DiraChart MDS item reference
J1100Section Jv1.20.1Manual page J-25
Shortness of Breath (dyspnea)
Item Rationale
Quick codingAnswer Codes
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Response format: Instruction / group heading
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Item-specific instructionsCoding Guidance
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RAI Manual v1.20.1Steps for Assessment
Interview the resident about shortness of breath. Many residents, including those with mild to
moderate dementia, may be able to provide feedback about their own symptoms.
1. If the resident is not experiencing shortness of breath or trouble breathing during the
interview, ask the resident if shortness of breath occurs when they engage in certain
activities.
2. Review the medical record for staff documentation of the presence of shortness of breath or
trouble breathing. Interview staff on all shifts, and family/significant other regarding resident
history of shortness of breath, allergies or other environmental triggers of shortness of breath.
3. Observe the resident for shortness of breath or trouble breathing. Signs of shortness of breath
include: increased respiratory rate, pursed lip breathing, a prolonged expiratory phase,
audible respirations and gasping for air at rest, interrupted speech pattern (only able to say a
few words before taking a breath) and use of shoulder and other accessory muscles to
breathe.
4. If shortness of breath or trouble breathing is observed, note whether it occurs with certain
positions or activities.
J1100: Shortness of Breath (dyspnea) (cont.)
Manual page J-25RAI Manual v1.20.1Coding Instructions
Check all that apply during the 7-day look-back period.
Any evidence of the presence of a symptom of shortness of breath should be captured in this item.
A resident may have any combination of these symptoms.
•
Check J1100A: if shortness of breath or trouble breathing is present when the resident
is engaging in activity. Shortness of breath could be present during activity as limited as
turning or moving in bed during daily care or with more strenuous activity such as
transferring, walking, or bathing. If the resident avoids activity or is unable to engage in
activity because of shortness of breath, then code this as present.
•
Check J1100B: if shortness of breath or trouble breathing is present when the resident
is sitting at rest.
•
Check J1100C: if shortness of breath or trouble breathing is present when the resident
attempts to lie flat. Also code this as present if the resident avoids lying flat because of
shortness of breath.
•
Check J1100Z: if the resident reports no shortness of breath or trouble breathing and
the medical record and staff interviews indicate that shortness of breath appears to be
absent or well controlled with current medication.
Manual page J-25 MDS item matrixAssessment Applicability
See where this item applies across Nursing Home, Swing Bed, discharge, required-use, OBRA, and program or policy columns.
16 relationships7 groups+
OBRA Stand Alone Assessments
OBRA Admission A=01, B=99, F=99, G=^, H=0
MDS Item Matrix v1.20.1 v4
OBRA Quarterly A=02, B=99, F=99, G=^, H=0
MDS Item Matrix v1.20.1 v4
OBRA Annual / Sig Chg A=03, B=99, F=99, G=^, H=0 A= 04, B=99, F=99, G=^, H=0
MDS Item Matrix v1.20.1 v4
OBRA Discharge A=99, B=99, F=10, 11, G=1, 2, H=0
MDS Item Matrix v1.20.1 v4
D/C Items (Only when A0310F = 10 or 11)
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