45981-8
Deprecated MDS full assessment form - version 2.0
Deprecated
Status Information
- Status
- DEPRECATED
Term Description
(Status in last 7 days, unless other time frame indicated)
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 full assessment form |
Panel Hierarchy
Details for each LOINC in Panel LHC-Forms
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 45981-8 | Deprecated MDS full assessment form - version 2.0 | |||
| Indent45982-6 | Identification and background information section | |||
| Indent Indent45965-1 | Resident Name | |||
| Indent Indent Indent45394-4 | Patient Last (Family) name | |||
| Indent Indent Indent45392-8 | Patient First (Given) name | |||
| Indent Indent Indent45393-6 | Middle initial | |||
| Indent Indent Indent45395-1 | Jr/Sr | |||
| Indent Indent45403-3 | Room number [Location] | |||
| Indent Indent54593-9 | Assessment reference date - observation end date during assessment period [CMS Assessment] | {mm/dd/yyyy} | ||
| Indent Indent Indent45453-8 | Date of last day of MDS observation period [Minimum Data Set] | |||
| Indent Indent Indent45454-6 | Original or corrected copy of form # [Minimum Data Set] | |||
| Indent Indent45455-3 | Date of reentry to facility [Minimum Data Set] | |||
| Indent Indent45404-1 | Marital status | |||
| Indent Indent46106-1 | Medical record no. | |||
| Indent Indent45984-2 | Current payment sources for nursing home stay Set | |||
| Indent Indent Indent45456-1 | Medicaid per diem [Minimum Data Set] | |||
| Indent Indent Indent45457-9 | Medicare per diem [Minimum Data Set] | |||
| Indent Indent Indent45458-7 | Medicare ancillary part A [Minimum Data Set] | |||
| Indent Indent Indent45459-5 | Medicare ancillary part B [Minimum Data Set] | |||
| Indent Indent Indent45460-3 | CHAMPUS Per Diem [Minimum Data Set] | |||
| Indent Indent Indent45461-1 | VA Per Diem [Minimum Data Set] | |||
| Indent Indent Indent45462-9 | Self or family pays for full per diem [Minimum Data Set] | |||
| Indent Indent Indent45463-7 | Medicaid resident liability or Medicare copayment [Minimum Data Set] | |||
| Indent Indent Indent45464-5 | Private insurance per diem [Minimum Data Set] | |||
| Indent Indent Indent45465-2 | Other per diem [Minimum Data Set] | |||
| Indent Indent50943-0 | Reasons for assessment (full) Set | |||
| Indent Indent Indent50787-1 | Primary reason for assessment [Minimum Data Set (MDS) full] | |||
| Indent Indent Indent45409-0 | Codes for assessments required for Medicare PPS or the State [Minimum Data Set] | |||
| Indent Indent45985-9 | Responsibility/legal guardian Set | |||
| Indent Indent Indent45466-0 | Legal guardian [Minimum Data Set] | |||
| Indent Indent Indent45467-8 | Other legal oversight [Minimum Data Set] | |||
| Indent Indent Indent45468-6 | Health care durable power attorney [Minimum Data Set] | |||
| Indent Indent Indent45469-4 | Financial durable power attorney [Minimum Data Set] | |||
| Indent Indent Indent45470-2 | Family member responsible [Minimum Data Set] | |||
| Indent Indent Indent45471-0 | Patient responsible for self [Minimum Data Set] | |||
| Indent Indent Indent45472-8 | Responsibility - none of above [Minimum Data Set] | |||
| Indent Indent45986-7 | Advance directives Set | |||
| Indent Indent Indent45473-6 | Advance directive/living will completed | |||
| Indent Indent Indent45474-4 | Advance directive - do not resuscitate [Minimum Data Set] | |||
| Indent Indent Indent45475-1 | Advance directive - do not hospitalize [Minimum Data Set] | |||
| Indent Indent Indent45476-9 | Advance directive - organ donation [Minimum Data Set] | |||
| Indent Indent Indent45477-7 | Advance directive - autopsy request [Minimum Data Set] | |||
| Indent Indent Indent45478-5 | Advance directive - feeding restrictions [Minimum Data Set] | |||
| Indent Indent Indent45479-3 | Advance directive - medication restrictions [Minimum Data Set] | |||
| Indent Indent Indent45480-1 | Advance directive - other treatment restrictions [Minimum Data Set] | |||
| Indent Indent Indent45481-9 | Advance directive - none [Minimum Data Set] | |||
| Indent45987-5 | Cognitive patterns section | |||
| Indent Indent54597-0 | Comatose during assessment period [CMS Assessment] | |||
| Indent Indent45988-3 | Memory Set | |||
| Indent Indent Indent45483-5 | Short-term memory OK [Minimum Data Set] | |||
| Indent Indent Indent45484-3 | Long-term memory OK [Minimum Data Set] | |||
| Indent Indent45989-1 | Memory recall/ability Set | |||
| Indent Indent Indent45485-0 | Can recall current season [Minimum Data Set] | |||
| Indent Indent Indent45486-8 | Can recall location of own room [Minimum Data Set] | |||
| Indent Indent Indent45487-6 | Can recall staff names/faces [Minimum Data Set] | |||
| Indent Indent Indent45488-4 | Can recall that he or she is in nursing home [Minimum Data Set] | |||
| Indent Indent Indent45489-2 | Memory/recall - none of above are recalled [Minimum Data Set] | |||
| Indent Indent45490-0 | Cognitive skills for daily decision making [Minimum Data Set] | |||
| Indent Indent45990-9 | Indicators of delirium - periodic disorded thinking or awareness Set | |||
| Indent Indent Indent45491-8 | Easily distracted [Minimum Data Set] | |||
| Indent Indent Indent45492-6 | Periods of altered perception or awareness of surroundings [Minimum Data Set] | |||
| Indent Indent Indent45493-4 | Episodes of disorganized speech [Minimum Data Set] | |||
| Indent Indent Indent45494-2 | Periods of restlessness [Minimum Data Set] | |||
| Indent Indent Indent45495-9 | Periods of lethargy [Minimum Data Set] | |||
| Indent Indent Indent45496-7 | Mental function varies over the course of the day [Minimum Data Set] | |||
| Indent Indent45497-5 | Change in cognitive status [Minimum Data Set] | |||
| Indent45991-7 | Communication and hearing patterns section | |||
| Indent Indent45498-3 | Hearing [Minimum Data Set] | |||
| Indent Indent45992-5 | Communication devices and techniques Set | |||
| Indent Indent Indent45499-1 | Hearing aid present and used [Minimum Data Set] | |||
| Indent Indent Indent45500-6 | Hearing aid present and not used regularly [Minimum Data Set] | |||
| Indent Indent Indent45501-4 | Other receptive communication techniques used [Minimum Data Set] | |||
| Indent Indent Indent45502-2 | No communication device [Minimum Data Set] | |||
| Indent Indent45993-3 | Modes of expression Set | |||
| Indent Indent Indent45503-0 | Uses speech [Minimum Data Set] | |||
| Indent Indent Indent45504-8 | Uses written messages to express or clarify needs [Minimum Data Set] | |||
| Indent Indent Indent45505-5 | Uses American sign language or Braille [Minimum Data Set] | |||
| Indent Indent Indent45506-3 | Uses signs/gestures/sounds [Minimum Data Set] | |||
| Indent Indent Indent45507-1 | Uses communication board [Minimum Data Set] | |||
| Indent Indent Indent45508-9 | Uses other modes of expression [Minimum Data Set] | |||
| Indent Indent Indent45509-7 | Modes of expression - none of above [Minimum Data Set] | |||
| Indent Indent45510-5 | Making self understood [Minimum Data Set] | |||
| Indent Indent45511-3 | Speech clarity [Minimum Data Set] | |||
| Indent Indent45405-8 | Ability to understand others [Minimum Data Set] | |||
| Indent Indent45406-6 | Change in communication/hearing [Minimum Data Set] | |||
| Indent45994-1 | Vision patterns section | |||
| Indent Indent45407-4 | Vision [Minimum Data Set] | |||
| Indent Indent45995-8 | Visual limitations and dificulties Set | |||
