55762-9 Comatose

Observation ID in Form

A

Fully-Specified Name

Component

Comatose

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.64

Panel Type

Panel

Member of these Panels

Related Names

• CARE Survey
• Point in time
• Random
• Survey

45482-7 Persistent vegetative state/no discrenible consciousness at the time of admission

Term Description

(Persistent vegetative state/no discernible consciousness)
Source: Regenstrief LOINC

Observation ID in Form

A1

Type of Entry

Question expects user entry - requires response [Q]

Skip Logic

If Yes, skip to G6. Pain Observational Assessment.

Form Coding Instructions

Complete during the 2-day assessment period

Fully-Specified Name

Component

Comatose

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.MDS

Type

Surveys

First Released

Version 2.17

Last Updated

Version 2.77

Change Reason

Release 2.69: METHOD_TYP: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC Committee.;

Normative Answer List LL251-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.MDS

Related Codes

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

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

52488-4 Temporal Orientation/Mental Status

Observation ID in Form

B

Fully-Specified Name

Component

Temporal Orientation &or Mental Status

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.64

Panel Type

Panel

Member of these Panels

Related Names

• CARE Survey
• Point in time
• Random
• Survey
• Temporal Orientation/Mental Status

52489-2 Interview Attempted

Observation ID in Form

B1

Fully-Specified Name

Component

Interview attempted

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.64

Panel Type

Panel

Member of these Panels

Related Names

• CARE Survey
• Point in time
• Random
• Survey

52594-9 Interview attempted

Observation ID in Form

B1a

Skip Logic

If Yes, skip to B2. BIMS.

Fully-Specified Name

Component

Brief interview for mental status was attempted

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.64

Normative Answer List LL251-0

Member of these Panels

Related Names

• BIMS
• BIMS attempted
• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

52595-6 Indicate reason that the interview was not attempted

Observation ID in Form

B1b

Skip Logic

If interview not attempted, Skip to Section C. Observational Assessment of Cognitive Status:

Fully-Specified Name

Component

Reason brief interview for mental status was not attempted

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.64

Normative Answer List LL558-8

Member of these Panels

Related Names

• BIMS
• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Reason BIMS was not attempted
• Screen
• Survey

69966-0 Brief interview for mental status (BIMS) [CARE]

Observation ID in Form

B3

Fully-Specified Name

Component

Brief interview for mental status

Property

-

Time

Pt

System

^Patient

Scale

-

Method

CARE

Basic Attributes

Class

PANEL.SURVEY.CARE

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.64

Panel Type

Panel

Member of these Panels

Related Names

• BIMS
• CARE Survey
• Continuity assessment record and evaluation
• Continuity Assessment Record and Evaluation (CARE) Pnl
• Pan
• Panel
• Panl
• Pnl
• Point in time
• Random
• Survey

52731-7 Repetition of three words # [BIMS]

Observation ID in Form

B3a

Form Coding Instructions

After the patient's first attempt say: "I will repeat each of the three words with a cue and ask you about them later: sock, something to wear; blue, a color; bed, a piece of furniture." You may repeat the words up to two more times

Fully-Specified Name

Component

Repetition of three words

Property

Num

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Removed "Observed." from method to make consistent with other survey methods; Changed property to Num to match answer list

Order vs. Observation

Observation

Normative Answer List LL687-5

Member of these Panels

Related Names

• 3
• Brief Interview for Mental Status
• Cnt
• Count
• Number
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

52492-6 Year, Month, Day

Observation ID in Form

B3b

Fully-Specified Name

Component

Year, Month, Day

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

PANEL.SURVEY.BIMS

Type

Surveys

First Released

Version 2.24

Last Updated

Version 2.64

Panel Type

Panel

Member of these Panels

Related Names

• Brief Interview for Mental Status (BIMS) Pnl
• Pan
• Panel
• Panl
• Pnl
• Point in time
• Random
• Survey

52732-5 Temporal orientation - current year [BIMS]

Observation ID in Form

B3b.1

Skip Logic

If answered 1. Missed by 2 to 5 years, or 0. Missed by more than 5 years or no answer, complete D. Confusion Assessment Method.

