special equipment for oral hygiene
Dry mouth caused by dehydration/medication
Treatment history and other relevant factors
Mouth pain or sensitivity
Presence of lesions, ulcers, inflammation, bleeding,
swelling or rashes
Broken, loose or carious teeth
No dentures
Examination by dentist since problem noted
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
RAP 16: Pressure Sores
Review this protocol with a registered nurse and/or the
resident’s general practitioner
PROBLEM
Pressure sores (also known as bedsores, decubitus ulcers
and pressure ulcers) are areas of localised damage to the
skin and underlying tissue caused by pressure, shear or
friction. They usually occur over bony prominences such
as the sacrum, heels, hips and elbows, most often in
immobile older people. Pressure sores are commonly
graded using the following criteria:
Stage 1. A persistent area of skin redness (without a
break in the skin) that does not disappear when pressure
is relieved.
Stage 2. A partial thickness loss of skin layers that
presents clinically as an abrasion, blister, or shallow
crater.
Stage 3. A full thickness of skin is lost, exposing the
subcutaneous tissues - presents as a deep crater with or
without undermining adjacent tissue.
Stage 4. A full thickness of skin and subcutaneous tissue
is lost exposing muscle or bone.
Pressure sores can have serious consequences for older
people and are costly and time consuming to treat.
However, they are one of the most common, preventable
and treatable conditions among older people who have
restricted mobility. Successful outcomes can be expected
with preventive and treatment programmes.
Assessment goals should be: (1) to ensure that a
treatment plan is in place for residents with pressure
sores; and (2) to identify residents at risk of developing a
pressure sore who are not currently receiving any
preventive care.
TRIGGERS
Pressure sore present [P] or there is a risk of occurrence
[R] if one or more of following present:
■ Pressure sore(s) present [P] [M2a = 1,2,3,4](a)
■ Bed mobility problem [R] [G1aA = 2,3,4,8](b)
■ Bedfast [R] [G6a = ticked]
■ Bowel incontinence [R] [H1a = 1,2,3,4]
■ Peripheral vascular disease [R] [I1j = ticked]
■ Previous pressure sore [R] [M3 = 1]
RAP 16
■ Skin desensitised to pain or pressure [R] [M4e =
ticked]
■ Daily trunk restraint [R] [P4c = 2](c)
Good practice would also suggest that bladder
incontinence and poor nutrition should be considered.
(a) Note: Codes 2, 3, and 4 also trigger on the Nutritional Status RAP
(b) Note: Codes 2, 3, and 4 also trigger on the ADL RAP
(c) Note: This code also triggers on the Falls and Physical Restraint
RAP
GUIDELINES
Review the MDS items listed on the RAP OVERVIEW to
gain an understanding of the type of care that may be
required.
Diagnoses, conditions and treatments that
present complications
There are several pressure sore risk scales which may
help to identify those residents most at risk (Waterlow,
1991; Norton et al 1975). However, these are not the
only means of monitoring residents and do not replace
clinical judgement. The following conditions and
treatments may either place residents at higher risk of
developing pressure sores or complicate their treatment.
Diabetes
Alzheimer’s disease and other dementias
Impairment in cognitive ability, particularly in severe
dementia, can lead to immobility.
Oedema
The presence of extravascular fluid can impair blood
flow. If prolonged or excess pressure is applied to an area
with oedema, skin breakdown can occur.
Antidepressants and anxiolytics/hypnotics
These medications can produce or contribute to lessened
mobility, worsen incontinence, and lead to or increase
confusion.
Interventions/programmes to consider if the
resident develops a new pressure sore, or a pressure sore
being treated is not resolved
A variety of factors may be responsible but current
interventions should always be evaluated and the care
plan modified as appropriate. It should be noted that
although pressure sores are commonly referred to as bed
sores residents are equally at risk if they are sitting for
 Chapter 4: Completing the Resident Assessment Protocols (RAPs) RAP 16

long periods in a chair. Older people at risk of pressure OVERVIEW OF PRESSURE SORES RAP
sores could be provided either with a low pressure foam GUIDELINES
mattress, or if at higher risk, with a large celled
Other factors to consider that influence or complicate
alternating pressure mattress or a low air loss or air-
treatment of pressure sores and/or risk of pressure sores:
fluidised bed.

■ Review the resident’s physical condition, medications, Diagnoses or conditions

and other risk factors to determine whether the care Diabetes
plan (for prevention or cure) addresses all potential Alzheimer’s disease/other dementia
causes or complications. Hemiplegia/hemiparesis
■ Review the care plan to determine whether it is being Multiple sclerosis
followed (e.g. is the resident’s position in bed or chair Oedema
being changed often enough to prevent pressure sores
developing). Intervention programmes
Pressure relieving mattress/chair cushion/bed
Things to consider if the resident is at risk for pressure
Turning repositioning programme
sores but is not receiving preventive skin care
Nutrition and/or hydration programme
Even if the resident does not have pressure sores you
should determine why no preventive intervention is being Wound care
provided. Application of prescribed treatments
Preventative or protective skin care
■ Is the resident new to the home?

