103949-4
Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
Active
Panel Hierarchy
Details for each LOINC in Panel LHC-Forms
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 103949-4 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment] | |||
| Indent93217-8 | Administrative Information | |||
| Indent Indent58198-3 | Type of Record | |||
| Indent Indent54581-4 | Facility Provider Numbers | |||
| Indent Indent Indent76468-8 | National Provider Identifier (NPI) | |||
| Indent Indent Indent69417-4 | CMS Certification Number (CCN) | |||
| Indent Indent Indent45398-5 | State Medicaid Provider Number | |||
| Indent Indent85632-8 | Type of Provider | |||
| Indent Indent54593-9 | Assessment Reference Date. Observation end date | {mm/dd/yyyy} | ||
| Indent Indent52455-3 | Admission Date | {mm/dd/yyyy} | ||
| Indent Indent52454-6 | Reason for Assessment | |||
| Indent Indent93230-1 | Patient Demographic Information | |||
| Indent Indent Indent54503-8 | Legal Name of Patient | |||
| Indent Indent Indent Indent45392-8 | Patient First (Given) name | |||
| Indent Indent Indent Indent45393-6 | Middle initial | |||
| Indent Indent Indent Indent45394-4 | Patient Last (Family) name | |||
| Indent Indent Indent Indent45395-1 | Suffix | |||
| Indent Indent Indent45966-9 | Social Security and Medicare numbers | |||
| Indent Indent Indent Indent45396-9 | Social Security Number | |||
| Indent Indent Indent Indent45397-7 | Medicare number (or comparable railroad insurance number) | |||
| Indent Indent Indent45400-9 | Medicaid Number | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent Indent69854-8 | Ethnicity. Are you of Hispanic, Latino/a, or Spanish origin? | 1..4 | ||
| Indent Indent Indent103708-4 | Race. What is your race? | 1..14 | ||
| Indent Indent Indent93186-5 | Language | |||
| Indent Indent Indent Indent54899-0 | What is your preferred language? | |||
| Indent Indent Indent Indent54588-9 | Do you need or want an interpreter to communicate with a doctor or health care staff? | |||
| Indent Indent Indent45404-1 | Marital Status | |||
| Indent Indent Indent101351-5 | Transportation | |||
| Indent Indent Indent52556-8 | Payer Information | 1..13 | ||
| Indent Indent Indent85815-9 | Pre-Admission Service Use | |||
| Indent Indent Indent Indent85398-6 | Admitted From | |||
| Indent93214-5 | Hearing, Speech, and Vision | |||
| Indent Indent54597-0 | Comatose | |||
| Indent Indent95744-9 | Hearing | |||
| Indent Indent95745-6 | Vision | |||
| Indent Indent103709-2 | Health Literacy | |||
| Indent Indent95737-3 | Expression of Ideas and Wants | |||
| Indent Indent95740-7 | Understanding Verbal and Non-Verbal Content | |||
| Indent93213-7 | Cognitive Patterns | |||
| Indent Indent54605-1 | Should Brief Interview for Mental Status (C0200-C0500) be Conducted? | |||
| Indent Indent103694-6 | Brief Interview for Mental Status (BIMS) | |||
| Indent Indent Indent103696-1 | Repetition of Three Words | |||
| Indent Indent Indent103702-7 | Temporal Orientation | |||
| Indent Indent Indent Indent103697-9 | Able to report correct year | |||
| Indent Indent Indent Indent103698-7 | Able to report correct month | |||
| Indent Indent Indent Indent103703-5 | Able to report correct day of the week | |||
| Indent Indent Indent103695-3 | Recall | |||
| Indent Indent Indent Indent103699-5 | Able to recall "sock" | |||
| Indent Indent Indent Indent103700-1 | Able to recall "blue" | |||
| Indent Indent Indent Indent103701-9 | Able to recall "bed" | |||
| Indent Indent Indent103704-3 | BIMS Summary Score | {score} | ||
| Indent Indent95816-5 | Signs and Symptoms of Delirium (from CAM) | |||
| Indent Indent Indent95813-2 | Acute Onset Mental Status Change. Is there evidence of an acute change in mental status from the patient's baseline? | |||
| Indent Indent Indent95812-4 | Inattention - Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said? | |||
| Indent Indent Indent95814-0 | Disorganized thinking - Was the patient's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)? | |||
| Indent Indent Indent95815-7 | Altered level of consciousness - Did the patient have altered level of consciousness, as indicated by any of the following criteria? | |||