| Indent Indent Indent45512-1 | Side vision problems [Minimum Data Set] | |||
| Indent Indent Indent45513-9 | Sees halos or rings around lights, flashes of light, or curtains over eyes [Minimum Data Set] | |||
| Indent Indent Indent45514-7 | No visual limitations [Minimum Data Set] | |||
| Indent Indent45515-4 | Visual appliances [Minimum Data Set] | |||
| Indent45996-6 | Mood and behavior patterns section | |||
| Indent Indent45997-4 | Indicators of depression, anxiety, sad mood Set | |||
| Indent Indent Indent45998-2 | Verbal expressions of distress Set | |||
| Indent Indent Indent Indent45516-2 | Resident made negative statements [Minimum Data Set] | |||
| Indent Indent Indent Indent45517-0 | Repetitive questions [Minimum Data Set] | |||
| Indent Indent Indent Indent45518-8 | Repetitive verbalizations [Minimum Data Set] | |||
| Indent Indent Indent Indent45519-6 | Persistent anger with self or others [Minimum Data Set] | |||
| Indent Indent Indent Indent45520-4 | Self deprecation [Minimum Data Set] | |||
| Indent Indent Indent Indent45521-2 | Expression of what appear to be unrealistic fears [Minimum Data Set] | |||
| Indent Indent Indent Indent45522-0 | Recurrent statements that something terrible is about to happen [Minimum Data Set] | |||
| Indent Indent Indent Indent45547-7 | Repetitive health complaints [Minimum Data Set] | |||
| Indent Indent Indent Indent45548-5 | Repetitive anxious complaints or concerns [Minimum Data Set] | |||
| Indent Indent Indent45999-0 | Sleep-cycle issues Set | |||
| Indent Indent Indent Indent45549-3 | Unpleasant mood in morning [Minimum Data Set] | |||
| Indent Indent Indent Indent45550-1 | Insomnia/change in sleeping pattern [Minimum Data Set] | |||
| Indent Indent Indent46000-6 | Sad, apethetic, anxious appearance Set | |||
| Indent Indent Indent Indent45551-9 | Sad, pained, or worried facial expressions [Minimum Data Set] | |||
| Indent Indent Indent Indent45552-7 | Crying or tearfulness [Minimum Data Set] | |||
| Indent Indent Indent Indent45553-5 | Repetitive physical movements [Minimum Data Set] | |||
| Indent Indent Indent46107-9 | Loss of interest Set | |||
| Indent Indent Indent Indent45554-3 | Withdrawal from activities of interest [Minimum Data Set] | |||
| Indent Indent Indent Indent45555-0 | Reduced social interaction [Minimum Data Set] | |||
| Indent Indent45556-8 | Mood persistence [Minimum Data Set] | |||
| Indent Indent45557-6 | Change in mood [Minimum Data Set] | |||
| Indent Indent46001-4 | Behavioral symptoms Set | |||
| Indent Indent Indent45558-4 | Frequency of wandering [Minimum Data Set] | |||
| Indent Indent Indent45559-2 | Alterability of wandering [Minimum Data Set] | |||
| Indent Indent Indent45560-0 | Frequency of verbally abusive behavioral symptoms [Minimum Data Set] | {#} | ||
| Indent Indent Indent45561-8 | Alterability of verbally abusive behavioral symptoms [Minimum Data Set] | |||
| Indent Indent Indent45562-6 | Frequency of physically abusive behavioral symptoms [Minimum Data Set] | {#} | ||
| Indent Indent Indent45563-4 | Alterability of physically abusive behavioral symptoms [Minimum Data Set] | |||
| Indent Indent Indent45564-2 | Frequency of socially inappropriate or disruptive behavioral symptoms [Minimum Data Set] | {#} | ||
| Indent Indent Indent45565-9 | Alterability of socially inappropriate or disruptive behavioral symptoms [Minimum Data Set] | |||
| Indent Indent Indent45566-7 | Frequency of resists care [Minimum Data Set] | {#} | ||
| Indent Indent Indent45567-5 | Alterability of resists care [Minimum Data Set] | |||
| Indent Indent45568-3 | Change in behavioral symptoms [Minimum Data Set] | |||
| Indent46002-2 | Psychosocial well-being section | |||
| Indent Indent46003-0 | Sense of initiative/involvement Set | |||
| Indent Indent Indent45569-1 | At ease interacting with others [Minimum Data Set] | |||
| Indent Indent Indent45570-9 | At ease doing planned or structured activities [Minimum Data Set] | |||
| Indent Indent Indent45571-7 | At ease doing self-initiated activities [Minimum Data Set] | |||
| Indent Indent Indent45572-5 | Establishes own goals [Minimum Data Set] | |||
| Indent Indent Indent45573-3 | Pursues involvement in life of facility [Minimum Data Set] | |||
| Indent Indent Indent45574-1 | Accepts invitations to most group activities [Minimum Data Set] | |||
| Indent Indent Indent45575-8 | Sense of initiative - none of above [Minimum Data Set] | |||
| Indent Indent46004-8 | Unsettled releationships Set | |||
| Indent Indent Indent45576-6 | Covert/open conflict with or repeated criticism of staff [Minimum Data Set] | |||
| Indent Indent Indent45577-4 | Unhappy with roommate [Minimum Data Set] | |||
| Indent Indent Indent45578-2 | Unhappy with residents other than roommate [Minimum Data Set] | |||
| Indent Indent Indent45579-0 | Openly expresses conflict/anger with family/friends [Minimum Data Set] | |||
| Indent Indent Indent45580-8 | Absence of contact with family/friends [Minimum Data Set] | |||
| Indent Indent Indent45581-6 | Recent loss of close family member/friend [Minimum Data Set] | |||
| Indent Indent Indent45582-4 | Does not adjust easily to change in routines [Minimum Data Set] | |||
| Indent Indent Indent45583-2 | No unsettled relationships [Minimum Data Set] | |||
| Indent Indent46005-5 | Past roles Set | |||
| Indent Indent Indent45584-0 | Strong identification with past roles and life status [Minimum Data Set] | |||
| Indent Indent Indent45585-7 | Expresses sadness/anger/empty feeling over lost roles/status [Minimum Data Set] | |||
| Indent Indent Indent45586-5 | Resident perceives that daily routine (customary routine, activities) is very different from prior pattern in the community [Minimum Data Set] | |||
| Indent Indent Indent45587-3 | Past roles - none of above [Minimum Data Set] | |||
| Indent46006-3 | Physical functioning and stuctural problems section Set | |||
| Indent Indent46007-1 | ADL self performance or support Set | |||
| Indent Indent Indent45588-1 | Bed mobility - self-performance during assessment period [CMS Assessment] | |||
| Indent Indent Indent45589-9 | Bed mobility - support provided during assessment period [CMS Assessment] | |||
| Indent Indent Indent45590-7 | Transfer - self-performance during assessment period [CMS Assessment] | |||
| Indent Indent Indent45591-5 | Transfer - support provided during assessment period [CMS Assessment] | |||
| Indent Indent Indent45592-3 | Walk in room - self-performance during assessment period [CMS Assessment] | |||
| Indent Indent Indent45593-1 | Walk in room - support provided during assessment period [CMS Assessment] | |||
| Indent Indent Indent45594-9 | Walk in corridor - self-performance during assessment period [CMS Assessment] | |||
| Indent Indent Indent45595-6 | Walk in corridor - support provided during assessment period [CMS Assessment] | |||
| Indent Indent Indent45596-4 | Locomotion on unit - self-performance during assessment period [CMS Assessment] | |||
| Indent Indent Indent45597-2 | Locomotion on unit - support provided during assessment period [CMS Assessment] | |||
| Indent Indent Indent45598-0 | Locomotion off unit - self-performance during assessment period [CMS Assessment] | |||
| Indent Indent Indent45599-8 | Locomotion off unit - support provided during assessment period [CMS Assessment] | |||
| Indent Indent Indent45600-4 | Dressing - self-performance during assessment period [CMS Assessment] | |||
