0
No
if the resident did not have major surgery during the 100 days prior to
admission.
DiraChart MDS item reference
J2000Section Jv1.20.1Manual page J-42
Prior Surgery
Item Rationale
Quick coding
Answer Codes
Use the item-specific response choices below when structured codes apply.
Response format: Coded response
1
Yes
if the resident had major surgery during the 100 days prior to admission.
8
Unknown
if it is unknown or cannot be determined whether the resident had
major surgery during the 100 days prior to admission.
Item-specific instructions
Coding Guidance
Review what the item asks, how to choose the response, and what should be verified before submission.
Steps for Assessment
1. Ask the resident and their family or significant other about
any surgical procedures in the 100 days prior to admission.
2. Review the resident’s medical record to determine whether
the resident had major surgery during the 100 days prior to
admission.
Medical record sources include medical records received
from facilities where the resident received health care
during the previous 100 days, the most recent history and
physical, transfer documents, discharge summaries,
progress notes, and other resources as available.
Coding Instructions
•
Code 0, No: if the resident did not have major surgery during the 100 days prior to
admission.
•
Code 1, Yes: if the resident had major surgery during the 100 days prior to admission.
•
Code 8, Unknown: if it is unknown or cannot be determined whether the resident had
major surgery during the 100 days prior to admission.
DEFINITION
MAJOR SURGERY
Refers to a procedure that
meets the following criteria:
1. The resident was an
inpatient in an acute care
hospital for at least 1 day
in the 100 days prior to
admission to the skilled
nursing facility (SNF), and
2. The surgery carried some
degree of risk to the
resident’s life or the
potential for severe
disability.
J2000: Prior Surgery (cont.)
MDS item matrixAssessment Applicability
See where this item applies across Nursing Home, Swing Bed, discharge, required-use, OBRA, and program or policy columns.
6 relationships3 groups+
Assessment Applicability
See where this item applies across Nursing Home, Swing Bed, discharge, required-use, OBRA, and program or policy columns.
Nursing Home Subsets
Swing Bed Subsets
Program and Policy Use
Official CMS source
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Reference details
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