Fully-Specified Name

Component

Temporal orientation - current year

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Order vs. Observation

Observation

Normative Answer List LL643-8

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

52733-3 Temporal orientation - current month [BIMS]

Observation ID in Form

B3b.2

Skip Logic

If answered 1. Missed by 6 days to 1 month, or 0. Missed by more than 1 month or no answer, complete D. Confusion Assessment Method.

Fully-Specified Name

Component

Temporal orientation - current month

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Removed "Observed." from method to follow convention of other survey terms

Order vs. Observation

Observation

Normative Answer List LL644-6

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

54609-3 Temporal orientation - current day of the week [BIMS]

Observation ID in Form

B3b.3

Skip Logic

If answered 1. Incorrect or no answer, complete D. Confusion Assessment Method.

Fully-Specified Name

Component

Temporal orientation - current day of the week

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Removed "Observed." and ".MDS" from method to follow convention of other survey terms and to include term across CMS assessments

Order vs. Observation

Observation

Normative Answer List LL645-3

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

52493-4 Recall [BIMS]

Observation ID in Form

B3c

Form Coding Instructions

Ask patient: "Let's go back to the first question. What were those three words that I asked you to repeat?" If unable to remember a word, give cue (i.e. something to wear; a color; a piece of furniture) for that word

Fully-Specified Name

Component

Recall

Property

-

Time

Pt

System

^Patient

Scale

-

Method

BIMS

Basic Attributes

Class

PANEL.SURVEY.BIMS

Type

Surveys

First Released

Version 2.24

Last Updated

Version 2.67

Change Reason

Added method of BIMS

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Brief Interview for Mental Status (BIMS) Pnl
• Pan
• Panel
• Panl
• Pnl
• Point in time
• Random
• Survey

52735-8 Able to recall "sock"

Observation ID in Form

B3c.1

Fully-Specified Name

Component

Recall - sock

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Removed "Observed." from method to follow survey convention

Order vs. Observation

Observation

Normative Answer List LL646-1

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

52736-6 Able to recall "blue"

Observation ID in Form

B3c.2

Fully-Specified Name

Component

Recall - blue

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Removed "Observed." from method to follow survey convention

Order vs. Observation

Observation

Normative Answer List LL647-9

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

52737-4 Able to recall "bed"

Observation ID in Form

B3c.3

Fully-Specified Name

Component

Recall - bed

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

BIMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Removed "Observed." from method to follow survey convention

Order vs. Observation

Observation

Normative Answer List LL648-7

Member of these Panels

Related Names

• Brief Interview for Mental Status
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

52494-2 Observational Assessment of Cognitive Status

Observation ID in Form

C

Skip Logic

Complete this section only if patient could not be interviewed.

Form Coding Instructions

Complete during the 2-day assessment period

Form Coding Instructions

Check all that apply

Fully-Specified Name

Component

Observational Assessment of Cognitive Status at 2D Assessment Period

Property

-

Time

2D

System

^Patient

Scale

-

Method

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.64

Panel Type

Panel

Member of these Panels

Related Names

• 2 days
• 48 hours
• CARE Survey
• Survey

52596-4 Memory/recall ability

Observation ID in Form

C1

Form Coding Instructions

Check all that apply

Fully-Specified Name

Component

Memory &or recall ability during 2D assessment period

Property

Find

Time

2D

System

^Patient

Scale

Nom

Method

CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.64

Normative Answer List LL566-1

Member of these Panels

Related Names

• 2 days
• 48 hours
• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• Memory/recall ability
• Nominal
• Survey

52597-2 Specify reason

Observation ID in Form

C1f

Fully-Specified Name

Component

Unable to assess memory &or recall ability during 2D assessment period .specified reason

Property

Find

Time

2D

System

^Patient

Scale

Nom

Method

CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.64

Member of these Panels

Related Names

• 2 days
• 48 hours
• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• Memory/recall ability
• Nominal
• Survey

52495-9 Confusion Assessment Method (CAM)

Reference Information

Observation ID in Form

D

Skip Logic

Complete on all patients

Fully-Specified Name

Component

Confusion Assessment Method (CAM)

