101608-8 Determination of Pressure Ulcer/Injury Risk

Observation ID in Form

M0100

Fully-Specified Name

Component

CMS - Determination of Pressure Ulcer/Injury Risk

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.75

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;

Order vs. Observation

Observation

Normative Answer List LL6336-3

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Injury
• Nominal
• Pressure injuries
• pressure injury
• Report period
• Survey
• Ulcer

Related Codes

58214-8 Unhealed Pressure Ulcers/Injuries

Observation ID in Form

M0210

Skip Logic

If 0, Skip to N0415, High-Risk Drug Classes: Use and Indication. If 1, Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.

Form Context

Does this resident have one or more unhealed pressure ulcers/injuries?

Fully-Specified Name

Component

One or more unhealed pressure injuries stage 1 or higher

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: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Normative Answer List LL251-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• i
• Ordinal
• Pressure ulcer
• Pressure Ulcers
• 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.

101611-2 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage

Observation ID in Form

M0300

Fully-Specified Name

Component

CMS - Current number of unhealed pressure injuries at each stage

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.75

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;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• No
• Num
• Pressure ulcer
• Pressure Ulcers
• Report period
• Survey

Related Codes

55124-2 Number of Stage 2 pressure ulcers

Term Description

A stage 2 pressure ulcer is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M0300B1

Skip Logic

If 0, Skip to M0300C, Stage 3

Form Context

Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister

Fully-Specified Name

Component

Number of pressure injuries - stage 2

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

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 from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• II
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54886-7 Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry

Observation ID in Form

M0300B2

Form Coding Instructions

Enter how many were noted at the time of admission/entry or reentry

Fully-Specified Name

Component

Number of pressure injuries present upon admission &or reentry - stage 2

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

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: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• II
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

55125-9 Number of Stage 3 pressure ulcers

Term Description

A stage 3 pressure ulcer is defined as full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M0300C1

Skip Logic

If 0, Skip to M0300D, Stage 4.

Form Context

Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling

Fully-Specified Name

Component

Number of pressure injuries - stage 3

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

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 from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• III
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54887-5 Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry

Observation ID in Form

M0300C2

Form Coding Instructions

Enter how many were noted at the time of admission/entry or reentry

Fully-Specified Name

Component

Number of pressure injuries present upon admission &or reentry - stage 3

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

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: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• III
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

55126-7 Number of Stage 4 pressure ulcers

Term Description

A stage 4 pressure ulcer is defined as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M0300D1

Skip Logic

If 0, Skip to M0300E. Unstageable - Non-removable dressing/device

Form Context

Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling

Fully-Specified Name

Component

Number of pressure injuries - stage 4

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

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 from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54890-9 Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry

Observation ID in Form

M0300D2

Form Coding Instructions

Enter how many were noted at the time of admission/entry or reentry

Fully-Specified Name

Component

Number of pressure injuries present upon admission &or reentry - stage 4

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

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: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54893-3 Number of unstageable pressure ulcers/injuries due to non-removable dressing/device

Term Description

A pressure ulcer that is unstageable due to a non-removable dressing is defined as a known pressure ulcer that is covered by a non-removable dressing or device, such as a surgical dressing, cast, other orthopedic device, or dressing not to be removed per physician's order.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M0300E1

Skip Logic

If 0, Skip to M0300F. Unstageable - Slough and/or eschar

Form Context

Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device

Fully-Specified Name

Component

Number of pressure injuries - unstageable due to non-removable dressing or device

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

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: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Removed "at assessment" from COMPONENT because it is implied by TIMING of "Pt".; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54894-1 Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry

Observation ID in Form

M0300E2

Form Coding Instructions

Enter how many were noted at the time of admission/entry or reentry

Fully-Specified Name

Component

Number of pressure injuries present upon admission &or reentry - unstageable due to non-removable dressing

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

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: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54946-9 Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar

Term Description

Slough tissue is defined as non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Eschar tissue is defined as dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scablike.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M0300F1

Skip Logic

If 0, Skip to M0300G. Unstageable - Deep tissue injury

Form Context

Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar

Fully-Specified Name

Component

Number of pressure injuries - unstageable due to coverage of wound bed by slough &or eschar

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

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: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Removed "at assessment" from COMPONENT because it is implied by TIMING of "Pt";Updated COMPONENT from "and or" to "&or" to match convention; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54947-7 Number of these unstageable pressure ulcers that were present upon admission/entry or reentry

Observation ID in Form

M0300F2

Form Coding Instructions

Enter how many were noted at the time of admission/entry or reentry

Fully-Specified Name

Component

Number of pressure injuries present upon admission &or reentry - unstageable due to coverage of wound bed by slough &or eschar

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

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: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54950-1 Number of unstageable pressure injuries presenting as deep tissue injury

Term Description

A pressure ulcer that is unstageable due to deep tissue injury has purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M0300G1

Skip Logic

If 0, Skip to N0410, Medications Received.

Fully-Specified Name

Component

Number of pressure injuries - unstageable with suspected deep tissue injury in evolution

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

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: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Removed "at assessment" from COMPONENT because it is implied by TIMING of "Pt"; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey
• Ulcer

Example Units

Related Codes

54951-9 Number of these unstageable pressure injuries that were present upon admission/entry or reentry

Observation ID in Form

M0300G2

Form Coding Instructions

Enter how many were noted at the time of admission/entry or reentry

Fully-Specified Name

Component

Number of pressure injuries present upon admission &or reentry - unstageable with suspected deep tissue injury in evolution

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

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: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey
• Ulcer

Example Units

Related Codes