■ Do few or many risk factors for the development of Medications

pressure sores apply to this resident? Antipsychotics
■ Are staff concentrating on other problems (e.g. Anxiolytics
resolution of behaviour problems) so that the risk of Antidepressants
pressure sores is being masked? Hypnotics
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
RAP 17: Psychotropic Drug Use
This protocol should be reviewed with resident’s general
practitioner and/or community psychiatric nurse
PROBLEM
Psychotropic (e.g. sedative hypnotic) drugs are often
prescribed for the elderly. When used appropriately and
judiciously, these medications can enhance the quality of
life of residents who need them. However, all
psychotropic drugs have the potential for producing
undesirable side effects or aggravating existing
conditions. For example, acute confusional state can be a
side effect of psychotropic medications. The severity of
this is related to the class and dosage of drug,
interactions with other drugs and the age, and health
status of the resident.
Care goals should focus around maximising the resident’s
functional potential and well-being while minimising the
hazards associated with drug side effects. In reviewing a
psychotropic drug regime there are several rules of
thumb:
■ The need for the drug should be evaluated (e.g.
consider amount and type of distress, response to
nonpharmacologic interventions, pros and cons of drug
side effects in relation to distress without the drug).
■ If needed, psychotropic drugs should be started at
lowest dosage possible. To minimise side effects,
doses should be increased slowly until either there is a
therapeutic effect, side effects emerge, or the
maximum recommended dose is reached.
■ Each drug has its own set of actions and side effects,
some more serious than others. These should be
evaluated in terms of each user’s medical-status
profile, including interaction with other medications.
■ Consider symptoms or decline in functional status as
a potential side effect of medication.
TRIGGERS
To be triggered, resident must first be taking a
Psychotropic Drug [Anti-psychotic, antidepressant, or
anxiolytic] [O4a,b, or c = 1-7]. If a psychotropic drug is
being taken and in addition one or more of following are
present continue working through the guidelines to
review medication.
Potential for drug-related low blood pressure or gait dis-
turbances if:
RAP 17
■ Repetitive physical movement(a) [E1n = 1,2]
■ Balance while sitting [G3b = 1,2,3]
■ Low blood pressure [I1i = ticked]
■ Dizziness/vertigo(b) [J1f = ticked]
■ Fainting [J1m = ticked]
■ Unsteady gait [J1n = ticked]
■ Fell in past month(b) [J4a = ticked]
■ Fell in past 1 – 6 months(b) [J4b = ticked]
■ Hip fracture [J4c = ticked]
■ Swallowing problem [K1b = ticked]
Potential for drug-related cognitive/behavioural impair-
ment if:(c)
■ Acute confusional state/disordered thinking
– Easily distracted [B5a = 2]
– Periods of altered perception or awareness of
surroundings [B5b = 2]
– Episodes of disorganised speech [B5c = 2]
– Periods of restlessness [B5d = 2]
– Periods of lethargy [B5e = 2]
– Mental function varies over the course of the day
[B5f = 2]
■ Deterioration in cognitive status(c) [B6 = 2]
■ Deterioration in communication [C7 = 2]
■ Deterioration in mood(c) [E3 = 2]
■ Deterioration in behavioural symptoms(c) [E5 = 2]
■ Depression [I1ee = ticked]
■ Hallucinations [J1i = ticked]
Potential for drug related discomfort if:
■ Constipation [H2b = ticked]
■ Faecal impaction [H2d = ticked]
■ Lung aspiration [J1k = ticked]
(a) Note: This item also triggers on the Mood RAP
(b) Note: These items also trigger on the Falls RAP
(c) Note: All of these items also trigger on the Acute Confusional State
RAP
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
GUIDELINES
If any of the triggered conditions are present complete
the following:
Step one
Conduct the following reviews:
1. Drug review [from record]
■ Length of time between when the drug was first taken
and onset of problem
■ Dose of drug and how frequently taken
■ Number of psychotropics taken
■ Reason drug prescribed
2. Review resident’s conditions that impair drug metabo-
lism/excretion
■ Acute condition(s)
■ Dehydration
3. Review behaviour/mood/psychiatric status
■ Current problem status
■ Recent changes in mood and behaviour
■ Behaviour management programme
■ Psychiatric conditions
Step two
It is important that the presence of any side effects are
reported to the resident’s general practitioner, psychiatrist
or community psychiatric nurse as a change of drug
regime may be necessary. Compare the drugs the
resident is currently taking with common side effects
listed below.
Clarifying information if drug related low blood pressure
present
Postural hypotension (decrease in blood pressure upon
standing) is one of the major risk factors for falls related
to psychotropic drugs. It is commonly seen with the low-
potency anti-psychotic drugs (e.g. Largactil, Melleril) and
with tricyclic antidepressants. Both classes of drugs have
anticholinergic properties - symptoms include dry mouth,
constipation, urinary retention, blurred vision, agitation
and restlessness, and confusion. Within each class of
these drugs those with the most potent anticholinergic
properties also seem to produce the greatest hypotensive
effects. Symptoms of dizziness/vertigo upon sitting or
standing from a lying position, fainting, and
falls/fractures, should be seriously considered as potential
RAP 17
indicators of psychotropic-drug-induced hypotension. In
addition, these symptoms may be due to a disturbance of
heart rhythm, which could be aggravated by a tricyclic
antidepressant. The occurrence of any of the
aforementioned symptoms requires assessment of
postural vital signs and heart rhythm by a qualified nurse
or doctor.
Clarifying information if drug related movement disorder
present
High fever AND/OR muscular rigidity. Anti-psychotic
drugs can interfere with temperature regulation, which
can lead to the potentially fatal problem of hyperthermia.
When high fever is accompanied by severe muscular
rigidity the condition of “neuroleptic malignant”
syndrome must be suspected. Antidepressants with
anticholinergic properties may also aggravate fever by
impairing sweating.
Parkinson’s disease. This condition is known to be
aggravated by all anti-psychotic drugs. At times, it is
difficult to know whether parkinsonian symptoms (e.g.
tremors, especially of hands; pill-rolling of hands; muscle
rigidity of limbs, necks, trunk) are due to Parkinson’s
disease or to present or recent anti-psychotic drug
therapy. There should be a strong bias in favour of
reducing or eliminating anti-psychotic drugs in residents
with Parkinson’s disease unless there are compelling
behavioural or psychotic indications. Antiparkinson drugs
should be considered when anti-psychotic drugs are
clinically necessary in residents with Parkinson’s disease.
Five movement disorders are commonly encountered in
residents on anti-psychotic drugs. All of these
disturbances can adversely affect a resident’s quality of
life as well as increase his/her risk of accidents. To clarify
whether the resident is suffering from one of these
disorders, all residents on anti-psychotic drugs should be
periodically screened for the following conditions:
1. Parkinsonism. As with Parkinson’s disease, this
condition may involve ANY combination of tremors,
postural unsteadiness, and rigidity of muscles in the
limbs, neck, or trunk. Although the most common is a
pill-rolling or alternating tremor of the hands, other kinds
of tremors are occasionally seen. At times, a resident with
Parkinsonism will have no tremor, only rigidity and
shuffling gait.
2. Akinesia. This condition is characterised by marked
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
decrease in spontaneous movement, often accompanied
by nonparticipation in activity and self-care.
3. Dystonia. This disorder is marked by holding of the
neck or trunk in a rigid, unnatural posture. Usually the
head is either hyperextended or turned to the side.
4. Akathisia (the inability to sit still). The resident with this
disorder is driven to constant movement, including
pacing, rocking, or fidgeting, which can, at times persist
for weeks, even after the anti-psychotic drug is stopped.
5. Tardive dyskinesia (persistent, sometimes permanent
movements induced by long-term anti-psychotic drug
therapy). Most typical are thrusting movements of the
tongue, movements of the lips, or chewing or puckering
movements. These involuntary movements can clearly
interfere with chewing and swallowing.
Other variations of tardive dyskinesia include abnormal
limb movements, such as peculiar and recurrent postures
of the hands and arms, or rocking or writhing trunk
movements. There is no consistently effective treatment.
Withdrawal of the anti-psychotic drug leads to eventual
reversal of the symptoms over many months, in about
50% of cases.
Clarifying information if drug related gait
disturbance present (other than that induced by anti-psy-
chotics as described above)
Long-acting benzodiazepine anxiolytic drugs (e.g.
Valium) have been implicated in increasing the risk of
falls and consequent injury by producing disturbances of
balance, gait, and positioning ability. They also produce
marked sedation, often manifested by short-term
memory loss, decline in cognitive abilities, slurred
speech, drowsiness in the morning, daytime sedation,
and little/no activity involvement.
Clarifying information if drug related cognitive/behaviour
impairment present
Acute confusional state. Acute confusional state can be
caused or aggravated by psychotropic drugs of any of the
major classes. If the resident does not have acute
confusion related to a medical illness or severe
depression consider the psychotropic drug as a cause.
The most helpful information in establishing a
relationship is the linkage between starting the drug and
the occurrence of the change in cognitive status.
Depression. Both anxiolytic and anti-psychotic drugs may
RAP 17
cause symptoms of depression as a side effect, or may
aggravate depression in a resident with a depressive
disorder who receives these drugs rather than specific
antidepressant therapy.
Hallucinations/delusions. While these are often symptoms
of mental illness, all of the major classes of psychotropic
drugs can actually produce or aggravate hallucinations.
Visual hallucinations in the aged are virtually always
indicative of brain related disturbance (e.g. acute
confusional state) rather than a psychiatric disorder.
Major differences in AM/PM self-performance. All classes
of psychotropic drugs can have an effect on a resident’s
ability to perform activities of daily living. Establishing a
link between the time a drug is taken and the change in
self-performance is helpful in evaluating the problem.
Decline in cognition/communication. Decline in these
areas signals the possibility that this is drug-induced and
there is a need to review the relationship of the decline
with the start or change in drug therapy. While memory
loss in home residents is caused most frequently by
dementia and other neurologic diseases, all major classes
of psychotropics can cause impairment of memory and
other cognitive skills. In contrast, appropriate treatment of
depression or psychosis can actually improve memory,
which is very much disrupted by severe psychiatric
illness.
Decline in mood. (See reference to depression above.)
Decline in behaviour. Problem behaviours may be
aggravated and worsened by psychotropic drugs as they
can contribute to confusion, perceptual difficulties, and
agitation.
Decline in ADL status. Drug side effects must always be
considered if a resident becomes more dependent in
ADLs. In addition, psychotropic drugs can precipitate or
worsen bladder incontinence either through a change in
cognition or through a direct action on bladder function.
Clarifying issues if drug-related discomfort
present
Dehydration; reduced dietary bulk; lack of exercise.
Constipation/faecal impaction. Any psychotropic drug
with anticholinergic effects can cause or aggravate con-
stipation; the effects are pronounced with tricyclic antide-
pressants and with low-potency anti-psychotic drugs.
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
Milder cases of constipation can be treated with stool sof-
teners, bulk-forming agents, and increased fluid.
Anxiolytic drugs can contribute to constipation if they
sedate the resident to the point that fluid intake or exer-
cise is impaired.
Urinary retention. This condition may be manifested by
the inability to urinate, or new onset or worsening of
urinary incontinence (caused by overflow of urine from a
full bladder that cannot empty properly). Any
psychotropic drug with anticholinergic properties can
produce or aggravate urinary retention.
Dry mouth. This symptom is a common side effect of any
psychotropic drug with anticholinergic properties. Dry
mouth can aggravate chewing and swallowing problems.
The use of a mouth wash, sugar-free mints or sweets may
help.
OVERVIEW OF PSYCHOTROPIC DRUG USE RAP
GUIDELINES
If RAP triggered, review the following
Drug review
Length of time between when drug first taken and onset
of problem
Doses of drug and how frequently taken
Number of classes of psychotropics taken
Reason drug prescribed
Review resident’s conditions that affect drug metabo-
lism/excretion
Acute condition
Dehydration
Review behaviour/mood status
Current problem status
Recent changes
Behaviour management programme
Psychiatric conditions
Clarifying information if drug related low blood pressure
present
Postural changes in vital signs (e.g. blood pressure)
Drugs with marked anticholinergic properties
Clarifying information if drug related movement disorder
RAP 17
present
High fever AND/OR muscular rigidity
Tremors, especially of hands. (Parkinsonism)
Marked decrease in spontaneous movement (Akinesia)
Rigid, unnatural, uncomfortable posture of neck or trunk
(Dystonia)
Restlessness, inability to sit still (Akathisia)
Persistent movements of the mouth AND/OR peculiar
and recurrent postures of limbs, trunk (Tardive
Dyskinesia)
Clarifying information if drug related gait
disturbances present (other than induced by antipsy-
chotics)
Long acting benzodiazepines - recent dosage increase
Short term memory loss or decline in cognition
Slurred speech
Decreased morning wakefulness
Daytime sedation
Little or no activity involvement
Clarifying information if drug related cognitive/
behavioural impairment present
If neither of following are present, psychotropic drug side
effects can be considered as a major cause of problem:
Acute confusion related to medical illness
Depression
Clarifying issues if drug-related discomfort present
Dehydration
Reduced dietary bulk
Lack of exercise
Constipation
Faecal impaction
Urinary retention
Dry mouth
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
RAP 18: Physical Restraints
This protocol should be reviewed with a registered nurse
PROBLEM
In broad terms restraint means restricting someone’s
behaviour to prevent harm, either to the person being
restrained or to other people. The use of restraint is always an
emotive issue. There are those who argue for its complete
abolition and those who favour it as the only means to ensure
the safety of a resident, the staff or other residents. Staff
cannot remove all risks from a resident’s life and it is not
acceptable for example, to immobilise a resident in a chair
with a table over it all day just in case they fall over. Restraint
should only be used for short periods and as a final resort
when all other measures for preventing harm have been tried.
Methods often used for restraining people include bedsides,
sedative drugs, inappropriate use of night-clothes during
waking hours and arranging furniture to impede movement. It
is important to make clear why a particular form of restraint is
being used in a given situation. Use of restraints should be
discussed by the whole care team, be fully documented and
be reviewed regularly.
The Royal College of Nursing and the British Medical
Association recommend the following principles:
■ Residents should be permitted the maximum amount of
freedom and privacy compatible with safety.
■ The method used should always be the minimum
possible in the circumstances and should be used only
for as long as necessary to end or reduce significantly the
threat to the resident or other people.
■ Residents may wish to accept certain risks in order to
enjoy greater freedom and staff should be careful not to
overprotect individuals by unduly limiting their activities.
■ Restraint should never be used merely to aid the smooth
running of the home, as a substitute for insufficient staff
or as a punishment.
The use of physical restraints undermines the major goals of
long-term care – which are to maximise independence,
functional ability, and quality of life. Physical restraints
should not be used except as a last resort and alternative
practices should be employed to deal with challenging
behaviour and promote the safety of residents. Physical
restraint has many negative consequences which include a
decline in residents’ physical functioning (e.g. ability to walk)
and muscle condition causing contractures of limbs,
increased incidence of infections, and development of
pressure sores, confusion, agitation, and incontinence.
RAP 18
Moreover, restraints have been found in some cases to
increase the incidence of falls and other accidents (e.g.
strangulation). Residents who are restrained lose autonomy,
dignity and self-respect.
The primary reason given for applying restraints is to
protect residents from falls and accidents. Other reasons
cited for restraint use include: to provide postural support
or positioning for residents, to facilitate treatment (e.g.
preventing residents from pulling out intravenous lines),
and to manage behaviours such as wandering or physical
aggression.
Usually such goals can be met without the use of physical
restraints. Quality care involves identifying and treating
health, functional, or psychosocial problems that may be
causing the condition for which restraints were ordered (e.g.
falls, wandering, and agitation). Minimising the use of
restraints also involves: modifying the environment to make
it safer; maintaining an individual’s usual routine; using less
intrusive methods of administering medications and food;
and recognising and responding to residents’ needs for
psychosocial support, responsive care, meaningful activities,
and regular exercise.
TRIGGERS
Physical restraints refer to any means or method attached
or adjacent to the resident that restricts his/her freedom
of movement or normal access to his/her body and that
the resident cannot easily remove. The use of trunk and
limb restraints is not advocated in UK care home settings.
Further review is suggested if any of the following are
triggered.
■ Use of trunk restraint✳ [P4c = 1,2]
■ Use of limb restraint [P4d = 1,2]
■ Use of chair that prevents rising [P4e = 1,2]
✳Note: Code 2 also triggers on the Pressure Sores RAP. Both codes
trigger on the Falls RAP
GUIDELINES
In evaluating and reconsidering the use of restraints for a
resident it is important to consider the needs, problems,
conditions, or risk factors (e.g. for falls) which, if addressed,
could eliminate the need for using restraints. Refer to the
RAP OVERVIEW for specific MDS items to consider as you
review the following issues.
 Chapter 4: Completing the Resident Assessment Protocols (RAPs)
Why are restraints used?
The first step in determining whether use of a restraint can
be reduced or eliminated is to identify the reasons a restraint
was applied.
Review the resident’s record and consult primary caregivers
to determine reason for use.
Ask the following questions:
■ Why is the resident restrained?
■ What type(s) of restraint is used?
■ What time of day is each type(s) used?
■ Where is the resident restrained (e.g. own room in bed,
chair in hallway)?
■ How long is the resident restrained each day?
■ Under what circumstances (e.g. when left alone, after
family leave, when not involved in structured activity,
when eating)?
■ Who suggested that the resident be restrained?
Conditions associated with restraint use
It is often possible to identify and resolve the
health/functional/psychosocial needs, risks, or problems that
caused restraints to be used. Addressing the underlying
condition(s) and cause(s) may eliminate the apparent need
for the restraint(s). In addition, a review of underlying needs,
risks, or problems may help to identify other potential kinds
of interventions. After determining why and how a restraint
is used, review the appropriate areas described below.
Problem behavioural symptoms
To determine presence of a behavioural symptom, review
the MDS. If the behavioural symptom for which the resident
is restrained was not exhibited in the last 7 days, was it
because the restraint prohibited the behaviour from
occurring (e.g. resident was restrained and could not
wander)? If a behavioural symptom was present during the
last 7 days or the resident was restrained to prevent a
behavioural symptom, consider the resident to have a
behavioural symptom and review Behavioural Symptoms
RAP as indicated.
Risk of falls
Although restraints have not been shown to safeguard
residents from injury, one of the most common reasons
given for restraining residents is to prevent falls. In some
instances, restraints have been reported to contribute to falls
RAP 18
and injuries. Because of the complications associated with
restraint use, alternatives for preventing falls, such as treating
health problems and making environmental modifications
should always be explored.
■ Review risk factors for falls in RAP OVERVIEW. Refer to
Falls RAP if these risks are present or if the restraint is
being used to prevent falls.
Conditions and treatments
Another reason given for using restraints is to prevent a
resident from removing tubes and lines. If the resident is
being restrained to manage resistance to any type of tube or
mechanical device (e.g. indwelling/external catheter, feeding
tube, intravenous line, oxygen mask/cannula, wound
dressing), review the following:
■ Is the tube/mechanical device used to treat a life-
threatening condition?
■ Does the resident actually need a particular intervention
that may be potentially burdensome to him/her? Are
there less intrusive treatment options?
■ Why is the resident resisting the tube/mechanical device?
(e.g. Does the device produce discomfort or irritation? Is
the resident really resisting or is the device just something
to fidget with? Is the treatment compatible with the
resident’s wishes? Does the resident understand the
reason for the method of treatment? Has the
resident/family been informed about the risks and
benefits of treatment options?) Is the resident bored or
depressed or needing more social interaction?
Independence in ADLs
Review the MDS, to determine if the restraint contributes to
the resident’s independence in an activity (e.g. a wheelchair
belt supports trunk while resident wheels self, or a chair with
attached table used only at meals enables wandering
resident to eat independently).
Confounding problems to be considered
Many problem behaviours are often caused by unmet
health, functional, and/or psychosocial needs that can often
be reduced, eliminated, or managed by addressing the
conditions that produced them. (See RAP on Behavioural
Symptoms). Conditions associated with behavioural
symptoms and restraint use include:
■ Acute confusional state
■ Impaired cognition (e.g. Alzheimer’s disease)
 Chapter 4: Completing the Resident Assessment Protocols (RAPs) RAP 18

■ Impaired communication (e.g. difficulty making In considering the use of restraints for a resident, consider
needs/wishes understood or understanding others) the philosophy, values, attitudes, and wishes of the
■ Unmet psychosocial needs (e.g. social isolation, resident regarding restraint use, as well as those of his
disruption of familiar routines, angry with family) family/significant others, and caregivers. Consider the
impact of restraints on your environment and other
■ Sad or anxious mood
resident’s and staff morale.
■ Resistance to treatment, medication, nourishment
■ Is there consensus or differences of opinion amongst
■ Psychotropic drug side effects (e.g. pacing, confusion, those concerned, in choosing between resident
poor balance/walking) independence and freedom on the one hand and
■ If a behaviour management programme is in place, does presumed safety on the other?
it adequately address the causes of the resident’s OVERVIEW OF RESTRAINTS RAP GUIDELINES
particular problem behaviours?
Review factors and complications associated with restraint
Other factors to be considered use
Resident’s response to restraints Behavioural symptoms
In evaluating restraint use, it is important to review the Repetitive physical movements
resident’s reaction to restraints (e.g. positive and negative, Behavioural symptoms
such as passivity, anger, increased agitation, withdrawal, Behavioural programme
pleas for release, calls for help, constant attempts to
untie/release self). This will help determine whether Risk of falls
presumed benefits are outweighed by negative side effects. Dizziness
Review MDS items on other potential negative effects of Anxiolytic medications
restraint use, such as a decline in function, body control, Antidepressant medications
skin condition, mood and cognition, since restraints have
Conditions and treatments
been in use.
Catheter
Alternatives to restraints Hip fracture
Many interventions may be as effective or even more Unstable/acute condition
effective than restraints in managing a resident’s needs, Intravenous line and/or feeding tube
safety risks, and problems. To be effective the intervention Wound care/treatment
must address the underlying problem. Oxygen mask/cannula

■ Review the resident’s notes and ask staff to determine ADL self performance
whether alternatives to restraints have been tried.
Confounding problems to be considered
■ If alternatives to restraints have been tried, what were Acute confusional state
they? Cognitive loss/dementia
■ How long were the alternatives tried? Impaired communication
Sad/anxious mood
■ What was the resident’s response to the alternatives at
Resistance to treatment/medications/nourishment
the time?
Unmet psychosocial needs
■ If the alternative(s) attempted were ineffective, what else Psychotropic drug use
was attempted?
Other factors to be considered
■ How recently were alternatives other than restraints
Resident’s response to restraint
attempted?
Use of alternatives to restraints
Philosophy and attitudes Family/resident values, wishes and beliefs about restraint.
Resident Assessment Protocol Trigger Legend
Key
● = One item required to trigger
❷ = Two items required to trigger
✴ = One of these three items, plus at least
one other item required to trigger
@ = When both ADL triggers present,
maintenance takes precedence

Proceed to RAP Review once triggered

Acute Confusional State (1)