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Observed.CAM.CARE

Basic Attributes

Class

PANEL.SURVEY.CAM

Type

Surveys

First Released

Version 2.24

Last Updated

Version 2.64

Panel Type

Panel

Member of these Panels

Related Names

• Confusion Assessment Method (CAM) Pnl
• Continuity assessment record and evaluation
• Meth
• Method of
• Pan
• Panel
• Panl
• Pnl
• Point in time
• Random
• Survey

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/

52738-2 Inattention

Term Description

The patient has difficulty focusing attention (e.g., easily distracted, out of touch, or difficulty keeping track of what is said).
Source: Regenstrief LOINC

Reference Information

Observation ID in Form

D1

Fully-Specified Name

Component

Inattention during 2D assessment period

Property

Find

Time

2D

System

^Patient

Scale

Ord

Method

Observed.CAM.CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.54

Normative Answer List LL567-9

Member of these Panels

Related Names

• 2 days
• 48 hours
• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Screen
• Survey

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/

52739-0 Disorganized thinking

Term Description

The patient's thinking is disorganized or incoherent (e.g., rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching of topics or ideas).
Source: Regenstrief LOINC

Reference Information

Observation ID in Form

D2

Fully-Specified Name

Component

Disorganized thinking during 2D assessment period

Property

Find

Time

2D

System

^Patient

Scale

Ord

Method

Observed.CAM.CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.54

Normative Answer List LL567-9

Member of these Panels

Related Names

• 2 days
• 48 hours
• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Screen
• Survey

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/

52740-8 Altered level of consciousness/alertness

Term Description

The patient has an altered level of consciousness: vigilant (e.g., startles easily to any sound or touch), lethargic (e.g., repeatedly dozes off when asked questions, but responds to voice or touch), stuporous (e.g., very difficult to arouse and keep arou
Source: Regenstrief LOINC

Reference Information

Observation ID in Form

D3

Fully-Specified Name

Component

Altered level of consciousness &or alertness during 2D assessment period

Property

Find

Time

2D

System

^Patient

Scale

Ord

Method

Observed.CAM.CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.54

Normative Answer List LL567-9

Member of these Panels

Related Names

• 2 days
• 48 hours
• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• Levels
• Levl
• LV
• LVL
• Ordinal
• Ql
• Qual
• Qualitative
• Screen
• Survey

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/

52741-6 Psychomotor retardation

Term Description

Patient has an unusually decreased level of activity (e.g., sluggishness, staring into space, staying in one position, moving very slowly).
Source: Regenstrief LOINC

Reference Information

Observation ID in Form

D4

Fully-Specified Name

Component

Psychomotor retardation during 2D assessment period

Property

Find

Time

2D

System

^Patient

Scale

Ord

Method

Observed.CAM.CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.54

Normative Answer List LL567-9

Member of these Panels

Related Names

• 2 days
• 48 hours
• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Screen
• Survey

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/

52496-7 Has the patient exhibited any of the following behaviors during the 2-day assessment period?

Observation ID in Form

E

Form Coding Instructions

Complete during the 2-day assessment period

Fully-Specified Name

Component

Behavioral Signs & Symptoms

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.64

Panel Type

Panel

Survey Question

Text

Has the patient exhibited any of the following behaviors during the 2-day assessment period?

Source

CARE I.E

Member of these Panels

Related Names

• CARE Survey
• Point in time
• Random
• Survey
• Sx

52598-0 Physical behavioral symptoms directed toward others

Term Description

e.g., hitting, kicking, pushing
Source: Regenstrief LOINC

Observation ID in Form

E1

Fully-Specified Name

Component

Physical behavioral symptoms directed toward others during 2D assessment period

Property

Find

Time

2D

System

^Patient

Scale

Ord

Method

CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.64

Survey Question

Text

Physical behavioral symptoms directed toward others.

Source

CARE I.e01

Normative Answer List LL251-0

Member of these Panels

Related Names

• 2 days
• 48 hours
• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Screen
• Survey
• Sx

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

52599-8 Verbal behavioral symptoms directed towards others

Term Description

e.g., threatening, screaming at others
Source: Regenstrief LOINC

Observation ID in Form

E2

Fully-Specified Name

Component

Verbal behavioral symptoms directed towards others during 2D assessment period

Property

Find

Time

2D

System

^Patient

Scale

Ord

Method

CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.64

Survey Question

Text

Verbal behavioral symptoms directed towards others.

