54557-4 Pain Management

Observation ID in Form

J0100

Form Coding Instructions

Complete for all residents, regardless of current pain level

Fully-Specified Name

Component

Pain management

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.74

Change Reason

Release 2.70: TIME_ASPCT: Updated Timing to align with panel children and based on the new model for representing a range of reporting periods (e.g. 3 day, 7 day, etc.) across CMS assessments.; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee. Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Subset

Common Test Rank Get Info

5268

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

Related Codes

71447-7 At any time in the last 5 days, has the resident: Received scheduled pain medication regimen?

Observation ID in Form

J0100A

Fully-Specified Name

Component

Received scheduled pain medication regimen

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.70

Change Reason

Release 2.70: TIME_ASPCT: Updated Timing based on the new model for representing various reporting periods across CMS assessments.; COMPONENT: Removed "in last 5D"; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL251-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Received sched pain meds
• Report period
• Screen
• Survey

Related Codes

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

71448-5 At any time in the last 5 days, has the resident: Received PRN pain medications OR was offered and declined?

Observation ID in Form

J0100B

Fully-Specified Name

Component

Received PRN pain medications or was offered and declined

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.70

Change Reason

Release 2.70: COMPONENT: Removed "in the last 5D"; TIME_ASPCT: Updated Timing based on the new model for representing various reporting periods across CMS assessments.; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL251-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Received PRN pain meds
• Report period
• Screen
• Survey

Related Codes

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

71449-3 At any time in the last 5 days, has the resident: Received non-medication intervention for pain?

Observation ID in Form

J0100C

Fully-Specified Name

Component

Received non-medication intervention for pain

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.70

Change Reason

Release 2.70: COMPONENT: Removed "in last 5D"; TIME_ASPCT: Updated Timing based on the new model for representing various reporting periods across CMS assessments.; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL251-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Received non-med pain intervention
• Report period
• Screen
• Survey

Related Codes

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

54828-9 Should Pain Assessment Interview be Conducted?

Observation ID in Form

J0200

Skip Logic

If resident is comatose, skip to J1100, Shortness of Breath (dyspnea). If 0, Skip to and complete J0800, Indicators of Pain or Possible Pain. If 1, Continue to J0300, Pain Presence.

Form Coding Instructions

Attempt to conduct interview with all residents

Fully-Specified Name

Component

Pain assessment interview should be conducted

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL691-7

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

101326-7 Pain Assessment Interview

Fully-Specified Name

Component

MDS v3.0 - RAI v1.18.11 - Pain assessment interview

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.74

Last Updated

Version 2.75

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

54829-7 Pain Presence

Observation ID in Form

J0300

Skip Logic

If 0, Skip to J1100, Shortness of Breath. If 1, Continue to J0410, Pain Frequency. If 9, Skip to J0800, Indicators of Pain or Possible Pain.

Form Coding Instructions

Ask resident: "Have you had pain or hurting at any time in the last 5 days?"

Fully-Specified Name

Component

Pain presence

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.70

Change Reason

Release 2.70: TIME_ASPCT: Updated Timing to align with the new model representing various reporting periods across CMS assessment.; COMPONENT: Removed "in last 5D"; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL665-1

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

54830-5 Pain Frequency

Observation ID in Form

J0410

Form Coding Instructions

Ask resident: "How much of the time have you experienced pain or hurting over the last 5 days?"

Fully-Specified Name

Component

Pain frequency

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.70

Change Reason

Release 2.70: COMPONENT: Removed "in last 5D"; TIME_ASPCT: Updated Timing to align with the new model representing various reporting periods across CMS assessment.; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL5497-4

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

93156-8 Pain Effect on Sleep

Observation ID in Form

J0510

Form Coding Instructions

Ask resident: "Over the past 5 days, how much of the time has pain made it hard for you to sleep at night?"

Fully-Specified Name

Component

How much of the time has pain made it hard for you to sleep at night

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.67

Last Updated

Version 2.74

Change Reason

Release 2.74: TIME_ASPCT: policy change to not indicate specific amount of days;

Order vs. Observation

Observation

Normative Answer List LL6300-9

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

93160-0 Pain Interference with Therapy Activities

Observation ID in Form

J0520

Form Coding Instructions

Ask resident: "Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain?"

Fully-Specified Name

Component

How often have you limited your participation in rehabilitation therapy sessions due to pain over

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.67

Last Updated

Version 2.74

Change Reason

Release 2.74: TIME_ASPCT: policy change not to specify number of days;

Order vs. Observation

Observation

Normative Answer List LL5382-8

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• LMTED
• LTD
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

93158-4 Pain Interference with Day-to-Day Activities

Observation ID in Form

J0530

Form Coding Instructions

Ask resident: "Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain?"