| Indent93170-9 | Mood | |||
| Indent Indent54635-8 | Patient Mood Interview (PHQ-2 to 9) (from Pfizer Inc.©) | |||
| Indent Indent Indent86843-0 | Symptom Presence | |||
| Indent Indent Indent Indent54636-6 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent54638-2 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent54640-8 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent54642-4 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent54644-0 | Poor appetite or overeating | |||
| Indent Indent Indent Indent54646-5 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent54648-1 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent54650-7 | Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual | |||
| Indent Indent Indent Indent54652-3 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent Indent86844-8 | Symptom Frequency | |||
| Indent Indent Indent Indent54637-4 | Little interest or pleasure in doing things | |||
| Indent Indent Indent Indent54639-0 | Feeling down, depressed or hopeless | |||
| Indent Indent Indent Indent54641-6 | Trouble falling or staying asleep, or sleeping too much | |||
| Indent Indent Indent Indent54643-2 | Feeling tired or having little energy | |||
| Indent Indent Indent Indent54645-7 | Poor appetite or overeating | |||
| Indent Indent Indent Indent54647-3 | Feeling bad about yourself - or that you are a failure or have let yourself or your family down | |||
| Indent Indent Indent Indent54649-9 | Trouble concentrating on things, such as reading the newspaper or watching television | |||
| Indent Indent Indent Indent54651-5 | Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual | |||
| Indent Indent Indent Indent54653-1 | Thoughts that you would be better off dead, or of hurting yourself in some way | |||
| Indent Indent103705-0 | Total Severity Score | {score} | ||
| Indent Indent93159-2 | Social Isolation | |||
| Indent103998-1 | Functional Abilities - Admission | |||
| Indent Indent85642-7 | Prior Functioning: Everyday Activities | |||
| Indent Indent Indent85071-9 | Indoor Mobility (Ambulation) | |||
| Indent Indent83234-5 | Prior Device Use | 1..3 | ||
| Indent Indent95859-5 | Self-Care - Admission Performance | |||
| Indent Indent Indent95019-6 | Eating | |||
| Indent Indent Indent95018-8 | Oral hygiene | |||
| Indent Indent Indent95017-0 | Toileting hygiene | |||
| Indent Indent96099-7 | Mobility - Admission Performance | |||
| Indent Indent Indent95011-3 | Roll left and right | |||
| Indent Indent Indent95010-5 | Sit to lying | |||
| Indent Indent Indent95009-7 | Lying to sitting on side of bed | |||
| Indent Indent Indent95007-1 | Chair/bed-to-chair transfer | |||
| Indent Indent Indent95006-3 | Toilet transfer | |||
| Indent Indent Indent95005-5 | Car transfer | |||
| Indent Indent Indent95004-8 | Walk 10 feet | |||
| Indent Indent Indent95003-0 | Walk 50 feet with two turns | |||
| Indent Indent Indent95002-2 | Walk 150 feet | |||
| Indent Indent Indent95001-4 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent95000-6 | 1 step (curb) | |||
| Indent Indent Indent94999-0 | 4 steps | |||
| Indent Indent Indent94998-2 | 12 steps | |||
| Indent Indent Indent94997-4 | Picking up object | |||
| Indent Indent Indent95738-1 | Does the patient use a wheelchair and/or scooter? | |||
| Indent Indent Indent94992-5 | Wheel 50 feet with two turns | |||
| Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent Indent Indent94991-7 | Wheel 150 feet | |||
| Indent Indent Indent95739-9 | Indicate the type of wheelchair or scooter used | |||
| Indent95863-7 | Bladder and Bowel | |||
| Indent Indent95735-7 | Bladder Continence | |||
| Indent Indent95736-5 | Bowel Continence | |||
| Indent95864-5 | Active Diagnoses | |||
| Indent Indent96095-5 | Indicate the patient's primary medical condition category | |||
| Indent Indent52797-8 | Other medical condition | |||
| Indent Indent83243-6 | Comorbidities and Co-existing Conditions | |||
| Indent93177-4 | Health Conditions | |||