Source

CARE I.e02

Normative Answer List LL251-0

Member of these Panels

Related Names

• 2 days
• 48 hours
• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Screen
• Survey
• Sx

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

52600-4 Other disruptive or dangerous behavioral symptoms not directed towards others, including self-injurious behaviors

Term Description

e.g., hitting or scratching self, attempts to pull out IVs, pacing
Source: Regenstrief LOINC

Observation ID in Form

E3

Fully-Specified Name

Component

Other disruptive or dangerous behavioral symptoms not directed towards others, including self-injurious behaviors during 2D assessment period

Property

Find

Time

2D

System

^Patient

Scale

Ord

Method

CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.64

Survey Question

Text

Other disruptive or dangerous behavioral symptoms not directed towards others, including self-injurious behaviors.

Source

CARE I.e03

Normative Answer List LL251-0

Member of these Panels

Related Names

• 2 days
• 48 hours
• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• Ordinal
• Othr
• QL
• Qual
• Qualitative
• Screen
• Survey
• Sx

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

52497-5 Mood

Observation ID in Form

F

Form Coding Instructions

Complete during the 2-day assessment period

Fully-Specified Name

Component

Mood

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.64

Panel Type

Panel

Member of these Panels

Related Names

• CARE Survey
• Point in time
• Random
• Survey

52601-2 Mood Interview Attempted?

Observation ID in Form

F1

Skip Logic

If No, skip to G1. Pain Interview.

Fully-Specified Name

Component

Mood interview was attempted

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.64

Survey Question

Text

Mood Interview Attempted?

Source

CARE I.f01

Normative Answer List LL251-0

Member of these Panels

Related Names

• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

52498-3 Patient Health Questionnaire 2 item (PHQ-2) [Reported PHQ-2 CARE]

Term Description

The Patient Health Questionnaire-2 (PHQ-2) is a shorter version of the PHQ-9 containing two screening questions: one about the frequency of depressed mood and another about loss of interest in activities. A positive to either question indicates further testing is required.
Source: Regenstrief LOINC

Reference Information

Observation ID in Form

F2

Fully-Specified Name

Component

Patient health questionnaire 2 item

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Reported.PHQ-2.CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.64

Panel Type

Panel

Member of these Panels

Related Names

• CARE Survey
• Continuity assessment record and evaluation
• II
• Patient Health Questionnaire
• PHQ
• PHQ 2
• PHQ2
• Point in time
• Random
• Survey

Copyright

Organization

Pfizer, Inc

Copyright

Copyright © Pfizer Inc. All rights reserved.

Terms of Use

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.

URL

https://www.phqscreeners.com/

44250-9 Little interest or pleasure in doing things

Observation ID in Form

F2a

Skip Logic

If No, skip to F2c

Fully-Specified Name

Component

Little interest or pleasure in doing things in last 2W

Property

Find

Time

2W

System

^Patient

Scale

Ord

Method

Basic Attributes

Class

SURVEY.PHQ

Type

Surveys

First Released

Version 2.17

Last Updated

Version 2.72

Change Reason

Release 2.72: AnswerListId: Updated to a more general list without associated codes; METHOD_TYP: Removed Method because this concept is not specific to PHQ; SURVEY_QUEST_TEXT: Moved from the individual term level to the instance of this term in the panel; ANSWER_LIST_TYPE: Updated from Normative to Example for increased usability; EXTERNAL_COPYRIGHT_LINK: Removed copyright because this concept is not specific to PHQ9; SURVEY_QUEST_SRC: Moved from the individual term level to the instance of this term in the panel.;

Order vs. Observation

Observation

Normative Answer List LL358-3

Member of these Panels

Related Names

• 14 days
• 2 weeks
• Finding
• Findings
• Mental health
• MentalHealth
• Ordinal
• Past
• Patient Health Questionnaire
• Psych
• Psychiatry
• Ql
• Qual
• Qualitative
• Screen
• Survey
• SURVEY.PHQ

Related Codes

54637-4 Little interest or pleasure in doing things in last 2 weeks.frequency [Reported PHQ-9 CMS]

