| ENTRY SPECIFICATION |
{"name": "CASE MIX",
{"id": "c5156", "text": "2. 6 month", "quickKey": 2},
"columns": 1,
"choices":[
{"id": "c5080", "text": "0. Can get in and out of a bed or chair without help of any kind?", "quickKey": 0},
{"id": "c5081", "text": "1. Need somebody to be there to guide you but can move in and out of a bed or
chair?", "quickKey": 1},
{"id": "c5082", "text": "2. * Need one other person to help you?", "quickKey": 2},
{"id": "c5083", "text": "3. * Need two other people or a mechanical aid to help you?", "quickKey": 3},
{"id": "c5084", "text": "4. * Never get out of a bed or chair?", "quickKey": 4}
]},
{"id": "q8541", "type": "ChoiceQuestion", "required": true, "inline": false,
{"id": "c5157", "text": "3. Annual", "quickKey": 3},
"text": "Q7. WALKING<br /> How well are you able to walk around, either without any help
or with a cane or walker, but not<br /> including a wheelchair? (If asked,
clarify that independence in walking refers to the ability to walk<br /> short
distances around the house. Independence in walking does not include climbing
stairs.) <br /> Would you say that you:",
"intro": " ",
"columns": 1,
"choices":[
{"id": "c5085", "text": "0. Walk without help of any kind?", "quickKey": 0},
{"id": "c5086", "text": "1. Can walk with help of a cane, walker, crutch, or push wheelchair?", "quickKey": 1},
{"id": "c5158", "text": "4. Change in level of care", "quickKey": 4}
{"id": "c5087", "text": "2. * Need and get help from one person to help you walk?", "quickKey": 2},
{"id": "c5088", "text": "3. * Need and get help from two people to help you walk?", "quickKey": 3},
{"id": "c5089", "text": "4. * Cannot walk at all?", "quickKey": 4}
]},
{"id": "q8542", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "Q8. BEHAVIOR",
"intro": " ",
"columns": 1,
"choices":[
{"id": "c5090", "text": "0. Behavior requires no intervention.", "quickKey": 0},
]},
{"id": "c5091", "text": "1. Needs and receives occasional staff intervention in the form of cues
because the person is anxious, irritable, lethargic or demanding. Person responds to cues.", "quickKey": 1},
{"id": "c5092", "text": "2. * Needs and receives regular staff intervention in the form of redirection
because the person has episodes of disorientation, hallucinates, wanders, is withdrawn or exhibits similar
behaviors. Person may be resistive but responds to redirection.", "quickKey": 2},
{"id": "c5093", "text": "3. * Needs and receives behavior management and staff intervention because
person exhibits disruptive behavior such as verbally abusing others, wandering into private areas,
removing or destroying property, or acts in a sexually aggressive manner. Person may be resistant to redirection.",
"quickKey": 3},
{"id": "c5094", "text": "4. * Needs and receives behavior management and staff intervention because person is
{"id": "q8581", "type": "DateQuestion", "required": false, "inline": true,
physically abusive to self and others. Person may physically resist redirection.", "quickKey": 4}
]},
{"id": "q8543", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "Q9. COMMUNICATION<br /> How effective are you at making yourself understood?
