DiraChart MDS item reference
DEFINITIONS
Use the item-specific response choices below when structured codes apply.
This row introduces a grouped MDS item. Complete the applicable child items shown in the current item set.
Review what the item asks, how to choose the response, and what should be verified before submission.
1. Review the medical record, interview staff on all shifts and observe the resident for any
indication that the resident had vomiting, fever, potential signs of dehydration, or internal
bleeding during the 7-day look-back period.
Check all that apply (blue box)
•
J1550A, fever
•
J1550B, vomiting
•
J1550C, dehydrated
•
J1550D, internal bleeding
•
J1550Z, none of the above
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Fever: Fever is defined as a temperature 2.4 degrees F higher than baseline. The
resident’s baseline temperature should be established prior to the Assessment Reference
Date.
•
Fever assessment prior to establishing base line temperature: A
temperature of 100.4 degrees F (38 degrees C) on admission (i.e., prior to the
establishment of the baseline temperature) would be considered a fever.
•
Vomiting: Regurgitation of stomach contents; may be caused by many factors (e.g.,
drug toxicity, infection, psychogenic).
J1550: Problem Conditions (cont.)
•
Dehydrated: Check this item if the resident presents with two or more of the following
potential indicators for dehydration:
1. Resident takes in less than the recommended 1,500 ml of fluids daily (water or
liquids in beverages and water in foods with high fluid content, such as gelatin and
soups). Note: The recommended intake level has been changed from 2,500 ml to
1,500 ml to reflect current practice standards.
2. Resident has one or more potential clinical signs (indicators) of dehydration,
including but not limited to dry mucous membranes, poor skin turgor, cracked
lips, thirst, sunken eyes, dark urine, new onset or increased confusion, fever, or
abnormal laboratory values (e.g., elevated hemoglobin and hematocrit, potassium
chloride, sodium, albumin, blood urea nitrogen, or urine specific gravity).
3. Resident’s fluid loss exceeds the amount of fluids they take in (e.g., loss from
vomiting, fever, diarrhea that exceeds fluid replacement).
•
Internal Bleeding: Bleeding may be frank (such as bright red blood) or occult (such
as guaiac positive stools). Clinical indicators include black, tarry stools, vomiting “coffee
grounds,” hematuria (blood in urine), hemoptysis (coughing up blood), and severe
epistaxis (nosebleed) that requires packing. However, nose bleeds that are easily
controlled, menses, or a urinalysis that shows a small amount of red blood cells should
not be coded as internal bleeding.
See where this item applies across Nursing Home, Swing Bed, discharge, required-use, OBRA, and program or policy columns.
MDS Item Matrix v1.20.1 v4
MDS Item Matrix v1.20.1 v4
MDS Item Matrix v1.20.1 v4
MDS Item Matrix v1.20.1 v4
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