Cognitive Loss/Dementia (2)
Visual Function (3)
Communication (4)
ADL-Rehabilitation Trigger A@ (5)
ADL-Maintenance Trigger B @ (5)
Urinary Incontinence and
Indwelling Catheter (6)
Psychosocial Well-Being (7)
Mood State (8)
Behavioural Symptoms (9)
Activities Trigger A (10)
Activities Trigger B (10)
Falls (11)
Nutritional Status (12)
Feeding Tubes (13)
Dehydration/Fluid Maintenance
(14)
Dental Care (15)
Pressure Sores (16)
Psychotropic Drug Use (17)
Physical Restraints (18)

MDS Item CODE

B2a Short term memory 1 ● B2a

B2b Long term memory 1 ● B2b

B4 Decision making 1,2,3 ● B4

B4 Decision making 3 ● B4

B5a-B5f Indicators of acute 2 B5a-B5f

confusion ● ●
B6 Change in cognitive 2 B6
Status ● ●
C1 Hearing 1,2,3 ● C1

C4 Understood by others 1,2,3 ● C4

C6 Understands others 1,2,3 ● ● C6

C7 Change in 2 C7
●
D1 Vision 1,2,3 ● D1

D2a Side vision problem ✓ ● D2a

E1a to Indicators of depression, 1,2 E1a to E1p

●
E1n Repetitive movement 1,2 ● E1n

E1o Withdrawal from activities 1,2 ● E1o

E2 Mood persistence 1,2 ● E2

E3 Change in mood 2 ● ● E3

E4aA Wandering 1,2,3 ● E4aA

E4aA - Behavioural 1,2,3 E4aA-E4eA

●
 Key
● = One item required to trigger
❷ = Two items required to trigger
✴ = One of these three items, plus at least
one other item required to trigger
@ = When both ADL triggers present,
maintenance takes precedence

Proceed to RAP Review once triggered

Acute Confusional State (1)

Cognitive Loss/Dementia (2)
Visual Function (3)
Communication (4)
ADL-Rehabilitation Trigger A@ (5)
ADL-Maintenance Trigger B @ (5)
Urinary Incontinence and
Indwelling Catheter (6)
Psychosocial Well-Being (7)
Mood State (8)
Behavioural Symptoms (9)
Activities Trigger A (10)
Activities Trigger B (10)
Falls (11)
Nutritional Status (12)
Feeding Tubes (13)
Dehydration/Fluid Maintenance
(14)
Dental Care (15)
Pressure Sores (16)
Psychotropic Drug Use (17)
Physical Restraints (18)

MDS Item CODE

E5 Change in behavioural 1 E5
symptoms ●
E5 Change in behavioural 2 E5
symptoms ● ●
F1d Establishes own goals ✓ ● F1d

F2a to F2d Unsettled relationships ✓ ● F2a to F2d

F3a Strong i.d. past roles ✓ ● F3a

F3b Lost roles ✓ ● F3b

F3c Daily routine different ✓ ● F3c

G1aA - ADL self-performance 1,2,3,4 G1aA - G1jA

●
G1aA Bed mobility 2,3,4,8 ● G1aA

G2A Bathing 1,2,3,4 G2A

●
G3b Balance while sitting 1,2,3 ● G3b

G6a Bedfast ✓ ● G6a

G8a,b Resident staff believe ✓ ● G8a,b

H1a Bowel incontinence 1,2,3,4 ● H1a

H1b Bladder incontinence 2,3,4 ● H1b

H2b Constipation ✓ ● H2b

H2d Faecal impaction ✓ ● H2d

H3c,d,e Catheter use ✓ ● H3c,d,e

H3g Use of pads/briefs ✓ ● H3g

I1i Low blood pressure ✓ ● I1i

I1j Peripheral vascular ✓ ● I1j

 Key
● = One item required to trigger
❷ = Two items required to trigger
✴ = One of these three items, plus at least
one other item required to trigger
@ = When both ADL triggers present,
maintenance takes precedence

Proceed to RAP Review once triggered

Acute Confusional State (1)

Cognitive Loss/Dementia (2)
Visual Function (3)
Communication (4)
ADL-Rehabilitation Trigger A@ (5)
ADL-Maintenance Trigger B@ (5)
Urinary Incontinence and
Indwelling Catheter (6)
Psychosocial Well-Being (7)
Mood State (8)
Behavioural Symptoms (9)
Activities Trigger A (10)
Activities Trigger B (10)
Falls (11)
Nutritional Status (12)
Feeding Tubes (13)
Dehydration/Fluid Maintenance
(14)
Dental Care (15)
Pressure Sores (16)
Psychotropic Drug Use (17)
Physical Restraints (18)

MDS Item CODE

I1ee Depression ✓ ● I1ee

I1jj Cataracts ✓ ● I1jj

I1II Glaucoma ✓ ● I1II

I2j UTI ✓ ● I2j

I3 Dehydration diagnosis noted ● I3

J1a Weight fluctuation ✓ ● J1a

J1c Dehydrated ✓ ● J1c

J1d Insufficient fluids ✓ ● J1d

J1f Dizziness ✓ ● ● J1f

J1h Fever ✓ ● J1h

J1i Hallucinations ✓ ● J1i

J1j Internal bleeding ✓ ● J1j

J1k Lung aspirations ✓ ● J1k

J1m Fainting ✓ ● J1m

J1n Unsteady gait ✓ ● J1n

J4a,b Fell ✓ ● ● J4a,b

J4c Hip fracture ✓ ● J4c

K1b Swallowing problem ✓ ● K1b

K1c Mouth pain ✓ ● K1c

K3a Weight loss 1 ● K3a

K4a Taste alteration ✓ ● K4a

K4c Leave 25% food ✓ ● K4c

K5a Parenteral/IV feeding ✓ ● ● K5a

 Key
● = One item required to trigger
❷ = Two items required to trigger
✴ = One of these three items, plus at least
one other item required to trigger
@ = When both ADL triggers present,
maintenance takes precedence

Proceed to RAP Review once triggered

Acute Confusional State (1)

Cognitive Loss/Dementia (2)
Visual Function (3)
Communication (4)
ADL-Rehabilitation Trigger A@ (5)
ADL-Maintenance Trigger B@ (5)
Urinary Incontinence and
Indwelling Catheter (6)
Psychosocial Well-Being (7)
Mood State (8)
Behavioural Symptoms (9)
Activities Trigger A (10)
Activities Trigger B (10)
Falls (11)
Nutritional Status (12)
Feeding Tubes (13)
Dehydration/Fluid Maintenance
(14)
Dental Care (15)
Pressure Sores (16)
Psychotropic Drug Use (17)
Physical Restraints (18)

MDS Item CODE

K5b Feeding tube ✓ ● ● K5b

K5c Mechanically altered ✓ ● K5c

K5d Syringe feeding ✓ ● K5d

K5e Therapeutic diet ✓ ● K5e

L1a,c,d,e Dental ✓ ● L1a,c,d,e

L1f Daily cleaning teeth Not ✓ ● L1f

M2a Pressure sore 2,3,4 ● M2a

M2a Pressure sore 1,2,3,4 ● M2a

M3 Previous pressure sore 1 ● M3

M4e Impaired tactile sense ✓ ● M4e

N1a Awake morning ✓ ❷ N1a

N2 Involved in activities 0 ❷ N2

N2 Involved in activities 2,3 ● N2

N5a,b Prefers change in daily routine 1,2 ● N5a,b

O4a Antipsychotics 1-7 ✴ O4a

O4b Anxiolytic 1-7 ● ✴ O4b

O4c Antidepressants 1-7 ● ✴ O4c

O4e Diuretic 1-7 ● O4e

P4c Trunk restraint 1,2 ● ● P4c

P4c Trunk restraint 2 ● P4c

P4d Limb restraint 1,2 ● P4d

P4e Chair prevents rising 1,2 ● P4e

 Resident Assessment Protocol (RAP) Summary

Resident name: Numeric identifier:

1. Tick if RAP is triggered.

2. For each triggered RAP, use the RAP guidelines to identify areas needing further assessment. Document relevant
assessment information regarding the resident’s status including the following:

■ Nature of the condition (may include presence or lack of objective data and subjective complaints).

■ Complications and risk factors that affect your decision to proceed to care planning.

■ Factors that must be considered in developing individualised care plan interventions.

■ Need for referrals/further evaluation by appropriate health professional.

■ Reason for proceeding with care plan for triggered RAP and interventions seen as appropriate.

3. Indicate under the location and date of RAP assessment documentation column where information related to the RAP
assessment can be found, for example in the resident’s notes. The Care Planning Decision column should ideally be completed
within 7 days of completing the RAI (MDS and RAPs). Please tick if Care Plan now addresses identified problem.

RAP Problem Area Tick if Triggered Location and Date of RAP Care Planning
Assessment Documentation Decision - tick
if addressed in
care plan

1. Acute Confusional State ■ ■

2. Cognitive Loss/Dementia ■ ■
3. Visual Function ■ ■
4. Communication ■ ■
5. ADL Function/ ■ ■
Rehabilitation Potential

6. Urinary Incontinence ■ ■
and Indwelling Catheter

7. Psychosocial Well-Being ■ ■
8. Mood State ■ ■
9. Behavioural Symptoms ■ ■
10. Activities ■ ■
11. Falls ■ ■
12. Nutritional Status ■ ■
13. Feeding Tubes ■ ■
14. Dehydration/Fluid ■ ■
Maintenance

15. Dental Care ■ ■

16. Pressure Sores ■ ■
17. Psychotropic Drug Use ■ ■
18. Physical Restraints ■ ■

Signature of person completing care planning decision: Date:

