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Matrix Column
OBRA Stand Alone Assessments
OBRA Quarterly A=02, B=99, F=99, G=^, H=0
A \u2014 Identification Information
A0050
Type of Record
x Applies
›
A0100
Facility Provider Numbers
x Applies
›
A0200
Type of Provider
x Applies
›
A0310
Type of Assessment
x Applies
›
A0410
Unit Certification or Licensure Designation
x Applies
›
A0500
Legal Name of Resident
x Applies
›
A0600
Social Security and Medicare Numbers
x Applies
›
A0700
Medicaid Number
x Applies
›
A0810
Sex
x Applies
›
A0900
Birth Date
x Applies
›
A1005
Ethnicity
x Applies
›
A1010
Race
x Applies
›
A1110
Language
x Applies
›
A1200
Marital Status
x Applies
›
A1300
Optional Resident Items
x Applies
›
A1600
Entry Date
x Applies
›
A1700
Type of Entry
x Applies
›
A1805
Entered From
x Applies
›
A1900
Admission Date (Date this episode of care in this facility
x Applies
›
A2300
Assessment Reference Date
x Applies
›
A2400
Medicare Stay
x Applies
›
B \u2014 Hearing, Speech, and Vision
C \u2014 Cognitive Patterns
C0100
Should Brief Interview for Mental Status Be Conducted?
x Applies
›
C0200
Repetition of Three Words
x Applies
›
C0300
Temporal Orientation (Orientation to Year, Month,
x Applies
›
C0400
Recall
x Applies
›
C0500
BIMS Summary Score
x Applies
›
C0600
Should the Staff Assessment for Mental Status (C0700–
x Applies
›
C0700
Short-term Memory OK
x Applies
›
C0800
Long-term Memory OK
x Applies
›
C0900
Memory/Recall Ability
x Applies
›
C1000
Cognitive Skills for Daily Decision Making
x Applies
›
C1310
Signs and Symptoms of Delirium (from CAM©)
x Applies
›
D \u2014 Mood
E \u2014 Behavior
GG \u2014 Functional Abilities and Goals
H \u2014 Bladder and Bowel
J \u2014 Health Conditions
J0100
Pain Management
x Applies
›
J0200
Should Pain Assessment Interview Be Conducted?
x Applies
›
J0300
Pain Presence
x Applies
›
J0410
Pain Frequency
x Applies
›
J0510
Pain Effect on Sleep
x Applies
›
J0520
Pain Interference with Therapy Activities
x Applies
›
J0530
Pain Interference with Day-to-Day Activities
x Applies
›
J0600
Pain Intensity
x Applies
›
J0700
Should the Staff Assessment for Pain be Conducted?
x Applies
›
J0800
Indicators of Pain
x Applies
›
J0850
Frequency of Indicator of Pain or Possible Pain
x Applies
›
J1100
Shortness of Breath (dyspnea)
x Applies
›
J1400
Prognosis
x Applies
›
J1550
Problem Conditions
x Applies
›
J1700
Fall History on Admission/Entry or Reentry
x Applies
›
J1800
Any Falls Since Admission/Entry or Reentry or Prior
x Applies
›
J1900
Number of Falls Since Admission/Entry or Reentry or Prior
x Applies
›
K \u2014 Swallowing and Nutritional Status
L \u2014 Oral/Dental Status
M \u2014 Skin Conditions
M0100
Determination of Pressure Ulcer/Injury Risk
x Applies
›
M0150
Risk of Pressure Ulcers/Injuries
x Applies
›
M0210
Unhealed Pressure Ulcers/Injuries
x Applies
›
M1030
Number of Venous and Arterial Ulcers
x Applies
›
M1040
Other Ulcers, Wounds and Skin Problems
x Applies
›
M1200
Skin and Ulcer/Injury Treatments
x Applies
›
N \u2014 Medications
O \u2014 Special Treatments, Procedures, and Programs
P \u2014 Restraints and Alarms
Q \u2014 Participation in Assessment and Goal Setting
Q0110
Participation in Assessment and Goal Setting
x Applies
›
Q0310
Resident’s Overall Goal
x Applies
›
Q0400
Discharge Plan
x Applies
›
Q0490
Resident’s Documented Preference to Avoid Being Asked
x Applies
›
Q0500
Return to Community
x Applies
›
Q0550
Resident’s Preference to Avoid Being Asked Question
x Applies
›
Q0610
Referral
x Applies
›
Q0620
Reason Referral to Local Contact Agency (LCA) Not
x Applies
›
Z \u2014 Assessment Administration
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