MDS Assessment Section

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Resident: Unnamed resident  |  Assessment ID: 52  |  Status: In progress

Section A

Identification Information
MDS 3.0 NC Version 1.20.1 — Effective 10/01/2025
A0050
Type of Record
Select the action being taken on this record. For a new admission assessment, select "Add new record".
A0100. Facility Provider Numbers
A0100A
A. National Provider Identifier (NPI)
A0100B
B. CMS Certification Number (CCN)
The CCN is a 6-digit number assigned by CMS to identify the facility.
A0100C
C. State Provider Number
A0200
A0200. Type of Provider
A0310. Type of Assessment
A0310A
A. Federal OBRA Reason for Assessment
For an admission assessment required by day 14, select 01.
A0310B
B. PPS Assessment
Select 99 if this is an OBRA-only assessment with no Medicare Part A PPS component.
A0310E
E. Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry?
A0310F
F. Entry/discharge reporting
A0500. Legal Name of Resident
A0500_first
A. First name
A0500_mi
B. Middle initial
A0500_last
C. Last name
A0500_suffix
D. Suffix (Jr., Sr., etc.)
A0600. Social Security and Medicare Numbers
A0600A
A. Social Security Number
For training purposes, use a fictitious SSN. Format: XXX-XX-XXXX
A0600B
B. Medicare Number
A0700
A0700. Medicaid Number
Enter the Medicaid number, "+" if pending, or "N" if not a Medicaid recipient.
A0810
A0810. Sex
A0900
A0900. Birth Date
A1005
A1005. Ethnicity — Are you of Hispanic, Latino/a, or Spanish origin?
Resident self-report is preferred. Check all that apply.
A1010
A1010. Race — What is your race?
Check all that apply.
A1110. Language
A1110A
A. What is your preferred language?
A1110B
B. Do you need or want an interpreter to communicate with a doctor or health care staff?
A1200
A1200. Marital Status
A1300. Optional Resident Items
A1300A
A. Medical record number
A1300B
B. Room number
A1300C
C. Name by which resident prefers to be addressed
A1300D
D. Lifetime occupation(s) — put "/" between two occupations
A1500
A1500. Preadmission Screening and Resident Review (PASRR)
Complete only if A0310A = 01, 03, 04, or 05.
Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?
A1510
A1510. Level II PASRR Conditions — Complete only if A1500 = 1
A1550
A1550. Conditions Related to ID/DD Status — Check all conditions related to ID/DD status manifested before age 22 and likely to continue indefinitely
Most Recent Admission/Entry or Reentry into this Facility
A1600
A1600. Entry Date
A1700
A1700. Type of Entry
A1805
A1805. Entered From
A1900
A1900. Admission Date (Date this episode of care in this facility began)
This is the date the current episode of care began — the day the resident was admitted to the facility.
A2300
A2300. Assessment Reference Date — Observation end date
The Assessment Reference Date (ARD) is the last day of the observation period. For admission assessments, the ARD must be no later than 14 days after the admission date (A1900).
A2400. Medicare Stay — Complete only if A0310G1 = 0
A2400A
A. Has the resident had a Medicare-covered stay since the most recent entry?
A2400B
B. Start date of most recent Medicare stay
A2400C
C. End date of most recent Medicare stay (enter dashes if ongoing)