 Chapter 5: Linking Assessment to Individualised Care Plans
OVERVIEW OF THE RAI AND CARE PLANNING
Throughout this book the concept of linkages has been
stressed. That is, good assessment forms the basis for an
effective care plan, and the Resident Assessment
Protocols (RAPs) serve as the link between the MDS and
care planning.
This chapter provides a discussion of how the care plan
is driven not only by identified resident problems, but
also by a resident’s unique characteristics, strengths and
needs. When the care plan is implemented in accordance
with standards of good practice, then the care plan
becomes powerful, practical and represents the best
approach to providing for the quality of care and quality
of life needs of an individual resident.
The process of care planning is one of looking at a
resident as a whole, building on the individual resident
characteristics measured using standardised MDS items
and definitions. The MDS was designed to allow the
interdisciplinary team to observe and evaluate the
resident’s status with these detailed, consistently applied
definitions. Once the separate items in the MDS have
been reviewed, the RAP process provides guidance to
staff on how to use this information to assess triggered
problems and ultimately to arrive at a holistic view of the
person.
Once the resident has been assessed using triggered
RAPs, the opportunity for development or changes to the
care plan exists. The triggering of a RAP indicates the
need for further review, which is carried out using the
guidelines that have been developed for each RAP. Staff
use RAP guidelines to determine whether a new care
plan is needed or changes are needed in a resident’s
existing care plan. It is important to remember that even
though a RAP may not have been “triggered” in the
assessment process, the team must address, in the care
plan, a resident problem in that area if warranted.
It is not the intention of this chapter to specify a care plan
structure or format. Rather, it is to emphasise that the
care plan should be based upon information gathered by
the MDS and further assessment “triggered” by the MDS
(RAPs) to develop an appropriate plan for meeting the
needs of the individual resident. An appropriate care plan
results from analysis of the resident’s needs by the
interdisciplinary team based on information about the
resident that is reliable, consistent and understood by all
team members. This benefits the resident by ensuring
that members of the care team are following the same
process based upon a common knowledge base.
Used appropriately, the assessment and care planning
processes can flow together into an ongoing process that:
■ Looks at each resident as a “whole person” with
unique characteristics and strengths.
■ Breaks the resident’s needs into distinct functional
areas for the purpose of gaining knowledge about the
resident’s functional status (MDS).
■ Re-groups the information gathered to identify
possible problems the resident may have (Triggers).
■ Provides additional assessment of potential problems
by looking at possible causes and risks, and how these
causes and risks can be addressed to provide for a
resident’s highest practicable level of well-being (RAP
guidelines).
■ Develops and implements an interdisciplinary care
plan based on the complete assessment information
gathered by the RAI process, with necessary
monitoring and follow-up.
■ Re-evaluates the resident’s status at regular intervals
(e.g. annually, or if a significant change in status
occurs) using the RAI and then modifies the resident’s
care plan as appropriate and necessary.
THE CARE PLANNING PROCESS
Care planning is a process that has several steps that may
occur at the same time or in sequence. The following list
of care planning stages and issues may help the
interdisciplinary team finalise the care plan after
completing the comprehensive assessment:
1. Completion of the MDS and RAPs forms the basis for
care plan decision-making.
2. The team may find during their discussions that
several problem conditions have related causes but
appear as one problem for the resident. They may also
find that they stand alone and are unique. Goals and
approaches for each problem condition may be
overlapping and consequently the interdisciplinary team
may decide to address the problem conditions in
combination on the care plan.
3. After using RAP guidelines to assess the resident, a
decision may be made that a “triggered” condition does
not affect the resident’s functioning or well-being and
 Chapter 5: Linking Assessment to Individualised Care Plans
therefore should not be addressed on the care plan.
4. The existence of a care planning issue (i.e. a resident
problem, need or strength) should be documented as
part of the RAP documentation. Documentation may be
carried out by individual staff members who have
completed assessments using the RAP guidelines or who
participated in care planning, or jointly by members of
the interdisciplinary team.
5. The resident, family or significant other should be part
of the team discussion or join the care planning process
whenever they choose. The individual team members
may have already discussed preliminary care plan ideas
with the resident, family or significant other in order to
get suggestions, confirm agreement, or clarify reasons for
developing specific goals and approaches.
6. In some cases a resident may refuse particular services
or treatments that the interdisciplinary team believes may
assist the resident to meet their highest practicable level
of well-being. The resident’s wishes should be
documented in the resident record.
7. When the interdisciplinary team has identified
problems, conditions, limitations, maintenance levels or
improvement possibilities, etc. they should be stated, to
the extent possible, in functional or behavioural terms
(e.g. how is the condition a problem for the resident;
how does the condition limit or jeopardise the resident’s
ability to complete the tasks of daily life or affect the
resident’s well-being in some way).
Examples
■ Mr. Smith cannot find his room independently.
■ Mrs. Jones slaps at the faces of staff while they are
giving personal care.
■ Mr. Brown is unable to walk more than 15 feet
because of shortness of breath.
8. The interdisciplinary team agrees on intermediate
goal(s) that will lead to an outcome objective.
9. The intermediate goal(s) should be measurable and
have a time frame for completion or evaluation.
10. The parts of the goal statement should include:
Person – Action – Specifics – Time frame
Person Action Specifics Time frame
Mr Jones will walk up and down 5 stairs daily for the
with the help of one next 30 days
nursing assistant
11. Depending upon the conclusions of the assessment,
types of goals may include improvement goals,
prevention goals, palliative goals or maintenance goals.
12. Specific, individualised steps or approaches that staff
will take to assist the resident to achieve the goal(s) will
be identified. These approaches serve as instructions for
resident care and provide for continuity of care by all
staff. Short and concise instructions, which can be
understood by all staff, should be written down.
13. The final care plan should be discussed with the
resident and, where appropriate, the resident’s next of
kin.
14. The goals and their accompanying approaches are to
be communicated to all staff who were not directly
involved in the development of the care plan.
15. The effectiveness of the care plan must be evaluated
from its initiation and modified as necessary.
16. Changes to the care plan should occur as needed in
accordance with professional standards of practice and
documentation (e.g. signing and dating entries to the
care plan). Communication about care plan changes
should be ongoing among interdisciplinary team
members.
KEY ISSUES IN CARE PLANNING
In order to provide a background for understanding care
planning and how it is supported by the RAI process, this
section has been organised around a frequently asked
question and answer format.
Q: Is the care plan oriented toward preventing avoidable
decline in functioning or functional levels?
A: The care plan is a guide for all staff to ensure that
decline is avoided, if possible. Not only is the resolution
of problems important (e.g. treatment of a pressure sore),
so is the prevention of further decline. For example, for
the resident with pressure sores, a programme of bed
mobility as well as efforts at improving the resident’s
mood to increase willingness to get out of bed, will
improve chances for slowing decline. There must be a
realistic, directed effort to provide quality care in
addressing immediate concerns while, at the same time,
attempting to ensure that functional decline does not
occur. This is “proactive” involvement by the
interdisciplinary team to make sure that declines in
 Chapter 5: Linking Assessment to Individualised Care Plans
resident functioning are avoided if possible.
Q: How does the care plan attempt to manage risk fac-
tors?
A: The RAPs help to identify factors that may increase
the chance of decline or for a problem to develop. Risk
factors must not be overlooked when designing an
effective care plan. Through the RAP review, the
interdisciplinary team can identify certain resident
characteristics that put the resident at risk of problems.
For example, a resident may suddenly become at risk of
falls when a change is made to certain medications. The
team should identify this potential risk and identify the
necessary precautions as part of the care plan.
Q: Does the care plan build on resident strengths?
A: Care planning is usually thought of as a staff effort to
solve or eliminate resident problems. While this view is
often valid, it is also important for the interdisciplinary
team to carefully look at the resident’s strengths and use
them to prevent decline or improve the resident’s
functional status. The full assessment process not only
identifies concerns but also pinpoints areas of resident
ability. These strengths should be used in the care
planning process to improve resident quality of care and
quality of life through improved function and self-esteem.
Q: Does the care plan reflect standards of
current professional practice?
A: It is important for all staff to be aware of and utilise
current standards of professional practice and local
protocols. This can be accomplished through a routine,
up-to-date in-house training programme or through the
use of qualified external training resources. New and
more effective treatment approaches, resident activities,
etc. are continually being identified which will benefit
residents if built into their care plans.
Q: Do treatment objectives have measurable
outcomes?
A: Measurable outcomes require current knowledge
about the resident to establish a baseline (e.g. how many
times does a resident behaviour occur in a certain time
frame or how does a resident experience pain). Next, a
target, goal or outcome is required (e.g. reduction of
behaviours to a certain level or reduction of pain).
Finally, some way of measuring if the care plan has
moved the resident from the baseline to the target
outcome is needed. Without measurable outcomes there
is no way to truly identify that a care plan has been
successful. The care plan is a dynamic document that
needs to be continually evaluated and appropriately
modified based on measurable outcomes. This continual
evaluation takes into consideration resident change
relative to the initial baseline – in other words, if the
resident has declined, stayed the same, or improved at a
lesser rate than expected, then a modification in the care
plan may be necessary.
Q: Has information regarding the resident’s goals and
wishes for care been obtained –
especially if a resident wishes to refuse certain forms of
care? Has the resident been given
sufficient information so that an informed choice can be
made?
A: Residents should, wherever possible, be involved in
planning their care. This means that staff must talk to the
resident about what goals the resident would like to
achieve and whether they believe these goals can be
achieved. Residents also have a right to refuse certain
forms of care. The interdisciplinary team should ensure
that the resident has all of the necessary information
about care they receive and their general well-being so
that the resident can make an informed choice.
Q: If a resident refuses interventions, does the care plan
reflect the efforts to find alternative means to address the
problem?
A: If a resident refuses interventions, the team should seek
options with the help of the GP, resident, resident’s family
and all those involved in care. Often one method of care
may not be acceptable to a resident, but another choice
of treatment may. For example, a resident may refuse to
take a prescribed anti-depressant medication for treatment
of depression. Alternative courses of action could be
explored with the resident that would use the expertise of
mental health professionals. Consequently, rather than a
care plan which indicates only that a resident refused
treatment, the care plan would reflect other goals and
methods of addressing the problem(s). Involve staff who
have regular, first hand knowledge of the resident (e.g.
nursing or care assistants) in reviewing possible options.
They can provide insights on why the resident may be
refusing care and how to devise a better approach to the
problem.
Q: Was interdisciplinary expertise utilised to develop a
 Chapter 5: Linking Assessment to Individualised Care Plans
care plan to improve a resident’s
functional abilities?
A: It is of the utmost importance that the staff most
knowledgeable about the resident, in coordination with
staff having the most expertise in a given resident problem
area, work with the resident and their family in the care
planning process.
Each member of the interdisciplinary team brings a
unique perspective and body of knowledge to the care
planning process. As such, each member’s contribution
should be sought and valued.
Q: In what ways do staff involve residents,
families, and other resident representatives in care plan-
ning?
A: The resident is the most appropriate individual to
describe what is meaningful in his or her life. Family and
friends may also contribute in a very meaningful way in
describing what is important to a resident, especially for
those residents who cannot speak for themselves.
Although they may be knowledgeable about the resident
and care practices, interdisciplinary team members do
not know all of a resident’s life history and experience
which may affect his or her individual needs or dictate
approaches.
It is important for team members to speak directly with
the resident and the resident’s family, friends and
significant others during both the assessment and care
planning process if an appropriate care plan is to be
developed which will address all of the resident’s
individual quality of life and quality of care needs. If
there is a legally designated proxy, staff should be aware
of this fact and that individual should be given the
opportunity to participate in the assessment and care
planning process.
Q: Are the immediate needs of newly admitted residents
catered for, prior to the completion of the first assess-
ment?
A: Some resident’s needs occur at or straight after
admission. These needs, at a minimum, should include
dietary, medication and immediate physical and mental
health needs until staff can conduct a comprehensive
resident assessment and develop an interdisciplinary care
plan.
The interdisciplinary team may wish to conduct an initial
RAP review for any identified problem or potential
problem even before the MDS is completed. This review
can be documented at the time, and a written update
completed when the interdisciplinary team completes the
RAI process and documents final care plan decisions.
For example if a resident is incontinent of urine on
admission, or newly incontinent at re-admission, good
practice would dictate that early response is appropriate.
Again, the Urinary Incontinence RAP can be used to
guide the immediate care plan intervention. The
documentation of the RAP review would then be updated
following the completion of the MDS assessment.
Q: Are care staff fully informed about the care, services
and expected outcomes of the care they provide? Do
care staff have general knowledge of the care and servic-
es provided by other staff and the relationship of those
services to the
resident’s expected outcomes?
A: All staff must be directly involved in the care planning
process. The importance of communication between all
members of the care team cannot be overstated. Since
care staff have the most frequent contact with residents,
they may be the most knowledgeable about a resident’s
daily life, needs, problems and strengths.
Staff who have not participated in the formal care plan
decision-making process must be informed about how
care they provide is intended to improve, maintain or
minimise decline in the resident’s condition and well-
being. Without knowing the reasons they are performing
particular tasks, staff may not understand the relationship
between their care for a resident and the expected
outcomes for the resident. Similarly, to understand how
the resident is responding to a plan of care, the input of
all staff is crucial. In many ways, they are the best source
of information on how the care plan has been
implemented, how the resident has responded, and
whether specific care plan changes might be useful.
Q: What are some general care planning areas that could
be considered in the long term care setting?
The following are six general care planning areas that are
useful in the long term care setting. This list is not
prescriptive or all-inclusive. Ultimately the resident’s status
determines what should be addressed in the care plan.
Functional status
Functional status limitations are identified using the MDS
and triggers. All conditions identified as needing care
 Chapter 5: Linking Assessment to Individualised Care Plans

plan intervention, after using the RAPs to guide further
assessment, must appear on the care plan. The
conditions identified by the MDS/RAI should be clearly
linked to the problems addressed in the care plan.
needs that are specific to the resident and are out of the
ordinary must be addressed on the care plan. Staff
should use their professional judgment when making

Rehabilitation these decisions.

A resident’s potential for physical, occupational, speech,
and other types of rehabilitation needs to be assessed Medications
and included in the care plan. The risk of immobility, for The care plan should alert staff to medication side effects
example, should be assessed, and restorative
interventions planned accordingly. Complications of for which the resident is at particular risk. The
immobility, such as damage to the muscular system as interdisciplinary team should determine if any
indicated by weakness, difficulty walking, posture
medications that the resident is taking are listed in a
problems, contractures, oedema, constipation, calcium
depletion, depression, agitation, etc. should be assessed triggered RAP. If so, use of the medication needs to be
as appropriate. These assessments may include causes,
assessed as a potential contributing cause to the RAP
particular risk factors, general impressions and the need
for referrals to appropriate specialists. concerned.

Health maintenance CONCLUSION

Health maintenance includes monitoring of disease
processes that are currently being treated. These would This chapter has described the care planning process, the
include both stable and unstable conditions that need effective integration and utilisation of the material
monitoring such as a history of cardiac problems, high
gathered in the MDS/RAI process. It has not offered a
blood pressure, congestive heart failure, pain,
dehydration, mental illness, etc. If a resident is taking prescription of the care planning documentation to be
medications for conditions, regular monitoring of
used, but rather has focused upon the principles and
potential side effects may be appropriate.
processes of effective care planning. This can be seen as
The interdisciplinary team may also decide whether or
not to list problems on the care plan that no longer affect one step in the continuous Assessment ➝ Care plan ➝
the resident, are controlled or need no monitoring. This
Implementation ➝ Re-assessment process of the
will depend on the team’s decision about how a given
problem affects the resident’s overall functioning or well- MDS/RAI described in Chapter 2.
being.
This manual has provided a detailed description of the
Other areas of health maintenance may include terminal
care, and special treatments such as dialysis (in the case rationale for the MDS, the content of the assessment
of kidney failure). form, the assessment protocols and the care planning

Discharge potential process. The purpose of such detailed material is the

The assessment for discharge potential should focus on
improvement of the quality of life and quality of care of
what needs to happen before the resident can safely be
discharged. If the resident has discharge potential or if residents in continuing care settings, whether hospitals,
discharge is actively being pursued, documentation nursing or residential homes. Improved assessment and
should appear in the resident’s plan of care.
care planning are designed to permit needs to be met
Daily care needs
more effectively and appropriately, and this manual is
Some homes put all resident daily care needs and
standard practice approaches on the care plan. Daily care one important step towards that goal.
 UK Minimum Data Set (MDS)
For Home Resident Assessment and Care Screening
Basic Assessment Tracking Form

Resident: Numeric identifier:

Section AA. Identification Information

1 Resident name a. (First name)

b. (Middle initial)

c. (Last name)

d. (Title)

2 Gender 1. Male

2. Female

3 Date of birth
Day Month Year

4 Race 1. European-Caucasian 7. Chinese

2. African-Caribbean 8. Other Asian
3. African
9. Other ethnic minority
4. Pakistani
5. Bangladeshi (specify)
6. Indian 10. Not known

5 N.H.S. number

6 N.I. number

7 Reason for Primary reason for assessment:

1. Admission assessment (usually within 14 days)
assessment 2. Annual assessment
3. Significant change in status assessment
4. Significant correction of prior assessment
5. Review assessment
0. NONE OF ABOVE

8 Name of home

9 Home identifier

10 Signatures Signatures Title Date

of persons
completing
these items 216

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 UK Minimum Data Set (MDS)
For Home Resident Assessment and Care Screening
Background (Face Sheet) Information at Admission

Resident: Numeric identifier:

Section AB. Demographic Information

1 Date of entry Date the stay began. Note - Does not include readmission if record was closed at time of
temporary discharge to hospital, etc. In such cases, use prior admission date.

Day Month Year

2 Admitted from 1. Private home/flat with no health/personal social services 6. Nursing home
2. Private home/flat with health/personal social services 7. Acute care hospital
(at entry)
3. Sheltered housing 8. Psychiatric hospital
4. Board and care/assisted living/group home 9. Rehabilitation hospital
5. Residential home 10. Other

3 Lived alone 0. No 2. In other home

1. Yes 7. Unknown
(prior to entry)
4 Postcode
(prior to entry)
5 Residential history 5 (Tick all settings resident lived in during 5 years prior to date of entry given in item AB1 above)

years prior to entry ■ a. Prior stay at this home

■ b. Stay in other home
■ c. Other residential facility - board and care home, assissted living, group home
■ d. Mental health setting
■ e. NONE OF ABOVE

6 Lifetime occupation(s)
(Put “/” between two
occupations)

7 Education Age at leaving full time schooling. Tick if applicable

■ a. College/apprenticeship
■ b. University level education

8 Language Primary language

0. English
1. Other (specify)

9 Mental health history Does resident’s record indicate any history of mental illness or learning disability?
0. No 1. Yes
& learning disability
10 Date background
information completed Day Month Year

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 UK Minimum Data Set (MDS)
For Home Resident Assessment and Care Screening
Background (Face Sheet) Information at Admission

Resident: Numeric identifier:

Section AC. Daily Routine

1 Daily routine (Tick all that apply. If all information UNKNOWN, tick last box only.)
(In year prior to
Cycle of daily events
DATE OF ENTRY)
■ a. Stays up late at night (e.g. after 9pm)
■ b. Naps regularly during day (at least 1 hour)
■ c. Goes out 1+ days a week
■ d. Stays busy with hobbies, reading, or fixed daily routine
■ e. Spends most of time alone or watching TV
■ f. Moves independently indoors (with appliances, if used)
■ g. Use of tobacco products at least daily.
■ h. NONE OF ABOVE

Eating patterns

■ i. Distinct food preferences

■ j. Eats between meals all or most days
■ k. Use of alcoholic beverage(s) at least weekly.
■ l. NONE OF ABOVE

ADL patterns

■ m. In bedclothes much of the day

■ n. Wakens to toilet all or most nights
■ o. Has irregular bowel movement pattern
■ p. Showers for bathing
■ q. Bathing in PM
■ r. NONE OF ABOVE

Involvement patterns

■ s. Daily contact with relatives/close friends.