| Indent Indent Indent45601-2 | Dressing - support provided during assessment period [CMS Assessment] | |||
| Indent Indent Indent45602-0 | Eating - self-performance during assessment period [CMS Assessment] | |||
| Indent Indent Indent45603-8 | Eating - support provided during assessment period [CMS Assessment] | |||
| Indent Indent Indent45604-6 | Toilet use - self-performance during assessment period [CMS Assessment] | |||
| Indent Indent Indent45605-3 | Toilet use - support provided during assessment period [CMS Assessment] | |||
| Indent Indent Indent45606-1 | Personal hygiene - self-performance during assessment period [CMS Assessment] | |||
| Indent Indent Indent45607-9 | Personal hygiene - support provided during assessment period [CMS Assessment] | |||
| Indent Indent46008-9 | Bathing during assessment period [CMS Assessment] | |||
| Indent Indent Indent45608-7 | Bathing - self-performance during assessment period [CMS Assessment] | |||
| Indent Indent Indent45609-5 | Bathing - support provided during assessment period [CMS Assessment] | |||
| Indent Indent46009-7 | Test for balance Set | |||
| Indent Indent Indent45610-3 | Balance while standing [Minimum Data Set] | |||
| Indent Indent Indent45523-8 | Balance while sitting - position, trunk control [Minimum Data Set] | |||
| Indent Indent46010-5 | Functional limitation in range of motion Set | |||
| Indent Indent Indent45524-6 | Range of motion Neck [Minimum Data Set] | |||
| Indent Indent Indent45525-3 | Voluntary movement Neck [Minimum Data Set] | |||
| Indent Indent Indent45526-1 | Range of motion Upper extremity [Minimum Data Set] | |||
| Indent Indent Indent45527-9 | Voluntary movement Upper extremity [Minimum Data Set] | |||
| Indent Indent Indent45528-7 | Range of motion Hand [Minimum Data Set] | |||
| Indent Indent Indent45529-5 | Voluntary movement Hand [Minimum Data Set] | |||
| Indent Indent Indent45530-3 | Range of motion Lower extremity [Minimum Data Set] | |||
| Indent Indent Indent45531-1 | Voluntary movement Lower extremity [Minimum Data Set] | |||
| Indent Indent Indent45532-9 | Range of motion Foot [Minimum Data Set] | |||
| Indent Indent Indent45533-7 | Voluntary movement Foot [Minimum Data Set] | |||
| Indent Indent Indent45534-5 | Other limitation or loss - range of motion [Minimum Data Set] | |||
| Indent Indent Indent45535-2 | Other limitation or loss - voluntary movement [Minimum Data Set] | |||
| Indent Indent46011-3 | Modes of locomotion Set | |||
| Indent Indent Indent45536-0 | Uses cane, walker or crutch [Minimum Data Set] | |||
| Indent Indent Indent45537-8 | Wheeled self [Minimum Data Set] | |||
| Indent Indent Indent45538-6 | Other person wheeled [Minimum Data Set] | |||
| Indent Indent Indent45539-4 | Wheelchair primary mode of locomotion [Minimum Data Set] | |||
| Indent Indent Indent45540-2 | No modes of locomotion [Minimum Data Set] | |||
| Indent Indent46012-1 | Modes of transfer Set | |||
| Indent Indent Indent45541-0 | Bedfast all or most of the time [Minimum Data Set] | |||
| Indent Indent Indent45542-8 | Bed rails used for bed mobility or transfer [Minimum Data Set] | |||
| Indent Indent Indent45543-6 | Lifted manually [Minimum Data Set] | |||
| Indent Indent Indent45544-4 | Lifted mechanically [Minimum Data Set] | |||
| Indent Indent Indent45545-1 | Transfer aid [Minimum Data Set] | |||
| Indent Indent Indent45546-9 | No mode of transfer [Minimum Data Set] | |||
| Indent Indent45611-1 | Task segmentation [Minimum Data Set] | |||
| Indent Indent46013-9 | ADL functional rehabilitation potential Set | |||
| Indent Indent Indent45612-9 | Resident believes he or she is capable of increased independence in at least some ADLs [Minimum Data Set] | |||
| Indent Indent Indent45613-7 | Direct care staff believe resident is capable of increased independence in at least some ADLs during assessment period [CMS Assessment] | |||
| Indent Indent Indent45614-5 | Resident able to perform tasks or activity but is very slow [Minimum Data Set] | |||
| Indent Indent Indent45615-2 | Difference in ADL Self-Performance or ADL Support, comparing mornings to evenings [Minimum Data Set] | |||
| Indent Indent Indent45616-0 | Activities of daily living rehabilitation potential - none of above [Minimum Data Set] | |||
| Indent Indent45617-8 | Change in activities of daily living function [Minimum Data Set] | |||
| Indent46014-7 | Continence in last 14 days section Set | |||
| Indent Indent46015-4 | Continence self-control categories Set | |||
| Indent Indent Indent45619-4 | Bladder continence [Minimum Data Set] | |||
| Indent Indent Indent45618-6 | Bowel continence [Minimum Data Set] | |||
| Indent Indent46016-2 | Bowel elimination pattern Set | |||
| Indent Indent Indent45620-2 | Bowel elimination pattern regular - at least one movement every three days [Minimum Data Set] | |||
| Indent Indent Indent45621-0 | Constipation [Minimum Data Set] | |||
| Indent Indent Indent45622-8 | Diarrhea [Minimum Data Set] | |||
| Indent Indent Indent45623-6 | Fecal impaction [Minimum Data Set] | |||
| Indent Indent Indent45624-4 | Bowel elimination pattern - none of above [Minimum Data Set] | |||
| Indent Indent46017-0 | Continence appliances and programs Set | |||
| Indent Indent Indent45625-1 | Any scheduled toileting plan [Minimum Data Set] | |||
| Indent Indent Indent45626-9 | Bladder retraining program [Minimum Data Set] | |||
| Indent Indent Indent45627-7 | External catheter [Minimum Data Set] | |||
| Indent Indent Indent45628-5 | Indwelling catheter [Minimum Data Set] | |||
| Indent Indent Indent45629-3 | Intermittent catheter [Minimum Data Set] | |||
| Indent Indent Indent45630-1 | Did not use toilet room/commode/urinal [Minimum Data Set] | |||
| Indent Indent Indent45631-9 | Pads/briefs used [Minimum Data Set] | |||
| Indent Indent Indent45632-7 | Enemas/irrigation [Minimum Data Set] | |||
| Indent Indent Indent45633-5 | Ostomy present [Minimum Data Set] | |||
| Indent Indent Indent45634-3 | Continence appliances and programs - none of above [Minimum Data Set] | |||
| Indent Indent45635-0 | Change in urinary continence [Minimum Data Set] | |||
| Indent46018-8 | Disease Diagnoses | |||
| Indent Indent46019-6 | Diseases | |||
| Indent Indent Indent46020-4 | Endocrine/Metabolic/Nutritional | |||
| Indent Indent Indent Indent45636-8 | Diabetes mellitus [Minimum Data Set] | |||
| Indent Indent Indent Indent45637-6 | Hyperthyroidism [Minimum Data Set] | |||
| Indent Indent Indent Indent45638-4 | Hypothyroidism [Minimum Data Set] | |||
| Indent Indent Indent46021-2 | Heart/Circulation | |||
| Indent Indent Indent Indent45639-2 | Arteriosclerotic heart disease [Minimum Data Set] | |||
| Indent Indent Indent Indent45640-0 | Cardiac dysrhythmias [Minimum Data Set] | |||
| Indent Indent Indent Indent45641-8 | Congestive heart failure [Minimum Data Set] | |||
| Indent Indent Indent Indent45642-6 | Deep vein thrombosis [Minimum Data Set] | |||
| Indent Indent Indent Indent45643-4 | Hypertension [Minimum Data Set] | |||
| Indent Indent Indent Indent45644-2 | Hypotension [Minimum Data Set] | |||
| Indent Indent Indent Indent45645-9 | Peripheral vascular disease [Minimum Data Set] | |||
| Indent Indent Indent Indent45646-7 | Other cardiovascular disease [Minimum Data Set] | |||
| Indent Indent Indent46022-0 | Musculoskeletal | |||
| Indent Indent Indent Indent45647-5 | Arthritis [Minimum Data Set] | |||
| Indent Indent Indent Indent45648-3 | Hip fracture [Minimum Data Set] | |||
