Toward a National Health Information Infrastructure: A Key Strategy for Improving Quality in Long-Term Care

APPENDICES

APPENDIX A. ACOVE INDICATORS: Pressure Ulcers; Pain Management; Urinary Incontinence

APPENDIX B. TERMS ABSTRACTED FROM DOMAIN EXPERTS REPORTS: DOMAIN FOCUS: Pressure Ulcer Risk; DOMAIN FOCUS: Chronic Pain; DOMAIN FOCUS: Urinary Incontinence

APPENDIX C. EXAMPLES OF MDS-DERIVED QUALITY INDICATORS: Prevalence of Stage 1-4 Pressure Ulcer; Prevalence of Bowel of Bladder Incontinence

APPENDIX D. EXAMPLES OF MDS-DERIVED QUALITY MEASURES: Percent of Residents with Pressure Sores with Additional Level of Risk Adjustments; Percent of Short-Stay Residents with Pain

APPENDIX E. CONTACT INFORMATION, TERMINOLOGY CODING SYSTEMS: SNOMED CT; ICF; ICNP

APPENDIX F. TERMS ABSTRACTED FROM THE MDS: MDS Terms Classified as "Administrative Information"; MDS Terms Classified as "Resident History"; MDS Terms Classified as "Assessments"; MDS Terms Classified as "Treatments"; MDS Terms Classified as "Other"

APPENDIX G. TERMS PROVIDED BY DOMAIN EXPERTS, PARTIAL OR NO MATCHES: Terms From Domain Experts, Partial Match or No Match to MDS; Terms From Domain Experts, Partial Match or No Match to SNOMED CT

APPENDIX H. REFERENCES PROVIDED BY DOMAIN EXPERTS: Chronic Pain References; Pressure Ulcer References; Urinary Incontinence References

APPENDIX A. ACOVE INDICATORS

Pressure Ulcers
Risk Assessment	IF a vulnerable elder is admitted to an intensive care unit or a medical or surgical unit of a hospital and cannot reposition himself or herself or has limited ability to do so, THEN risk assessment to pressure ulcers should be done on admission.
Preventive Intervention	IF a vulnerable elder is identified as at risk for pressure ulcer development or a pressure ulcer risk assessment score indicates that the person is at risk. THEN a preventive intervention addressing repositioning needs and pressure reduction (or management of tissue loads) must be instituted within 12 hours.
Nutritional Intervention	IF a vulnerable elder is identified as at risk for pressure ulcer development and has malnutrition (involuntary weight loss of >10% over 1 year or low albumin or prealbumin levels,) THEN nutritional intervention or dietary consultation should be instituted.
Evaluation	IF vulnerable elder presents with a pressure ulcer, THEN the pressure ulcer should be assessed for location, depth, and stage, size, and presence of necrotic tissue.
Management	IF a vulnerable elder presents with a clean full-thickness pressure ulcer and has no improvement after 4 weeks of treatment, THEN the appropriateness of the treatment plan and the presence of cellulitis or osteomyelitis should be assessed. IF a vulnerable elder presents with a partial-thickness pressure ulcer and has no improvement after 2 weeks of treatment, THEN the appropriateness of the treatment plan should be assessed.
Debridement	IF a vulnerable elder presents with a full-thickness sacral or trochanteric pressure ulcer covered with necrotic debris or eschar, THEN debridement by using sharp, mechanical, enzymatic, or autolytic procedures should be done within 3 days of diagnosis.
Cleaning	IF a vulnerable elder has a stage 2 or greater pressure ulcer, THEN topical antiseptic should not be used on the wound.
Systemic Infection	IF a vulnerable elder with a full-thickness pressure ulcer presents with systemic signs and symptoms of infection, such as elevated temperature, leukocytosis, confusion, and agitation, and these signs and symptoms do not have another identified cause, THEN the ulcer should be debrided of necrotic tissue within 12 hours IF a vulnerable elder with a full-thickness pressure ulcer presents with systemic signs and symptoms of infection, such as elevated temperature, leukocytosis confusion, and agitation, and these signs and symptoms do not have another identified cause, THEN a tissue biopsy or needle aspiration sample should be obtained and sent for culture and sensitivity testing within 12 hours.
Topical Dressing	IF vulnerable elder presents with a clean full-thickness or a partial-thickness pressure ulcer, THEN a moist-healing environment should be provided with a topical dressing.

Pain Management
Screening for Pain	ALL vulnerable elders should be screened for chronic pain during initial evaluation period. ALL vulnerable adults should be screened for chronic pain every 2 years.
Target History and Physical Examination	IF a vulnerable adult has a newly reported chronic pain condition, THEN a targeted history and physical examination should be initiated within 1 month.
Addressing Risks of NSAIDs	IF a vulnerable adult ahs been prescribed a cyclooxygenase nonselective NSAID for the treatment of chronic pain, THEN the medical record should indicate whether he or she has a history of peptic ulcer disease and, if a history is present, justification of the NSAID should be documented.
Constipation with Opioid Use	IF a vulnerable elder with chronic pain is treated with opioids, THEN he or she should be offered a bowel regimen, or the medical record should document the potential for constipation or explain why bowel treatment is not needed.
Treating Pain	IF a vulnerable elder has a newly reported chronic painful condition, THEN treatment should be offered.
Reassessment of Pain Control	IF a vulnerable elder is treated for a chronic painful condition, THEN he or she should be assessed for a response within 6 months.
Related Indicators	Evaluate depression in patients with chronic pain. Palliative care. Educate concerning side effects of new medication. Avoid meperidine. Assess pain and function annually for osteoarthritis. Acetaminophen use for osteoarthritis. NSAID use for osteoarthritis.

Urinary Incontinence
Initial Evaluation	ALL vulnerable elders should have documentation of the presence or absence of urinary incontinence during the initial evaluation.
Annual Evaluation	ALL vulnerable elders should have annual documentation of the presence or absence of urinary incontinence.
Targeted History	IF a vulnerable elder has a new urinary incontinence that persists for more than 1 month or urinary incontinence at the time of a new evaluation, THEN a targeted history should be obtained that documents each of the following: (1) characteristics of voiding, (2) ability to get to the toilet, (3) previous treatment for urinary incontinence, (4) importance of the problem to the patient, and (5) mental status.
Targeted Physical Examination	IF a vulnerable elder has new urinary incontinence that persists for more than 1 month or urinary incontinence at the time of a new evaluation, THEN a targeted physical examination should be performed that documents (1) rectal examination (2) a genital system examination (including a pelvic examination for women).
Diagnostic Tests	IF a vulnerable elder has a new urinary incontinence that persists for more than 1 month or urinary incontinence at the time of a new evaluation, THEN a dipstick urinalysis and post-void residual should be obtained.
Discussion of Treatment Options	IF a vulnerable elder has a new urinary incontinence or urinary incontinence at the time of a new evaluation, THEN treatment options should be discussed.
Behaviorial Therapy	IF a cognitively intact vulnerable elder who is capable independent toileting has documented stress, urge, or mixed incontinence without evidence of hematuria or high post-void residual, THEN behavioral treatment should be offered.
Urodynamic Testing	IF a vulnerable elder undergoes surgery or periurethral injections for urinary incontinence, THEN subtracted cystometry should be performed before the procedure.
Surgery for Stress Incontinence	IF a female vulnerable elder has documented stress urinary incontinence caused by isolated intrinsic sphincter deficiency or intrinsic sphincter deficiency with coexistent hypermobility, and she undergoes surgical correction, THEN a sling or artificial procedure should be used.
Catheter Use	IF a vulnerable elder has clinically significant newly discovered overflow urinary incontinence and indwelling urethral catheterization is used, THEN there should be documentation that the patient is not a candidate for alternative interventions as a result of severe physical or mental impairments or does not want to alternative interventions.