Would you say that on a regular basis you are:",
"intro": " ",
"columns": 1,
"choices":[
{"id": "c5095", "text": "0. Understood?", "quickKey": 0},
{"id": "c5096", "text": "1. Usually Understood?", "quickKey": 1},
"text": " Anticipated Start Date ",
{"id": "c5097", "text": "2. Sometimes Understood?", "quickKey": 2},
{"id": "c5098", "text": "3. Rarely/Never Understood?", "quickKey": 3}
]},
{"id": "q8544", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "Q10. TOILETING<br /> How well can you manage using the toilet? (Using the toilet
independently includes<br /> adjusting clothing, getting to and on the toilet,
and cleaning one's self. If reminders<br /> are needed to use the toilet this
counts as some help.) Would you say that you:",
"intro": " ",
"columns": 1,
"controlWidth": 120, "daysBack": 30, "daysAhead": 365},
"choices":[
{"id": "c5099", "text": "0. Can use the toilet without help, including adjusting clothing?", "quickKey": 0},
{"id": "c5100", "text": "1. * Need some help to get to and on the toilet but don't have accidents?", "quickKey": 1},
{"id": "c5101", "text": "2. * Have accidents sometimes, but not more than once a week?", "quickKey": 2},
{"id": "c5102", "text": "3. * Only have accidents at night?", "quickKey": 3},
{"id": "c5103", "text": "4. * Have accidents more than once a week?", "quickKey": 4},
{"id": "c5104", "text": "5. * Have bowel movements in your clothes more than once a week?", "quickKey": 5},
{"id": "c5105", "text": "6. * Wet your pants and have bowel movements in your clothes very often?", "quickKey": 6},
{"id": "c5106", "text": "7. * Are enrolled in VA Bowel and Bladder Program?", "quickKey": 7}
]},
{"id": "q8582", "type": "ChoiceQuestion", "required": false, "inline": false,
{"id": "q8545", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "Q11. MDS HC 2.0/CPS Cognitive Skill for Daily Decision Making",
"intro": " ",
"columns": 1,
"choices":[
{"id": "c5107", "text": "0. Independent - decisions consistent/reasonable.", "quickKey": 0},
{"id": "c5108", "text": "1. Modified Independence - some difficulty in new situations only.", "quickKey": 1},
{"id": "c5109", "text": "2. Moderately Impaired - decisions poor; cues/supervision required.", "quickKey": 2},
{"id": "c5110", "text": "3. Severely Impaired - never/rarely made decisions.", "quickKey": 3}
]},
"text": " Anticipated Length of Service",
{"id": "q8546", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "Q12. MDS 2.0/CPS: Short Term Memory (recall of what was learned or known)",
"intro": " ",
"columns": 1,
"choices":[
{"id": "c5111", "text": "0. Short-term memory okay- seems/appears to recall after 5 minutes", "quickKey": 0},
{"id": "c5112", "text": "1. Memory problem", "quickKey": 1}
]},
{"id": "q8547", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "Q13. SPECIAL TREATMENTS",
"columns": 1,
"intro": " ",
"columns": 1,
"choices":[
{"id": "c5113", "text": "0. No TX", "quickKey": 0}, {"id": "c5114", "text": "1. Tube Feedings", "quickKey": 1},
{"id": "c5115", "text": "2. One or more TX such as:", "quickKey": 2}
]},
{"id": "q8548", "type": "CheckQuestion", "required": false, "inline": false,
"text": "Q13a. Check all that apply:",
"intro": " ",
"columns": 1,
"restartDays": 2,
"choices":[
"choices":[
{"id": "c5116", "text": "1. Intravenous Fluid", "quickKey": 1},
{"id": "c5117", "text": "2. Intravenous Medications", "quickKey": 2},
{"id": "c5118", "text": "3. Drainage Tubes", "quickKey": 3},
