Version 2.77

Status Information


Term Description

This form contains Identification Information Items 1-9, which consists of identifying information needed to uniquely identify each resident, the nursing facility in which he or she resides, the reason(s) for assessment; and Items AA9 a-l, Signatures of Persons Completing a Portion of the MDS or Tracking form. The information contained on this form must accompany each comprehensive, full, MPAF, or Quarterly assessment, as well as every Distcharge and Reentry Tracking form, submitted electronically to the State MDS database. This includes Federally required assessment records, (e.g., Admission, Annual, Significant Change in Status, and Quarterly assessments), as well as assessments required for Medicare or by the State. This section also contains the Attestation Statement that staff members must sign and date attesting to the accuracy of the portions of the MDS completed by each member of the interdisciplinary team.
Source: Regenstrief LOINC

Reference Information

Type Source Reference
Original Form Centers for Medicare & Medicaid Services Original form upon which the LOINC panel is based. MDS basic assessment tracking form

Panel Hierarchy

Details for each LOINC in Panel LHC-Forms

LOINC Name R/O/C Cardinality Example UCUM Units
45963-6 Deprecated MDS basic assessment tracking form - version 2.0
Indent45964-4 Identification information section
IndentIndent45965-1 Resident Name
IndentIndentIndent45394-4 Patient Last (Family) name
IndentIndentIndent45392-8 Patient First (Given) name
IndentIndentIndent45393-6 Middle initial
IndentIndentIndent45395-1 Jr/Sr
IndentIndent46098-0 Gender
IndentIndent21112-8 Birth date {mm/dd/yyyy}
IndentIndent32624-9 Race
IndentIndent45966-9 Social Security and Medicare numbers
IndentIndentIndent45396-9 Social Security number [Identifier]
IndentIndentIndent45397-7 Medicare or comparable number
IndentIndent45967-7 Facility provider numbers Set
IndentIndentIndent45398-5 State provider number for Facility
IndentIndentIndent45399-3 Federal provider number Facility
IndentIndent45400-9 Medicaid number
IndentIndent45968-5 Reasons for assessment (basic) Set
IndentIndentIndent45408-2 Primary reason for assessment [Minimum Data Set (MDS) basic]
IndentIndentIndent45409-0 Codes for assessments required for Medicare PPS or the State [Minimum Data Set]

Fully-Specified Name

MDS basic assessment tracking form - version 2.0

Basic Attributes

First Released
Version 2.17
Last Updated
Version 2.73
Change Reason
Release 2.73: Status: LOINC will keep most current version and one prior version of CMS assessments active and discourage all older versions.;
Order vs. Observation
Panel Type

LOINC Terminology Service (API) using HL7® FHIR® Get Info

CodeSystem lookup$lookup?system=
Questionnaire definition