DiraChart MDS item reference
Assessment (OBRA or Scheduled PPS), whichever is more
Use the item-specific response choices below when structured codes apply.
if the resident has not had any fall since the last assessment. Skip to
Swallowing Disorder item (K0100) if the assessment being completed is an OBRA
assessment. If the assessment being completed is a Scheduled PPS assessment, skip to
Prior Surgery item (J2000).
if the resident has fallen since the last assessment. Continue to Number
of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or
Scheduled PPS) item (J1900), whichever is more recent.
Example 1. An incident report describes an event in which Resident S was walking down the hall and
appeared to slip on a wet spot on the floor. They lost their balance and bumped into the wall,
but were able to grab onto the hand rail and steady themself.
Coding: J1800 would be coded 1, yes.
Rational
Review what the item asks, how to choose the response, and what should be verified before submission.
1. If this is the first assessment/entry or reentry (A0310E = 1), review the medical record for the
time period from the admission date to the ARD.
2. If this is not the first assessment/entry or reentry (A0310E = 0), the review period is from the
day after the ARD of the last MDS assessment to the ARD of the current assessment.
3. Review all available sources for any fall since the last assessment, no matter whether it
occurred while out in the community, in an acute hospital, or in the nursing home. Include
medical records generated in any health care setting since last assessment.
4. Review nursing home incident reports, fall logs and the medical record (physician, nursing,
therapy, and nursing assistant notes).
5. Ask the resident and family about falls during the look-back period. Resident and family
reports of falls should be captured here whether or not these incidents are documented in the
medical record.
DEFINITION
PRIOR ASSESSMENT
Most recent MDS
assessment that reported on
falls.
J1800: Any Falls Since Admission/Entry or Reentry or Prior
Assessment (OBRA or Scheduled PPS), whichever is more
recent (cont.)
•
Code 0, no: if the resident has not had any fall since the last assessment. Skip to
Swallowing Disorder item (K0100) if the assessment being completed is an OBRA
assessment. If the assessment being completed is a Scheduled PPS assessment, skip to
Prior Surgery item (J2000).
•
Code 1, yes: if the resident has fallen since the last assessment. Continue to Number
of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or
Scheduled PPS) item (J1900), whichever is more recent.
Example
1. An incident report describes an event in which Resident S was walking down the hall and
appeared to slip on a wet spot on the floor. They lost their balance and bumped into the wall,
but were able to grab onto the hand rail and steady themself.
Coding: J1800 would be coded 1, yes.
Rationale: An intercepted fall is considered a fall.
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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