This information was taken from the CMS training
materials which you can find on
the CMS site. There is a more comprehensive glossary on CMS.
This is an amended listing of terms relevant to the activity/recreation
RAI - Resident Assessment Instrument
: A standardized assessment tool utilized in nursing homes and
residential health care facilities. Mandated by the Federal government.
Consists of two parts, the MDS (Minimum Data Set) and the RAP's
(Resident Assessment Protocols).
MDS - Minimum Data Set : A core set of screening,
clinical assessment, and functional status elements, including
common definitions and coding categories that form the foundation
of the comprehensive assessment for all residents of long-term
care facilities certified to participate in Medicare and Medicaid
and for patients receiving SNF services in non-critical access
hospitals with a swing bed agreement.
Ability to Understand Others : Comprehension
of direct person-to-person communication whether spoken, written,
or in sign language or Braille. Includes the resident’s ability
to process and understand language.
Acute Change in Mental Status : Alteration
in mental status (e.g., orientation, inattention, organization
of thought, level of consciousness, psychomotor behavior, change
in cognition) that was new or worse for this resident, usually
over hours to days.
Assessment Period : The time period
during which the assessment coordinator starts the assessment
until it is signed as complete.
Assessment Reference Date ARD: The specific
end point for look-back periods in the MDS assessment process.
Almost all MDS items refer to the resident’s status over a designated
time period referring back in time from the ARD. Most frequently,
this look-back period, also called the observation or assessment
period, is a 7-day period ending on the ARD. Look-back periods
may cover the 7 days ending on this date, 14 days ending on this
Assessment Submission and Processing System
ASAP : The CMS system that receives submissions of MDS 3.0
data files, validates records for accuracy and appropriateness,
and stores validated records in the CMS database.
Assessment Window: The period of time
defined by Medicare regulations that specifies when the ARD must
Baseline: An individual's usual, customary,
initial, or most common (depending on the item) range or level
of something; for example, behavior, laboratory values, mood,
endurance, function, vital signs, etc. "Baseline" information
is often used as a basis for comparing findings or results over
Brief Interview for Mental Status BIMS :
The BIMS is a brief screener that aids in detecting cognitive
impairment. It does not assess all possible aspects of cognitive
Care Area Assessment Process : This
process is designed to assist the assessor to systematically interpret
the information recorded on the MDS. Once a care area has been
triggered, nursing home providers use current, evidence-based
clinical resources to conduct an assessment of the potential problem
and determine whether or not to care plan for it. The CAA process
helps the clinician to focus on key issues identified during the
assessment process so that decisions as to whether and how to
intervene can be explored with the resident. The CAA process is
explained in detail in Chapter 4. Specific components of the CAA
process include: — Care Area Triggers (CATs) are specific resident
responses for one or a combination of MDS elements. The triggers
identify residents who have or are at risk for developing specific
functional problems and require further assessment.
— CAA Resources are a list of resources that may be helpful in
performing the assessment of a triggered care area. These resources
are included in Appendix C and represent neither an all-inclusive
list nor government endorsement.
— CAA Summary (Section V of the MDS 3.0) provides a location for
documentation of the care area(s) that have triggered from the
MDS and the decisions made during the CAA process regarding whether
or not to proceed to care planning.
Care Area Assessment CAA: The review
of one or more of the twenty conditions, symptoms, and other areas
of concern that are commonly identified or suggested by MDS findings.
Care areas are triggered by responses on the MDS item set.
Care Area Triggers CAT: A set of items
and responses from the MDS that are indicators of particular issues
and conditions that affect nursing facility residents.
Centers for Medicare & Medicaid Services
CMS : CMS is the Federal agency that administers the Medicare,
Medicaid, and Child Health Insurance Programs
Comatose (Coma) : Pathological state
in which neither arousal (wakefulness, alertness) nor awareness
exists. The person is unresponsive and cannot be aroused; he or
she may or may not open his or her eyes, does not speak, and does
not move his or her extremities on command or in response to noxious
stimuli (e.g., pain). Comprehensive Assessment Requires completion
of the MDS and review of CAAs, followed by development or review
of the comprehensive care plan.
Confusion Assessment Method CAM : An
instrument that screens for overall cognitive impairment as well
as features to distinguish delirium or reversible confusion from
other types of cognitive impairments.