Fully-Specified Name

Component

How often have you limited your day-to-day activities because of pain

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.67

Last Updated

Version 2.74

Change Reason

Release 2.74: TIME_ASPCT: policy change not to specify number of days;

Order vs. Observation

Observation

Normative Answer List LL6300-9

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• LMTED
• LTD
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

54560-8 Pain Intensity

Observation ID in Form

J0600

Form Coding Instructions

Administer ONLY ONE of the following pain intensity questions (A or B)

Fully-Specified Name

Component

Pain intensity

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.74

Change Reason

Release 2.70: TIME_ASPCT: Updated Timing to align with panel children and based on the new model for representing a range of reporting periods (e.g. 3 day, 7 day, etc.) across CMS assessments.; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee. Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments.

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

Related Codes

54833-9 Numeric Rating Scale (00-10)

Observation ID in Form

J0600A

Form Coding Instructions

Ask resident: "Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine." (Show resident 00 -10 pain scale)

Form Coding Instructions

Enter two-digit response. Enter 99 if unable to answer

Fully-Specified Name

Component

Pain severity

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.70

Change Reason

Release 2.70: TIME_ASPCT: Updated Timing to align with the new model representing various reporting periods across CMS assessment.; COMPONENT: Removed "in last 5D"; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

54834-7 Verbal Descriptor Scale

Observation ID in Form

J0600B

Form Coding Instructions

Ask resident: "Please rate the intensity of your worst pain over the last 5 days." (Show resident verbal scale)

Fully-Specified Name

Component

Rate pain severity using verbal descriptor scale

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.70

Change Reason

Release 2.70: TIME_ASPCT: Updated Timing to align with the new model representing various reporting periods across CMS assessment.; COMPONENT: Removed "in last 5D"; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL667-7

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

58117-3 Should the Staff Assessment for Pain be Conducted?

Observation ID in Form

J0700

Skip Logic

If 0 (J0410 = 1 thru 4), Skip to J1100, Shortness of Breath (dyspnea). If 1 (J0410 = 9), Continue to J0800, Indicators of Pain or Possible Pain

Fully-Specified Name

Component

Staff pain assessment interview should be conducted

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL4624-4

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

86672-3 Staff Assessment for Pain

Fully-Specified Name

Component

Staff assessment for pain

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.74

Change Reason

Release 2.70: TIME_ASPCT: Updated Timing to align with panel children and based on the new model for representing a range of reporting periods (e.g. 3 day, 7 day, etc.) across CMS assessments.;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

86673-1 Indicators of Pain or Possible Pain in the last 5 days

Observation ID in Form

J0800

Skip Logic

If Z, Skip to J1100, Shortness of Breath (dyspnea)

Form Coding Instructions

Check all that apply

Fully-Specified Name

Component

Indicators of pain or possible pain

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.70

Change Reason

Release 2.70: COMPONENT: Removed "in the last 5D"; TIME_ASPCT: Updated Timing to align with the new model representing various reporting periods across CMS assessment.;

Order vs. Observation

Observation

Normative Answer List LL4632-7

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Indicator
• Nominal
• Report period
• Survey

Related Codes

58118-1 Frequency of Indicator of Pain or Possible Pain in the last 5 days

Observation ID in Form

J0850

Form Context

Frequency with which resident complains or shows evidence of pain or possible pain

Fully-Specified Name

Component

Frequency of indicator of pain or possible pain

Property

NRat

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.70

Change Reason

Release 2.70: COMPONENT: Removed "in last 5D"; TIME_ASPCT: Updated Timing to align with the new model representing various reporting periods across CMS assessment.; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments.; Changed Property from Find to Nrat as decided by the CMS PAC team

Order vs. Observation

Observation

Normative Answer List LL851-7

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Count/time
• nRate
• Number rate
• Number Rate = Count/Time
• Ordinal
• QL
• Qual
• Qualitative
• Report period
• Screen
• Survey

Example Units

Related Codes

86674-9 Other Health Conditions

Fully-Specified Name

Component

Other health conditions

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.78

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Othr
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

86675-6 Shortness of Breath (dyspnea)

Observation ID in Form

J1100

Form Coding Instructions

Check all that apply

Fully-Specified Name

Component

Shortness of breath

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.70

Change Reason

Release 2.70: TIME_ASPCT: Updated Timing to align with the new model representing various reporting periods across CMS assessment.; COMPONENT: Removed "in last 7D"; Release 2.67: ANSWER_LIST_TYPE: Answer List Type changed to Example to accommodate Override Answer Lists

Order vs. Observation

Observation

Example Answer List LL4606-1

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Nominal
• Report period
• Survey

Related Codes

54846-1 Prognosis

Observation ID in Form

J1400

Form Context

Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months?

