106523-4
Outcome and assessment information set (OASIS) form - version E1 - Start of Care 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 |
|---|---|---|---|---|
| 106523-4 | Outcome and assessment information set (OASIS) form - version E1 - Start of Care during assessment period [CMS Assessment] | |||
| Indent99132-3 | Administrative Information | |||
| Indent Indent68468-8 | National Provider Identifier (NPI) for the attending physician who has signed the plan of care | |||
| Indent Indent69417-4 | CMS Certification Number | |||
| Indent Indent46494-1 | Branch State | |||
| Indent Indent46495-8 | Branch ID Number | |||
| Indent Indent46496-6 | Patient ID Number | |||
| Indent Indent54503-8 | Patient Name | |||
| Indent Indent Indent45392-8 | (First) | |||
| Indent Indent Indent45393-6 | (MI) | |||
| Indent Indent Indent45394-4 | (Last) | |||
| Indent Indent Indent45395-1 | (Suffix) | |||
| Indent Indent46499-0 | Patient State of Residence | |||
| Indent Indent45401-7 | Patient ZIP Code | |||
| Indent Indent45396-9 | Social Security Number | |||
| Indent Indent45397-7 | Medicare Number | |||
| Indent Indent45400-9 | Medicaid Number | |||
| Indent Indent46098-0 | Gender | |||
| Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
| Indent Indent69854-8 | Ethnicity: Are you of Hispanic, Latino/a, or Spanish origin? | |||
| Indent Indent103708-4 | Race: What is your race? | |||
| Indent Indent57199-2 | Current Payment Sources for Home Care | 1..11 | ||
| Indent Indent93186-5 | Language | |||
| Indent Indent Indent54899-0 | What is your preferred language? | |||
| Indent Indent Indent54588-9 | Do you need or want an interpreter to communicate with a doctor or health care staff? | |||
| Indent Indent46497-4 | Start of Care Date | {mm/dd/yyyy} | ||
| Indent Indent46500-5 | Discipline of Person Completing Assessment | |||
| Indent Indent46501-3 | Date Assessment Completed | {mm/dd/yyyy} | ||
| Indent Indent57200-8 | This Assessment is Currently Being Completed for the Following Reason | |||
| Indent Indent57201-6 | Date of Physician-ordered Start of Care (Resumption of Care) | {mm/dd/yyyy} | ||
| Indent Indent57202-4 | Date of Referral | {mm/dd/yyyy} | ||
| Indent Indent101351-5 | Transportation | |||
| Indent Indent57204-0 | From which of the following Inpatient Facilities was the patient discharged within the past 14 days? | 1..7 | ||
| Indent Indent86470-2 | Inpatient Discharge Date (most recent) | {mm/dd/yyyy} | ||
| Indent99138-0 | Hearing, Speech, and Vision | |||
| Indent Indent95744-9 | Hearing | |||
| Indent Indent95745-6 | Vision | |||
| Indent Indent103709-2 | Health Literacy | |||
| Indent99140-6 | Cognitive Patterns | |||
| Indent Indent46589-8 | Cognitive Functioning | |||
| Indent Indent58104-1 | When Confused | |||
| Indent Indent86495-9 | When Anxious | |||
| Indent Indent54605-1 | Should Brief Interview for Mental Status (C0200-C0500) be Conducted? | |||
| Indent Indent103694-6 | Brief Interview for Mental Status | |||
| 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) | |||
| 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 | |||
| Indent99144-8 | Behavior | |||
| Indent Indent46473-5 | Cognitive, Behavorial, and Psychiatric Symptoms that are demonstrated at least once a week (reported or observed) | |||
| Indent Indent46592-2 | Frequency of Disruptive Behavior Symptoms (reported or observed): Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety. | |||
| Indent99147-1 | Preferences for Customary Routine Activities | |||
| Indent Indent85950-4 | Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? | |||
| Indent Indent88465-0 | Types and Sources of Assistance | |||
| Indent Indent Indent57265-1 | Supervision and safety (for example, due to cognitive impairment) | |||
| Indent99148-9 | Functional Status | |||
| Indent Indent46595-5 | Grooming: Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or make up, teeth or denture care, or fingernail care). | |||
| Indent Indent46597-1 | Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps. | |||
| Indent Indent46599-7 | Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes. | |||
| Indent Indent57243-8 | Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair). | |||
| Indent Indent57244-6 | Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode. | |||
| Indent Indent57245-3 | Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, includes cleaning area around stoma, but not managing equipment. | |||
| Indent Indent57246-1 | Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast. | |||
| Indent Indent57247-9 | Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces. | |||
| Indent89572-2 | Functional Abilities | |||