Observation ID in Form

F2b

Fully-Specified Name

Component

Little interest or pleasure in doing things in last 2W.frequency

Property

Find

Time

2W

System

^Patient

Scale

Ord

Method

Reported.PHQ-9.CMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Updated METHOD to Reported.PHQ-9.CMS to use term across CMS instruments

Order vs. Observation

Observation

Normative Answer List LL654-5

Member of these Panels

Related Names

• 14 days
• 2 weeks
• Finding
• Findings
• Mental health
• MentalHealth
• Ordinal
• Past
• Patient Health Questionnaire
• PHQ9
• Psych
• Psychiatry
• Ql
• Qual
• Qualitative
• Screen
• Survey

Related Codes

Copyright

Organization

Pfizer, Inc

Copyright

Copyright © Pfizer Inc. All rights reserved.

Terms of Use

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.

URL

https://www.phqscreeners.com/

44255-8 Feeling down, depressed, or hopeless

Observation ID in Form

F2c

Skip Logic

If No, skip to F3

Fully-Specified Name

Component

Feeling down, depressed, or hopeless in last 2W

Property

Find

Time

2W

System

^Patient

Scale

Ord

Method

Basic Attributes

Class

SURVEY.PHQ

Type

Surveys

First Released

Version 2.17

Last Updated

Version 2.72

Change Reason

Release 2.72: METHOD_TYP: Removed Method because this concept is not specific to PHQ; EXTERNAL_COPYRIGHT_LINK: Removed copyright because this concept is not specific to PHQ; SURVEY_QUEST_SRC: Moved from the individual term level to the instance of this term in the panel.; SURVEY_QUEST_TEXT: Moved from the individual term level to the instance of this term in the panel.; AnswerListId: Updated to a more general list without associated codes; ANSWER_LIST_TYPE: Updated from Normative to Example for increased usability;

Order vs. Observation

Observation

Normative Answer List LL358-3

Member of these Panels

Related Names

• 14 days
• 2 weeks
• Finding
• Findings
• Mental health
• MentalHealth
• Ordinal
• Past
• Patient Health Questionnaire
• Psych
• Psychiatry
• Ql
• Qual
• Qualitative
• Screen
• Survey
• SURVEY.PHQ

Related Codes

54639-0 Feeling down, depressed or hopeless in last 2 weeks.frequency [Reported PHQ-9 CMS]

Observation ID in Form

F2d

Fully-Specified Name

Component

Feeling down, depressed or hopeless in last 2W.frequency

Property

Find

Time

2W

System

^Patient

Scale

Ord

Method

Reported.PHQ-9.CMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Updated METHOD to Reported.PHQ-9.CMS to use term across CMS instruments

Order vs. Observation

Observation

Normative Answer List LL654-5

Member of these Panels

Related Names

• 14 days
• 2 weeks
• Finding
• Findings
• Mental health
• MentalHealth
• Ordinal
• Past
• Patient Health Questionnaire
• PHQ9
• Psych
• Psychiatry
• Ql
• Qual
• Qualitative
• Screen
• Survey

Related Codes

Copyright

Organization

Pfizer, Inc

Copyright

Copyright © Pfizer Inc. All rights reserved.

Terms of Use

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.

URL

https://www.phqscreeners.com/

52499-1 Feeling sad panel

Observation ID in Form

F3

Fully-Specified Name

Component

Feeling sad

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.73

Change Reason

Release 2.73: LONG_COMMON_NAME: Panel is discouraged; tool no longer maintained however to eliminate duplicate LCN added "panel" to name;

Panel Type

Panel

Member of these Panels

Related Names

• CARE Survey
• Point in time
• Random
• Survey

52602-0 Ask patient: "During the past 2 weeks, how often would you say, 'I feel sad'?"

Observation ID in Form

F3

Fully-Specified Name

Component

Feeling sad

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.64

Survey Question

Text

Ask patient: "During the past 2 weeks, how often would you say, 'I feel sad'?"

Source

CARE I.f03

Normative Answer List LL568-7

Member of these Panels

Related Names

• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

52500-6 Pain

Observation ID in Form

G

Form Coding Instructions

Complete during the 2-day assessment period

Fully-Specified Name

Component

Pain

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.26

Last Updated

Version 2.64

Panel Type

Panel

Member of these Panels

Related Names

• CARE Survey
• Point in time
• Random
• Survey

52603-8 Pain Interview Attempted?