| Indent Indent Indent Indent45649-1 | Missing limb [Minimum Data Set] | |||
| Indent Indent Indent Indent45650-9 | Osteoporosis [Minimum Data Set] | |||
| Indent Indent Indent Indent45651-7 | Pathological bone fracture [Minimum Data Set] | |||
| Indent Indent Indent46023-8 | Neurological | |||
| Indent Indent Indent Indent45652-5 | Alzheimer's disease [Minimum Data Set] | |||
| Indent Indent Indent Indent45653-3 | Aphasia [Minimum Data Set] | |||
| Indent Indent Indent Indent45654-1 | Cerebral palsy [Minimum Data Set] | |||
| Indent Indent Indent Indent45655-8 | Cerebrovascular accident [Minimum Data Set] | |||
| Indent Indent Indent Indent45656-6 | Dementia other than Alzheimer's disease [Minimum Data Set] | |||
| Indent Indent Indent Indent45657-4 | Hemiplegia or hemiparesis [Minimum Data Set] | |||
| Indent Indent Indent Indent45658-2 | Multiple sclerosis [Minimum Data Set] | |||
| Indent Indent Indent Indent45659-0 | Paraplegia [Minimum Data Set] | |||
| Indent Indent Indent Indent45660-8 | Parkinson's disease [Minimum Data Set] | |||
| Indent Indent Indent Indent45661-6 | Quadriplegia [Minimum Data Set] | |||
| Indent Indent Indent Indent45662-4 | Seizure disorder [Minimum Data Set] | |||
| Indent Indent Indent Indent45663-2 | Transient ischemic attack [Minimum Data Set] | |||
| Indent Indent Indent Indent45664-0 | Traumatic brain injury [Minimum Data Set] | |||
| Indent Indent Indent46024-6 | Psychiatric/Mood | |||
| Indent Indent Indent Indent45665-7 | Anxiety disorder [Minimum Data Set] | |||
| Indent Indent Indent Indent45666-5 | Depression [Minimum Data Set] | |||
| Indent Indent Indent Indent45667-3 | Manic depression [Minimum Data Set] | |||
| Indent Indent Indent Indent45668-1 | Schizophrenia [Minimum Data Set] | |||
| Indent Indent Indent46025-3 | Pulmonary | |||
| Indent Indent Indent Indent45669-9 | Asthma [Minimum Data Set] | |||
| Indent Indent Indent Indent45670-7 | Emphysema or COPD [Minimum Data Set] | |||
| Indent Indent Indent46026-1 | Sensory | |||
| Indent Indent Indent Indent45671-5 | Cataracts [Minimum Data Set] | |||
| Indent Indent Indent Indent45672-3 | Diabetic retinopathy [Minimum Data Set] | |||
| Indent Indent Indent Indent45673-1 | Glaucoma [Minimum Data Set] | |||
| Indent Indent Indent Indent45674-9 | Macular degeneration [Minimum Data Set] | |||
| Indent Indent Indent46027-9 | Other | |||
| Indent Indent Indent Indent45675-6 | Allergies | |||
| Indent Indent Indent Indent45676-4 | Anemia [Minimum Data Set] | |||
| Indent Indent Indent Indent45677-2 | Cancer [Minimum Data Set] | |||
| Indent Indent Indent Indent45678-0 | Renal failure [Minimum Data Set] | |||
| Indent Indent Indent Indent45679-8 | None of the listed diseases or conditions [Minimum Data Set] | |||
| Indent Indent46028-7 | Infections Set | |||
| Indent Indent Indent45680-6 | Antibiotic resistant infection [Minimum Data Set] | |||
| Indent Indent Indent45681-4 | Infection with Clostridioides difficile [Minimum Data Set] | |||
| Indent Indent Indent45682-2 | Conjunctivitis [Minimum Data Set] | |||
| Indent Indent Indent45683-0 | HIV infection [Minimum Data Set] | |||
| Indent Indent Indent45684-8 | Pneumonia [Minimum Data Set] | |||
| Indent Indent Indent45685-5 | Respiratory infection [Minimum Data Set] | |||
| Indent Indent Indent45686-3 | Septicemia [Minimum Data Set] | |||
| Indent Indent Indent45687-1 | Sexually transmitted diseases [Minimum Data Set] | |||
| Indent Indent Indent45688-9 | Tuberculosis [Minimum Data Set] | |||
| Indent Indent Indent45689-7 | Urinary tract infection in last 30 days [Minimum Data Set] | |||
| Indent Indent Indent45690-5 | Viral hepatitis [Minimum Data Set] | |||
| Indent Indent Indent45691-3 | Wound infection [Minimum Data Set] | |||
| Indent Indent Indent45692-1 | Infections - none of above [Minimum Data Set] | |||
| Indent Indent46029-5 | Other current or more detailed diagnoses and ICD9 codes Set | |||
| Indent Indent Indent45693-9 | Other current or more detailed diagnoses and ICD9 codes [Minimum Data Set] | |||
| Indent Indent Indent45958-6 | Other current or more detailed diagnoses and ICD9 codes # 2 [Minimum Data Set] | |||
| Indent Indent Indent45959-4 | Other current or more detailed diagnoses and ICD9 codes # 3 [Minimum Data Set] | |||
| Indent Indent Indent45960-2 | Other current or more detailed diagnoses and ICD9 codes # 4 [Minimum Data Set] | |||
| Indent Indent Indent45961-0 | Other current or more detailed diagnoses and ICD9 codes # 5 [Minimum Data Set] | |||
| Indent46030-3 | Health conditions section | |||
| Indent Indent46105-3 | Problem conditions Set | |||
| Indent Indent Indent46031-1 | Indicators of fluid status Set | |||
| Indent Indent Indent Indent45694-7 | Weight gain or loss of 3+ Lbs. within a 7 day period [Minimum Data Set] | |||
| Indent Indent Indent Indent45695-4 | Inability to lie flat due to shortness of breath [Minimum Data Set] | |||
| Indent Indent Indent Indent45696-2 | Dehydrated [Minimum Data Set] | |||
| Indent Indent Indent Indent45697-0 | Insufficient fluid; did NOT consume all or almost all liquids provided during last 3 days [Minimum Data Set] | |||
| Indent Indent Indent46032-9 | Other indicators Set | |||
| Indent Indent Indent Indent45698-8 | Delusions [Minimum Data Set] | |||
| Indent Indent Indent Indent45699-6 | Dizziness or vertigo [Minimum Data Set] | |||
| Indent Indent Indent Indent45700-2 | Edema [Minimum Data Set] | |||
| Indent Indent Indent Indent45701-0 | Fever [Minimum Data Set] | |||
| Indent Indent Indent Indent45702-8 | Hallucinations [Minimum Data Set] | |||
| Indent Indent Indent Indent45703-6 | Internal bleeding [Minimum Data Set] | |||
| Indent Indent Indent Indent45704-4 | Recurrent lung aspirations in last 90 days [Minimum Data Set] | |||
| Indent Indent Indent Indent45705-1 | Shortness of breath [Minimum Data Set] | |||
| Indent Indent Indent Indent45706-9 | Syncope [Minimum Data Set] | |||
| Indent Indent Indent Indent45707-7 | Unsteady gait [Minimum Data Set] | |||
| Indent Indent Indent Indent45708-5 | Vomiting [Minimum Data Set] | |||
| Indent Indent Indent45709-3 | Problem conditions - none of above [Minimum Data Set] | |||
| Indent Indent46033-7 | Pain symptoms Set | |||
| Indent Indent Indent45710-1 | Pain frequency [Minimum Data Set] | |||
| Indent Indent Indent45711-9 | Pain intensity [Minimum Data Set] | |||
| Indent Indent46034-5 | Pain site Set | |||
| Indent Indent Indent45712-7 | Back pain [Minimum Data Set] | |||
| Indent Indent Indent45713-5 | Bone pain [Minimum Data Set] | |||
| Indent Indent Indent45714-3 | Chest pain while doing usual activities [Minimum Data Set] | |||
| Indent Indent Indent45715-0 | Headache [Minimum Data Set] | |||
| Indent Indent Indent45716-8 | Hip pain | |||
| Indent Indent Indent45717-6 | Incisional pain [Minimum Data Set] | |||
| Indent Indent Indent45718-4 | Joint pain [Minimum Data Set] | |||
| Indent Indent Indent45719-2 | Soft tissue pain [Minimum Data Set] | |||
| Indent Indent Indent45720-0 | Stomach pain [Minimum Data Set] | |||
| Indent Indent Indent45721-8 | Other pain [Minimum Data Set] | |||
| Indent Indent46035-2 | Accidents Set | |||
| Indent Indent Indent45722-6 | Fell in past 30 days [Minimum Data Set] | |||
| Indent Indent Indent45723-4 | Fell in past 31-180 days [Minimum Data Set] | |||
| Indent Indent Indent45724-2 | Hip fracture in last 180 days [Minimum Data Set] | |||
| Indent Indent Indent45725-9 | Other fracture in last 180 days [Minimum Data Set] | |||