| Indent Indent83239-4 | Prior Functioning: Everyday Activities | |||
| Indent Indent Indent85070-1 | Self-Care | |||
| Indent Indent Indent85071-9 | Indoor Mobility (Ambulation) | |||
| Indent Indent Indent85072-7 | Stairs | |||
| Indent Indent Indent85073-5 | Functional Cognition | |||
| Indent Indent83234-5 | Prior Device Use | 1..5 | ||
| Indent Indent89479-0 | Self-Care - SOC/ROC Performance | |||
| Indent Indent Indent95019-6 | Eating | |||
| Indent Indent Indent95018-8 | Oral hygiene | |||
| Indent Indent Indent95017-0 | Toileting hygiene | |||
| Indent Indent Indent95015-4 | Shower/bathe self | |||
| Indent Indent Indent95014-7 | Upper body dressing | |||
| Indent Indent Indent95013-9 | Lower body dressing | |||
| Indent Indent Indent95012-1 | Putting on/taking off footwear | |||
| Indent Indent89477-4 | Mobility - SOC/ROC 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 Indent95008-9 | Sit to stand | |||
| 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 | |||
| Indent88496-5 | Bladder and Bowel | |||
| Indent Indent46552-6 | Has this patient been treated for a Urinary Tract Infection in the past 14 days? | |||
| Indent Indent46553-4 | Urinary Incontinence or Urinary Catheter Presence | |||
| Indent Indent46587-2 | Bowel Incontinence Frequency | |||
| Indent Indent86471-0 | Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay; or b) necessitated a change in medical or treatment regimen? | |||
| Indent99146-3 | Active Diagnoses | |||
| Indent Indent83243-6 | Active Diagnoses-Comorbidities and Co-existing Conditions | 1..2 | ||
| Indent Indent88488-2 | Primary Diagnosis & Other Diagnoses | |||
| Indent Indent Indent88489-0 | Primary Diagnosis | |||
| Indent Indent Indent Indent86255-7 | Primary Diagnosis: ICD-10-code | |||
| Indent Indent Indent Indent85920-7 | Primary Diagnosis Symptom Control Rating | |||
| Indent Indent Indent88490-8 | Other Diagnoses | |||
| Indent Indent Indent Indent81885-6 | Other Diagnoses: ICD-10-CM | |||
| Indent Indent Indent Indent85920-7 | Other Diagnoses Symptom Control Rating | |||
| Indent99142-2 | Health Conditions | |||
| Indent Indent57319-6 | Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? | 1..9 | ||
| 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? | |||
| Indent Indent57237-0 | When is the patient dyspneic or noticeably Short of Breath? | |||
| Indent99152-1 | 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 Indent93178-2 | Nutritional Approaches - On Admission. Check all of the following nutritional approaches that apply on admission | 1..4 | ||
| Indent Indent57248-7 | Feeding or Eating: Current ability to feed self meals and snacks safely | |||
| Indent88463-5 | Skin Conditions | |||
| Indent Indent85918-1 | Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable? | |||
| Indent Indent88494-0 | Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage | |||
| 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/injuries 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 | {#} | ||
| Indent Indent46536-9 | Current Number of Stage 1 Pressure Injuries | {#} | ||
| Indent Indent57231-3 | Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable | |||
| Indent Indent57232-1 | Does this patient have a Stasis Ulcer? | |||
| Indent Indent57233-9 | Current Number of Stasis Ulcer(s) that are Observable | {#} | ||
| Indent Indent57234-7 | Status of Most Problematic Stasis Ulcer that is Observable | |||
| Indent Indent57235-4 | Does this patient have a Surgical Wound? | |||
| Indent Indent57236-2 | Status of Most Problematic Surgical Wound that is Observable | |||
| Indent99151-3 | 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 agency 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? | |||
| Indent Indent57257-8 | Patient/Caregiver High-Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur? | |||
| Indent Indent57285-9 | Management of Oral Medications: Patient's current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals | |||
| Indent Indent57284-2 | Management of Injectable Medications: Patient's current ability to prepare and take all prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals | |||
| Indent99143-0 | Special Treatment, Procedures, and Programs | |||
| Indent Indent83252-7 | Special Treatments, Procedures, and Programs - On Admission. Check all of the following treatments, procedures, and programs that apply on admission |
Fully-Specified Name
- Component
- Outcome and assessment information set (OASIS) form - version E1 - Start of Care
- Property
- -
- Time
- RptPeriod
- System
- ^Patient
- Scale
- -
- Method
- CMS Assessment
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Order
- Panel Type
- Panel
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