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APPENDIX B. TERMS ABSTRACTED FROM DOMAIN EXPERTS REPORTS

DOMAIN FOCUS: Pressure Ulcer Risk
Purpose for Which Term Provides Information	Term
Provider Information	NA, RN, LPN
Patient Tracking Information
Patient Information	Age Gender
Pressure Ulcer	Assess for recurrence of pressure ulcer Location of pressure ulcer Stage of pressure ulcer Ulcer healing
Risk Status	At risk for developing pressure ulcers High risk for pressure ulcers Risk assessment tools Braden scale Norton scale Skin inspection Periodic reassessment
Cognition/Mental Status	Comatose Cognitive skill Distracted Awareness Restlessness Lethargy Mental function Altered level of consciousness Depression score Mental status
Can Request Help	Speech Verbal responses
Ability to Move Activity Mobility	Bed mobility Bed bound Chair bound Transfer ability Walking ability Locomotion Dressing ability Motion of: neck, arm, hand, leg, foot ADL function Activities of daily living Restraint use Body control Mobility device Difficulty with repositioning Impaired ability to reposition Immobility Spinal cord injury Physical status
Nutrition	Eating ability Nutritional intake Oral/nutritional status Oral problems Oral nutritional supplements Enteral feeding Modular products Vitamin/mineral supplements Weight loss BMI Poor meal intake Dietary intake Albumin Nitrogen balance Nutritional status Dietary intake of protein Dietary intake of calories Malnutrition Nutrition screening Nutritional assessment
Risk for Moisture Exposure Moisture	Toilet use Personal hygiene Bathing Bowel incontinence Bladder incontinence Briefs Protective padding Underpads Skin hydration
Pressure	Bony prominence
Risk for Delaying Healing	Infections
Outcome and Risk Factor	History of ulcers Hospital stays
Risk for Decreased Tissue Perfusion	Skin pliability Tobacco use CABG
Treatment for Pressure Ulcers	Ulcer care plan Application of dressings Clean dry dressings Dressings that keep ulcer bed continuously moist Protective dressings Cleanse wound Mild cleansing agent Whirlpool treatment Wet to dry dressings Debridement Topical debriding agents Autolytic debridement Enzymatic debridement Mechanical debridement Wound irrigation Foam Gel Growth factors Hormones Hyperbaric oxygen Infrared ultraviolet Hydrotherapy Normal saline Topical agents Topical amioglycoside treatment Topical antibiotics Topical treatment with iodine containing agents Avoid massage over bony prominences Moisturizers Lubricants (corn starch and cream) Electrical stimulation therapy Low energy laser irradiation Assisted oral feeding Oral supplements Devices that totally relieve pressure Distribution of weight Proper postural alignment Characteristics of support surfaces Dynamic support surface Low air loss bed Pressure relief Pressure reducing beds Pressure reducing mattresses Pressure reducing overlays Maintain position in bed or chair Nutritional management Aggressive nutritional interventions Air fluidized beds Plan of nutritional support Patient education Repositioning schedule Surgical flap Postoperative viability of the surgical site Evaluate adequacy of treatment
Condition Factors	Radiation treatment
Fiction/Shear	Friction injuries Bed linen to move Lifting devices Minimize force and friction Positioning devices Transferring support Turning techniques

DOMAIN FOCUS: Chronic Pain
Purpose for Which Term Provides Information	Terms
Risk Factors for Chronic Pain in Long-Term Care Facilities	Presence of diagnoses known to be painful: osteoarthritis, low back pain, fibromyalgia, spinal stenosis, post-herpetic neuralgia, peripheral neuropathy, myofascial pain syndromes, vasogenic claudication, phantom limb pain, headaches, vasculitic pain syndromes, osteoporosis with fractures, cancer, contractures, peripheral vascular disease, pheumatoid arthritis
Risk of Unrecognized and Thus Untreated Pain	Dementia Delirium
Location	Pain map Drawing Description
Intensity or Severity of Pain	Numeric estimate (0-100) Verbal descriptors scale: no pain, moderate, severe, excruciating, worst pain possible, most intense pain imaginable Faces pain scale
Quality	Terms within McGill pain questionnaire
Duration	Intermittent, continuous, lasting minutes or hours
Pattern	When starts, what started it, what makes it better, what makes it worse
Pain Behaviors	Facial (wrinkled forehead, tightly closed eyes, grimacing, frowning) Nonverbal behavior (bracing, rubbing, guarding) Vocalizations (crying, yelling, groaning, moaning)
Nonverbal Indicators of Discomfort	Aggressive, crying, fearful, negative vocalization, noisy respirations, pacing, repetitive, restlessness, rocking, confusion irritability, increased activity, withdrawal, tense, calling out, grunting, knees pulled up. Other changes in usual activities or behavior patterns/routines.
Impact of Pain on Quality of Life Outcomes	Physical function, sleep, appetite, interpersonal relationship/interactions with others, mood (anxiety, depression), mental status (ability to think clearly/ concentration/confusion), energy/fatigue
Treatments	Pain intensity monitoring Appropriate use of medications Appropriate use of non-pharmacologic interventions

DOMAIN FOCUS: Urinary Incontinence
Purpose for Which Term Provides Information	Terms
Target History Mental Status Characteristics of Voiding and Non-Invasive Bladder Diagnosis Ability to Toilet Prior Treatment for Incontinence Importance of Problem to Resident	MDS recall scale, MDS item B3, or Cognitive performance scale derived from MDS items Frequency of incontinence Status of incontinence: day and night Symptoms on urination Symptoms to distinguish between urge incontinence (short interval between sensation to void and bladder contraction) and stress incontinence (urine loss during physical movements) Mobility problems on MDS and provider notes
Targeted Physical	Rectal exam to exclude fecal impaction Skin exam to evaluate skin problems associated with urinary incontinence Genital system exam to identify physical abnormalities that may explain incontinence (e.g., pelvic prolapse)
Factors Associated with UI	Lab reports Primary care provider notes
Toileting Responsiveness Assessments	How often person voids when prompted on a routine basis Voiding record Non-invasive diagnoses of bladder function
Urodynamic Analyses of Bladder Functioning
Intervention	Prompted toileting Prompted voiding Scheduled toileting Timed voiding

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APPENDIX C. EXAMPLES OF MDS-DERIVED QUALITY INDICATORS

Prevalence of Stage 1-4 Pressure Ulcer
Numerator	Residents with pressure ulcers (Stage 1-4) on most recent assessment.
Denominator	All residents on most recent assessment.
MDS 2.0 Quarterly Variable Definition	Pressure ulcer (M2a > 0, or 13 = ICD-9 CM 707.0)
Risk Adjustment	High Risk: Impaired transfer or bed mobility (G1a or b = 3 or 4-Box A) OR comatose (B1 = 1) OR malnutrition (13 = ICD-9 CM 260,261, 262, 263.0, 263.1, 263.2, 263.8, or 263.9) OR end stage disease (J5c is checked) most recent assessment
Risk Adjustment	Low Risk: All others at most recent assessment.

Prevalence of Bowel or Bladder Incontinence
Numerator	Residents who were frequently incontinent or incontinent on most recent assessment.
Denominator	All residents, except as noted in exclusion. Exclude: Residents who are comatose residents (B1 = 1) OR have indwelling catheter (H3d is checked) OR have an ostomy (H3i is checked) at most recent assessment
MDS 2.0 Quarterly Variable Definition	Bladder incontinence (H1b = 3 or 4) Bowel incontinence (H1a = 3 or 4)
Risk Adjustment	High Risk: Severe cognitive impairment AND short-term memory problems (B4 = 3 and B2a = 1) OR Totally ADL dependent in mobility ADLs (G1a, b, e-Box A self- performance = 4 in all areas) at most recent assessment
Risk Adjustment	Low Risk: All others at most recent assessment.