| Indent Indent Indent45726-7 | Accidents - none of above [Minimum Data Set] | |||
| Indent46036-0 | Stability of conditions Set | |||
| Indent Indent45727-5 | Conditions/diseases make resident's cognitive, ADL, mood or behavior patterns unstable [Minimum Data Set] | |||
| Indent Indent45728-3 | Resident experiencing an acute episode or a flare-up of a recurrent or chronic problem [Minimum Data Set] | |||
| Indent Indent45729-1 | End-Stage disease, 6 or fewer months to live [Minimum Data Set] | |||
| Indent Indent45730-9 | Stability of conditions - none of above [Minimum Data Set] | |||
| Indent46037-8 | Oral and nutritional status section | |||
| Indent Indent46038-6 | Oral problems Set | |||
| Indent Indent Indent45731-7 | Chewing problem [Minimum Data Set] | |||
| Indent Indent Indent45732-5 | Swallowing problem [Minimum Data Set] | |||
| Indent Indent Indent45733-3 | Mouth pain [Minimum Data Set] | |||
| Indent Indent Indent45734-1 | Oral problems - none of above [Minimum Data Set] | |||
| Indent Indent46039-4 | Height and weight Set | |||
| Indent Indent Indent3137-7 | Body height Measured | [in_us];cm;m | ||
| Indent Indent Indent3141-9 | Body weight Measured | 0..1 | [lb_av];kg | |
| Indent Indent46040-2 | Weight change Set | |||
| Indent Indent Indent45735-8 | Weight loss [Minimum Data Set] | |||
| Indent Indent Indent45736-6 | Weight gain [Minimum Data Set] | |||
| Indent Indent46041-0 | Nutritional problems Set | |||
| Indent Indent Indent45737-4 | Complains about the taste of many foods [Minimum Data Set] | |||
| Indent Indent Indent45738-2 | Regular or repetitive complaints of hunger [Minimum Data Set] | |||
| Indent Indent Indent45739-0 | Leaves 25%+ food uneaten at most meals [Minimum Data Set] | |||
| Indent Indent Indent45740-8 | Nutritional problems - none of above [Minimum Data Set] | |||
| Indent Indent46042-8 | Nutritional approaches Set | |||
| Indent Indent Indent45741-6 | Parenteral IV [Minimum Data Set] | |||
| Indent Indent Indent45742-4 | Feeding tube [Minimum Data Set] | |||
| Indent Indent Indent45743-2 | Mechanically altered diet [Minimum Data Set] | |||
| Indent Indent Indent45744-0 | Syringe or oral feeding [Minimum Data Set] | |||
| Indent Indent Indent45745-7 | Therapeutic diet [Minimum Data Set] | |||
| Indent Indent Indent45746-5 | Dietary supplement between meals [Minimum Data Set] | |||
| Indent Indent Indent45747-3 | Plate guard, stabilized built-up utensil, etc. [Minimum Data Set] | |||
| Indent Indent Indent45748-1 | On a planned weight change program [Minimum Data Set] | |||
| Indent Indent Indent45749-9 | Nutritional approaches - none of above [Minimum Data Set] | |||
| Indent Indent46043-6 | Parenteral or enteral intake Set | |||
| Indent Indent Indent45750-7 | Proportion of total calories received through parenteral or tube feeding in last 7 days [Minimum Data Set] | |||
| Indent Indent Indent86684-8 | Mean fluid intake per day by IV or tube feeding during entire 7 days [CMS Assessment] | mL/d;L/d | ||
| Indent46044-4 | Oral or dental status section | |||
| Indent Indent46045-1 | Oral status and disease prevention Set | |||
| Indent Indent Indent45769-7 | Debris - soft, easily movable substances - present in mouth prior to going to bed at night [Minimum Data Set] | |||
| Indent Indent Indent45770-5 | Has dentures or removable bridge [Minimum Data Set] | |||
| Indent Indent Indent45771-3 | Some or all natural teeth lost but does not have or use dentures or partial plates [Minimum Data Set] | |||
| Indent Indent Indent45772-1 | Broken, loose, or carious teeth [Minimum Data Set] | |||
| Indent Indent Indent45773-9 | Inflamed, swollen, or bleeding gums, oral abscesses; ulcers or rashes [Minimum Data Set] | |||
| Indent Indent Indent45774-7 | Daily cleaning of teeth or dentures or mouth care by resident or staff [Minimum Data Set] | |||
| Indent Indent Indent45775-4 | Oral status/disease prevention - none of above [Minimum Data Set] | |||
| Indent46046-9 | Skin condition section | |||
| Indent Indent46047-7 | Ulcers Set | |||
| Indent Indent Indent45776-2 | Ulcers.stage 1 # [Minimum Data Set] | {#} | ||
| Indent Indent Indent45777-0 | Ulcers.stage 2 # [Minimum Data Set] | {#} | ||
| Indent Indent Indent45778-8 | Ulcers.stage 3 # [Minimum Data Set] | {#} | ||
| Indent Indent Indent45779-6 | Ulcers.stage 4 # [Minimum Data Set] | {#} | ||
| Indent Indent46048-5 | Type of ulcer Set | |||
| Indent Indent Indent45780-4 | Pressure injury stage [Minimum Data Set] | |||
| Indent Indent Indent45781-2 | Stasis ulcer stage [Minimum Data Set] | |||
| Indent Indent45782-0 | History of resolved ulcers [Minimum Data Set] | |||
| Indent Indent46049-3 | Other skin problems or lesions present Set | |||
| Indent Indent Indent45783-8 | Abrasions or bruises [Minimum Data Set] | |||
| Indent Indent Indent45784-6 | Second or third degree burns [Minimum Data Set] | |||
| Indent Indent Indent45785-3 | Open lesions other than ulcers, rashes, cuts [Minimum Data Set] | |||
| Indent Indent Indent45786-1 | Rashes [Minimum Data Set] | |||
| Indent Indent Indent45787-9 | Skin desensitized to pain or pressure [Minimum Data Set] | |||
| Indent Indent Indent45788-7 | Skin tears or cuts (other than surgery) [Minimum Data Set] | |||
| Indent Indent Indent45789-5 | Surgical wounds [Minimum Data Set] | |||
| Indent Indent Indent45790-3 | Other skin problems - none of above [Minimum Data Set] | |||
| Indent Indent46050-1 | Skin treatments Set | |||
| Indent Indent Indent45791-1 | Pressure relieving devices for chair [Minimum Data Set] | |||
| Indent Indent Indent45792-9 | Pressure relieving devices for bed [Minimum Data Set] | |||
| Indent Indent Indent45793-7 | Turning or repositioning program [Minimum Data Set] | |||
| Indent Indent Indent45794-5 | Nutrition or hydration intervention to manage skin problems [Minimum Data Set] | |||
| Indent Indent Indent45795-2 | Ulcer care [Minimum Data Set] | |||
| Indent Indent Indent45796-0 | Surgical wound care [Minimum Data Set] | |||
| Indent Indent Indent45797-8 | Application of dressings (with or without topical medications) other than to feet [Minimum Data Set] | |||
| Indent Indent Indent45798-6 | Application of ointments or medications other than to feet [Minimum Data Set] | |||
| Indent Indent Indent45799-4 | Other preventative or protective skin care other than to feet [Minimum Data Set] | |||
| Indent Indent Indent45800-0 | Skin treatments - none of above [Minimum Data Set] | |||
| Indent Indent46051-9 | Foot problems and care Set | |||
| Indent Indent Indent45801-8 | One or more foot problems [Minimum Data Set] | |||
| Indent Indent Indent45802-6 | Infection of foot [Minimum Data Set] | |||
| Indent Indent Indent45803-4 | Open lesions on the foot [Minimum Data Set] | |||
| Indent Indent Indent45804-2 | Nails/calluses trimmed during last 90 days [Minimum Data Set] | |||
| Indent Indent Indent45805-9 | Received preventative or protective foot care [Minimum Data Set] | |||
| Indent Indent Indent45806-7 | Application of dressings (foot) - with or without topical medications [Minimum Data Set] | |||
| Indent Indent Indent45807-5 | Foot problems and care - none of above [Minimum Data Set] | |||
| Indent46052-7 | Activity pursuit patterns section | |||
| Indent Indent46053-5 | Time awake Set | |||
| Indent Indent Indent45808-3 | Awake in morning [Minimum Data Set] | |||
| Indent Indent Indent45809-1 | Awake in afternoon [Minimum Data Set] | |||