{"id": "c5119", "text": "4. Symptom Control for Terminal Illness", "quickKey": 4},
{"id": "c5120", "text": "5. Isolation Precautions", "quickKey": 5},
{"id": "c5121", "text": "6. Hyperalimentation/Hickman Catheter", "quickKey": 6},
{"id": "c5122", "text": "7. Oxygen & Respiratory Therapy", "quickKey": 7},
{"id": "c5123", "text": "8. Ostomies & Catheters", "quickKey": 8},
{"id": "c5124", "text": "9. Wound Care/Decubiti", "quickKey": 9},
{"id": "c5159", "text": "1. Less than 90 days", "quickKey": 1},
{"id": "c5125", "text": "10. Skin Care", "quickKey": 10},
{"id": "c5126", "text": "11. Other", "quickKey": 11}
]},
{"id": "q8549", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "Q14. CLINICAL MONITORING",
"intro": " ",
"columns": 1,
"choices":[
{"id": "c5127", "text": "0. Less than once a day", "quickKey": 0},
{"id": "c5128", "text": "1. 1-2 shifts a day", "quickKey": 1},
{"id": "c5160", "text": "2. 3 months", "quickKey": 2},
{"id": "c5129", "text": "2. All shifts", "quickKey": 2}
]},
{"id": "q8550", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "Q15. SPECIAL NURSING<br /> In order to code this item \u0022yes,\u0022 the person
must receive either tube feeding only,<br /> or a combination of other special
treatment (2 in Q13) and clinical monitoring (2 in Q14)",
"intro": " ",
"columns": 1,
"choices":[
{"id": "c5130", "text": "1. Yes", "quickKey": 1},
{"id": "c5161", "text": "3. 6 months", "quickKey": 3},
{"id": "c5131", "text": "2. No", "quickKey": 2}
]},
{"id": "i2454", "type": "IntroText",
"text": "<em>NEURODIAGNOSIS (ICD-10 Codes)</em><br /> <br />Diseases of the nervous system
excluding sense organs<br /> G00-99, excluding G30.9 and G47<br />Cerebrovascular
Disease<br /> I60-I69<br />Fracture of the skull</br > S02.0XXA<br />Spinal Cord
Injury without evidence of spinal bone injury</br> S14.101A-S14.104A<br />Injury
to nerve roots and spinal plexusM<br /> S14.2XXA<br />Neoplasms of the brain and
spine<br /> C41.2, C41.4, C71.0-71.9, C79.31, C74.49, C79.32,<br /> D16.6, D16.8,
D33.2-D33.9, D42.0, D42.1, D42.9, D49.6"
{"id": "c5162", "text": "4. 12 months", "quickKey": 4}
},
{"id": "q8551", "type": "ChoiceQuestion", "required": false, "inline": false,
"text": "Q16. NEUROMUSCULAR DIAGNOSIS",
"intro": "NEURODIAGNOSIS (ICD-10 Codes)<br /> <br />Diseases of the nervous system
excluding sense organs (G00-99, excluding G30.9 and G47)<br />Cerebrovascular
Disease (I60-I69)<br />Fracture of the skull (S02.0XXA)<br />Spinal Cord
Injury without evidence of spinal bone injury (S14.101A-S14.104A)<br />Injury
to nerve roots and spinal plexus (S14.2XXA)<br />Neoplasms of the brain and
spine (C41.2, C41.4, C71.0-71.9, C79.31, C74.49, C79.32, D16.6, D16.8,
D33.2-D33.9, D42.0, D42.1, D42.9, D49.6)",
]},
"columns": 1,
"choices":[
{"id": "c5132", "text": "1. Yes", "quickKey": 1},
{"id": "c5133", "text": "2. No", "quickKey": 2}
]},
{"id": "q8552", "type": "MemoQuestion", "required": false,
"text": "COMMENTS. on Functional Strengths/ADLs/Community Supports Plan/Supervision
Implications",
"intro": " ",
"controlWidth": 658},
{"id": "i2434", "type": "IntroText",
{"id": "q8553", "type": "CheckQuestion", "required": false, "inline": false,
"text": "SOURCES. Please select the sources of information that were used to determine the
patient's ability to manage <br />their activities of daily living (dressing,
grooming, bathing, eating, walking, toileting, transferring, and bed mobility).
<br />Check all that apply:",
"intro": " ",
"columns": 1,
"choices":[
{"id": "c5134", "text": "1. Person", "quickKey": 1},
{"id": "c5135", "text": "2. Informant", "quickKey": 2},
"text": " "
{"id": "c5136", "text": "3. Medical Record", "quickKey": 3},
{"id": "c5137", "text": "4. Observation", "quickKey": 4}
]}],
"rules":[
{"question": "q8547", "operator": "NE", "value": "c5115",
"skips":["q8548"]}]
}
},
{"id": "q8535", "type": "ChoiceQuestion", "required": true, "inline": false,
"printTitle": "Case Mix & Budget Tool",
"text": "Q1. DRESSING<br /> How well are you able to manage dressing? By dressing, we mean
laying out the clothes and<br /> putting them on, including shoes, and fastening
clothes. Would you say that you:",
"intro": " ",
"columns": 1,
"choices":[
{"id": "c5056", "text": "0. Can dress without help of any kind?", "quickKey": 0},
{"id": "c5057", "text": "1. Need and get minimal supervision or reminding?", "quickKey": 1},
{"id": "c5058", "text": "2. * Need some help from another person to put your clothes on?", "quickKey": 2},
{"id": "c5059", "text": "3. * Cannot dress yourself and somebody dresses you?", "quickKey": 3},
"content":[
{"id": "c5060", "text": "4. * Are never dressed?", "quickKey": 4}
]},
{"id": "q8536", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "Q2. GROOMING<br /> Now I have some questions about how you manage with grooming
activities like combing your hair,<br /> putting on makeup, shaving, and
brushing your teeth. Would you say that you:",
"intro": " ",
"columns": 1,
"choices":[
{"id": "c5061", "text": "0. Can comb your hair, wash your face, shave or brush your teeth without help of
{"id": "q8580", "type": "ChoiceQuestion", "required": false, "inline": false,
any kind?", "quickKey": 0},
{"id": "c5062", "text": "1. Need and get supervision or reminding or grooming activities?", "quickKey": 1},
{"id": "c5063", "text": "2. * Needs and get daily help from another person?", "quickKey": 2},
{"id": "c5064", "text": "3. * Are completely groomed by somebody else?", "quickKey": 3}
]},
{"id": "q8537", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "Q3. BATHING<br /> How well can you bathe or shower yourself? (Bathing or
showering by yourself means running<br /> the water, taking the bath or shower
without any help, and washing all parts of the body, including<br /> our hair
and face.) Would you say that you:",
"text": " Type of Evaluation",
"intro": " ",
"columns": 1,
"choices":[
{"id": "c5065", "text": "0. Can bathe or shower without any help?", "quickKey": 0},
{"id": "c5066", "text": "1. Need and get minimal supervision or reminding?", "quickKey": 1},
{"id": "c5067", "text": "2. Need and get supervision only?", "quickKey": 2},
{"id": "c5068", "text": "3. Need and get help getting in and out of the tub?", "quickKey": 3},
{"id": "c5069", "text": "4. * Need and get help washing and drying your body?", "quickKey": 4},
{"id": "c5070", "text": "5. * Cannot bathe or shower, need complete help?", "quickKey": 5}
]},
"columns": 1,
{"id": "q8538", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "Q4. EATING<br /> How well can you manage eating by yourself? Eating by yourself
means drinking and eating without<br /> help from anybody else, but you can use
special utensils and straws. It also means cutting most foods<br /> on your own.
Would you say that you:",
"intro": " ",
"columns": 1,
"choices":[
{"id": "c5071", "text": "0. Can eat without help of any kind?", "quickKey": 0},
{"id": "c5072", "text": "1. Need and get minimal reminding or supervision?", "quickKey": 1},
"choices":[
{"id": "c5073", "text": "2. * Need and get help in cutting food, buttering bread or arranging food?", "quickKey": 2},
{"id": "c5074", "text": "3. * Need and get some personal help with feeding or someone needs to be sure
that you don't choke?", "quickKey": 3},
{"id": "c5075", "text": "4. * Need to be fed completely or tube feeding or IV feeding?", "quickKey": 4}
]},
{"id": "q8539", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "Q5. BED MOBILITY<br /> How well can you manage sitting up or moving around in
bed? Would you say that you:",
"intro": " ",
"columns": 1,
{"id": "c5155", "text": "1. Initial", "quickKey": 1},
"choices":[
{"id": "c5076", "text": "0. Can move in bed without any help?", "quickKey": 0},
{"id": "c5077", "text": "1. Need and get help sometimes to sit up?", "quickKey": 1},
{"id": "c5078", "text": "2. * Always need and get help to sit up?", "quickKey": 2},
{"id": "c5079", "text": "3. * Always need and get help to be turned or change positions?", "quickKey": 3}
]},
{"id": "q8540", "type": "ChoiceQuestion", "required": true, "inline": false,
"text": "Q6. TRANSFERRING<br /> How well can you get in and out of a bed or chair? Would
you say that you:",
"intro": " ",
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