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APPENDIX D. EXAMPLES OF MDS-DERIVED QUALITY MEASURES

Percent of Residents with Pressure Sores with Additional Level of Risk Adjustments (A QM for Long-Stay Residents)
Numerator	Number of residents with pressure ulcers (stage 1-4) on full or quarterly assessment (M2A > 0 or I3a-e = 707.0)
Denominator	All residents with valid full (AA8a = 01, 02, 03, 04) or quarterly assessment (AA8a = 05 10) Exclusions: Most recent assessment is the admission assessment (AA8a = 01); the QM is not triggered (resident is not included numerator) AND the value of M2a is missing on the target assessment.
Resident is a facility with a chronic care sample size =0 (i.e., over the last 12 months no residents with a non-PPS assessment - AA8a= 01 and AA8b=blank or 6) Facility Admission Profile Considers prevalence of stage 1-4 PU (M2a>0 OR I3a-e=707.0 among admissions (AA8a=01) occurring over the previous 12 months Numerator: admission assessments (AA8a=01) w/ M2A.0 OR I3a-e=707.0 Denominator: all admission assessments (AA8a=01) Exclusions: admission assessments (AA8a=01) that do not satisfy the numerator conditions AND have missing data on M2a.

Percent of Short-Stay Residents with Pain (A QM for Short-Stay Residents)
Numerator	Number of residents who experience moderate pain at least daily (J2a = 2 and J2b = 2) OR horrible excruciating pain at any freqency (J2b = 3) as noted on the SNF PPS 14 day
Denominator	All residents with valid SNF PPS 14 day assessment (AA8b = 7) Exclusions: J2a or J2b missing from SNF PPS 14 day assessment; J2a or J2b inconsistent on the SNF PPS 14 day assessment (e.g., coding pain frequency as "no pain" while simultaneously coding intensity of pain as "moderate"); resident is in a facility with a post-acute care sample size =0 (i.e., SNF PPS 5 day assessment AA8b=1 over the last 12 months).
Uses SNF PPS 14 day assessment (AA8b=7) with valid preceding 5 day SNF PPS assessment (AA8b=1)

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APPENDIX E. CONTACT INFORMATION, TERMINOLOGY CODING SYSTEMS

SNOMED CT
Purpose Reported by Developers	Terminology system that facilitates coding and retrieval of clinically relevant information.
Copyright	SNOMED International, a division of the College of American Pathologists (CAP)
Contact Information	SNOMED International 325 Waukegan Road Northfield, IL 60093-2750 Phone: (800) 323-4040 ext. 7700 U.S. (847) 832-7700 Canada E-mail: snomed@cap.org

ICF
Purpose Reported by Developers	A classification of health and health related domains that describe body functions and structures, activities and participation.
Copyright	World Health Organization (WHO)
Contact Information	World Health Organization Coordinator Classification, Assessment Surveys and Terminology Unit 20, Avenue Appia 1211 Geneva, Switzerland E-mail: ustunb@who.int

ICNP
Purpose Reported by Developers	Facilitate the crossmapping of local terms and existing nursing vocabularies and classifications.
Copyright	International Council of Nurses
Contact Information	ICNP® Programme Director Marquette University, College of Nursing P.O. Box 1881 Milwaukee, WI 53201 FAX: (414) 288 1939 E-mail: amy.coenen@marquette.edu

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APPENDIX F. TERMS ABSTRACTED FROM THE MDS

MDS Terms Classified as "Administrative Information" (n=87)

MDS
Identification Information
Resident Name
First
Middle
Last
Jr/Sr
Gender
Birthdate
Race/ethnicity
Social security number and Medicare Number
Facility Provider Number
State number
Federal Number
Medicaid Number
Reasons for Assessment
Primary reason for assessment
Admission assessment
Annual assessment
Significant change in status assessment
Significant correction of prior full assessment
Quarterly review assessment
Significant correction of prior quarterly assessment
Medicare 5 day assessment
Medicare 30 day assessment
Medicare 60 day assessment
Medicare 90 day assessment
Medicare readmission/return assessment
Other state required assessment
Medicare 14 day assessment
Other Medicare required assessment
Signature of Persons Completing a Portion of the Assessment
Signature
Title
Date
Demographic Information
Date of Entry
Admitted from
Zip Code of Prior Primary Residence
Date Background Information Completed
Not applicable no MR/DD
Identification and Background Information
Middle initial
Room Number
Assessment Reference Date
Last day of MDS observation period
Marital Status
Medical Record Number
Current Payment Sources for NH Stay
Medicaid per diem
Medicare per diem
Medicare ancillary part A
Medicare ancillary part B
CHAMPUS per diem
VA per diem
Self or family pays for full per diem
Medicaid resident liability of Medicare co-payment
Private insurance per diem
Other per diem
Significant change in status assessment
Discharged return not anticipated
Discharged return anticipated
Discharged prior to completing initial assessment
Reentry
Codes for assessments required for Medicare PPS or the state
Responsibility/Legal Guardian
Legal guardian
Other legal oversight
Durable power of attorney/health care
Durable power attorney/financial
Family member responsible
Advanced Directives
Living will
Do not resuscitate
Do not hospitalize
Organ donation
Autopsy request
Hospital Stay(s)
Emergency Room (ER) Visit(s)
Physician Orders
Assessment Information
Participation in Assessment
Resident
Family
Significant other
Signature of Person Coordinating the Assessment
Patient responsible for self

MDS Terms Classified as "Resident History" (n=143 )

Private home without home health services
Private home with home health services
Board and care assisted living group home
Nursing home
Acute care hospital
Psychiatric hospital MR/DD facility
Rehabilitation hospital
Lived Alone (Prior to entry)
Residential History 5 Years Prior to Entry
Prior stay at this nursing home
Stay in other nursing home
Other residential facility - board and care home, assisted li
MH/psychiatric setting
MR/DD setting
Lifetime Occupation(s)
Education
No schooling
8^th grade/less
9-11 grades
High school
Technical or trade school
Some college
Bachelor's degree
Graduate degree
Language
English
Spanish
French
Primary language
Down's syndrome
Autism
Epilepsy
Other organic condition related to MR/DD
MR/DD with no organic condition
Mental health history
Conditions related to MR/DD status
MR/DD with organic condition
Other organic condition related to MR/DD
MR/DD with no organic condition
Customary Routine
Cycle of Daily Events
Stays up late at night
Naps regularly during day
Goes out 1+ days a week
Stays busy with hobbies, reading or fixed daily routine
Spends most of time alone of watching TV
Moves independently indoors
Use of tobacco products at least daily
Eating Patterns
Distinct food preferences
Eats between meals all or most days
Use of alcoholic beverage(s) at least weekly
ADL Patterns
No change in ADL function
Improved
Deteriorated
In bedclothes much of day
Wakens to toilet all or most nights
Has irregular bowel movement patterns
Showers for bathing
Bathing in PM
Involvement Patterns
Daily contact with relatives/close friends
Usually attends church, temple, synagogue
Finds strength in faith
Daily animal companion/presence
Involved in group activities
Past Roles
Frequently incontinent
Incontinent
Disease Diagnosis
Diseases
Endocrine/metabolic/nutritional
Diabetes mellitus
Hyperthyroidism
Hypothyroidism
Heart/circulation
ASHD
Cardiac dysrythmias
Congestive heart failure
Deep vein thrombosis
Hypertension
Hypotension
Peripheral vascular disease
Other cardiovascular disease
Musculoskeletal
Arthritis
Hip fracture
Missing limb
Osteoporosis
Pathological bone fracture
Neurological
Alzheimer's disease
Aphasia
Cerebral palsy
Cerebrovascular accident
Dementia other than Alzheimer's disease
Hemiplegia/hemiparesis
Multiple sclerosis
Paraplegia
Parkinson's disease
Quadriplegia
Seizure disorder
Transient ischemic attack
Traumatic brain injury
Psychiatric/mood
Anxiety disorder
Depression
Manic depression
Schizophrenia
Pulmonary
Asthma
Emphysema
Sensory
Cataracts
Diabetic retinopathy
Glaucoma
Macular degeneration
Allergies
Anemia
Cancer
Renal failure
Infections
Antibiotic resistant infection
Clostridium difficile
Conjunctivitis
HIV infection
Pneumonia
Respiratory infection
Septicemia
Sexually transmitted disease
Tuberculosis
Urinary tract infection in last 30 days
Viral hepatitis
Wound infection
Other Current or more Detailed Diagnoses and ICD-9 Codes
Accidents
Fell in past 30 days
Fell in past 31-180 days
Hip fracture in last 180 days
Other fracture in last 180 days
End-stage disease
History of Resolved Ulcers