■ t. Usually attends church, chapel, synagogue (etc).
■ u. Finds strength in faith
■ v. Daily animal companion/presence
■ w. Involved in group activities.
■ x. NONE OF ABOVE

■ y. Unknown - Resident/family unable to provide information

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 UK Minimum Data Set (MDS)
For Home Resident Assessment and Care Screening
Background (Face Sheet) Information at Admission

Resident: Numeric identifier:

Section AD. Face Sheet Signatures

a. Signature of Assessment Coordinator

b. Date Assessment Coordinator signed as complete

Day Month Year

c. Other signatures Title Sections Date

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 UK Minimum Data Set (MDS)
For Home Resident Assessment and Care Screening
Full Assessment Form (Status in last 7 days unless other time frame indicated)

Resident: Numeric identifier:

Section A. Identification and Background Information

1 Resident name a. (First name)

b. (Middle initial)

c. (Last name)

d. (Title)

2 Room number

3 Assessment Last date of MDS observation period

reference date
Day Month Year

4a Date of re-entry Date of re-entry from most recent temporary discharge to a hospital in last 3 months (or since
last assessment or admission if less than 3 months)

Day Month Year

5 Marital status ■ a. Never married ■ d. Separated

■ b. Married ■ e. Divorced
■ c. Widowed

6 Current payment (Tick all that apply)

sources ■ a. National Health Service ■ f. Self or family pays

■ b. Social Services ■ g. Private long term care insurance
■ c. DSS ■ h. Other (Specify)
■ d. Charity
7 Reason for ■ e. Third party top up
Primary reason for assessment:

assessment 1. Admission assessment (usually within 14 days) 4. Significant correction of prior assessment
2. Annual assessment 5. Review assessment
3. Significant change in status assessment 0. NONE OF ABOVE

8 Responsibility/ legal (Tick all that apply)

guardian ■ a. Legal guardian ■ d. Family member responsible

■ b. Enduring power of attorney ■ e. Patient responsible for self
■ c. Court of protection ■ f. NONE OF ABOVE

9 Advanced Check the resident’s record for supporting documentation on the following
(see notes for guidance):
directives
■ a. Living will ■ e. Feeding restrictions
■ b. Do not resuscitate ■ f. Medication restrictions
■ c. Do not hospitalise ■ g. Other treatment restrictions
■ d. Organ donation ■ h. NONE OF ABOVE

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section B. Cognitive Patterns
1 Comatose (Persistant vegetative state/unconscious)
0. No
1. Yes (If yes, skip to section G)

2 Memory (Recall of what was learned or known)

a. Short-term memory OK - seems/appears to recall after 5 minutes
0. Memory OK
2
1. Memory Problem

b. Long-term memory OK - seems/appears to recall long past

0. Memory OK
2
1. Memory Problem

3 Memory/recall (Tick all that resident was normally able to recall during last 7 days)

ability ■ a. Current season

■ b. Location of own room
■ c. Staff names/faces
■ d. That he/she is in a care home
■ e. NONE OF ABOVE are recalled

4 Cognitive skills for (Made decisions regarding tasks of daily life)

daily decision- 0. Independent - decisions consistent/reasonable

2
making 1. Modified independence - some difficulty in new situations only
2
2. Moderately impaired - decisions poor; cues/supervision required
2,5
3. Severely impaired - never/rarely made decision

5 Indicators of (Code for behaviour in the last 7 days.) [note: accurate assessment requires conversations
with staff and family who have direct knowledge of resident’s behaviour over this time].
acute confusion -
0. Behaviour not present
periodic disordered
1. Behaviour present, not of recent onset
thinking/awareness 2. Behaviour present, over last 7 days appears different from resident’s usual functioning
1,17
(eg. new onset or worsening)

■ a. Easily distracted -
1,17
(eg. difficulty paying attention; gets sidetracked)

■ b. Periods of altered perception or awareness of surroundings-

(eg. moves lips or talks to someone not present; believes he/she is
1,17
somewhere else; confuses night and day)

■ c. Episodes of disorganised speech -

(eg. speech is incoherent, nonsensical, irrelevant, or rambling from
1,17
subject to subject; loses train of thought)

■ d. Periods of restlessness -
(eg. fidgeting or picking at skin, clothing, napkins, etc; frequent
1,17
position changes; repetitive physical movements or calling out)

■ e. Periods of lethargy -
(eg. sluggishness; staring into space; difficult to arouse;
1,17
little body movement)

■ f. Mental function varies over the course of the day -

(eg. sometimes better, sometimes worse; behaviours sometimes
1,17
present, sometimes not)

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section B. Cognitive Patterns Continued
6 Change in Resident’s cognitive status, skills, or abilities have changed as compared to status of 3
months ago (or since last assessment if less than 3 months ago)
cognitive status
0. No change
1. Improved
1,17
2. Deteriorated

Section C. Communication/Hearing Patterns

1 Hearing (With hearing appliance, if used)
0. Hears adequately - normal talk, TV, phone
4
1. Minimal difficulty - when not in quiet setting
2. Hears in special situations only -
4
speaker has to adjust tonal quality and speak distinctly
4
3. Highly impaired - absence of useful hearing

2 Communication (Tick all that apply during last 7 days)

devices/techniques ■ a. Hearing aid, present and used

■ b. Hearing aid, present and not used regularly
■ c. Other receptive communication techniques used (eg. lip reading)
■ d. NONE OF ABOVE

3 Modes of (Tick all used by resident to make needs known)

expression ■ a. Speech

■ b. Writing messages to express or clarify needs

■ c. Sign language or Braille

■ d. Signs/gestures/sounds

■ e. Communication board

■ f. Other

■ g. NONE OF ABOVE

4 Making self 0. Understood

4
understood 1. Usually understood - difficulty finding words or finishing thoughts
4
2. Sometimes understood - ability is limited to making concrete requests
4
3. Rarely/never understood

5 Speech clarity (Code for speech in the last 7 days)

0. Clear speech - distinct intelligible words
1. Unclear speech - slurred, mumbled words
2. No speech - absence of spoken words

6 Ability to (Understanding verbal information content - however able)

understand others 0. Understands

2,4
1. Usually understands - may miss some part/intent of message
2,4
2. Sometimes understands - responds adequately to simple, direct communication
2,4
3. Rarely/never understands

7 Change in Resident’s ability to express, understand, or hear information has changed as

compared to status of 3 months ago (or since last assessment if less than 3 months)
communication/ 0. No change
hearing 1. Improved
17
2. Deteriorated

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section D. Vision Patterns
1 Vision (Ability to see in adequate light and with glasses if used)
0. Adequate - sees fine detail, including regular print in newspapers/books
3
1. Impaired - sees large print, but not regular print in newspapers/books
2. Moderately impaired - limited vision; not able to see newspaper headlines,
3
but can identify objects
3. Highly impaired - object identification in question, but eyes appear to
3
follow objects
4. Severely impaired - no vision or sees only light, colours, or shapes;
eyes do not appear to follow objects

2 Visual limitations/ ■ a. Side vision problems - decreased peripheral vision (eg. leaves food on one side of
difficulties tray, difficulty travelling, bumps into people and objects, misjudges placement of chair
3
when seating self)

■ b. Experiences any of the following: sees halos or rings around lights; sees flashes of
light; sees ‘curtains’ over eyes

■ c. NONE OF ABOVE

3 Visual appliances Glasses; contact lenses; magnifying glass

0. No
1. Yes
Specify

Section E. Mood and Behaviour Patterns

1 Indicators of depres- (Code for indicators observed in last month, irrespective of the assumed cause)

sion, 0. Indicator not exhibited in last month

7,8,17
anxiety, sad mood 1. Indicator of this type exhibited up to five days a week
7,8,17
2. Indicator of this type exhibited daily or almost daily (6,7 days a week)

Verbal expressions of distress

a. Resident made negative statements - eg. “Nothing matters; Would rather be dead;
8
What’s the use; Regrets having lived so long; Let me die”

8
b. Repetitive questions - eg. “Where do I go; What do I do?”

8
c. Repetitive verbalisations - eg. calling out for help (“God help me”)

d. Persistent anger with self or others - eg. easily annoyed, anger at placement in a
8
home; anger at care received

8
e. Self deprecation - eg. “I am nothing; I am of no use to anyone”

f. Expressions of what appear to be unrealistic fears - eg. fear of being abandoned,

8
left alone, being with others

g. Recurrent statements that something terrible is about to happen - eg. believes he

8
or she is about to die, have a heart attack

h. Repetitive health complaints - eg. persistently seeks medical attention, obsessive con-
8
cern with body functions

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section E. Mood and Behaviour Patterns Continued
1 Indicators of depres- i Repetitive anxious complaints/concerns (non-health related) eg. persistently seeks
attention/reassurance regarding schedules, meals, laundry, clothing, relationship issues
sion, 8

anxiety, sad mood Sleep-cycle issues

continued j. Unpleasant mood in the morning
8

k. Insomnia/change in usual sleep pattern

8

Sad, apathetic, anxious appearance

l. Sad, pained, worried facial expressions - eg. furrowed brows
8

m. Crying tearfulness
8

n. Repetitive physical movements - eg. pacing, hand wringing, restlessness,

fidgeting, picking
8,17

Loss of interest
o. Withdrawal from activities of interest - eg. no interest in long standing activities or
being with family/friends
7,8

p. Reduced social interaction

8

2 Mood persistence One or more indicators of depressed, sad or anxious mood were not easily altered by
attempts to “cheer up”, console, or reassure the resident over last 7 days
0. No mood indicators
8
1. Indicators present, easily altered
8
2. Indicators present, not easily altered

3 Change in mood Resident’s mood status has changed as compared to status of 3 months ago (or since last
assessment if less than 3 months)
0. No change
1. Improved
1,17
2. Deteriorated

4 Behavioural (A) Behavioural symptoms frequency in last 7 days

symptoms 0. Behaviour not exhibited in last 7 days

9,11
1. Behaviour of this type occurred 1 to 3 days in last 7 days
9,11
2. Behaviour of this type occurred 4 to 6 days but less than daily
9,11
3. Behaviour of this type occurred daily
(B) Behavioural symptoms alterability in last 7 days
0. Behaviour not present OR behaviour was easily altered
1. Behaviour was not easily altered
A B
a. Wandering (moved with no rational purpose, seemingly oblivious to
9,11
needs or safety)
b. Verbally abusive behavioural symptoms (others were threatened,
9
screamed at, cursed at)

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section E. Mood and Behaviour Patterns Continued
4 Behavioural A B

symptoms c. Physically abusive behavioural symptoms (others were hit, shoved,

9
scratched, sexually abused)
continued
d. Socially inappropriate/disruptive behavioural symptoms (made
disruptive sounds, noisiness, screaming, self-abusive acts, sexual behaviour
or disrobing in public, smeared/threw food/faeces, hoarding, rummaged
9
through others’ belongings)
e. Resists care (resisted taking medications/injections, ADL assistance,
9
or eating)

5 Change in Resident’s behaviour status has changed as compared to status of 3 months ago (or since
last assessment if less than 3 months)
behavioural
0. No change
symptoms 1. Improved
9

1,17
2. Deteriorated

Section F. Psychosocial Well-Being

1 Sense of initiative/ ■ a. At ease interacting with others
involvement ■ b. At ease doing planned or structured activities

■ c. At ease doing self-initiated activities

7
■ d. Establishes own goals

■ e. Pursues involvement in life of home (eg. makes/keeps friends; involved in group

activities; reponds positively to new activities; assists in religious services)

■ f. Accepts invitations into most group acitvities

■ g. NONE OF ABOVE

2 Unsettled ■ a. Covert/open conflict with or repeated criticism of staff

7

relationships ■ b. Unhappy with roommate

7

7
■ c. Unhappy with residents other than roommate
7
■ d. Openly expresses conflict/anger with family/friends

■ e. Absence of personal contact with family/friends

■ f. Recent loss of close family member/friend

■ g. Does not adjust easily to change in routines

■ h. NONE OF ABOVE

3 Past roles ■ a. Strong identification with past roles eg. occupation, head of family
7

7
■ b. Express sadness/anger/empty feeling over lost roles/status

■ c. Resident perceives that daily routine is very different from prior pattern in the
7
community

■ d. NONE OF ABOVE

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section G. Mobility and Activities of Daily Living
1 A. Activities of Daily Living (ADL) Self Performance
Ability to perform eg. eating/drinking/mobility/dressing
(Code for resident’s performance over all shifts during last 7 days)

0. Independent - No help or oversight - or - Help/oversight provided only 1 or 2 times dur-

ing last 7 days
1. Supervision - Oversight, encouragement or cueing provided 3 or more times during last 7
days - or- Supervision (3 or more times) plus physical assistance provided only 1 or 2 times
5
during last 7 days.
2. Limited assistance - Resident highly involved in activity; received physical help in guided
manoeuvering of limbs or other nonweight bearing assistance 3 or more times -
5,16
or - More help provided only 1 or 2 times during last 7 days.
3. Extensive assistance - While resident performed part of activity, over last 7 day period,
help of following type(s) provided 3 or more times:
• Weight bearing support
5,16
• Full staff performance during part (but not all) of last 7 days
4. Total dependence - Full staff performance of activity during entire 7 days 5,16

16
8. Activity did not occur during entire 7 days

B. ADL Support provided

Code for most support provided over all shifts during last 7 days; code regardless of
resident’s self performance classification
0. No initial or physical help from staff
1. Initial help only
2. One person physical assistance
3. Two+ persons physical assistance
4. ADL activity itself did not occur during entire 7 days

a Bed mobility
A B
How resident moves to and from lying position, turns side to side,
5,16
and positions body while in bed

b Transfer
A B
How resident moves between surfaces - to/from: bed, chair, wheelchair,
5
standing position. (Exclude to/from bath/toilet)

c Walk in room
A B
How resident walks between locations in his/her room 5

d Walk in corridor
A B
5
How resident walks in corridor in home

e Mobility around immediate space

A B
How resident moves between locations in his/her room and adjacent
corridor on same floor. If in wheelchair, self-sufficiency once in chair 5

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section G. Mobility and Activities of Daily Living Continued
f Mobility around home
A B How resident moves to and returns from off unit locations (eg. areas set
aside for dining, activities, or treatments). If home has only one floor, how
resident moves to and from distant areas on the floor. If in wheelchair, self-
5
sufficiency once in chair

g Dressing
A B
How resident puts on, fastens, and takes off all items of day clothing,
5
including donning/removing prosthesis

h Eating
A B
How resident eats and drinks (regardless of skill), includes intake of
5
nourishment by other means (eg. tube feeding)

i Toilet use
A B
How resident uses the toilet (or commode, bedpan, urinal); transfers on/off
toilet, cleanses, changes pad, manages ostomy or catheter;
5
adjusts clothes

j Personal hygiene
A B
How resident maintains personal hygiene, including combing hair, brushing
teeth, shaving, applying make-up, washing/drying face, hands, and post
5
toilet use. (Exclude baths and showers)

2 Bathing How resident takes full-body bath/shower, sponge bath, and transfers in/out of bath/shower
(Exclude washing of back and hair).