| Indent Indent93156-8 | Pain Effect on Sleep. Over the past 5 days, how much of the time has pain made it hard for you to sleep at night? | |||
| Indent Indent93160-0 | Pain Interference with Therapy Activities. Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain? | |||
| Indent Indent93158-4 | Pain Interference with Day-to-Day Activities. Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain? | |||
| Indent93176-6 | Swallowing/Nutritional Status | |||
| Indent Indent54567-3 | Height and Weight - While measuring, if the number is X.1 - X.4 round down; X.5 or greater round up. | |||
| Indent Indent Indent103692-0 | Height (in inches) | [in_us];cm;m | ||
| Indent Indent Indent103693-8 | Weight (in pounds) | [lb_av];kg | ||
| Indent Indent93180-8 | Nutritional Approaches - Check all of the following nutritional approaches that apply on admission. | |||
| Indent85055-2 | Skin Conditions | |||
| Indent Indent58214-8 | Unhealed Pressure Ulcers/Injuries | |||
| Indent Indent83246-9 | Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage | |||
| Indent Indent Indent54884-2 | Number of Stage 1 pressure injuries | {#} | ||
| Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
| Indent Indent Indent55125-9 | Number of Stage 3 pressure ulcers | {#} | ||
| Indent Indent Indent55126-7 | Number of Stage 4 pressure ulcers | {#} | ||
| Indent Indent Indent54893-3 | Number of unstageable pressure ulcers/injuries due to non-removable dressing/device | {#} | ||
| Indent Indent Indent54946-9 | Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar | {#} | ||
| Indent Indent Indent54950-1 | Number of unstageable pressure injuries presenting as deep tissue injury | {#} | ||
| Indent93169-1 | Medications | |||
| Indent Indent93155-0 | High-Risk Drug Classes: Use and Indication | |||
| Indent Indent Indent93153-5 | Is taking. Check if the patient is taking any medications by pharmacological classification, not how it is used, in the following classes | 1..6 | ||
| Indent Indent Indent93154-3 | Indication noted. If column 1 [Is Taking] is checked, check if there is an indication noted for all medications in the drug class | 0..6 | ||
| Indent Indent57255-2 | Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues? | |||
| Indent Indent57281-8 | Medication Follow-up: 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? | |||
| Indent93205-3 | Special Treatments, Procedures, and Programs | |||
| Indent Indent83252-7 | Special Treatments, Procedures, and Programs. Check all of the following treatments, procedures, and programs that apply on admission | |||
| Indent Indent93203-8 | Spontaneous Breathing Trial (SBT) (including Tracheostomy Collar Trial (TCT) or Continuous Positive Airway Pressure (CPAP) Breathing Trial) by Day 2 of the LTCH Stay | |||
| Indent Indent Indent87539-3 | Invasive Mechanical Ventilation Support upon Admission to the LTCH | |||
| Indent Indent Indent93202-0 | Ventilator Weaning Status | |||
| Indent Indent Indent87538-5 | Assessed for readiness for SBT by day 2 of the LTCH stay | |||
| Indent Indent Indent87540-1 | Deemed medically ready for SBT by day 2 of the LTCH stay | |||
| Indent Indent Indent87541-9 | Is there documentation of reason(s) in the patient's medical record that the patient was deemed medically unready for SBT by day 2 of the LTCH stay? | |||
| Indent Indent Indent87542-7 | If the patient was deemed medically ready for SBT, was SBT performed by day 2 of the LTCH stay? | |||
| Indent87223-4 | Assessment Administration | |||
| Indent Indent85648-4 | Signature of Persons Completing the Assessment | |||
| Indent Indent70127-6 | Signature of Person Verifying Assessment Completion | |||
| Indent Indent Indent70127-6 | Signature: | |||
| Indent Indent Indent30947-6 | LTCH CARE Data Set Completion Date: | {mm/dd/yyyy} |
Fully-Specified Name
- Component
- Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1
- Property
- -
- Time
- RptPeriod
- System
- ^Patient
- Scale
- -
- Method
- CMS Assessment
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.77
- Last Updated
- Version 2.77
- Order vs. Observation
- Order
- Panel Type
- Panel
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