MDS Terms Classified as "Assessments" (n=273)

Cognitive Patterns
Comatose
Memory
Short-term memory OK
Long-term memory OK
Memory/recall Ability
Current season
Location of own room
Staff names/faces
That he/she is in a nursing home
Cognitive skills for Daily Decision Making
Indicators of Delirium-Periodic Disordered Thinking/Awareness
Easily distracted
Periods of altered perception or awareness of surroundings
Episodes of disorganized speech
Periods of restlessness
Periods of lethargy
Mental function varies over the course of the day
Change in Cognitive Status
Communication/Hearing patterns
Hearing
Hears adequately
Minimal difficulty hearing
Hears in special situations only
Highly impaired hearing
Communication Devices/Techniques
Hearing aid present and used
Hearing aid present and not used regularly
Other receptive comm. Techniques used
Modes of Expression
Speech
Writing messages to express or clarify needs
American sign language or Braille
Signs/gestures/sounds
Communication board
Making Self Understood
Understood
Usually understood
Sometimes understood
Rarely/Never understood
Speech clarity
Clear speech
Unclear speech
No speech
Ability to Understand Others
Understands
Usually understands
Sometimes understands
Rarely/Never understands
Change in Communication/Hearing
Vision Patterns
Vision
Adequate
Impaired
Moderately impaired
Highly impaired
Severely impaired
Visual Limitations/Difficulties
Side vision problems
Experiences any of following:
Mood and Behavior Patterns
Indicators of Depression, Anxiety, Sad Mood
Verbal expressions of distress
Resident made negative statements
Repetitive questions
Repetitive verbalizations
Persistent anger with self or others
Self deprecation
Expressions of what appear to be unrealistic fears
Recurrent statements that something terrible is about to happen
Repetitive health complaints
Repetitive anxious complaints/concerns
Sleep cycle issues
Unpleasant mood in morning
Insomnia/change in usual sleep pattern
Sad, apathetic, anxious appearance
Sad, pained, worried facial expressions
Crying, tearfulness
Repetitive physical movements
Loss of interest
Withdrawal from activities of interest
Reduced social interaction
Mood Persistence
Change in Mood
Behavioral Symptoms
Wandering
Verbally abusive behavioral symptoms
Physically abusive behavioral symptoms
Socially inappropriate/disruptive behavioral symptoms
Resists care
Change in Behavioral Symptoms
Psychosocial Well-Being
Sense of Initiative/Involvement
At ease interacting with others
At ease doing planned or structured activities
At ease doing self-initiated activities
Establishes own goals
Pursues involvement in life of facility
Accepts invitations into most group activities
Unsettled Relationships
Covert/open conflict with or repeated criticism of staff
Unhappy with roommate
Unhappy with residents other than roommate
Openly expressed conflict/anger with family/friends
Recent loss of close family member/friend
Does not adjust easily to change in routines
Strong identification with past roles and life status
Expresses sadness/anger/empty feeling over lost roles/status
Resident perceives that daily routine is very different from prior pattern in the community
Physical Functioning and Structural Problems
ADL Self Performance/ADL support provided
Bed mobility
Transfer
Walk in room
Walk in corridor
Locomotion off unit
Dressing
Eating
Toilet use
Personal hygiene
Bathing
ADL self-performance
Independent
Supervision
Limited assistance
Extensive assistance
Total dependence
Activity did not occur
ADL support provided
No setup or physical help from staff
One person physical assist
Two + person physical assist
Test for Balance
Balance while standing
Balance while sitting
Functional Limitation in Range of Motion
Neck
Arm
Hand
Leg
Foot
Other limitation or loss
Modes of Locomotion
Cane/walker/crutch
Wheeled self
Other person wheeled
Wheelchair primary mode of locomotion
Modes of Transfer
Bedfast all or most of time
Bed rails used for bed mobility or transfer
Lifted manually
Lifted mechanically
Transfer aid
Task Segmentation
ADL Functional Rehabilitation Potential
Resident believes he/she is capable of increased independence
Direct care staff believe resident is capable of increased in
Resident able to perform tasks/activity but is very slow
Difference in ADL self-performance or ADL support, comparing mornings to evenings
Change in Function
Continence in Last 14 Days
Continence Self-Control Categories
Continent
Usually Continent
Occasionally incontinent
Bowel continence
Bladder continence
Bowel elimination pattern
Regular
Constipation
Diarrhea
Fecal impaction
Did not use toilet room/commode/urinal
Change in urinary continence
Health Conditions
Problem Conditions
Indicators of fluid status
Weight gain or loss of 3 or more pounds within a 7 day period
Inability to lie flat due to shortness of breath
Dehydrated; output exceeds input
Insufficient fluid; did not consume all/almost all liquids provided during last 3 days
Delusions
Dizziness/vertigo
Edema
Fever
Hallucinating
Internal bleeding
Recurrent lung aspirations in last 90 days
Shortness of breath
Syncopy
Unsteady gait
Vomiting
Pain Symptoms
Frequency
Intensity
Pain Site
Back
Bone
Chest pain while doing usual activities
Headache
Hip
Incisional pain
Joint pain
Soft tissue pain
Stomach pain
Stability of Conditions
Conditions/diseases make resident's cognitive, ADL, mood or behavior patterns unstable
Resident experiencing an acute episode or a flare-up of a recurrent or chronic problem
Oral/Nutritional Status
Oral Problems
Chewing problem
Swallowing problem
Mouth pain
Height
Weight
Weight Change
Weight loss
Weight gain
Nutritional Problems
Complains about the taste of many foods
Regular or repetitive complaints of hunger
Leaves 25% or more of food uneaten at most meals
Oral/Dental Status
Oral Status and Disease Prevention
Debris present in mouth prior to going to bed at night
Has dentures or removable bridge
Some/all natural teeth lost
Broken, loose, or carious teeth
Inflamed gums
Daily cleaning of teeth/dentures or daily mouth care
Skin condition
Ulcers
Stage 1
Stage 2
Stage 3
Stage 4
Type of Ulcer
Pressure ulcer
Stasis ulcer
Other skin Problems or Lesions Present
Abrasions
Burns
Open lesions other than ulcers, rashes, cuts
Rashes
Skin desensitized to pain or pressure
Skin tears or cuts
Surgical wounds
Resident has one or more foot problems
Infection of the foot
Open lesions on the foot
Activity Pursuit Patterns
Time Awake
Average Time Involved in Activities
Preferred Activity Settings
General Activity Preferences
Prefers Change in Daily Routine
Type of activities in which resident is currently involved
Extent of resident involvement in activities
Intake/output
Evaluation by a licensed mental health specialist in last 90 days
Transfer
Walking
Dressing or grooming
Eating or swallowing
Amputation/prosthesis care
Communication
Abnormal Lab Values
Discharge Potential and Overall Status
Discharge Potential
Resident expresses/indicates preference to return to the community
Resident has a support person who is positive towards discharge
Stay projected to be of a short duration
Overall Change in Care Needs