Code for most dependent in self-performance and support

A. Bathing self-performance codes appear below

0. Independent - No help provided

5
A B 1. Supervision - Oversight help only
5
2. Physical help limited to transfer only

3. Physical help in part of bathing activity 5

5
4. Total dependence

8. Activity itself did not occur during entire 7 days

3 Test for balance Code for ability during the last 7 days

(see manual) 0. Maintained position for 10 seconds

17
1. Unsteady, but able to rebalance self without physical support
2. Partial physical support during test; or stands (sits) but does not follow
17
directions for test
17
3. Not able to attempt test without physical help

a. Balance while standing

17
b. Balance while sitting - position, trunk control

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section G. Mobility and Activities of Daily Living Continued
4 Functional Consider limitations during last 7 days that interfered with daily functions or placed resident at
risk of injury
limitation in range
Code A range of motion
of motion
0. No limitation
(see manual)
1. Limitation on one side
2. Limitation on both sides
Code B voluntary movement
0. No loss
1. Partial loss
2. Full loss
A B

a. Neck

b. Arm - including shoulder or elbow

c. Hand - including wrist or fingers

d. Leg - including hip or knee

e. Foot - including ankle or toes

f. Other limitation or loss

5 Modes of Tick all that apply during last 7 days

locomotion ■ a. Stick/zimmer frame/crutches/tripod

■ b. Wheeled self

■ c. Other person wheeled

■ d. Wheelchair primary mode of locomotion

■ e. NONE OF ABOVE

6 Modes of Tick all that apply during last 7 days

16
transfer ■ a. Bedfast all or most of time

■ b. Bed rails used for bed mobility or transfer

■ c. Lifted manually

■ d. Lifted mechanically

■ e. Transfer aid (eg. slide board/stick/zimmer frame)

■ f. NONE OF ABOVE

7 Task segmentation Some or all of ADL activities were broken into subtasks during last 7 days so that
resident could perform them. eg preparing clothes, cutting food.

0. No

1. Yes

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section G. Mobility and Activities of Daily Living Continued
8 Potential for ■ a. Resident believes he/she is capable of increased independence in at least some
5
rehabilitation ADLs - ask resident

■ b. Care staff believe resident is capable of increased independence in at least some

5
ADLs

■ c. Resident able to perform tasks/activity but is very slow

■ d. Difference in ADL Self Performance or ADL Support, comparing mornings

to evenings
Specify:

■ e. NONE OF ABOVE

9 Change in ADL Resident’s ADL self-performance status has changed as compared to status of 3 months

function ago (or last assessment if less than 3 months)

0. No change

1. Improved

2. Deteriorated

Section H. Continence in Last 14 Days

1 Continence categories (Code for resident’s performance over all shifts)
0. Continent - Complete control (includes use of indwelling urinary catheter or ostomy
device that does not leak urine or stool)
1. Usually continent - bladder, incontinent episodes once a week or less;
16
bowel, Less than weekly
2. Occasionally incontinent - bladder, 2 or more times a week but not daily;
6,16
bowel, once a week
3. Frequent incontinent - bladder, tended to be incontinent daily, but some control present
6,16
(eg. on day shift); bowel, 2-3 times a week
4. Incontinent - had inadequate control bladder, multiple daily episodes; bowel, all (or
6,16
almost all) of the time

a. Bowel continence Control of bowel movement, by self, appliance or bowel continence

16
programmes if used.

b. Bladder continence Control of urinary bladder function (if dribbles, volume insufficient to soak through
6
underpants), with appliances (eg catheter) or continence programmes if used

2 Bowel elimination ■ a. Bowel elimination pattern regular - at least one movement every three days
pattern ■ b. Constipation
17

■ c. Diarrhoea
17
■ d. Faecal impaction

■ e. NONE OF ABOVE
Specify normal pattern:

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section H. Continence in Last 14 Days Continued
3 Appliances and pro- ■ a. Any scheduled toileting plan
grammes ■ b. Bladder retraining programme
6
■ c. External catheter
6
■ d. Indwelling catheter
6
■ e. Intermittent catheter

■ f. Did not use toilet room/commode/urinal

6
■ g. Pads/briefs used

■ h. Enemas/irrigation

■ i. Ostomy present

■ j. NONE OF ABOVE

4 Change in urinary Resident’s urinary continence has changed as compared to status of 3 months ago (or since

continence last assessment if less than 3 months)

0. No change
1. Improved
2. Deteriorated

Section I. Disease Diagnoses

Tick only those diseases that have a relationship to current ADL status, cognitive status, mood and behaviour status, medical
treatments, nursing monitoring, or risk of death.

1 Diseases If none apply, tick the none of above box

Endocrine/metabolic/nutritional
■ a. Diabetes mellitus
■ b. Hyperthyroidism
■ c. Hypothyroidism

Heart/circulation
■ d. Arteriosclerotic heart disease
■ e. Cardiac dysrhythmias
Refer to appropriate professional

■ f. Congestive heart failure

eg GP/District Nurse or notes

■ g. Deep vein thrombosis

■ h. High blood pressure
17
■ i. Low blood pressure
16
■ j. Peripheral vascular disease
■ k. Other cardiovascular disease

Musculoskeletal
■ l. Arthritis
■ m. Hip fracture
■ n. Missing limb (eg. amputation)
■ o. Osteoporosis
■ p. Pathological bone fracture (eg. Paget’s disease)

Neurological
■ q. Alzheimer’s disease
■ r. Aphasia
■ s. Cerebral palsy
■ t. Cerebrovascular accident (CVA/stroke)

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section I. Disease Diagnoses Continued
1 Diseases continued Neurological continued
■ u. Dementia other than Alzheimer’s disease
■ v. Hemiplegia/hemiparesis
■ w. Multiple sclerosis
■ x. Paraplegia
■ y. Parkinson’s disease
Refer to appropriate professional eg GP/District Nurse or notes ■ z. Quadriplegia
■ aa. Seizure disorder (epilepsy)
■ bb. Transient ischaemic attack (TIA)
■ cc. Traumatic brain injury

Psychiatric/mood
■ dd. Anxiety disorder
17
■ ee. Depression
■ ff. Manic depression (bipolar disease)
■ gg. Schizophrenia

Pulmonary
■ hh. Asthma
■ ii. Emphysema/COPD

Sensory
3
■ jj. Cataracts
■ kk. Diabetic retinopathy
3
■ ll. Glaucoma
■ mm. Macular degeneration

Other
■ nn. Allergies
■ oo. Anaemia
■ pp. Cancer
■ qq. Renal failure
■ rr. NONE OF ABOVE

2 Infections If none apply tick the none of above box

■ a. Antibiotic resistant infection

■ b. Clostridium difficile (C. diff)
■ c. Conjunctivitis
■ d. HIV infection
Refer to appropriate professional

■ e. Pneumonia
eg GP/District Nurse or notes

■ f. Respiratory infection
■ g. Septicaemia
■ h. Sexually transmitted diseases
■ i. Tuberculosis
14
■ j. Urinary tract infection in last month
■ k. Viral hepatitis
■ l. Wound infection
■ m. NONE OF ABOVE

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section I. Disease Diagnoses Continued
3 Other current a
diagnoses b

e
14
If dehydration is currently diagnosed above this triggers

Section J. Health Conditions

1 Problem Tick all problems present in last 7 days unless other timeframe is indicated

conditions Indicators of fluid status

14
■ a. Weight gain or loss of 3 or more pounds within a 7-day period
■ b. Inability to lie flat due to shortness of breath
14
■ c. Dehydrated; output exceeds input
14
■ d. Insufficient fluid; did not consume all/almost all liquids provided during last 3 days
Other
■ e. Delusions
11,17
■ f. Dizziness/vertigo
■ g. Oedema
14
■ h. Fever
17
■ i. Hallucinations
14
■ j. Internal bleeding
17
■ k. Recurrent lung aspirations in last 3 months
■ l. Shortness of breath
17
■ m. Fainting
17
■ n. Unsteady gait
■ o. Vomiting
■ p. NONE OF ABOVE

2 Pain symptoms Code the highest level of pain present in the last 7 days
A. Frequency with which resident complains or shows evidence of pain
0. No pain (Skip to J4)
1. Pain less than daily
2. Pain daily
B. Intensity of pain
1. Mild pain
2. Moderate pain
3. Times when pain is horrible or excruciating

3 Pain site If pain present, tick all sites that apply in last 7 days

■ a. Back pain
■ b. Bone pain
■ c. Chest pain while doing usual activities
■ d. Headache
■ e. Hip pain
■ f. Incisional pain (eg. recent operation)
■ g. Joint pain (other than hip)
■ h. Soft tissue pain (eg. lesion, muscle)
■ i. Stomach pain
■ j. Other/specify location

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section J. Health Conditions Continued
4 Accidents Tick all that apply
11,17
■ a. Fell in past month
11,17
■ b. Fell in past 1-6 months
17
■ c. Hip fracture in last 6 months
■ d. Other fracture in last 6 months
■ e. NONE OF ABOVE

5 Stability of ■ a. Conditions/diseases make resident’s cognitive, ADL, mood or behaviour pattern

conditions unstable - (fluctuating, precarious, or deteriorating)
■ b. Resident experiencing an acute episode of a flare-up of a recurrent or chronic prob-
lem
■ c. End-stage disease, 6 or fewer months to live
■ d. NONE OF ABOVE

Section K. Oral/Nutritional Status

1 Oral problems ■ a. Chewing problem
17
■ b. Swallowing problem
15
■ c. Mouth pain
■ d. NONE OF ABOVE

2 Height and weight Record (A) height in cms or inches and (B) weight in kilos or pounds. Base weight on most
recent measures in last month; measure weight consistently in accord with standard facility
practice eg. in am after voiding, before meal, with shoes off, and in nightclothes.

Height in cms or inches

Weight in kilos or pounds

3 Weight change a. Weight loss - 5% or more in last month; or 10% or more in last 6 months

0. No
12
1. Yes

b. Weight gain - 5% or more in last month; or 10% or more in last 6 months

0. No
1. Yes

4 Nutritional ■ a. Complains about the taste of many foods

12

problems ■ b. Regular or repetitive complaints about hunger

12
■ c. Leaves 25% or more food uneaten at most meals
■ d. Does not eat at every mealtime
■ e. NONE OF ABOVE

5 Nutritional Tick all that apply in last 7 days

approaches ■ a. Parenteral/IV
12,14

■ b. Feeding tube 13,14

12
■ c. Mechanically altered diet
12
■ d. Syringe (oral feeding)
12
■ e. Therapeutic diet

Specify

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section K. Oral/Nutritional Status Continued
5 Nutritional
■ f. Dietary supplement between meals
approaches
Specify
continued
■ g. Plate guard, adapted cutlery

Specify

■ h. On a planned weight change programme

■ i. NONE OF ABOVE

6 Parenteral or enteral Skip to section L if neither 5a nor 5b is ticked

intake A. Code the proportion of total calories the B. Code the average fluid intake per day by
resident received through parenteral or tube IV or tube in last 7 days
feeding in the last 7 days
Refer to appro-
priate profes-
sional eg
Dietician

0. None 0. None
1. 1% to 25% 1. 1 to 500ml/day
2. 26% to 50% 2. 501 to 1000ml/day
3. 51% to 75% 3. 1001 to 1500 ml/day
4. 76% to 100% 4. 1501 to 2000 ml/day
5. 2001 to more ml/day

Section L. Oral/Dental Status

1 Oral status and ■ a. Debris (soft, easily movable substances) present in mouth prior to going to
15
disease prevention bed at night

■ b. Has dentures or removable bridge

■ c. Some/all natural teeth lost - does not have or does not use dentures
15
(or partial plates)
15
■ d. Broken, loose, or carious teeth
15
■ e. Inflamed gums (gingiva); swollen or bleeding gums; oral abcesses; ulcers or rashes

■ f. Daily cleaning of teeth/dentures or daily mouth care - by resident or staff

15
( if not ticked)

■ g. NONE OF ABOVE

Section M. Skin Condition

1 Ulcers Record the number of ulcers at each ulcer stage - regardless of cause. If none present at a

(Due to any cause) stage, record “0” (zero). Code all that apply during last 7 days. (Requires full body
examination)

Stage 1. A persistent area of skin redness (without a break in the skin) that does
professional for advice
eg District Nurse, GP

not disappear when pressure is relieved

Refer to appropriate

Stage 2. A partial thickness loss of skin layers that presents clinically as an

abrasion, blister, or shallow crater

Stage 3. A full thickness of skin is lost, exposing the subcutaneous tissues -

presents as a deep crater with or without undermining adjacent tissue

Stage 4. A full thickness of skin and subcutaneous tissue is lost exposing muscle
or bone

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section M. Skin Condition Continued
2 Type of ulcer For each type of ulcer, code the highest stage in the last 7 days as given in previous question.
a. Pressure sore - any lesion caused by pressure resulting in damage of
underlying tissue
16
If stage 1 coded
12,16
If stage 2 - 4 coded

b. Stasis ulcer - open lesion caused by poor circulation in the lower limb

3 History of resolved Resident had an ulcer that was resolved or cured in last 3 months

ulcers 0. No.
16
1. Yes

4 Other skin Tick all that apply in last 7 days

problems or ■ a. Abrasions, bruises

lesions present ■ b. Burns (second or third degree)

■ c. Open lesions other than ulcers, rashes cuts (eg. cancer lesions)
■ d. Rashes - eg intertrigo, eczema, drug rash, heat rash, herpes zoster
16
■ e. Skin desensitised to pain or pressure
■ f. Skin tears or cuts (other than surgery)
■ g. Surgical wounds
■ h. NONE OF ABOVE

5 Skin treatments Tick all that apply during last 7 days

■ a. Pressure relieving device(s) for chair

■ b. Pressure relieving device(s) for bed
■ c. Turning/repositioning programme
■ d. Nutrition or hydration intervention to manage skin problems
■ e. Ulcer care
■ f. Surgical wound care
■ g. Application of dressings (with or without topical medications) other than to feet
■ h. Application of ointments/medications (other than to feet)
■ i. Other preventative or protective skin care (other than to feet)
■ j. NONE OF ABOVE

6 Foot problems Tick all that apply in last 7 days

and care ■ a. Resident has one or more foot problems - eg. corns, callouses, bunions, hammer
toes, overlapping toes, pain, structural problems

■ b. Infection of the foot - eg. cellulitis, purulent discharge

■ c. Open lesions on the foot

■ d. Nails/calluses trimmed during last 3 months
■ e. Received preventative or protective footcare (eg. used special shoes, inserts, pads,
toe separators
■ f. Application of dressings (with or without topical medications)
■ g. NONE OF ABOVE

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section N. Activity Pursuit Patterns
1 Time awake Tick appropriate time period over last 7 days
Resident awake all or most of the time (ie. naps no more than one hour per time period) in
the:
10 (with N2=0)
■ a. Morning
■ b. Afternoon
■ c. Evening
Specify: In bed In chair

■ d. NONE OF ABOVE

If resident is unconscious skip to section O

2 Average time When awake and not receiving treatment or ADL care
10 (with N1a = ticked)
involved in activities 0. Most - more than 2/3 of time
1. Some - from 1/3 to 2/3 of time
10
2. Little - less than 1/3 of time
10
3. None

3 Preferred activity Tick all settings in which activities are preferred

settings ■ a. Own room

■ b. Day/activity room
■ c. Inside home
■ d. Outside home
■ e. NONE OF ABOVE

4 General activity Tick all preferences whether or not activity is currently available to resident

preferences ■ a. Cards/other games

(adapted to resident’s ■ b. Crafts/arts

current abilities)
■ c. Exercise/sport
■ d. Music
■ e. Reading/writing
■ f. Spiritual/religious activities
■ g. Trips/shopping
■ h. Walking/wheeling outdoors
■ i. Watching TV
■ j. Gardening or plants
■ k. Talking or conversing
■ l. Helping others
■ m. NONE OF ABOVE

Specify

5 Prefers change in Code for resident preferences in daily routine

daily routine 0. No change

10
1. Slight change
2. Major change 10

10
a. Type of activities in which resident is currently involved
10
b. Extent of resident involvement in activities

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section O. Medications
1 Number of Record the number of different medications used in the last 7 days; enter “0” if none used.

medications

2 New medications Resident currently receiving medication that was initiated during the last 3 months

0. No

1. Yes

3 Injections received Record the number of days injections of any type received during the last 7 days;
enter “0” if none used

4 Days received Record the number of days during last 7 days; enter “0” if not used. Note - enter “1” for
long-acting medications used less than weekly
the following
medication a. Antipsychotic 17
Refer to appropriate pro-

11,17
b. Anxiolytic
fessional eg GP

11,17
c. Antidepressant

d. Hypnotic

14
e. Diuretic

Note: 17 to trigger this RAP requires a, b, or c = 1 to 7 plus one other of triggers

for RAP 17 found elsewhere on the form. (listed in RAP 17, Chapter 4)

Section P. Special Treatments and Procedures

1 Special treatments A. Special care Tick treatments or programmes received during last 14 days

procedures and pro- Treatments

grammes ■ a Chemotherapy
■ b. Dialysis
■ c. IV medication
■ d. Intake/output monitoring
■ e. Monitoring acute medical condition
■ f. Ostomy care
■ g. Oxygen therapy
Refer to appropriate professional

■ h. Radiation
■ i. Suctioning
eg GP/District Nurse

■ j. Tracheostomy care
■ k. Transfusions
■ l. Ventilator

Programmes
■ m. Alcohol/drug treatment programme
■ n. Alzheimer’s/dementia special care unit
■ o. Hospice care
■ p. Respite care
■ q. Training in skills required to return to the community (eg. taking medications, house-
work, shopping, transportation, ADLs)
■ r. NONE OF ABOVE

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section P. Special Treatments and Procedures Continued
1 Special treatments B. Therapies Record the number of days and total minutes each of the following
therapies was administered (for at least 15 minutes a day) in the last week (Enter “0” if
procedures and pro-
none or less than 15 min. daily) Note - count only post admission therapies.
grammes
A = number of days administered for 15 minutes or more
continued
B = total number of minutes provided in last 7 days

Days Min
Refer to appropriate professional

A B

a. Speech therapy and audiology services

eg GP/District Nurse

b. Occupational therapy

c. Physiotherapy

d. Respiratory therapy

e. Psychological therapy (by a mental health team

professional)

2 Intervention Tick all interventions or strategies used in last 7 days - no matter where received

programmes for ■ a Special behaviour symptom evaluation programme

mood, behaviour, ■ b. Evaluation by a registered mental health specialist in last 3 months

■ c. Group therapy
cognitive loss ■ d. Resident-specific deliberate changes in the environment to address mood/
behaviour patterns - eg. providing cupboard in which to rummage, sensory room
■ e. Reorientation - eg. cueing
■ f. NONE OF ABOVE

3 Nursing Record the number of days each of the following rehabilitation or restorative techniques or
practices was provided to the resident for more than or equal to 15 minutes per day in the
rehabilitation/
last 7 days (Enter 0 if none or less than 15 min. daily)
restorative care
a. Range of motion (passive)

b. Range of motion (active)

c. Splint or brace assistance

Training and skill practice in:

d. Bed mobility

e. Transfer

f. Walking

g. Dressing or grooming

h. Eating or swallowing

i. Amputation/prosthesis care

j. Communication

k. Other

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section P. Special Treatments and Procedures Continued
4 Devices and Use the following codes for last 7 days
11,18 11,16,18
restraints 0. Not used 1. Used less than daily 2. Used daily

a. Full bed rails on all open sides of bed

b. Other types of bed rails used (eg. half rail, one side)

11,16,18
c. Trunk restraint eg. wheelchair safety strap

18
d. Limb restraint

18
e. Chair prevents rising

5 Hospital stay(s) Record number of times resident was admitted to hospital with an overnight stay in last 3
months (or since last assessment if less than 3 months)
Enter 0 if no hospital admissions

6 A&E visits Record number of times resident visited A&E without an overnight stay in last 3 months (or
since last assessment if less than 3 months)
Enter 0 if no A&E visits

7 Doctor visits In the last 14 days (or since admission if less than 14 days in home) how many days has the
doctor examined the resident?
Enter 0 if none

8 Doctor In the last 14 days (or since admission if less than 14 days in home) for how many days has
the doctor changed the resident’s treatment?
prescriptions/
Enter 0 if none
instructions
9 Abnormal blood tests Has the resident had any abnormal lab values during the last 3 months (or since admission)?

or other 0. No

laboratory 1. Yes
investigations

Section Q. Discharge Potential and Overall Status

1 Discharge a. Resident expresses/indicates preference to return home
0. No
potential 1. Yes
b. Resident has a support person who is positive towards discharge
0. No
1. Yes
c. Stay projected to be of a short duration - discharge projected within
3 months (do not include expected discharge due to death)
0. No
1. Within 1 month
2. Within 1-3 months
3. Discharge status uncertain - not planned

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section Q. Discharge Potential and Overall Status Continued
2 Overall change in Resident’s overall self sufficiency has changed significantly as compared to status of
3 months ago (or since last assessment if less than 3 months)
care needs
0. No change
1. Improved - receives fewer supports, needs less restrictive level of care
2. Deteriorated - receives more support

Section R. Assessment Information

1 Participation in a. Resident

assessment 0. No
1. Yes

b. Family

0. No
1. Yes

2. No family

c. Significant other

0. No
1. Yes
2. None
If yes, specify relationship eg. friend

2 Signatures of a. Signature of Assessment Coordinator

person(s)
completing the b. Date Assessment Coordinator signed as complete
assessment
Day Month Year

c. Other signatures Title Sections Date

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 UK Minimum Data Set (MDS)
For Home Resident Assessment and Care Screening
Discharge Tracking Form (Do not use for temporary visits home)

Resident: Numeric identifier:

Section AA. Identification Information

1 Resident name a. (First name)

b. (Middle initial)

c. (Last name)

d. (Title)

2 Gender 1. Male

2. Female

3 Date of birth
Day Month Year

4 Race 1. European-Caucasian 7. Chinese

2. African-Caribbean 8. Other Asian
3. African
9. Other ethnic minority
4. Pakistani
5. Bangladeshi (specify)
6. Indian 10. Not known

5 N.H.S. number

6 N.I. number

7 Reason for (Note - Other codes do not apply to this form)

completing form Primary reason for assessment:

6. Discharged - return not anticipated
7. Discharged - return anticipated
8. Discharged prior to completing initial assessment

8 Name of home

9 Home identifier

10 Signatures Signatures Title Date

of persons
completing form

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section AB. Demographic Information
(complete only for stays less than 14 days) (AA7 = code 8)

1 Date of entry Date the stay began. Note - Does not include readmission if record was closed at time of
temporary discharge to hospital, etc. In such cases, use prior admission date.

Day Month Year

2 Admitted from 1. Private home/flat with no health/personal social services

2. Private home/flat with health/personal social services
(at entry)
3. Sheltered housing
4. Board and care/assisted living/group home
5. Residential home
6. Nursing home
7. Acute care hospital
8. Psychiatric hospital
9. Rehabilitation hospital
10. Other

Section R Assessment/Discharge Information

3 Discharge status Code for resident location upon discharge
1. Private home/flat with no health/personal social services
2. Private home/flat with health/personal social services
3. Sheltered housing
4. Board and care/assisted living/group home
5. Residential home
6. Nursing home
7. Acute care hospital
8. Psychiatric hospital
9. Rehabilitation hospital
10. Deceased
11. Other

4 Discharge date Date of death or discharge

Day Month Year

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 UK Minimum Data Set (MDS)
For Home Resident Assessment and Care Screening
Re-entry Tracking Form

Resident: Numeric identifier:

Section AA. Identification Information

1 Resident name a. (First name)

b. (Middle initial)

c. (Last name)

d. (Title)

2 Gender 1. Male

2. Female

3 Date of birth
Day Month Year

4 Race 1. European-Caucasian 7. Chinese

2. African-Caribbean 8. Other Asian
3. African
9. Other ethnic minority
4. Pakistani
5. Bangladeshi (specify)
6. Indian 10. Not known

5 N.H.S. number

6 N.I. number

7 Reason for (Note - Other codes do not apply to this form)

completing form Primary reason for assessment:

9. Re-entry

8 Name of home

9 Home identifier

10 Signatures Signatures Title Date

of persons
completing form

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Section A. Identification and Background Information
4a Date of re-entry Date of re-entry

Day Month Year

4b Admitted from 1. Private home/flat with no health/personal social services

2. Private home/flat with health/personal social services
(at re-entry)
3. Sheltered housing
4. Board and care/assisted living/group home
5. Residential home
6. Nursing home
7. Acute care hospital
8. Psychiatric hospital
9. Rehabilitation hospital
10. Other

UK Minimum Data Set (MDS) Version 1.0 ©interRAI UK

 Appendix B: CPS Scoring Rules

Impairment Count
(Number of the following):
• Decision Making: Not Independent = 1-2
• Understood: Not Independent = 1-3
• Short-Term Memory: Not OK = 1

Severe Impairment Count

(Number of the following):
• Decision Making: Mod. Impaired = 2
• Understood: Sometimes/Never = 2-3
No (0) Yes (1)
Coma?

Decision Severely Impaired (3)

Not Severely Making
Impaired (0-2)

0 2 or 3
Impairment No Total Yes
Count Dependent
(0-3) Eating? (4)

0 Severe 2
Impairment
1
Count

Average mini mental

(2) (3) (4) (5) (6)
score in field trial (0) (1) Borderline
Mild Moderate Mod.Severe Severe Very Severe
where 30 is best and Intact intact
Impairment Impairment Impairment Impairment Impairment
0 is worst
24.9 21.9 19.2 15.4 6.9 5.1 0.4

Reference: Morris, J.N., Fries, B.F. et al MDS Cognitive Performance Scale. J. Gerontology 1994; 49, m174-m182
 Appendix C: Examples of ADL Self-Performance and Support Codings

The examples that follow clarify coding for both Self-Performance and Support (items G1a - G1j). The answers appear to the right of the resident descriptions. Cover the
answers, read and score the example, and then compare your answers with those provided.

Examples: ADL Self-Performance and Support Self-Perf. Support

Bed mobility

Resident was physically able to reposition self in bed but had a tendency to favour and remain on his left side. He received frequent reminders and 1 0
monitoring to reposition self while in bed.