| Indent Indent Indent45810-9 | Awake in evening [Minimum Data Set] | |||
| Indent Indent Indent45811-7 | Time awake - none of above [Minimum Data Set] | |||
| Indent Indent45812-5 | Average time involved in activities [Minimum Data Set] | |||
| Indent Indent46054-3 | Preferred activity settings Set | |||
| Indent Indent Indent45813-3 | Preferred activity setting - own room [Minimum Data Set] | |||
| Indent Indent Indent45814-1 | Preferred activity setting - day or activity room [Minimum Data Set] | |||
| Indent Indent Indent45815-8 | Preferred activity setting - inside NH/off unit [Minimum Data Set] | |||
| Indent Indent Indent45816-6 | Preferred activity setting - outside facility [Minimum Data Set] | |||
| Indent Indent Indent45817-4 | Preferred activitty setting - none of above [Minimum Data Set] | |||
| Indent Indent46055-0 | General activity preferences Set | |||
| Indent Indent Indent45818-2 | Activity preferences - cards or other games [Minimum Data Set] | |||
| Indent Indent Indent45819-0 | Activity preferences - crafts or arts [Minimum Data Set] | |||
| Indent Indent Indent45820-8 | Activity preferences - exercise or sports [Minimum Data Set] | |||
| Indent Indent Indent45821-6 | Activity preferences - music [Minimum Data Set] | |||
| Indent Indent Indent45822-4 | Activity preferences - reading or writing [Minimum Data Set] | |||
| Indent Indent Indent45823-2 | Activity preferences - spiritual or religious activities [Minimum Data Set] | |||
| Indent Indent Indent45824-0 | Activity preferences - trips or shopping [Minimum Data Set] | |||
| Indent Indent Indent45825-7 | Activity preferences - walking or wheeling outdoors [Minimum Data Set] | |||
| Indent Indent Indent45826-5 | Activity preferences - watching TV [Minimum Data Set] | |||
| Indent Indent Indent45827-3 | Activity preferences - gardening or plants [Minimum Data Set] | |||
| Indent Indent Indent45828-1 | Activity preferences - talking or conversing [Minimum Data Set] | |||
| Indent Indent Indent45829-9 | Activity preferences - helping others [Minimum Data Set] | |||
| Indent Indent Indent45830-7 | Activity preferences - none of above [Minimum Data Set] | |||
| Indent Indent46056-8 | Prefers change in daily routine Set | |||
| Indent Indent Indent45831-5 | Type of activities in which resident is currently involved [Minimum Data Set] | |||
| Indent Indent Indent45832-3 | Extent of resident involvement in activities [Minimum Data Set] | |||
| Indent46057-6 | Medications section | |||
| Indent Indent45833-1 | Number of medications [Minimum Data Set] | {#} | ||
| Indent Indent45834-9 | New medications [Minimum Data Set] | |||
| Indent Indent45835-6 | Number of days injections received [Minimum Data Set] | d | ||
| Indent Indent46058-4 | Days received the following medication Set | |||
| Indent Indent Indent45836-4 | Number of days antipsychotic medication received [Minimum Data Set] | d | ||
| Indent Indent Indent45837-2 | Number of days antianxiety medication received [Minimum Data Set] | d | ||
| Indent Indent Indent45838-0 | Number of days antidepressant medication received [Minimum Data Set] | d | ||
| Indent Indent Indent45839-8 | Number of days hypnotic medication received [Minimum Data Set] | d | ||
| Indent Indent Indent45840-6 | Number of days diuretic medication received [Minimum Data Set] | d | ||
| Indent46059-2 | Special treatments and procedures section | |||
| Indent Indent46060-0 | Special treatments, procedures and programs Set | |||
| Indent Indent Indent46061-8 | Special care Set | |||
| Indent Indent Indent Indent46062-6 | Treatments Set | |||
| Indent Indent Indent Indent Indent45841-4 | Chemotherapy [Minimum Data Set] | |||
| Indent Indent Indent Indent Indent45842-2 | Dialysis [Minimum Data Set] | |||
| Indent Indent Indent Indent Indent45843-0 | IV medication [Minimum Data Set] | |||
| Indent Indent Indent Indent Indent45844-8 | Intake/output [Minimum Data Set] | |||
| Indent Indent Indent Indent Indent45845-5 | Monitoring of acute medical condition [Minimum Data Set] | |||
| Indent Indent Indent Indent Indent45846-3 | Ostomy care [Minimum Data Set] | |||
| Indent Indent Indent Indent Indent45847-1 | Oxygen therapy [Minimum Data Set] | |||
| Indent Indent Indent Indent Indent45848-9 | Radiation [Minimum Data Set] | |||
| Indent Indent Indent Indent Indent45849-7 | Suctioning [Minimum Data Set] | |||
| Indent Indent Indent Indent Indent45850-5 | Tracheostomy care [Minimum Data Set] | |||
| Indent Indent Indent Indent Indent45851-3 | Transfusions [Minimum Data Set] | |||
| Indent Indent Indent Indent Indent45752-3 | Ventilator or respirator [Minimum Data Set] | |||
| Indent Indent Indent Indent46063-4 | Programs Set | |||
| Indent Indent Indent Indent Indent45753-1 | Alcohol or drug treatment program | |||
| Indent Indent Indent Indent Indent45754-9 | Alzheimer's or dementia special care unit [Minimum Data Set] | |||
| Indent Indent Indent Indent Indent45755-6 | Hospice care [Minimum Data Set] | |||
| Indent Indent Indent Indent Indent45756-4 | Pediatric unit [Minimum Data Set] | |||
| Indent Indent Indent Indent Indent45757-2 | Respite care [Minimum Data Set] | |||
| Indent Indent Indent Indent Indent45758-0 | Training in skills required to return to the community [Minimum Data Set] | |||
| Indent Indent Indent Indent Indent45759-8 | Special treatments/programs - none of above [Minimum Data Set] | |||
| Indent Indent Indent46064-2 | Therapies Set | |||
| Indent Indent Indent Indent45760-6 | Number of days with at least 15 minutes of speech language pathology and audiology services in the last 7 days [CMS Assessment] | d/(7.d) | ||
| Indent Indent Indent Indent45761-4 | Total minutes of speech language pathology and audiology services in the last 7 days [Minimum Data Set] | min | ||
| Indent Indent Indent Indent45762-2 | Number of days with at least 15 minutes of occupational therapy in the last 7 days [CMS Assessment] | d/(7.d) | ||
| Indent Indent Indent Indent45763-0 | Total minutes of occupational therapy in the last 7 days [Minimum Data Set] | min | ||
| Indent Indent Indent Indent45764-8 | Number of days with at least 15 minutes of physical therapy in the last 7 days [CMS Assessment] | d/(7.d) | ||
| Indent Indent Indent Indent45765-5 | Total minutes of physical therapy in the last 7 days [Minimum Data Set] | min | ||
| Indent Indent Indent Indent45766-3 | Number of days with at least 15 minutes of respiratory therapy in the last 7 days [CMS Assessment] | d/(7.d) | ||
| Indent Indent Indent Indent45767-1 | Total minutes of respiratory therapy in the last 7 days [CMS Assessment] | min | ||
| Indent Indent Indent Indent45768-9 | Number of days with at least 15 minutes of psychological therapy by any licensed mental health professional in the last 7 days [CMS Assessment] | d/(7.d) | ||
| Indent Indent Indent Indent45852-1 | Total minutes of psychological therapy by any licensed mental health professional in the last 7 days [CMS Assessment] | min | ||
| Indent Indent46065-9 | Intervention programs for mood, behavior and cognitive loss Set | |||
| Indent Indent Indent45853-9 | Special behavior symptom evaluation program [Minimum Data Set] | |||
| Indent Indent Indent45854-7 | Evaluation by a licensed mental health specialist in last 90 days [Minimum Data Set] | |||
| Indent Indent Indent45855-4 | Group therapy [Minimum Data Set] | |||
| Indent Indent Indent45856-2 | Resident-specific deliberate changes in the environment to address mood/behavior patterns [Minimum Data Set] | |||