MDS Terms Classified as "Treatments" (n= 93)

Feeding restrictions
Medication restrictions
Other treatment restrictions
Visual Appliances
Glasses
Contacts lenses
Magnifying glass
Appliances and programs
Any scheduled toileting plan
Bladder retraining program
External catheter
Indwelling catheter
Intermittent catheter
Pads/briefs used
Enemas/irrigation
Ostomy present
Nutritional Approaches
Parenteral/IV
Feeding tube
Mechanically altered diet
Syringe
Therapeutic diet
Dietary supplement between meals
Plate guard, stabilized built-up utensil
On a planned weight change program
Parenteral or Enteral Intake
Code the proportion of total calories the resident received through parenteral or tube feedings in the last 7 days
Skin Treatments
Pressure relieving device for chair
Pressure relieving device for bed
Turning/repositioning program
Nutrition or hydration intervention to manage skin problems
Ulcer care
Surgical wound care
Application of dressings
Application of ointments/ medications
Other preventative or protective skin care
Foot Problems and Care
Received preventive or protective foot care
Medications
Number of Medications
New Medications
Injections
Days Received the Following Medications
Antipsychotic
Antianxiety
Antidepressant
Hypnotic
Diuretic
Special Treatments and Procedures
Special Treatments, Procedures, and Programs
Special care
Treatments
Chemotherapy
Dialysis
IV medication
Monitoring acute medical condition
Ostomy care
Oxygen therapy
Radiation
Suctioning
Tracheostomy care
Transfusions
Ventilator or respirator
Programs
Alcohol/drug treatment program
Alzheimer's/dementia special care unit
Hospice care
Pediatric care
Respite care
Training in skills required to return to the community
Therapies
Occupational therapy
Physical therapy
Respiratory therapy
Psychological therapy
Intervention Programs for Mood, Behavior, Cognitive Loss
Special behavior symptoms evaluation program
Group therapy
Resident-specific deliberate changes in the environment to address mood/behavior patterns
Reorientation
Nursing Rehabilitation/Restorative Care
Range of motion (active)
Range of motion (passive)
Splint of brace assistance
Training and skill practice in:
Devices and Restraints
Bed rails
Full bed rails on all open sides of bed
Other types of side rails used
Trunk restraint
Limb restraint
Chair prevents rising

MDS Terms Classified as "Other" (n=43)

Section
If other, specify
Not applicable
Unknown
Face Sheet Signatures
Signatures of persons completing face sheet
Signature of RN assessment coordinator
Title
Original or corrected copy of form
Date of Reentry
other
none of above
None
1% to 25%
26% to 50%
51% to 75%
76% to 100%
Code the average fluid intake per day by IV or tube in last 7 days
1 to 500 cc/day
501 to 1000 cc/day
1001 to 1500 cc/day
1501 to 2000 cc/day
2001 or more cc/day
Morning
Afternoon
Evening
Own room
Day/activity room
Inside NH/off unit
Outside facility
Cards/other games
Crafts/arts
Exercise/sports
Music
Reading/writing
Spiritual/religious activities
Trips/shopping
Walking/wheeling outdoors
Watching TV
Gardening or plants
Talking or conversing
Helping others
Physician visits

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APPENDIX G. TERMS PROVIDED BY DOMAIN EXPERTS, PARTIAL OR NO MATCHES

Terms From Domain Experts, Partial Match or No Match to MDS
Terms from Domain Experts	Partial Match MDS	No Match MDS
Pressure Ulcer Terms
Adequacy of treatment		Adequacy of treatment
Air-fluidized bed	Pressure relieving device for bed
Avoid positioning directly on the trochanter		Avoid positioning directly on the trochanter
Body control		Body control
Bony prominences		Bony prominence
Braden scale		Braden scale
Cellulitis		Cellulitis
Characteristics of support surfaces		Characteristics of support surfaces
Clean dressings	Application of dressings
Complete history		Complete history
Complete physical examination		Complete physical examination
Debridement (sharp, mechanical, enzymatic, or autolytic)	Ulcer care
Dietary intake of protein		Dietary intake of protein
Depression score		Depression score
Dietary intake of calories	Calories received through parenteral or tube feedings in last 7 days
Dynamic support surface	Pressure relieving device for bed
Educational program for prevention of pressure ulcers	Nursing rehabilitation/restoration "other"
Electrical stimulation therapy	Ulcer care
Eschar		Eschar
Exudate		Exudate
Film dressing	Ulcer care
Friction		Friction
Friction injuries		Friction injuries
Hydrocolloid dressing	Ulcer care
Hydrotherapy	Ulcer care
Hyperbaric oxygen	Ulcer care
Inspect skin at least once a day, if early treatment		Inspect skin at least once a day, if early treatment
Irrigation pressure		Irrigation pressure
Lifting devices		Lifting devices
Low air-loss bed	Pressure relieving device for bed
Lubricants to reduce friction injuries		Lubricants to reduce friction injuries
Modular products		Modular products
Moisture exposure on intact skin		Moisture exposure on intact skin
Mineral supplements		Mineral supplements
Normal saline for cleansing	Ulcer care
Norton scale		Norton scale
Oral intake goals		Oral intake goals
Periodic reassessment (at least weekly)		Periodic reassessment
Poor meal intake		Poor meal intake
Positioning devices		Positioning devices
Positioning techniques		Positioning techniques
Postural alignment		Postural alignment
Protective films		Protective films
Protective dressings		Protective dressings
Protective padding		Protective padding
Range of motion		Range of motion
Risk for delayed healing		Risk for delayed healing
Risk for moisture exposure		Risk for moisture exposure
Risk for pressure ulcers		Risk for pressure ulcers
Shearing		Shearing
Sepsis
Severity of illness		Severity of illness
Shift weight every 15 minutes	Nursing rehabilitation/restoration "other"
Skin cleansed at routine intervals		Skin cleansed at routine intervals
Skin cleansed at time of soiling		Skin cleansed at time of soiling
Static support surface		Static support surface
Stryker frame		Stryker frame
Tissue viability of the surgical site (if operative repair of pressure ulcer)		Tissue viability of surgical site
Topical treatment with iodine containing agents	Application of ointments/medications
Transferring support	Modes of transfer
Treatment goals		Treatment goals
Ulcer care plan evaluated		Ulcer care plan evaluated
Vitamin supplements	Number of medications
Whirlpool treatment	Ulcer care
Chronic Pain Terms
Contractures		Contractures
Drawing of pain location		Drawing of pain location
Energy/fatigue		Energy/fatigue
Faces pain scale		Faces pain scale
Facial expressions (wrinkled forehead, tightly closed eyes, grimacing, frowning)	Sad, pained, worried facial expression
Fibromyalgia		Fibromyalgia
Grunting	Making self understood
Headaches		Headaches
Impact of pain on (quality of life outcomes, physical function, sleep, appetite, interpersonal relationships/interactions with others, mood, mental staus)		Impact of pain on (quality of life outcomes)
Irritability	Verbal expressions of distress (e.g., repetitive anxious complaints/concerns)
Knees pulled up		Knees pulled up
Lasting minutes or hours		Lasting minutes or hours
Low back pain		Low back pain
McGill pain questionnaire		McGill pain questionnaire
Monitoring pain intensity	Pain intensity
Myofascial pain syndromes		Myofascial pain syndromes
Non-pharmacologic interventions		Non-pharmacologic interventions
Nonverbal behaviors (bracing, rubbing, guarding)		Nonverbal behaviors (bracing, rubbing, guarding)
Numbness		Numbness
Osteoarthritis	Arthritis
Pain behaviors		Pain behaviors
Pain intensity	Pain intensity
Pain map		Pain map
Patient satisfaction associated with pain management		Patient satisfaction associated with pain management
Pattern of pain		Pattern of pain
Peripheral neuropathy		Peripheral neuropathy
Phantom limb pain		Phantom limb pain
Post-herpetic neuralgia		Post-herpetic neuralgia
Radiating pain		Radiating pain
Rheumatoid arthritis	Arthritis
Risk of unrecognized and thus untreated pain		Risk of unrecognized and thus untreated pain
Screening procedures		Screening procedures
Spinal stenosis		Spinal stenosis
Stabbing pain	Pain symptom
Throbbing pain	Pain symptom
Tingling		Tingling
Vasculitic pain syndromes		Vasculitic pain syndromes
Vasogenic claudication		Vasogenic claudication
Verbal descriptors scale		Verbal descriptors scale
What starts pain		What starts pain
What makes pain better		What makes pain better
What makes pain worse		What makes pain worse
When pain starts		When pain starts
Urinary Incontinence Terms
Ability to toilet	Toilet use
Characteristics of voiding and non-invasive bladder diagnosis		Characteristics of voiding and non-invasive bladder diagnosis
Factors associated with UI		Factors associated with UI
Genital system exam to identify physical abnormalities that may explain incontinence (e.g., pelvic prolapse)		Genital system exam to identify physical abnormalities that may explain incontinence (e.g., pelvic prolapse)
How often person voids when prompted on a routine basis		How often person voids when prompted on a routine basis
Importance of problem to resident		Importance of problem to resident
Lab reports		Lab reports
Non-invasive diagnoses of bladder function		Non-invasive diagnoses of bladder function
Primary care provider notes		Primary care provider notes
Prior treatment for incontinence		Prior treatment for incontinence
Prompted toileting	Any scheduled toileting plan
Prompted void
Rectal exam to exclude fecal impaction		Rectal exam to exclude fecal impaction
Skin exam to evaluate skin problems associated with uninary incontinence		Skin exam to evaluate skin problems associated with uninary incontinence
Status of incontinence: day and night	Bladder continence
Symptoms on urination		Symptoms on urination
Symptoms to distinguish between urge incontinence (short interval between sensation to void and bladder contraction) and stress incontinence (urine loss during physical movements)		Symptoms to distinguish between urge incontinence (short interval between sensation to void and bladder contraction) and stress incontinence (urine loss during physical movements)
Targeted history		Targeted history
Targeted physical		Targeted physical
Toileting responsiveness assessments		Toileting responsiveness assessments
Urodynamic analyses of bladder functioning		Urodynamic analyses of bladder functioning
Voiding record	Any scheduled toileting plan	Voiding record