Form Coding Instructions

Requires physician documentation

Fully-Specified Name

Component

Life expectancy of less than 6M

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL251-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

86676-4 Problem Conditions

Observation ID in Form

J1550

Form Coding Instructions

Check all that apply

Fully-Specified Name

Component

Problem conditions

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.70

Change Reason

Release 2.70: COMPONENT: Removed "in last 7D"; TIME_ASPCT: Updated Timing to align with the new model representing various reporting periods across CMS assessment.;

Order vs. Observation

Observation

Example Answer List LL4571-7

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Nominal
• Report period
• Survey

Related Codes

54849-5 Fall History on Admission/Entry or Reentry

Observation ID in Form

J1700

Skip Logic

Complete only if A0310A = 01 or A0310E = 1

Fully-Specified Name

Component

Fall history on admission

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.78

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments.

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Fall Hx on admission
• Hx
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

Related Codes

54850-3 Did the resident have a fall any time in the last month prior to admission/entry or reentry?

Observation ID in Form

J1700A

Fully-Specified Name

Component

Fall one or more times in the last Mo prior to admission

Property

Find

Time

1Mo

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Changed month to Mo in component based on current LOINC model. Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL1502-5

Member of these Panels

Related Names

• 1 month
• 1 month (30 days)
• 30 days
• Centers for Medicare and Medicaid Assessment
• Fall one or more times in the last month prior to admission
• Finding
• Findings
• month
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey

Related Codes

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

54851-1 Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry?

Observation ID in Form

J1700B

Fully-Specified Name

Component

Fall one or more times in the last 2 to 6Mo prior to admission

Property

Find

Time

6Mo

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL1502-5

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Fall one or more times in the last 2 to 6 months prior to admission
• Finding
• Findings
• II
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey

Related Codes

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

54852-9 Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry?

Observation ID in Form

J1700C

Fully-Specified Name

Component

Any fracture related to a fall in the 6Mo prior to admission

Property

Find

Time

6Mo

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL1502-5

Member of these Panels

Related Names

• Any fracture related to a fall in the 6 months prior to admission
• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Screen
• Survey

Related Codes

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

54853-7 Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent

Observation ID in Form

J1800

Skip Logic

If 0, Skip to J2000 Prior Surgery. If 1, Continue to J1900, Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS).

Form Context

Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent?

Fully-Specified Name

Component

Has the patient had any falls since admission or prior assessment

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL251-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

54854-5 Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent

Observation ID in Form

J1900

Fully-Specified Name

Component

Number of falls since admission or prior assessment

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.67

Change Reason

Updated METHOD from MDSv3 to CMS Assessment to use term across CMS assessments as approved by the Clinical LOINC committee; TIMING was changed from Pt to RptPeriod to accurately reflect the time interval addressed.

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• # falls since admission or prior assessment
• Centers for Medicare and Medicaid Assessment
• No
• Num
• Num of falls
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

Related Codes

54855-2 No injury

Term Description

Number of falls the patient/resident has experienced in which no evidence of any injury is noted on physical assessment by the nurse or primary care clinician, no complaints of pain or injury by the patient/resident, and no change in the patient/resident's behavior is noted after the fall.
Source: Regenstrief LOINC

Observation ID in Form

J1900A

Form Context

No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the resident; no change in the resident's behavior is noted after the fall

Fully-Specified Name

Component

Number of falls since admission or prior assessment - no injury

Property

Num

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.67

Change Reason

Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Timing was changed from Pt to RptPeriod to accurately reflect the time interval addressed.

Order vs. Observation

Observation

Normative Answer List LL670-1

Member of these Panels

Related Names

• # falls since admission or prior assessment
• # falls since admission or prior assessment - no injury
• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Num of falls
• Number
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey
• Ulcer

Related Codes

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

54856-0 Injury (except major)

Term Description

Number of falls the patient/resident has experienced that resulted in skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain.
Source: Regenstrief LOINC

Observation ID in Form

J1900B

Form Context

Skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the resident to complain of pain

Fully-Specified Name

Component

Number of falls since admission or prior assessment - injury except major

Property

Num

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.61

Change Reason

Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Timing was changed from Pt to RptPeriod to accurately reflect the time interval addressed.

Order vs. Observation

Observation

Normative Answer List LL670-1

Member of these Panels