| Indent Indent Indent45857-0 | Reorientation [Minimum Data Set] | |||
| Indent Indent Indent45858-8 | Mood, behavior, cognitive loss programs - none of above [Minimum Data Set] | |||
| Indent Indent46066-7 | Nursing rehabilitation and restorative care Set | |||
| Indent Indent Indent45859-6 | Number of days of passive range of motion [Minimum Data Set] | d | ||
| Indent Indent Indent45860-4 | Number of days of active range of motion [Minimum Data Set] | d | ||
| Indent Indent Indent45861-2 | Number of days of splint or brace assistance [Minimum Data Set] | d | ||
| Indent Indent Indent45862-0 | Number of days of training and skill practice in bed mobility [Minimum Data Set] | d | ||
| Indent Indent Indent45863-8 | Number of days of training and skill practice in transfer [Minimum Data Set] | d | ||
| Indent Indent Indent45864-6 | Number of days of training and skill practice in walking [Minimum Data Set] | d | ||
| Indent Indent Indent45865-3 | Number of days of training and skill practice in dressing or grooming [Minimum Data Set] | d | ||
| Indent Indent Indent45866-1 | Number of days of training and skill practice in eating or swallowing [Minimum Data Set] | d | ||
| Indent Indent Indent45867-9 | Number of days of training and skill practice in amputation or prosthesis care [Minimum Data Set] | d | ||
| Indent Indent Indent45868-7 | Number of days of training and skill practice in communication [Minimum Data Set] | d | ||
| Indent Indent Indent45869-5 | Other | d | ||
| Indent Indent46067-5 | Devices and restraints Set | |||
| Indent Indent Indent45870-3 | Bed rails - full bed rails on all open sides of bed [Minimum Data Set] | |||
| Indent Indent Indent45871-1 | Bed rails - other types of side rails used [Minimum Data Set] | |||
| Indent Indent Indent45872-9 | Trunk restraint [Minimum Data Set] | |||
| Indent Indent Indent45873-7 | Limb restraint [Minimum Data Set] | |||
| Indent Indent Indent45874-5 | Chair prevents rising [Minimum Data Set] | |||
| Indent Indent45875-2 | Number hospital admissions in last 90 days [Minimum Data Set] | {#}/(90.d) | ||
| Indent Indent45876-0 | Number of emergency room visits in last 90 days [Minimum Data Set] | {#}/(90.d) | ||
| Indent Indent45877-8 | Number of physician visits in last 14 days [Minimum Data Set] | {#}/(14.d) | ||
| Indent Indent45878-6 | Number of days physician orders changed in last 14 days [Minimum Data Set] | d/(14.d) | ||
| Indent Indent45879-4 | Abnormal lab values in last 90 days [Minimum Data Set] | |||
| Indent46068-3 | Discharge potential and overall status section | |||
| Indent Indent46069-1 | Discharge potential Set | |||
| Indent Indent Indent45880-2 | Resident expresses/indicates preference to return to the community [Minimum Data Set] | |||
| Indent Indent Indent45881-0 | Resident has a support person who is positive towards discharge [Minimum Data Set] | |||
| Indent Indent Indent45882-8 | Stay projected to be of a short duration - discharge projected within 90 days [Minimum Data Set] | |||
| Indent Indent45883-6 | Overall change in care needs [Minimum Data Set] | |||
| Indent46070-9 | Assessment information section | |||
| Indent Indent46071-7 | Participation in assessment Set | |||
| Indent Indent Indent45884-4 | Resident | |||
| Indent Indent Indent45885-1 | Family | |||
| Indent Indent Indent45957-8 | Significant other | |||
| Indent46072-5 | Therapy supplement for Medicare PPS section | |||
| Indent Indent46073-3 | Special treatments and procedures Set | |||
| Indent Indent Indent46074-1 | Recreational therapy Set | |||
| Indent Indent Indent Indent45886-9 | Number of days recreation therapy administered for greater than 15 minutes [Minimum Data Set] | d | ||
| Indent Indent Indent Indent45887-7 | Total recreation therapy in last 7 days [Minimum Data Set] | min | ||
| Indent Indent Indent46101-2 | Ordered therapies Set | |||
| Indent Indent Indent Indent45888-5 | Therapy orders to begin in 1st 14 days of stay [Minimum Data Set] | |||
| Indent Indent Indent Indent45889-3 | Through day 15, provide an estimate of the number of days when at least 1 therapy service can be expected to have been delivered [Minimum Data Set] | d | ||
| Indent Indent Indent Indent45890-1 | Through day 15, provide an estimate of the number of therapy minutes (across the therapies) that can be expected to be delivered [Minimum Data Set] | min | ||
| Indent Indent46075-8 | Walking when most self sufficient Set | |||
| Indent Indent Indent45891-9 | Furthest distance walked without sitting down during this episode [Minimum Data Set] | |||
| Indent Indent Indent45892-7 | Time walked without sitting down during this episode [Minimum Data Set] | |||
| Indent Indent Indent45893-5 | Self-Performance in walking during this episode [Minimum Data Set] | |||
| Indent Indent Indent45894-3 | Walking support provided [Minimum Data Set] | |||
| Indent Indent Indent45895-0 | Parallel bars used by resident in association with this episode [Minimum Data Set] | |||
| Indent46076-6 | Deprecated Minimum Data Set (MDS) supplemental items section - version 2.0 | |||
| Indent Indent46078-2 | Pneumococcal vaccine Set | |||
| Indent Indent Indent45956-0 | Reason pneumococcal vaccine not received during assessment period [CMS Assessment] | |||
| Indent Indent Indent45955-2 | Pneumococcal vaccine status up to date [Minimum Data Set] | |||
| Indent Indent45952-9 | National provider ID | |||
| Indent Indent46077-4 | Influenza vaccine Set | |||
| Indent Indent Indent55020-2 | Reason influenza virus vaccine not received during assessment period [CMS Assessment] | |||
| Indent Indent Indent55019-4 | Influenza virus vaccine received in facility during assessment period [CMS Assessment] | |||
| Indent46079-0 | Resident assessment protocol summary section | |||
| Indent Indent45896-8 | Delirium trigger [Minimum Data Set] | |||
| Indent Indent45917-2 | Resident assessment protocol 1--Delirium - proceed with care [Minimum Data Set] | |||
| Indent Indent45916-4 | Resident assessment protocol 1--Delirium - triggered [Minimum Data Set] | |||
| Indent Indent45897-6 | Cognitive loss or dementia trigger [Minimum Data Set] | |||
| Indent Indent45919-8 | Resident assessment protocol 2--Cognitive loss - proceed with care [Minimum Data Set] | |||
| Indent Indent45918-0 | Resident assessment protocol 2--Cognitive loss - triggered [Minimum Data Set] | |||
| Indent Indent45898-4 | Visual function trigger [Minimum Data Set] | |||
| Indent Indent45921-4 | Resident assessment protocol 3--Visual function - proceed with care [Minimum Data Set] | |||
| Indent Indent45920-6 | Resident assessment protocol 3--Visual function - triggered [Minimum Data Set] | |||
| Indent Indent45899-2 | Communication trigger [Minimum Data Set] | |||
| Indent Indent45923-0 | Resident assessment protocol 4--Communication - proceed with care [Minimum Data Set] | |||
| Indent Indent45922-2 | Resident assessment protocol 4--Communication - triggered [Minimum Data Set] | |||
| Indent Indent45900-8 | ADL-rehabilitation trigger A [Minimum Data Set] | |||
| Indent Indent45925-5 | Resident assessment protocol 5--ADL functional/Rehab - proceed with care [Minimum Data Set] | |||
| Indent Indent45924-8 | Resident assessment protocol 5--ADL functional/Rehab - triggered [Minimum Data Set] | |||
| Indent Indent45901-6 | ADL-rehabilitation trigger B [Minimum Data Set] | |||
| Indent Indent45902-4 | Urinary incontinence and indwelling catherter trigger [Minimum Data Set] | |||