Daily Decision Making : Includes: choosing
clothing; knowing when to go to scheduled meals; using environmental
cues to organize and plan (e.g., clocks, calendars, posted event
notices); in the absence of environmental cues, seeking information
appropriately (i.e. not repetitively) from others in order to
plan the day; using awareness of one’s own strengths and limitations
to regulate the day’s events (e.g., asks for help when necessary);
acknowledging need to use appropriate assistive equipment such
as a walker. Delirium Acute onset or worsening of impaired brain
function resulting in cognitive and behavioral symptoms such as
worsening confusion, disordered expression of thoughts, frequent
fluctuation in level of consciousness, and hallucinations. Delusion
A fixed, false belief not shared by others that the resident holds
even in the face of evidence to the contrary.
Disorganized Thinking : Having thoughts
that are fragmented or not logically connected.
Fall: Unintentional change in position
coming to rest on the ground or onto the next lower surface (e.g.,
onto a bed, chair, or bedside mat).
Hallucination : A perception in a conscious
and awake state, of something in the absence of external stimuli.
May be auditory or visual or involve smells, tastes, or touch.
Inattention: Reduced ability to maintain
attention to external stimuli and to appropriately shift attention
to new external stimuli.
Level of Consciousness
Alert: startles easily to any sound or touch.
Drowsy/Lethargic: repeatedly dozes off when you are asking questions
but responds to voice or touch.
Stuporous: very difficult to arouse and keep aroused for the interview.
Comatose: cannot be aroused despite shaking and shouting.
Look-Back Period : A timeframe defined
by counting backwards from the ARD that is used when coding each
item on the MDS.
Makes Self Understood: Able to express
or communicate requests, needs, opinions, and to conduct social
conversation in his or her primary language, whether in speech,
writing, sign language, gestures, or a combination of these. Deficits
in ability to make one’s self understood (expressive communication
deficits) can include reduced voice volume and difficulty in producing
sounds, or difficulty in finding the right word, making sentences,
writing, and/or gesturing.
Music Therapy : Music therapy is an
intervention that uses music to address physical, emotional, cognitive,
and social needs of individuals of all ages. Music therapy interventions
can be designed to promote wellness, manage stress, alleviate
pain, express feelings, enhance memory, improve communication,
and promote physical rehabilitation. In order for music therapy
to coded on the MDS, the service must be provided or directly
supervised by a qualified staff.
Non-pharmacological Intervention: Approaches
that do not involve the use of medication to address a medical
condition. Nursing Facility
Persistent Vegetative State PVS: PVS
is an enduring situation in which an individual has failed to
demonstrate meaningful cortical function but can sustain basic
body functions supported by noncortical brain activity.
Psychomotor Retardation : Visibly slowed
level of activity or mental processing in residents who are alert.
Psychomotor retardation should be differentiated from altered
level of consciousness (i.e. stupor) and lethargy.
Quality Indicator QI: The QIs represent
common conditions and important aspects of care, and are markers
that indicate either the presence or absence of quality of care
practices and outcomes. QI reports reflect a measure of the prevalence
or incidence of conditions based on MDS assessment data.
Recreational Therapy: Services that
are provided or directly supervised by a qualified recreational
therapist who holds a national certification in recreational therapy,
also referred to as a Certified Therapeutic Recreation Specialist.”
Recreational therapy includes, but is not limited to, providing
treatment services and recreation activities to individuals using
a variety of techniques, including arts and crafts, animals, sports,
games, dance and movement, drama, music, and community outings.
Recreation therapists treat and help maintain the physical, mental,
and emotional well-being of their clients by seeking to reduce
depression, stress, and anxiety; recover basic motor functioning
and reasoning abilities; build confidence; and socialize effectively.
Recreational therapists should not be confused with recreation
workers, who organize recreational activities primarily for enjoyment.
Religion : Belief in and reverence for
a supernatural power or powers regarded as creator and governor
of the universe. Can be expressed in practice of rituals associated
with various religious faiths, attendance and participation in
religious services, or in private prayer or religious study.
Respite : Short-term, temporary care
provided to residents to allow family members to take a break
from the daily routine of care giving. Skilled Nursing Facility
SNF A facility that primarily engaged in providing skilled nursing
care and related services to individuals who require medical or
nursing care or rehabilitation services of injured, disabled,
or sick persons.
Temporal Orientation: In general, the
ability to place oneself in correct time. For BIMS, it is the
ability to indicate correct date in current surroundings.
Check out the Documentation
Link Page for more information on the MDS
and the MDS 3.0 page.
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