Terms From Domain Experts, Partial Match or No Match to SNOMED CT
Terms from Domain Experts	Partial Match SNOMED CT	No Match SNOMED CT
Pressure Ulcer Terms
Activity	Type of activity	Activity
Adequacy of treatment		Adequacy of treatment
Awareness	Consciousness	(SNOMED term "state of awareness" is a retired concept)
Bed bound	Bed ridden
Bony prominences		Bony prominences
Braden scale		Braden scale
Can request help	Request for Ability to ask questions (specific types of help)	Help
Chair bound	Confined to chair
Characteristics of support surfaces		Characteristics of support surfaces
Condition factors		Condition factors
Difficulty with repositioning	Repositioning	Difficulty with repositioning
Distracted	Easily distracted	Distracted without modifier
Friction injuries		Friction injuries
Locomotion		Locomotion
Modular products		Modular products
Moisture		Moisture exposure
Motion of: neck, arm, hand, leg, foot	Motion Ability to move arm Ability to move hand Ability to move leg Ability to move foot	Motion
Norton scale		Norton scale
Periodic reassessment		Periodic reassessment
Poor meal intake	Food intake	Meal
Skin pliability	Skin assessment	Pliability
Ulcer care plan evaluated	Care plan Evaluation	Ulcer care plan
Verbal responses	Uses verbal communication
Viability of the surgical site		(SNOMED term "surgical site" has been retired)
Chronic Pain Terms
Description	Symptom description NOS	Description
Drawing		Drawing
Faces pain scale	Finding of present pain intensity	Faces pain scale
Facial expressions (wrinkled forehead, tightly closed eyes, grimacing, frowning)	Grimaces	Wrinkled forehead Tightly closed eyes Frowning
Grunting	Vocalization	(SNOMED includes term grunting but "is_a" animal vocalization)
Impact of pain on quality of life outcomes	Pain Determination of outcome	Impact Quality of life
Lasting minutes or hours	Time frame Intervals of minutes Intervals of hours	Lasting
Negative vocalization	Negative Vocalization	Negative vocalization
Nonverbal behavior (bracing, rubbing, guarding)		Nonverbal behavior (bracing, rubbing, guarding)
Nonverbal indicators of discomfort	Discomfort	Nonverbal indicators
Pain map		Map
Physical function		Physical function
Risk of unrecognized and thus untreated pain	Risk of Pain	Unrecognized Untreated
Vasculitic pain syndomes	Pain	Vasculitic pain syndomes
Withdrawal from activities of interest	Loss of interest	Withdrawal from activities
Urinary Incontinence Terms
Importance of problem to resident	Problem	Importance Resident
Targeted history	History taking Has focus	Targeted
Targeted physical	Physical exam Limited	Targeted

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APPENDIX H. REFERENCES PROVIDED BY DOMAIN EXPERTS

Chronic Pain References

Abrahm JL, and Snyder L. Pain assessment and management. Primary Care; Clinics in Office Practice. 2001;28(2):269-297.

Anonymous. Management of Cancer Pain. In: US Department of Health and Human Services, Public Health Service, eds. Management of Cancer Pain Guideline Panel. Vol Clinical Practice Guideline No. 9. Rockville, MD: US Agency for Health Care Policy and Research; 1994.

Anonymous. Practice guidelines for chronic pain management. In: A report by the American Society of Anesthesiologists, ed. Anesthesiology, Chronic Pain Section, Vol 86: Task Force on Pain Management, 1997:995-1004.

Anonymous. The management of chronic pain in older persons. AGS Panel on Chronic Pain in Older Persons. American Geriatrics Society. Geriatrics 1998;53 Suppl 3:S8-24.

Anonymous. Chronic Pain Management in the Long-Term care Setting--Clinical Practice Guideline. American Medical Directors Association. 1999.

Anonymous. The management of chronic pain in older persons. AGS Panel on Chronic Pain in Older Persons. American Geriatrics Society. Geriatrics. 2002;50:1-20.

Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly patients with cancer. SAGE Study Group. Systematic Assessment of Geriatric Drug Use via Epidemiology. [see comments.] [erratum appears in JAMA 1999 Jan 13;281(2):136.] JAMA 1998;279(23):1877-1882.

Berry, PH, and Dahl JL. The new JCAHO pain standards: implications for pain management nurses. Pain Management Nursing. 2000;1(1):3-12.

Beth. P, K. PR. Management of Chronic Pain in the Elderly: Pharmacology of Opoids and Other Analgesic Drugs. In: BR Ferrell, BA Ferrell, ed. Pain in the Elderly. Vol ASP Press. Seattle: IASP Press; 1996 ASP Press.

Buffum MD, Miaskowski C, Sands L, and Brod M. A pilot study of the relationship between discomfort and agitation in patients with dementia. Geriatric Nursing. 2001;22(2):80-85.

