54982-4 Injections

Observation ID in Form

N0300

Skip Logic

If 0, Skip to N0415, High-Risk Drug Classes: Use and Indication.

Form Coding Instructions

Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days

Fully-Specified Name

Component

Number of D injectable substances received in last 7D or since admission &or reentry if less than 7D

Property

NRat

Time

7D

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Number of days injectable substances received in last 7 days or since admission/reentry if less than 7 days [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.64 (NAM)

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.; Changed Property from Find to Nrat as decided by the CMS PAC team; Changed "injectable medications" to "injectable substances" because this term is intend to also include injectable vaccines, antigens, etc.

Order vs. Observation

Observation

Member of these Panels

Related Names

• # days injectable medications received in last 7D or since admission/reentry if less than 7D
• Centers for Medicare and Medicaid Assessment
• Count/time
• Dextro
• No
• nRate
• Num
• Number rate
• Number Rate = Count/Time
• Past
• QNT
• Quan
• Quant
• Quantitative
• Survey

Example Units

Related Codes

58217-1 Insulin

Part Descriptions

LP14676-8   Insulin
A protein hormone secreted by beta cells of the pancreas. Insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose. It is also an important regulator of protein and lipid metabolism. Insulin is used as a drug to control insulin-dependent diabetes mellitus. Source: National Library of Medicine, MeSH 2006

LP14676-8   Insulin
Insulin is a hormone secreted by the islet cells of the pancreas when an increase in blood glucose is detected. Insulin attaches to the insulin receptors on the surface of most of the cells. When insulin binds its receptor, other receptors are activated so that glucose is taken up by the cells. Intracellular glucose is used as a source of energy. Information from EndocrineWeb.com accessed 2008 08 18. Source: Regenstrief Institute

Observation ID in Form

N0350

Fully-Specified Name

Component

Insulin

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Long Common Name

Insulin during assessment period [CMS Assessment]

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.78 (PANEL)

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
• HUM
• Humulin
• IH7
• Insul
• Lente
• NPH
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Semilente
• Sliding
• Survey
• Ultralente

Related Codes

58127-2 Insulin injections

Observation ID in Form

N0350A

Form Coding Instructions

Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days

Fully-Specified Name

Component

Number of D insulin injections were received in last 7D or since admission &or reentry if less than 7D

Property

NRat

Time

7D

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Number of days insulin injections were received in last 7 days or since admission/reentry if less than 7 days [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.63 (NAM)

Change Reason

Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee, and corrected "in last 5D" in Component to "in last 7D"; 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

Member of these Panels

Related Names

• #days insulin injections were received in last 7D or since admission &or reentry if less than 7D
• Centers for Medicare and Medicaid Assessment
• Count/time
• Dextro
• HUM
• Humulin
• IH7
• Insul
• Lente
• No
• NPH
• nRate
• Num
• Number rate
• Number Rate = Count/Time
• Past
• QNT
• Quan
• Quant
• Quantitative
• Semilente
• Sliding
• Survey
• Ultralente

Example Units

Related Codes

58128-0 Orders for insulin

Observation ID in Form

N0350B

Form Coding Instructions

Record the number of days the physician (or authorized assistant or practitioner) changed the resident's insulin orders during the last 7 days or since admission/entry or reentry if less than 7 days

Fully-Specified Name

Component

Number of D the physician changed the resident's insulin orders in last 7D or since admission &or reentry if less than 7D

Property

NRat

Time

7D

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Number of days the physician changed the resident's insulin orders in last 7 days or since admission/reentry if less than 7 days [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.63 (MAJ)

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.; Changed Property from Find to NRat as decided by the CMS PAC team

Order vs. Observation

Observation

Member of these Panels

Related Names

• #days the physician changed the resident's insulin orders in last 7D or since admission &or reentry if less than 7D
• Centers for Medicare and Medicaid Assessment
• Count/time
• Dextro
• HUM
• Humulin
• IH7
• Insul
• Lente
• No
• NPH
• nRate
• Num
• Number rate
• Number Rate = Count/Time
• Past
• QNT
• Quan
• Quant
• Quantitative
• S prime
• Semilente
• Sliding
• Survey
• Ultralente

Example Units

Related Codes

93155-0 High-Risk Drug Classes: Use and Indication

Observation ID in Form

N0415

Fully-Specified Name

Component

IRF-PAI v4.0, LCDS v5.00, OASIS E - High risk drug classes - use and indication

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Long Common Name

IRF-PAI v4.0, LCDS v5.00, OASIS E - High risk drug classes - use and indication during assessment period [CMS Assessment]

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.67

Last Updated

Version 2.74 (PANEL)

Change Reason

Release 2.74: TIME_ASPCT: with current modeling, we no longer specify days/time - replace Pt with ReportPeriod for TIME instead to report assessment periods (eg, 7D) ; Release 2.72: COMPONENT: Updated to include current version of OASIS that uses this panel; Release 2.69: COMPONENT: Updated to include the versions of IRF-PAI and LCDS and use this panel.;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Drugs
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

