106708-1
SFV Symptom Impact
Active
Form Context
Since the last Symptom Impact assessment was completed, 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 Services106703-2 Pain
Observation ID in Form
J2053A
Fully-Specified Name
- Component
- SFV Symptom Impact - Pain
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
SFV 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] |
106702-4 Shortness of breath
Observation ID in Form
J2053B
Fully-Specified Name
- Component
- SFV Symptom Impact - Shortness of breath
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
SFV 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] |
106701-6 Anxiety
Observation ID in Form
J2053C
Fully-Specified Name
- Component
- SFV Symptom Impact - Anxiety
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
SFV 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] |
106700-8 Nausea
Observation ID in Form
J2053D
Fully-Specified Name
- Component
- SFV Symptom Impact - Nausea
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
SFV 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] |
106699-2 Vomiting
Observation ID in Form
J2053E
Fully-Specified Name
- Component
- SFV Symptom Impact - Vomiting
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
SFV 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] |
106698-4 Diarrhea
Observation ID in Form
J2053F
Fully-Specified Name
- Component
- SFV Symptom Impact - Diarrhea
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
SFV 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] |
106697-6 Constipation
Observation ID in Form
J2053G
Fully-Specified Name
- Component
- SFV Symptom Impact - Constipation
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
SFV 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] |
106696-8 Agitation
Observation ID in Form
J2053H
Fully-Specified Name
- Component
- SFV Symptom Impact - Agitation
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Long Common Name
SFV 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] |