Chodosh J, Ferrell BA, Shekelle PG, and Wenger NS. Quality indicators for pain management in vulnerable elders. Annals of Internal Medicine. 2001;135(8 Pt 2):731-735.

Cramer GW, Galer BS, Mendelson MA, and Thompson GD. A drug use evaluation of selected opioid and nonopioid analgesics in the nursing facility setting. Journal of the American Geriatrics Society. 2000;48(4):398-404.

Feldt KS. The checklist of nonverbal pain indicators (CNPI). Pain Management Nursing. 2000;1(1):13-21.

Feldt KS. Improving assessment and treatment of pain in cognitively impaired nursing home residents. Annuals of Long Term Care. 2000;8(9):36-42.

Ferrell BA, Ferrell BR, and Osterweil D. Pain in the nursing home. Journal of the American Geriatrics Society. 1990;38(4):409-414.

Ferrell BR, Grant M, Ritchey KJ, Ropchan R, and Rivera LM. The pain resource nurse training program: a unique approach to pain management. Journal of Pain and Symptom Management. 1993;8(8):549-556.

Ferrell BA. Pain evaluation and management in the nursing home. Annals of Internal Medicine. 1995;123(9):681-687.

Ferrell BA, Ferrell BR, and Rivera L. Pain in cognitively impaired nursing home patients. Journal of Pain and Symptom Management. 1995;10(8):591-598.

Ferrell BA. Pain management. Clinics in Geriatric Medicine. 2000;16(4):853-874.

Foley KM. Pain management in the elderly. In: Hazzard WR, Bierman EL, Blass JP, Ettiinger WH, and Halter JB, eds. Principles of Geriatric Medicine and Gerontology. New York: McGraw-Hill, Health Professions Divisions; 1994:317-331.

Gagliese L., and Melzack R. Age differences in the quality of chronic pain: a preliminary study. Pain Research and Management. 1997;2:157-162.

Gloth FM, 3rd. Pain management in older adults: prevention and treatment. Journal of the American Geriatrics Society. 2001;49(2):188-199.

Herr KA, and Mobily PR. Comparison of selected pain assessment tools for use with the elderly. Applied Nursing Research. 1993;6(1):39-46.

Herr KA, and Mobily PR. Pain management for the elderly in alternative care settings. In: Ferrell BA, Ferrell BR, eds. Pain in the Elderly. Seattle: IASP Press; 1996.

Herr KA, Mobily PR, Kohout FJ, and Wagenaar D. Evaluation of the Faces Pain Scale for use with the elderly. Clinical Journal of Pain. 1998;14(1):29-38.

Herr KA, Garand L. Assessment and measurement of pain in older adults. Clinics in Geriatric Medicine. 2001;17(3):457-478.

Herr K. Chronic pain in the older patient: management strategies. Journal of Gerontological Nursing. 2002;28(2):28-34; quiz 54-25.

Horgas AL, and Tsai PF. Analgesic drug prescription and use in cognitively impaired nursing home residents. [see comments.]. Nursing Research. 1998;47(4):235-242.

Huffman JC, and Kunik ME. Assessment and understanding of pain in patients with dementia. Gerontologist. 2000;40(5):574-581.

Hurley AC, Volicer BJ, Hanrahan PA, Houde S, and Volicer L. Assessment of discomfort in advanced Alzheimer patients. Research in Nursing and Health. 1992;15(5):369-377.

Katsma DL, and Souza CH. Elderly pain assessment and pain management knowledge of long-term care nurses. Pain Management Nursing. 2000;1(3):88-95.

Kovach CR, Weissman DE, Griffie J, Matson S, and Muchka S. Assessment and treatment of discomfort for people with late-stage dementia. Journal of Pain and Symptom Management. 1999;18(6):412-419.

Kovach CR, Griffie J, Muchka S, Noonan PE, and Weissman DE. Nurses' perceptions of pain assessment and treatment in the cognitively impaired elderly. It's not a guessing game. [see comments.]. Clinical Nurse Specialist. 2000;14(5):215-220.

Lanser P, and Gesell S. Pain management: the fifth vital sign. Healthcare Benchmarks. 2001;8(6):68-70.

Loeb J, and Pasero C. JCAHO standards in long-term care. American Journal of Nursing. 2000;100(5):22-23.

Luggen AS. Chronic pain in older adults. A quality of life issue. Journal of Gerontological Nursing. 1998;24(2):48-54.

Merboth MK, and Barnason S. Managing pain: the fifth vital sign. Nursing Clinics of North America. 2000;35(2):375-383.

Miller J, Neelon V, Dalton J, et al. The assessment of discomfort in elderly confused patients: a preliminary study. Journal of Neuroscience Nursing. 1996;28(3):175-182.

Morrison RS, and Siu AL. A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture. Journal of Pain and Symptom Management. 2000;19(4):240-248.

Parmelee PA, Katz IR, and Lawton MP. The relation of pain to depression among institutionalized aged. Journal of Gerontology. 1991;46(1):P15-21.

Parmelee PA, Smith B, and Katz IR. Pain complaints and cognitive status among elderly institution residents. Journal of the American Geriatrics Society. 1993;41(5):517-522.

Pasero C, McCaffery M, and Gordon DB. Build institutional commitment to improving pain management. Nursing Management (Springhouse). 1999;30(1):27-33; quiz 33-24.

Popp B, and Portenoy RK. Management of Chronic Pain in the Elderly: Pharmacology of Opioids and Other Analgesic Drugs. In: BR Ferrell, BA Ferrell, eds. Pain in the Elderly. Seattle: IASP Press; 1996:21-34.

Ryan M, Ambrosio DA, Gebhard C, and Kowalski J. Pain management: an organizational commitment. Pain Management Nursing. 2000;1(2):34-39.

Sengstaken EA, and King SA. The problems of pain and its detection among geriatric nursing home residents. Journal of the American Geriatrics Society. 1993;41(5):541-544.

Simons W, and Malabar R. Assessing pain in elderly patients who cannot respond verbally. Journal of Advanced Nursing. 1995;22(4):663-669.

Weiner D, Pieper C, McConnell E, Martinez S, and Keefe F. Pain measurement in elders with chronic low back pain: traditional and alternative approaches. Pain. 1996;67(2-3):461-467.

Weiner D, Peterson B, and Keefe F. Evaluating persistent pain in long term care residents: what role for pain maps? Pain. 1998;76(1-2):249-257.

Weiner D, Peterson B, and Keefe F. Chronic pain-associated behaviors in the nursing home: resident versus caregiver perceptions. Pain. 1999;80(3):577-588.

Weissman DE, and Matson S. Pain assessment and management in the long-term care setting. Theoretical Medicine and Bioethics. 1999;20(1):31-43.

Wynne CF, Ling SM, and Remsburg R. Comparison of pain assessment instruments in cognitively intact and cognitively impaired nursing home residents. Geriatric Nursing. 2000;21(1):20-23.

Pressure Ulcer References

Agostini JV, Bogardus ST, and Baker DI. Prevention of Pressure Ulcers in Older Patients. In: AHRQ AfHRaQ, ed. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Vol Publication No. 01-E058: Shojania KG, Duncan BW, McDonald KM, et al., eds; 2001.

AHCPR. Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guideline No. 3. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1992 AHCPR Publication no. 92-0047.

Allman RM. Pressure ulcers: using what we know to improve quality of care. [letter; comment.]. Journal of the American Geriatrics Society. 2001;49(7):996-997

Allman RM, Laprade CA, Noel LB, et al. Pressure sores among hospitalized patients. Annals of Internal Medicine. 1986;105(3):337-342.

Allman RM, Walker JM, Hart MK, Laprade CA, Noel LB, and Smith CR. Air-fluidized beds or conventional therapy for pressure sores. A randomized trial. Annals of Internal Medicine. 1987;107(5):641-648.

