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MED-PASS:  Designing Solutions for Senior Care

Resident Interviews MDS 3.0 Data Collection Tool-SAMPLE


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Capture all your MDS 3.0 resident interview responses on this 4-page form. The 4-page format consolidates all of the interviews to provide the MDS coordinator with a single, convenient document.
Each page documents a different interview:

  • Section C - BIMS
  • Section D - PHQ-9©
  • Section F - Daily/Activity Preferences
  • Section J - Pain
  • Language and format coincide with the MDS 3.0 data set
  • Each interview is on a separate page with a separate signature line so multiple disciplines can document on the same form.
  • Each interview includes prompts to confirm items A1100 (Language) and B0700 (Makes Self Understood) essential in the interview process
  • RAI Version 3.0 Manual page numbers pertinent to the interview topic are listed at the bottom of the page for quick reference
Size 11 x 17 folds to 8 1/2 x 11
Number of Pages 4
Other Info Handwritten
Hole Punch 5 holes left, 5 holes top