Appendix D of the RAI Manual: Increasing the Resident’s Voice and Why It Matters

Oct 9

5 min read

By Beth Kimmey, RN, RAC-CT, Director of Clinical Consulting

The MDS captures a significant amount of clinical information, but some of its most valuable information comes directly from the resident.

Appendix D of the RAI Manual is more than a reference section. It can help MDS professionals connect accurate assessment and coding with individualized care planning and interventions. The goal is not simply to complete the MDS. It is to use the assessment process to better understand the person receiving care and identify information that can influence that resident’s plan of care.

At the center of that process should be the resident’s voice.

When a resident is able to participate in an interview, their responses can provide information that may not be found elsewhere in the medical record. Through these conversations, residents have an opportunity to communicate their needs, concerns, preferences, symptoms and goals in their own words.

That perspective helps the interdisciplinary team see more than diagnoses and clinical data. It provides a more individualized picture of the resident and what may be affecting their daily life.

BIMS: Giving Residents an Opportunity to Demonstrate What They Know

The Brief Interview for Mental Status (BIMS) provides an opportunity to assess cognitive function through direct interaction with the resident.

Rather than relying solely on documentation or observations from others, the BIMS allows the resident to respond directly. Those responses provide information that can support the assessment process and care planning.

This is an important distinction. Whenever a resident is able to communicate their responses, the MDS process should recognize that individual as an active participant in the assessment.

CMS also provides educational resources for conducting cognitive assessments, including BIMS training materials and video tutorials to support appropriate assessment and coding.

PHQ-2 to 9: Hearing the Resident’s Experience of Mood

The Resident Mood Interview gives residents an opportunity to describe how frequently they have experienced symptoms such as feeling down, depressed or hopeless.

The value of the interview, however, should extend beyond the resulting MDS score.

When mood concerns are identified, the interdisciplinary team should consider what the resident is experiencing and whether further assessment or intervention is appropriate. Depending on the resident’s needs, findings may lead to psychosocial support, additional monitoring, changes in activities or social engagement behavioral health services, family involvement or further clinical evaluation.

The important connection is between what the resident tells us and what happens next.

CMS currently offers Section C and D training resources addressing standardized cognitive and mood assessments, including training specifically focused on the Resident Mood Interview and PHQ-2 to 9.

Preferences: Understanding What Matters to the Resident

Clinical needs are only part of a resident’s story. Daily routines, activities and personal preferences also affect the resident’s experience.

The Interview for Daily and Activity Preferences gives residents an opportunity to communicate what they enjoy and what is important to them. That information can help guide routines, activities, social opportunities and approaches to care.

Capturing these preferences moves the care plan beyond a list of clinical needs. It incorporates the resident’s choices and helps the interdisciplinary team create care that reflects the individual receiving it.

Pain: Listening to the Resident’s Own Report

Pain is another area where direct resident input can provide essential information.

When residents are able to communicate, their own report of pain should be part of the assessment. The interview may identify symptoms that otherwise could be overlooked or underestimated.

Those findings should not simply remain part of MDS documentation. They should inform appropriate assessment, treatment, monitoring and follow-up. Just as importantly, the resident’s response to interventions can help the team determine whether the approach is working or whether the plan needs to change.

CMS provides cue cards intended as supplemental communication tools for the BIMS in Writing, PHQ-2 to 9, Pain Assessment Interview, and Interview for Daily and Activity Preferences.

Connecting the Interview to the Plan of Care

Accurate interview coding can affect the plan of care because a resident’s responses may reveal needs requiring attention from the interdisciplinary team.

That creates an important responsibility for MDS professionals and the broader care team: connect the assessment finding to the clinical response.

What did we learn from the resident? What did we do with that information? Did the intervention help?

A completed BIMS, PHQ-2 to 9, preferences interview or pain interview should represent more than a completed section of the MDS whenever the resident is able to participate. Treating these interviews as a checkbox exercise can miss the reason the information is being gathered in the first place.

The better question is: “What did the resident tell us, and how are we using that information to improve their care?”

Documentation Should Tell the Same Story

Resident interviews do not exist separately from the rest of the clinical record. The resident interview, MDS coding, clinical documentation, care plan and interventions should tell a consistent story. When the assessment identifies a concern, the record should demonstrate how the team responded and how the resident’s needs continued to be evaluated.

For example, if a resident reports mood symptoms during the interview, that information should not end with an accurately coded MDS item. The clinical record and care plan should reflect the appropriate follow-up based on that resident’s individual circumstances.

This connection between assessment and action is where the resident’s voice can have a greater impact on person-centered care.

Bringing the Resident’s Voice Into Everyday MDS Practice

Appendix D can also be incorporated into staff education and competency efforts rather than being viewed only as a resource to consult when a coding question arises.

Facilities can use the guidance to:

Incorporate resident interview guidance into MDS orientation and competency education.
Use real-life case studies to discuss how resident responses translate into care planning and interventions.
Audit whether interview findings are reflected in the care plan and interdisciplinary follow-up.
Reinforce the use of current CMS resources and RAI Manual guidance when questions arise.

CMS maintains a library of SNF QRP training materials, including cognitive and mood assessment education, BIMS resources and resident interview cue cards.

Ultimately, increasing the resident’s voice in the MDS process does not require adding another task to the assessment. It requires getting more value from the conversations that are already part of it.

When resident responses inform assessment, documentation, care planning and follow-up, the MDS can become more than a compliance requirement. It can help the interdisciplinary team better understand the person behind the assessment and use that understanding to guide individualized care.

CMS Resources

MDS 3.0 Resident Assessment Instrument (RAI) Manual CMS maintains the current RAI Manual, MDS item sets and related resources on its RAI Manual page. As of September 17, 2026, CMS has released MDS 3.0 RAI User’s Manual v1.20.11, effective October 1, 2026.

SNF Quality Reporting Program Training CMS provides training materials and resources related to the MDS, including BIMS, cognitive and mood assessment resources, the PHQ-2 to 9 and resident interview cue cards.

Note: Always reference the current CMS MDS 3.0 RAI User’s Manual and applicable current item sets when applying coding guidance.