Related Codes

93153-5 Is taking

Observation ID in Form

N0415_1

Form Coding Instructions

Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days

Fully-Specified Name

Component

Drug classes of medications taken

Property

Type

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Long Common Name

Drug classes of medications taken during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.67

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: CMS policy change from Pt to RptPeriod;

Order vs. Observation

Observation

Normative Answer List LL6579-8

Member of these Panels

Related Names

• Addiction
• Centers for Medicare and Medicaid Assessment
• Drugs
• Drugs of abuse
• Illicit
• Nominal
• PotentialForAbuse
• Report period
• Survey
• Typ

Related Codes

93154-3 Indication noted

Observation ID in Form

N0415_2

Form Coding Instructions

If Column 1 is checked, check if there is an indication noted for all medications in the drug class

Fully-Specified Name

Component

Drug classes that have an indication documented

Property

Type

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Long Common Name

Drug classes that have an indication documented during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.67

Last Updated

Version 2.77 (MAJ)

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

Observation

Normative Answer List LL6578-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Drugs
• Nominal
• Report period
• Survey
• Typ

Related Codes

88295-1 Antipsychotic Medication Review

Observation ID in Form

N0450

Fully-Specified Name

Component

Antipsychotic medication review

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Long Common Name

Antipsychotic medication review during assessment period [CMS Assessment]

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.64

Last Updated

Version 2.78 (PANEL)

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
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

Related Codes

88296-9 Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent?

Observation ID in Form

N0450A

Skip Logic

If 0, Skip to N0450B, N0450C, N0450D, and N0450E. If 1, Continue to N0450B, Has a GDR been attempted? If 2, Continue to N0450B, Has a GDR been attempted? If 3, Continue to N0450B, Has a GDR been attempted?

Fully-Specified Name

Component

Antipsychotic medications since admission or entry or reentry or the prior OBRA assessment, whichever is more recent

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.64

Last Updated

Version 2.77 (MAJ)

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

Observation

Normative Answer List LL4762-2

Member of these Panels

Related Names

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

Related Codes

88297-7 Has a gradual dose reduction (GDR) been attempted?

Observation ID in Form

N0450B

Skip Logic

If 0, Skip to N0450D, Physician documented GDR as clinically contraindicated. If 1, Continue to N0450C, Date of last attempted GDR.

Fully-Specified Name

Component

Gradual dose reduction (GDR) attempted

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Gradual dose reduction (GDR) attempted during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.64

Last Updated

Version 2.77 (MAJ)

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

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 https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.

88298-5 Date of last attempted GDR

Observation ID in Form

N0450C

Fully-Specified Name

Component

Date of last attempted gradual dose reduction

Property

Date

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Date of last attempted gradual dose reduction during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.64

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Release 2.67: COMPONENT: Spelled out acronym for clarity

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Past
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

88299-3 Physician documented GDR as clinically contraindicated

Observation ID in Form

N0450D

Skip Logic

If 0, Skip N0450E Date physician documented GDR as clinically contraindicated. If 1. Yes, Continue to N0450E, Date physician documented GDR as clinically contraindicated.

Fully-Specified Name

Component

Physician documented GDR as clinically contraindicated

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Physician documented GDR as clinically contraindicated during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.64

Last Updated

Version 2.77 (MAJ)

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

Observation

Normative Answer List LL4764-8

Member of these Panels

Related Names

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

Related Codes

88300-9 Date physician documented GDR as clinically contraindicated

Observation ID in Form

N0450E

Fully-Specified Name

Component

Date physician documented GDR as clinically contraindicated

Property

Date

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Date physician documented GDR as clinically contraindicated during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.64

Last Updated

Version 2.77 (MAJ)

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

Observation

Member of these Panels

Related Names

• Arterial Stenosis
• Centers for Medicare and Medicaid Assessment
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

57255-2 Drug Regimen Review

Term Description

Indicates whether a drug regimen review indicate potential clinically significant medication issues.

Observation ID in Form

N2001

Skip Logic

Complete only if A0310B = 01

Form Context

Did a complete drug regimen review identify potential clinically significant medication issues?

Fully-Specified Name

Component

Drug regimen review identified potential medication issues

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Drug regimen review identified potential medication issues during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

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 from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms; Expanded Component to be more precise

Order vs. Observation

Observation

Normative Answer List LL5418-0

Member of these Panels

Related Names

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

Related Codes

57281-8 Medication Follow-up

Observation ID in Form

N2003

Skip Logic

Complete only if N2001 =1

Form Context

Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?

Fully-Specified Name

Component

Medication follow-up

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Medication follow-up during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

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 from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name 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 https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.

57256-0 Medication Intervention

Term Description

Indicates whether the agency contacted and complete physician (or physician-designee) prescribed/recommended actions each time potential clinically significant medication issues were identified.

Observation ID in Form

N2005

Skip Logic

Complete only if A0310H = 1

Form Context

Did the facility contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next calendar day each time potential clinically significant medication issues were identified since the admission?

Fully-Specified Name

Component

Medication intervention since admission &or reentry

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Medication intervention since admission/reentry during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

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 from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms; Added "since admission/reentry" to Component to reflect the element of the question text

Order vs. Observation

Observation

Normative Answer List LL4996-6

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 https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.