AMDA. Pressure Ulcers:Clinical Practical Guideline. Columbia, MD: American Medical Directors Association; 1996.

Aronovitch SA. A comparative, randomized, controlled study to determine safety and efficacy of preventive pressure ulcer systems: preliminary analysis. Advances in Wound Care. 1998;11(3 Suppl):15-16.

Bates-Jensen BM. The Pressure Sore Status Tool a few thousand assessments later. Advances in Wound Care. 1997;10(5):65-73.

Bates-Jensen BM. Quality indicators for prevention and management of pressure ulcers in vulnerable elders. Annals of Internal Medicine. 2001;135(8 Pt 2):744-751.

Bates-Jensen BM, Vredevoe DL, and Brecht ML. Validity and reliability of the Pressure Sore Status Tool. Decubitus. 1992;5(6):20-28.

Bergquist S. Subscales, subscores, or summative score: evaluating the contribution of Braden Scale items for predicting pressure ulcer risk in older adults receiving home health care. Journal of Wocn. 2001;28(6):279-289.

Bergstrom N, and Braden B. A prospective study of pressure sore risk among institutionalized elderly. Journal of the American Geriatrics Society. 1992;40(8):747-758.

Bergstrom, N, Braden B, Kemp M, Champagne M, and Ruby E. Multi-site study of incidence of pressure ulcers and the relationship between risk level, demographic characteristics, diagnoses, and prescription of preventive interventions. Journal of the American Geriatrics Society. 1996;44(1):22-30.

Bergstrom N, Braden B, Kemp M, Champagne M, and Ruby E. Predicting pressure ulcer risk: a multisite study of the predictive validity of the Braden Scale. [see comments.]. Nursing Research. 1998;47(5):261-269.

Bergstrom N, Braden BJ, Laguzza A, and Holman V. The Braden scale for predicting pressure sore risk. Nursing Research. 1987;36(4):205-210.

Berlowitz DR, Bezerra HQ, Brandeis GH, Kader B, and Anderson JJ. Are we improving the quality of nursing home care: the case of pressure ulcers. Journal of the American Geriatrics Society. 2000;48(1):59-62.

Berlowitz DR, Brandeis GH, Morris JN, et al. Deriving a risk-adjustment model for pressure ulcer development using the Minimum Data Set. [see comments.]. Journal of the American Geriatrics Society. 2001;49(7):866-871.

Berlowitz DR, and Wilking SV. Risk factors for pressure sores. A comparison of cross-sectional and cohort-derived data. Journal of the American Geriatrics Society. 1989;37(11):1043-1050.

Berlowitz DR, Young GJ, Brandeis GH, Kader B, and Anderson JJ. Health care reorganization and quality of care: unintended effects on pressure ulcer prevention. Medical Care. 2001;39(2):138-146.

Braden BJ, and Bergstrom N. Predictive validity of the Braden Scale for pressure sore risk in a nursing home population. Research in Nursing and Health. 1994;17(6):459-470.

Brandeis GH, Morris JN, Nash DJ, and Lipsitz LA. The epidemiology and natural history of pressure ulcers in elderly nursing home residents. [see comments.]. JAMA. 1990;264(22):2905-2909.

Brandeis GH, Ooi WL, Hossain M, Morris JN, and Lipsitz LA. A longitudinal study of risk factors associated with the formation of pressure ulcers in nursing homes. Journal of the American Geriatrics Society. 1994;42(4):388-393.

Castle NG. Administrator turnover and quality of care in nursing homes. Gerontologist. 2001;41(6):757-767.

Colin D, Kurring PA, and Yvon C. Managing sloughy pressure sores. Journal of Wound Care. 1996;5(10):444-446.

Cullum N, Deeks J, Sheldon TA, Song F, and Fletcher AW. Beds, mattresses and cushions for pressure sore prevention and treatment. Cochrane Database Syst Rev. 2000(2):CD001735.

Dlugacz YD, Stier L, and Greenwood A. Changing the system: a quality management approach to pressure injuries. Journal for Healthcare Quality: Promoting Excellence in Healthcare. 2001;23(5):15-19; quiz 19-20.

Fenner SP. Developing and implementing a wound care program in long-term care. Journal of Wocn. 1999;26(5):254-260.

Ferrell BA. The Sessing Scale for measurement of pressure ulcer healing. Advances in Wound Care. 1997;10(5):78-80.

Ferrell BA, Osterweil D, and Christenson P. A randomized trial of low-air-loss beds for treatment of pressure ulcers. [see comments.] [erratum appears in JAMA 1993 Jun 2;269(21):2739.]. JAMA. 1993;269(4):494-497.

Foresman PA, Payne DS, Becker D, Lewis D, and Rodeheaver GT. A relative toxicity index for wound cleansers. Wounds. 1993;5:226-231.

Goodridge DM, Sloan JA, LeDoyen YM, McKenzie JA, Knight WE, and Gayari M. Risk-assessment scores, prevention strategies, and the incidence of pressure ulcers among the elderly in four Canadian health-care facilities. Canadian Journal of Nursing Research. 1998; 30(2):23-44.

Gorse GJ, and Messner RL. Improved pressure sore healing with hydrocolloid dressings. Archives of Dermatology. 1987;123(6):766-771.

Gunningberg L, Lindholm C, Carlsson M, and Sjoden PO. Reduced incidence of pressure ulcers in patients with hip fractures: a 2-year follow-up of quality indicators. International Journal for Quality in Health Care. 2001;13(5):399-407.

Harrison MB, Wells G, Fisher A, Prince M. Practice guidelines for the prediction and prevention of pressure ulcers: evaluating the evidence. Applied Nursing Research. 1996;9(1):9-17.

Hellewell TB, Major DA, Foresman PA, Rodeheaver GT. A cytotoxicity evaluation of antimicrobial and non-antimicrobial wound cleanser. Wounds. 1997;9:15-20.

Kramer JD, and Kearney M. Patient, wound, and treatment characteristics associated with healing in pressure ulcers. Advances in Skin and Wound Care. 2000;13(1):17-24.

Lazarus GS, Cooper DM, Knighton DR, et al. Definitions and guidelines for assessment of wounds and evaluation of healing. Archives of Dermatology. 1994;130(4):489-493.

Lyder CH, Preston J, Grady JN, et al. Quality of care for hospitalized medicare patients at risk for pressure ulcers. Archives of Internal Medicine. 2001;161(12):1549-1554.

Martin SJ, Corrado OJ, and Kay EA. Enzymatic debridement for necrotic wounds. Journal of Wound Care. 1996;5(7):310-311.

McNees P, Braden B, Bergstrom N, and Ovington L. Beyond risk assessment: elements for pressure ulcer prevention. Ostomy Wound Management. 1998;44(3A Suppl):51S-58S.

Mohide EA, Pringle DM, Streiner DL, Gilbert JR, Muir G, and Tew M. A randomized trial of family caregiver support in the home management of dementia. Journal of the American Geriatrics Society. 1990;38(4):446-454.

Mulder GD. Evaluation of three nonwoven sponges in the debridement of chronic wounds. Ostomy Wound Management. 1995;41(3):62-64.

NPUAP. Statement on Pressure Ulcer Prevention. Reston, VA: National Pressure Ulcer Advisory Panel; 1992.

Pinchcofsky-Devin G.D., and Kaminski M.V. Jr. Correlation of pressure sores and nutritional status. Journal of the American Geriatrics Society. 1986;34:435-440.

Report: N. NPUAP Statement of Reverse Staging of Pressure Ulcers 1995.

Robson MC. Disturbances of wound healing. Annals of Emergency Medicine. 1988;17(12):1274-1278.

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