Definitions

4145.2 - Definitions (Rev. 1, 05-21-04) • Minimum Data Set (MDS) - A core set of screening and assessment elements, including common definitions and coding categories, that forms the foundation of the comprehensive assessment for all residents of long term care facilities certified to participate in Medicare and/or Medicaid. The items in the MDS standardize communication about resident problems and conditions within facilities, between facilities, and between facilities and outside agencies. • Common Definitions - Standardized instructions for how to interpret each element specified in the MDS. • Coding Categories - Levels of measurement for each element included in the MDS. • Triggers - Specific resident responses for one or a combination of MDS elements. These triggers identify residents who require further evaluation using resident assessment protocols designated within the State specified RAI. • Resident Assessment Protocols (RAPs) - A component of the utilization guidelines, the RAPs are structured, problem-oriented frameworks for organizing MDS information, and additional clinically relevant information about an individual that identifies medical problems and forms the basis for individualized care planning. • Resident Assessment Instrument (RAI) - An instrument which requires for completion the performance of a standardized assessment system, comprised of the MDS and utilization guidelines (including the RAPs and triggers). This assessment system provides a comprehensive, accurate, standardized, reproducible assessment of each long-term care facility resident’s functional capabilities and identifies medical problems. • Utilization Guidelines - Instructions concerning when and how to use the RAI. These include instructions for completion of the RAI as well as structured frameworks for synthesizing MDS and other clinical information. • Quarterly Review - Part of the Secretary’s designated instrument. The quarterly review is a subset of MDS items reviewed (i.e., reassessed) no less frequently than once every three months (92 days) to assure the continued accuracy of the care plan.