106682-8
Symptom Impact
Active
Form Context
Over the past 2 days, how has the patient been affected by each of the following symptoms? Base this on your clinical assessment (including input from patient and/or caregiver). Symptoms may impact multiple patient activities including, but not limited to, sleep, concentration, day to day activities, or ability to interact with others.
Source: Centers for Medicare & Medicaid Services106688-5 Pain
Observation ID in Form
J2051A
Fully-Specified Name
- Component
- Symptom Impact - Pain
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Symptom Impact - Pain during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106689-3 Shortness of breath
Observation ID in Form
J2051B
Fully-Specified Name
- Component
- Symptom Impact - Shortness of breath
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Symptom Impact - Shortness of breath during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106690-1 Anxiety
Observation ID in Form
J2051C
Fully-Specified Name
- Component
- Symptom Impact - Anxiety
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Symptom Impact - Anxiety during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106692-7 Nausea
Observation ID in Form
J2051D
Fully-Specified Name
- Component
- Symptom Impact - Nausea
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Symptom Impact - Nausea during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106691-9 Vomiting
Observation ID in Form
J2051E
Fully-Specified Name
- Component
- Symptom Impact - Vomiting
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Symptom Impact - Vomiting during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106693-5 Diarrhea
Observation ID in Form
J2051F
Fully-Specified Name
- Component
- Symptom Impact - Diarrhea
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Symptom Impact - Diarrhea during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106694-3 Constipation
Observation ID in Form
J2051G
Fully-Specified Name
- Component
- Symptom Impact - Constipation
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Symptom Impact - Constipation during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
106695-0 Agitation
Observation ID in Form
J2051H
Fully-Specified Name
- Component
- Symptom Impact - Agitation
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
Symptom Impact - Agitation during assessment period [CMS Assessment]
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.80
- Last Updated
- Version 2.80 (ADD)
- Order vs. Observation
- Observation
Normative Answer List LL6962-6
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not at all - symptom does not affect the patient, including symptoms well-controlled with current treatment | 0 | LA34627-2 | |
| Slight | 1 | LA11910-9 | |
| Moderate | 2 | LA6751-7 | |
| Severe | 3 | LA6750-9 | |
| Not applicable (the patient is not experiencing the symptom) | 9 | LA34628-0 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |