MDS 3.0: Recommended Form - Ucla - GeroNet

Section FPreferences for Customary Routineand ActivitiesF1. Should Interview for Daily and Activity Preferences be Conducted?—Attempt to interview all residents able tocommunicate. If resident is unable to complete, attempt to complete interview with family member or significant other.EnterCode0. No (resident is rarely/never understood and family not available) Instead complete F6, StaffAssessment of Daily and Activity Preferences1. Yes Continue to F2, Interview for Daily PreferencesF2. Interview for Daily PreferencesShow resident the response options and say: “While you are in this facility…”Enter Codea. how important is it to you to choose what clothes to wear?Coding:1. Very important2. Somewhat important3. Not very important4. Not important at all5. Important, but can’t do or nochoice9. No response or non-responsive Enter Codes in Boxes Enter CodeEnter CodeEnter CodeEnter CodeEnter CodeEnter CodeEnter Codeb. how important is it to you to take care of your personalbelongings or things?c. how important is it to you to choose between a tub bath,shower, bed bath, or sponge bath?d. how important is it to you to have snacks available betweenmeals?e. how important is it to you to choose your own bedtime?f. how important is it to you to have your family or a closefriend involved in discussions about your care?g. how important is it to you to be able to use the phone inprivate?h. how important is it to you to have a place to lock your thingsto keep them safe?F3. Interview for Activity PreferencesShow resident the response options and say: “While you are in this facility…”Enter Codea. how important is it to you to have books, newspapers, andmagazines to read?Enter Codeb. how important is it to you to listen to music you like?Coding:1. Very important2. Somewhat important3. Not very important4. Not important at all5. Important, but can’t do or nochoice9. No response or non-responsive Enter Codes in Boxes Enter CodeEnter CodeEnter CodeEnter CodeEnter Codec. how important is it to you to be around animals such aspets?d. how important is it to you to keep up with the news?e. how important is it to you to do things with groups ofpeople?f. how important is it to you to do your favorite activities?g. how important is it to you to go outside to get fresh air whenthe weather is good?Enter Codeh. how important is it to you to participate in religious servicesor practices?Recommended MDS 3.0 12