| Indent Indent45927-1 | Resident assessment protocol 6--Urinary incontinence - proceed with care [Minimum Data Set] | |||
| Indent Indent45926-3 | Resident assessment protocol 6--Urinary incontinence - triggered [Minimum Data Set] | |||
| Indent Indent45903-2 | Psychosocial well-being trigger [Minimum Data Set] | |||
| Indent Indent45929-7 | Resident assessment protocol 7--Psychosocial - proceed with care [Minimum Data Set] | |||
| Indent Indent45928-9 | Resident assessment protocol 7--Psychosocial - triggered [Minimum Data Set] | |||
| Indent Indent45904-0 | Mood state trigger [Minimum Data Set] | |||
| Indent Indent45931-3 | Resident assessment protocol 8--Mood state - proceed with care [Minimum Data Set] | |||
| Indent Indent45930-5 | Resident assessment protocol 8--Mood state - triggered [Minimum Data Set] | |||
| Indent Indent45905-7 | Behavioral symptoms trigger [Minimum Data Set] | |||
| Indent Indent45933-9 | Resident assessment protocol 9--Behavioral symptoms - proceed with care [Minimum Data Set] | |||
| Indent Indent45932-1 | Resident assessment protocol 9--Behavioral symptoms - triggered [Minimum Data Set] | |||
| Indent Indent45906-5 | Activities trigger A [Minimum Data Set] | |||
| Indent Indent45907-3 | Activities trigger B [Minimum Data Set] | |||
| Indent Indent45934-7 | Resident assessment protocol 10--Activities - triggered [Minimum Data Set] | |||
| Indent Indent45935-4 | Resident assessment protocol 10--Activities - proceed with care [Minimum Data Set] | |||
| Indent Indent45908-1 | Falls trigger [Minimum Data Set] | |||
| Indent Indent45937-0 | Resident assessment protocol 11--Falls - proceed with care [Minimum Data Set] | |||
| Indent Indent45936-2 | Resident assessment protocol 11--Falls - triggered [Minimum Data Set] | |||
| Indent Indent45909-9 | Nutritional status trigger [Minimum Data Set] | |||
| Indent Indent45938-8 | Resident assessment protocol 12--Nutritional status - triggered [Minimum Data Set] | |||
| Indent Indent45939-6 | Resident assessment protocol 12--Nutritional status - proceed with care [Minimum Data Set] | |||
| Indent Indent45910-7 | Feeding tubes trigger [Minimum Data Set] | |||
| Indent Indent45940-4 | Resident assessment protocol 13--Feeding tubes - triggered [Minimum Data Set] | |||
| Indent Indent45941-2 | Resident assessment protocol 13--Feeding tubes - proceed with care [Minimum Data Set] | |||
| Indent Indent45911-5 | Dehydration/fluid maintenance trigger [Minimum Data Set] | |||
| Indent Indent45942-0 | Resident assessment protocol 14--Dehydration/Fluid maint - triggered [Minimum Data Set] | |||
| Indent Indent45943-8 | Resident assessment protocol 14--Dehydration/Fluid maint - proceed with care [Minimum Data Set] | |||
| Indent Indent45912-3 | Dental care trigger [Minimum Data Set] | |||
| Indent Indent45944-6 | Resident assessment protocol 15--Dental care - triggered [Minimum Data Set] | |||
| Indent Indent45945-3 | Resident assessment protocol 15--Dental care - proceed with care [Minimum Data Set] | |||
| Indent Indent45913-1 | Pressure injuries trigger [Minimum Data Set] | |||
| Indent Indent45946-1 | Resident assessment protocol 16--Pressure injuries - triggered [Minimum Data Set] | |||
| Indent Indent45947-9 | Resident assessment protocol 16--Pressure injuries - proceed with care [Minimum Data Set] | |||
| Indent Indent45914-9 | Psychotropic drug use trigger [Minimum Data Set] | |||
| Indent Indent45948-7 | Resident assessment protocol 17--Psychotropic drug - triggered [Minimum Data Set] | |||
| Indent Indent45949-5 | Resident assessment protocol 17--Psychotropic drug - proceed with care [Minimum Data Set] | |||
| Indent Indent45915-6 | Physical restraints trigger [Minimum Data Set] | |||
| Indent Indent45950-3 | Resident assessment protocol 18--Physical restraints - triggered [Minimum Data Set] | |||
| Indent Indent45951-1 | Resident assessment protocol 18--Physical restraints - proceed with care [Minimum Data Set] |
Fully-Specified Name
- Component
- MDS full assessment form - version 2.0
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- -
- Method
Basic Attributes
- Class
- PANEL.SURVEY.MDS
- Type
- Surveys
- 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
- Order
- Panel Type
- Panel
LOINC Terminology Service (API) using HL7® FHIR® Get Info
Requests to this service require a free LOINC username and password. Below is a sample of the possible capabilities. See the LOINC Terminology Service documentation for more information.
- CodeSystem lookup
- https:
//fhir.loinc.org/CodeSystem/$lookup?system=http: //loinc.org&code=45981-8 - Questionnaire definition
- https:
//fhir.loinc.org/Questionnaire/?url=http: //loinc.org/q/45981-8
Copyright
- Organization
- interRAI
- Copyright
- InterRAI holds the copyright to Version 2.0 of the RAI for long term care outside of the US. Supplemental help and contextual information for MDS items in LOINC was derived from Version 2.0 of the RAI/MDS manual, and should not be reproduced outside of the United States without permission of InterRAI. Within the US, Version 2.0 is in the public domain.
- Terms of Use
- As a not for profit corporation under the US Tax Code, interRAI holds the copyright to a number of assessment systems, including the Resident Assessment Instrument (RAI) for long term care facilities outside of the US (the RAI is in the public domain within the US), as well as the assessment systems for Home Care (HC), Assisted Living (AL), Palliative Care (PC), Mental Health (MH) (outside of Canada), and Acute Care (RAI-AC). The scales, algorithms, and case-mix measures based on these assessment instruments cannot be copyrighted and are thus available to everyone (although the individual items on which they are based are usually copyrighted). The major clauses of our royalty-free licenses follow: * the instrument is not to be changed substantially (excepting individual identifiers and demographics); * the license is limited to non-commercial use (i.e., the instrument will not be not incorporated into products to be sold to others); * no royalties will be charged; * the organization will make appropriate efforts to inform others of the copyright status of the instrument; * interRAI's logo and copyright notice are to appear on the form; * authors, author institutions, and translators (as appropriate) are to be acknowledged in any document where authors would regularly be indicated (e.g., publication of a training manual); * publication of any training manual is limited to the period until a commercially-published version is available; * data from use of the instrument are to be shared with interRAI, subject to existing laws on confidentiality. Commercial use usually requires royalties. In this instance, interRAI may omit the data requirement, but retains the other requirements for a logo, attribution, etc. We will be pleased in any contract negotiations to acknowledge the participation of individuals or organizations which have played a substantial role in getting the instrument to the point of implementation. For more information on licensing with interRAI, please contact the president of the Board: Brant E. Fries, Ph.D. Institute of Gerontology University of Michigan 300 North Ingalls Ann Arbor, Michigan USA 48109 Email: bfries@umich.edu
- URL
- http://www.interrai.org
LOINC Copyright
Copyright © 2024 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright