Form Coding Instructions

Type of Assistance Needed. Patient needs assistance with (check all that apply). Support Needs/Caregiver Assistance. (If patient needs assistance, check one on each row)

Source: Centers for Medicare & Medicaid Services

52694-7 ADL assistance (e.g., transfer/ambulation, bathing, dressing, toileting, eating/feeding)

Fully-Specified Name

Component
ADL assistance needed
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
CARE

Long Common Name

ADL assistance needed [CARE]

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64 (MIN)

Normative Answer List LL595-0

AnswerCodeScoreAnswer ID
CG able1LA9945-2
CG will need training and/or other supportive services2LA9947-8
CG not likely to be able3LA9946-0
CG ability unclear4LA9944-5

Member of these Panels

LOINCLong Common Name
52745-7Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission

52695-4 IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances)

Fully-Specified Name

Component
IADL assistance needed
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
CARE

Long Common Name

IADL assistance needed [CARE]

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64 (MIN)

Normative Answer List LL595-0

AnswerCodeScoreAnswer ID
CG able1LA9945-2
CG will need training and/or other supportive services2LA9947-8
CG not likely to be able3LA9946-0
CG ability unclear4LA9944-5

Member of these Panels

LOINCLong Common Name
52745-7Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission

52696-2 Medication administration (e.g., oral, inhaled, or injectable)

Fully-Specified Name

Component
Medication administration assistance needed
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
CARE

Long Common Name

Medication administration assistance needed [CARE]

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64 (MIN)

Normative Answer List LL595-0

AnswerCodeScoreAnswer ID
CG able1LA9945-2
CG will need training and/or other supportive services2LA9947-8
CG not likely to be able3LA9946-0
CG ability unclear4LA9944-5

Member of these Panels

LOINCLong Common Name
52745-7Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission

52697-0 Medical procedures/treatments (e.g., changing wound dressing)

Fully-Specified Name

Component
Medical procedures &or treatments assistance needed
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
CARE

Long Common Name

Medical procedures/treatments assistance needed [CARE]

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64 (MIN)

Normative Answer List LL595-0

AnswerCodeScoreAnswer ID
CG able1LA9945-2
CG will need training and/or other supportive services2LA9947-8
CG not likely to be able3LA9946-0
CG ability unclear4LA9944-5

Member of these Panels

LOINCLong Common Name
52745-7Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission

52698-8 Management of equipment (includes oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment, or supplies)

Fully-Specified Name

Component
Management of equipment assistance needed
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
CARE

Long Common Name

Management of equipment assistance needed [CARE]

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64 (MIN)

Normative Answer List LL595-0

AnswerCodeScoreAnswer ID
CG able1LA9945-2
CG will need training and/or other supportive services2LA9947-8
CG not likely to be able3LA9946-0
CG ability unclear4LA9944-5

Member of these Panels

LOINCLong Common Name
52745-7Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission

52699-6 Supervision and safety

Fully-Specified Name

Component
Supervision and safety assistance needed
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
CARE

Long Common Name

Supervision and safety assistance needed [CARE]

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64 (MIN)

Normative Answer List LL595-0

AnswerCodeScoreAnswer ID
CG able1LA9945-2
CG will need training and/or other supportive services2LA9947-8
CG not likely to be able3LA9946-0
CG ability unclear4LA9944-5

Member of these Panels

LOINCLong Common Name
52745-7Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission

52700-2 Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments)

Fully-Specified Name

Component
Advocacy assistance needed
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
CARE

Long Common Name

Advocacy assistance needed [CARE]

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64 (MIN)

Normative Answer List LL595-0

AnswerCodeScoreAnswer ID
CG able1LA9945-2
CG will need training and/or other supportive services2LA9947-8
CG not likely to be able3LA9946-0
CG ability unclear4LA9944-5

Member of these Panels

LOINCLong Common Name
52745-7Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission

52701-0 None of the above or non-residential setting

Fully-Specified Name

Component
No assistance needed
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
CARE

Long Common Name

No assistance needed [CARE]

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64 (MIN)

Normative Answer List LL251-0

AnswerCodeScoreAnswer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value)0LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value)1LA33-6

Member of these Panels

LOINCLong Common Name
52745-7Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission