MEPAP Course and Independent Study Course

Resident Assessment Instrument
Terminology

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 department.

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 date, etc.

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 be set.

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 time.

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 impairment.

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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