Resident received supervision and verbal cueing for using a support for all bed mobility. On two occasions when arms were tired, he received 1 3
heavier physical assistance of two persons.

Resident usually repositioned himself in bed. However, because he sleeps with the head of the bed raised 30 degrees, he occasionally slides down
towards the foot of the bed. On three occasions night staff helped him to reposition by providing weight-bearing support as he bent his knees and 3 2
pushed up off the footboard.

To turn over, the resident always began by reaching for a side rail for support. He received physical assistance from one person to guide his legs 3 2
into position and complete the turn by guiding him with a lifting sling (using weight-bearing assistance).

Resident independently turned on his left side whenever he wanted. Because of left-sided weakness he received physical weight bearing help of 3 3
1-2 persons to turn to his right side or sit up in bed.

Because of severe, painful joint deformities, resident was totally dependent on two persons for all bed mobility. Although unable to contribute 4 3
physically to positioning process, she was able to cue staff for the position she wanted to assume and at what point she felt comfortable.
Examples: ADL Self-Performance and Support Self-Perf. Support

Transfer

Despite bilateral above-the-knee amputations, resident almost always moved independently from bed to wheelchair (and back to bed) using a
transfer board he retrieves independently from his bedside table. On one occasion in the past week, staff had to remind resident to retrieve the 0 2
transfer board. On one other occasion, the resident was lifted by a staff member from the wheelchair back into bed.

Resident was physically independent for all transfers. However, he would not get up in the morning until staff rearranged his bed covers and 0 1
released the half side rail on his bed.

Once someone correctly positioned the wheelchair in place and locked the wheels, the resident transferred independently to and from the bed. 0 1

Resident moved independently in and out of armchairs but always received light physical guidance of one person to get in and out of bed safely. 2 2

Transferring ability varied throughout each day. Resident received no assistance at some times and heavy weight-bearing assistance of one 3 2
person at other times.
Examples: ADL Self-Performance and Support Self-Perf. Support

Walk in room

Resident walked in his/her room while holding on to furniture for support. 0 0

Resident walked independently during the day and received non-weight bearing physical help of one person for getting to the bathroom in room 2 2
at night.

Resident received non-weight bearing physical assistance of one person for all walking in own room. 2 2

Resident did not walk but wheeled self independently in own room. 8 8

Walk in corridor

A timid, fearful resident is usually physically independent in walking. During the last week she was very anxious and fearful of falling, and therefore 1 0
received reassurance and encouragement from someone walking next to her while walking back to her room from meals in the dining room.

A resident with memory loss moved independently on the unit corridor with a walking frame. Several times a day she left her walking frame in the 1 1
bathroom, in the dining room, etc., necessitating that someone return it to her and offer her reminders to use it for safety.

Resident walked in corridor in the home by supporting self on one side with the handrail along the wall and receiving verbal cues from 1 0
another person.

Resident walked twice daily 4-6 feet in the corridor outside his room. He received weight-bearing assistance of one person for each walk. 3 2

Resident walked in room for short distances with heavy assistance of two persons but travelled independently in corridor by wheelchair. 8 8
Examples: ADL Self-Performance and Support Self-Perf. Support

Mobility around immediate space

Resident ambulated slowly pushing a wheelchair for support, stopping to rest every 15-20 feet. She has good safety awareness and has never 0 0
fallen. Staff felt she was reliable enough to be on her own.

A resident with a history of falling and an unsteady gait always received physical guidance (non-weight-bearing) of one person for walking. 2 2
Two nights last week the resident was found in his bathroom after getting out of bed and walking independently.

Resident mobilised independently around the home ‘ad lib’, socialising with others and attending activities during the day. Because she can become 2 2
afraid at night, she received help of one person to walk her to the bathroom at least twice every night.

During last week resident was learning to walk short distances with new leg prosthesis with heavy partial weight-bearing assistance of two persons. 3 3
He refuses to ride in a wheelchair.

Mobility around home

Resident independently walked with a stick to all meals in the dining room and social and recreational activities in the nearby day room. Received 0 0
no set-up or physical help during the assessment period.

Resident walked independently to the dining room for all meals. For one visit to a clinic held at the opposite end of the building she was given a 0 2
ride in a wheelchair by a volunteer.

Resident is independent in walking about her room and the immediate corridor. She does get lost and has difficulty finding her room but enjoys 1 0
stopping to chat with others. Because she would get lost, she was always accompanied by a staff member for her daily walks around the home.

Resident did not leave her room during the 7-day assessment period 8 8
Examples: ADL Self-Performance and Support Self-Perf. Support

Dressing

Resident usually dressed self. After a fit, she received total help from several staff members once during the week. 0 3

Resident is totally independent in dressing herself except for donning and removing TED (antithrombolitic) stockings. Care staff applied the TED 3 2
stockings each morning and removed them at bedtime.

Care staff provided physical weight-bearing help with dressing every morning. Later each day, as resident felt better (joints were more flexible), 3 2
she required staff assistance only to undo buttons and guide her arms in/out of sleeves every evening.

An overweight resident received total care by two persons in dressing. He did not participate by putting arms through sleeves, lifting legs into shoes, etc. 4 3
Examples: ADL Self-Performance and Support Self-Perf. Support

Eating

Resident arose daily after 9.00 am, preferring to skip breakfast and just munch on fresh fruit later in the morning. She ate lunch and dinner 0 0
independently in the home’s dining room.

Resident with a history of choking, ate independently as long as a staff member sat with him during every meal (stand-by assistance if necessary). 1 0

Resident is blind and confused. He ate independently once staff oriented him to types and whereabouts of food on his plate and instructed 1 1
him to eat.

A cognitively impaired resident ate independently when given one food item at a time and monitored to assure adequate intake of each item. 1 1

Resident fed self solid foods at all meals and snacks. Self administered all fluids and medications via gastric tube with supervision once set up 1 1
appropriately

Resident with difficulty initiating activity always ate independently after someone guided her hand with the first few bites and offered encouragement 3 2
to continue.

Resident with fine hand tremors fed self finger foods (e.g. sandwiches, raw vegetables, fruit slices, crackers) but always received supervision and 3 2
total physical assistance with liquids and foods requiring utensils.

Resident fed self with staff monitoring at breakfast and lunch but tired later in day. She was fed totally by staff at evening meal. 3 2

Resident who was being taken off tube feedings continued to receive total care for twice daily tube feedings. Additionally, she ate small amounts 3 2
of food by mouth with staff supervision.

Resident received tube feedings via a feeding tube for all nutritional intake. Feedings were given by a nurse. 4 2
Examples: ADL Self-Performance and Support Self-Perf. Support

Toileting use

Resident used bathroom independently once up in a wheelchair; used bedpan independently at night after it was set up on bedside table. 0 1

In the toilet room resident is independent. As a safety measure, the carer stays just outside the door, checking with her periodically. 1 0

Resident uses the toilet independently but occasionally required minor physical assistance for hygiene and straightening clothes afterwards. 0 2
She received such help twice during the last week.

When awake, resident was toileted every two hours with minor assistance of one person for all toileting activities (e.g. for transfers to/from toilet, 3 2
drying hands, fastening clothes). She required total care of one person several times each night after incontinence episodes.

Resident received heavy assistance of two persons to transfer on/off toilet. He was able to bear weight partially, and required only standby 3 3
assistance with hygiene (e.g. being handed toilet tissue or incontinence pads).

An overweight resident who is severely physically and cognitively impaired receives a mechanical lift for all transfers to and from her bed. It is
impossible to toilet her and she is incontinent. Complete personal hygiene is provided at least every 2 hours by two persons. 4 3
Examples: ADL Self-Performance and Support Self-Perf. Support

Personal hygiene

New resident, whilst adjusting to the home, liked to sleep in his clothes in case of fire. He remained in the same clothes for 2-3 days at a 0 0
time. He cleaned his hands and face independently and would not let others help with any personal hygiene activities.

Once grooming articles were laid out and arranged by staff, resident regularly performed the tasks of personal hygiene by receiving verbal 1 1
directions from one person throughout each task.

Resident carried out personal hygiene but was not motivated. She received daily cueing and positive feedback from nursing staff to keep 1 0
self clean and neat. Once started, she could be left alone to complete tasks successfully.

Resident shaves self with an electric razor, washes his face and hands, brushes his teeth, and combs his hair. Because he is losing his 1 1
sight, staff stand by to hand grooming articles to the resident and return articles to their proper location.

Resident performed all tasks of personal hygiene except shaving. This was undertaken by the staff of the home. 3 2

Resident required total daily help combing her long hair and arranging it in a bun. Otherwise she was independent in personal hygiene. 3 2
 References and Further Reading
REFERENCES
BMA and RCN (1995) The Older Person: Consent and Care.
BMA: London.
Brocklehurst, J., Carty, M., Leeming, J. and Robinson, J.
(1978) Care of the elderly: medical screening of old
people accepted for residential care. The Lancet, ii, 141 -
142.
Challis, D., Carpenter, I. and Traske, K. (1996)
Assessment in Continuing Care Homes: Towards a National
Standard Instrument. PSSRU, University of Kent:
Canterbury.
Cm 849 (1989) Caring for People. HMSO: London.
Cm 3807 (1997) The New NHS Modern. Dependable. The
Stationery Office: London.
Cm 4169 (1998) Modernising Social Services. The
Stationery Office: London.
Cm 4192-I (1999) With Respect to Old Age: Long Term Care
- Rights and Responsibilities. Report of the Royal
Commission on Long Term Care. The Stationery Office:
London.
Darton, R. and Brown, P. (1997) Survey of Admissions to
Residential Care Analyses of Six Month Follow-up. Discussion
Paper 1340. June 1997 PSSRU, University of Kent:
Canterbury.
Department of Health (1993) Monitoring and Development:
Assessment Special Study. Department of Health: London.
Department of Health (1997) Better Services for Vulnerable
People (EL (97)62, CI(97)24). Department of Health:
London.
Department of Health (1998) Modernising Health and Social
Services, National Priorities Guidance 1999/00 - 2001/02.
(LAC(98)22, HSC1998/159) Department of Health:
London.
Department of Health (1999) Modernising Health and Social
Services, National Priorities Guidance 2000/01 - 2002/03.
(LAC(99)38, HSC1999/242) Department of Health:
London.
Folstein, M. F., Folstein, S. E. and McHugh, P. R. (1975)
Mini-Mental State: A Practical Method for Grading the
Cognitive State of Patients for the Clinician. Journal of
Psychiatric Research. 12, 189-198.
Hansebo G., Kihlgren, M., Ljunggren, G. and Winblad,
B. (1998) Staff views on the Resident Assessment
Instrument, RAI/MDS, in nursing homes, and the use of
the Cognitive Performance Scale, CPS, in different levels
of care in Stockholm, Sweden. Journal of Advanced Nursing.
28 (3) 642-653.
Health Select Committee (1995) Long Term Care: NHS
responsibilities for meeting continuing health care needs. HC
19-1.
Mann, A. (1996) Characteristics of the Study Sample:
Depression, Medication and Health Needs. In: Mann, A.
et al. (1996) An Exploration of the Measures of Quality of
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Rubenstein, L.V., Calkins, D., Greenfields, S., Jette, A.M.,
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Care Financing Review. Annual supplement, 39-51.
Stewart, K., Challis, D., Carpenter, I. and Dickinson, E.
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FURTHER READING - SPECIFIC PROBLEMS
Pressure sores
Cullum, N., Deeks, J.J., Fletcher, A.W., Sheldon, T.A.
and Song, F. (1997) Pressure relieving beds and
mattresses for the prevention of pressure sores.
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Oxford: Update Software; 1998. Updated Quarterly.
Smith, D.M., Winsemius, D.K., and Besedine, R.W.
(1991) Pressure Sores in the Elderly: Can this Outcome
be Improved? Journal of General Internal Medicine. 6: 81-93.
University of York, NHS Centre for Reviews and
Dissemination; University of Leeds, Nuffield Institute for
Health (1995) The Prevention and Treatment of Pressure
Sores: How Effective are Pressure Relieving Interventions
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Incontinence
Chester, R. (1998) Towards Continence. Counsel and Care:
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Incontinence in Nursing Home Residents with Dementia:
the Mobility-Cognition Paradigm. Applied Nursing Research.
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Rands, G. and Malone-Lee, J. (1990/1) Urinary and
Faecal Incontinence in Long Stay Wards for the Elderly
Mentally Ill: Prevalence and Difficulties in Management.
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Roe, B. (1992) Clinical Nursing Practice: the Promotion and
Management of Continence. Prentice Hall: London.
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Nutrition
Butt, P. (1997) Dysphagia and aspiration – it may be
silent but it can be deadly. In: S. Bond (Ed) Eating matters.
Centre for Health Services Research: Newcastle.
Lennard-Jones, J.E. (1992) A Positive Approach to Nutrition
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RCN (1993) Nutrition Standards and the Older Adult. RCN:
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Smith, E.M. and Millard, P.H. (1997) The Future Care of
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London.
Use of restraints
RCN (1992) Focus on Restraint (2nd edn). RCN: London.
RCN (1994) The Privacy of Clients: Electronic Tagging and
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Falls
Houge, C. (1992) Managing Falls: the Current Bases for
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Dementia
Adams, T. and Clarke, C.l. (Eds) (1999) Dementia Care:
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London.
Kitwood, T. (1997) Dementia Reconsidered. Open
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FURTHER READING - GENERAL
Bains, E. (Ed) (1991) Perspectives on Gerontological
 References and Further Reading

Nursing. Sage: Newbury Park, California. London.

Bennett, G. and Ebrahim, S. (1995) The Essentials of
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Eliopoulos, C. (1997) Gerontological Nursing (4th Edn), Professional in a Changing Health Service. Sage: Milton
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Heath, H. and Schofield, I. (1999) Healthy ageing: nursing

The Lord Chancellor’s Department (1997) Who Decides?
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Morris, J.N., Lipsitz, L.A., Murphy, K. and Belleville-

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RCN (1993) The Value and Skill of Nurses Working with Older
People. RCN: London.

Sinclair A.J and Woodhouse, K.W. (1995) (Eds) Acute

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