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DiraChart MDS item reference
J1700BSection Jv1.20.1Manual page J-31
Fall history: fall 2-6 months before admission
This item is referenced against CMS MDS source materials. Verify coding against the current CMS RAI Manual, item set instructions, and facility documentation before submission.
Quick coding
Answer Codes
Use the item-specific response choices below when structured codes apply.
Response format: Coded response
1
yes
Manual page J-319
unable to determine
Manual page J-31Item-specific instructions
Coding Guidance
Review what the item asks, how to choose the response, and what should be verified before submission.
Steps for Assessment
The period of review is 180 days (6 months) prior to admission,
looking back from the resident’s entry date (A1600).
1. Ask the resident and family or significant other about a
history of falls in the month prior to admission and in the 6
months prior to admission. This would include any fall, no
matter where it occurred.
2. Review inter-facility transfer information (if the resident is
being admitted from another facility) for evidence of falls.
3. Review all relevant medical records received from facilities
where the resident resided during the previous 6 months;
also review any other medical records received for evidence
of one or more falls.
Coding Instructions
for J1700A, Did the Resident Have a Fall Any Time
in the Last Month Prior to Admission/Entry or Reentry?
•
Code 0, no: if resident and family report no falls and transfer records and medical
records do not document a fall in the month preceding the resident’s entry date item
(A1600).
•
Code 1, yes: if resident or family report or transfer records or medical records
document a fall in the month preceding the resident’s entry date item (A1600).
•
Code 9, unable to determine: if the resident is unable to provide the information or
if the resident and family are not available or do not have the information and medical
record information is inadequate to determine whether a fall occurred.
DEFINITION
FALL
Unintentional change in
position coming to rest on the
ground, floor or onto the next
lower surface (e.g., onto a
bed, chair, or bedside mat) or
the result of an overwhelming
external force (e.g., a
resident pushes another
resident).
An intercepted fall occurs
when the resident would
have fallen if they had not
caught themself or had not
been intercepted by another
person – this is still
considered a fall.
J1700: Fall History on Admission/Entry or Reentry (cont.)
Coding Tips
•
The fall may be witnessed, reported by the resident or an observer or identified when a
resident is found on the floor or ground.
•
Falls include any fall, no matter whether it occurred at home, while out in the community,
in an acute hospital or a nursing home.
•
CMS understands that challenging a resident’s balance and training them to recover from
a loss of balance is an intentional therapeutic intervention and does not consider
anticipated losses of balance that occur during supervised therapeutic interventions as
intercepted falls. However, if there is a loss of balance during supervised therapeutic
interventions and the resident comes to rest on the ground, floor or next lower surface
despite the clinician’s effort to intercept the loss of balance, it is considered a fall.
Coding Instructions for J1700B, Did the Resident Have a Fall Any
Time in the Last 2-6 Months prior to Admission/Entry or
Reentry?
•
Code 0, no: if resident and family report no falls and transfer records and medical
records do not document a fall in the 2-6 months prior to the resident’s entry date item
(A1600).
•
Code 1, yes: if resident or family report or transfer records or medical records
document a fall in the 2-6 months prior to the resident’s entry date item (A1600).
•
Code 9, unable to determine: if the resident is unable to provide the information,
or if the resident and family are not available or do not have the information, and medical
record information is inadequate to determine whether a fall occurred.
Coding Instructions for J1700C. Did the
Resident Have Any Fracture Related to a
Fall in the 6 Months prior to
Admission/Entry or Reentry?
•
Code 0, no: if resident and family report no fractures
related to falls and transfer records and medical records
do not document a fracture related to fall in the 6
months (0-180 days) preceding the resident’s entry date
item (A1600).
•
Code 1, yes: if resident or family report or transfer
records or medical records document a fracture related
to fall in the 6 months (0-180 days) preceding the
resident’s entry date item (A1600).
DEFINITION
FRACTURE RELATED
TO A FALL
Any documented bone
fracture (in a problem list
from a medical record, an x-
ray report, or by history of the
resident or caregiver) that
occurred as a direct result of
a fall or was recognized and
later attributed to the fall. Do
not include fractures caused
by trauma related to car
crashes or pedestrian versus
car accidents or impact of
another person or object
against the resident.
J1700: Fall History on Admission/Entry or Reentry (cont.)
•
Code 9, unable to determine: if the resident is unable to provide the information,
or if the resident and family are not available or do not have the information, and medical
record information is inadequate to determine whether a fall occurred.
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