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(M0030) Start of Care Date:
06/18/2025
(M1030) Therapies the patient receives at home: (Mark all that apply.)
(M1033) Therapies the patient receives at home: (Mark all that apply.).
1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months)
2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months
3 - Multiple hospitalizations (2 or more) in the past 6 months
4 - Multiple emergency department visits (2 or more) in the past 6 months
5 - Decline in mental, emotional, or behavioral status in the past 3 months
6 - Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) in the past 3 months
7 - Currently taking 5 or more medications
8 - Currently reports exhaustion
(M1200) Vision (with corrective lenses if the patient usually wears them):
(M1242) Frequency of Pain Interfering with patient's activity or movement:
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(M1400) When is the patient dyspneic or noticeably Short of Breath?
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2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)
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(M1610) Urinary Incontinence or Urinary Catheter Presence:
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2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]
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(M1620) Bowel Incontinence Frequency:
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4 - On a daily basis
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(M1630) Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, or b) necessitated a change in medical or treatment regimen?
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0 - Patient does not have an ostomy for bowel elimination.
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(M1800). Grooming: Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or make up, teeth or denture care, or fingernail care).
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2 - Someone must assist the patient to groom self.
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(M1810) Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps:
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2 - Someone must help the patient put on upper body clothing.
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(M1820) Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes:
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3 - Patient depends entirely upon another person to dress lower body.
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(M1830) Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair).
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3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.
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(M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.
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2 - Unable to get to and from the toilet but is able to use a bedside commode (with or without assistance).
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(M1850) Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.
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2 - Able to bear weight and pivot during the transfer process but unable to transfer self.
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(M1860) Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.
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3 - Able to walk only with the supervision or assistance of another person at all times.
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(M2030) Management of Injectable Medications: Patient's current ability to prepare and take all prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. Excludes IV medications.
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3 - Unable to take injectable medication unless administered by another person.
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Skilled Nursing