Observation ID in Form

G1

Skip Logic

If No, skip to G6. Pain Observational Assessment.

Fully-Specified Name

Component

Pain interview was attempted

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.26

Last Updated

Version 2.64

Survey Question

Text

Pain Interview Attempted?

Source

CARE I.g01

Normative Answer List LL251-0

Member of these Panels

Related Names

• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

52604-6 Pain Presence. Ask patient: "Have you had pain or hurting at any time during the last 2 days?"

Observation ID in Form

G2

Skip Logic

If No, skip to Section V. Impairments. If Unable, skip to G6. Pain Observational Assessment.

Fully-Specified Name

Component

Pain presence during last 2D

Property

Find

Time

2D

System

^Patient

Scale

Ord

Method

CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.26

Last Updated

Version 2.64

Survey Question

Text

Pain Presence. Ask patient: "Have you had pain or hurting at any time during the last 2 days?"

Source

CARE I.g02

Normative Answer List LL569-5

Member of these Panels

Related Names

• 2 days
• 48 hours
• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

52742-4 Pain Severity. Ask patient: "Please rate your worst pain during the last 2 days on a zero to 10 scale, with zero being no pain and 10 as the worst pain you can imagine."

Observation ID in Form

G3

Skip Logic

If patient does not answer or is unable to respond and skip to G6. Pain Observational Assessment.

Form Coding Instructions

Enter 88 if patient does not answer or is unable to respond

Fully-Specified Name

Component

Pain severity during last 2D

Property

Score

Time

2D

System

^Patient

Scale

Ord

Method

Reported

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.26

Last Updated

Version 2.52

Survey Question

Text

Please rate your worst pain during the last 2 days on a zero to 10 scale, with zero being no pain and 10 as the worst pain you can imagine.

Source

CARE I.g03

Preferred Answer List LL571-1

Member of these Panels

Related Names

• 2 days
• 48 hours
• CARE Survey
• Ordinal
• Pain severity in last 2D
• Past
• QL
• Qual
• Qualitative
• Scale
• Screen
• Survey

52605-3 Pain Effect on Sleep. Ask patient: "During the past 2 days, has pain made it hard for you to sleep?"

Observation ID in Form

G4

Fully-Specified Name

Component

Pain has made it hard to sleep during last 2D

Property

Find

Time

2D

System

^Patient

Scale

Ord

Method

CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.26

Last Updated

Version 2.64

Survey Question

Text

Pain Effect on Sleep. Ask patient: "During the past 2 days, has pain made it hard for you to sleep?"

Source

CARE I.g04

Normative Answer List LL569-5

Member of these Panels

Related Names

• 2 days
• 48 hours
• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

52606-1 Pain Effect on Activities. Ask patient: "During the past 2 days, have you limited your activities because of pain?"

Observation ID in Form

G5

Fully-Specified Name

Component

Limited activities because of pain during last 2D

Property

Find

Time

2D

System

^Patient

Scale

Ord

Method

CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.26

Last Updated

Version 2.64

Survey Question

Text

Pain Effect on Activities. Ask patient: "During the past 2 days, have you limited your activities because of pain?"

Source

CARE I.g05

Normative Answer List LL569-5

Member of these Panels

Related Names

• 2 days
• 48 hours
• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• LMTED
• LTD
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

52607-9 Pain Observational Assessment. If the patient could not be interviewed for pain assessment, check all indicators of of pain or possible pain

Observation ID in Form

G6

Form Coding Instructions

Check all that apply

Form Coding Instructions

Pain Observational Assessment. If patient could not be interviewed for pain assessment, check all indicators of pain or possible pain Check all that apply

Fully-Specified Name

Component

Pain Observational Assessment

Property

Find

Time

Pt

System

^Patient

Scale

Nom

Method

CARE

Basic Attributes

Class

SURVEY.CARE

Type

Surveys

First Released

Version 2.26

Last Updated

Version 2.64

Normative Answer List LL572-9

Member of these Panels

Related Names

• CARE Survey
• Continuity assessment record and evaluation
• Finding
• Findings
• Nominal
• Point in time
• Random
• Survey