52743-2
Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
Deprecated
Status Information
- Status
- DEPRECATED
- Comment
- Discouraged as items are from a legacy demonstration tool that is no longer maintained. No replacement term defined.
Term Description
The Continuity Assessment Record and Evaluation (CARE) tool measures the health and functional status, changes in severity and other outcomes, for Medicare post acute care (PAC) patients. It has been designed to measure outcomes in physical and medical treatments while controlling for factors that affect outcomes, such as cognitive impairments and social and environmental factors. Many of the items are already collected in hospitals, SNFs and HHAs, although the exact item form may be different. The assessment tool is being designed to eventually replace similar items on the existing Medicare assessment forms, including the OASIS, MDS, and IRFPAI tools. Four major domains are included in the tool: medical, functional, cognitive impairments, and social/environmental factors. These domains either measure case mix severity differences within medical conditions or predict outcomes such as discharge to home or community, rehospitalization, and changes in functional or medical status. The development of the CARE tool builds on prior research and incorporates lessons learned from clinicians treating the continuum of patients seen in all four settings. The tool targets a range of measures that document variations in a patient's level of care needs including factors related to treatment and staffing patterns such as predictors of physician, nursing, and therapy intensity.
Source: Regenstrief LOINC
Panel Hierarchy
Details for each LOINC in Panel LHC-Forms
| LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
|---|---|---|---|---|
| 52743-2 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care | |||
| Indent52452-0 | Administrative Items | |||
| Indent Indent52453-8 | Assessment Type | |||
| Indent Indent Indent70160-7 | Reason for assessment | |||
| Indent Indent Indent54593-9 | Assessment reference date - observation end date during assessment period [CMS Assessment] | {mm/dd/yyyy} | ||
| Indent Indent52457-9 | Provider Information | |||
| Indent Indent Indent52458-7 | Name Provider | |||
| Indent Indent69326-7 | Patient information | |||
| Indent Indent Indent45392-8 | Patient's First Name | |||
| Indent Indent Indent52461-1 | Patient's Middle Initial or Name | |||
| Indent Indent Indent45394-4 | Patient's Last Name | |||
| Indent Indent Indent52462-9 | Patient's Nickname (optional) | |||
| Indent Indent Indent45397-7 | Medicare or comparable number | |||
| Indent Indent Indent45400-9 | Patient's Medicaid Number | |||
| Indent Indent Indent52463-7 | Patient's Facility/Agency Identification Number (for internal tracking) | |||
| Indent Indent Indent52455-3 | Admission date | {mm/dd/yyyy} | ||
| Indent Indent Indent21112-8 | Birth date | {mm/dd/yyyy} | ||
| Indent Indent Indent45396-9 | Social Security number [Identifier] | |||
| Indent Indent Indent46098-0 | Gender | |||
| Indent Indent Indent46463-6 | Race or ethnicity | 1..7 | ||
| Indent Indent Indent52553-5 | Is English the patient's primary language? | |||
| Indent Indent Indent52554-3 | If English is not the patient's primary language, what is the patient's primary language? | |||
| Indent Indent Indent54588-9 | Interpreter needed | |||
| Indent Indent52556-8 | Current Payment Source (s) | 1..13 | ||
| Indent Indent52721-8 | Other (specify) | |||
| Indent52536-0 | Admission Information | |||
| Indent Indent52537-8 | Pre-admission Service Use | |||
| Indent Indent Indent52722-6 | Admitted From. Immediately preceding this admission, where was the patient? | |||
| Indent Indent Indent52723-4 | Other (specify) | |||
| Indent Indent Indent52724-2 | If admitted from a medical setting, what was the primary diagnosis being treated in the previous setting? | 0..4 | ||
| Indent Indent Indent52725-9 | In the last 2 months, what medical services other than those identified in A1. has the patient received? | 1..9 | ||
| Indent Indent Indent70129-2 | Within this acute care hospital stay, on what other units has the patient been treated prior to coming to this unit? | |||
| Indent Indent52538-6 | Patient History Prior to this Current Illness, Exacerbation, or Injury | |||
| Indent Indent Indent52726-7 | Prior to this recent illness, where did the patient live? | |||
| Indent Indent Indent52539-4 | If the patient lived in the community prior to this illness, provide the patient's zip code (if the patient 's residence was in U.S.). | |||
| Indent Indent Indent52727-5 | Lives outside U.S. | |||
| Indent Indent Indent52540-2 | ZIP Code unknown | |||
| Indent Indent Indent52541-0 | If the patient lived in the community prior to this illness, what help was used? | 0..4 | ||
| Indent Indent Indent52542-8 | If the patient lived in the community prior to this illness, who did the patient live with? | 0..4 | ||
| Indent Indent Indent52543-6 | If the patient lived in the community prior to this current illness, exacerbation, or injury, are there any structural barriers in the patient's prior residence that could interfere with the patient's discharge? | 0..7 | ||
| Indent Indent Indent52544-4 | Other (specify) | |||
| Indent Indent Indent52449-6 | Prior Functioning. Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury. | |||
| Indent Indent Indent Indent52545-1 | Self Care: Did the patient need help bathing, dressing, using the toilet, or eating? | |||
| Indent Indent Indent Indent52546-9 | Indoor Mobility (Ambulation): Did the patient need assistance with walking from room to room (with or without devices such as cane, crutch, or walker)? | |||
| Indent Indent Indent Indent52547-7 | Stairs (Ambulation): Did the patient need assistance with internal or external stairs (with or without devices such as cane, crutch, or walker)? | |||
| Indent Indent Indent Indent52548-5 | Indoor Mobility (Wheelchair): Did the patient need assistance with moving from room to room using a wheelchair, scooter, or other wheeled mobility device? | |||
| Indent Indent Indent Indent52549-3 | Functional Cognition: Did the patient need help planning regular tasks, such as shopping or remembering to take medication? | |||
| Indent Indent Indent52550-1 | Mobility devices and aids used prior to current illness, exacerbation, or injury [CARE] | 1..9 | ||
| Indent Indent Indent52551-9 | Other (specify) | |||
| Indent Indent Indent52552-7 | Falls in the past year | |||
| Indent52450-4 | Current Medical Information | |||
| Indent Indent52464-5 | Primary and Other Diagnoses, Comorbidities, and Complications | |||
| Indent Indent Indent18630-4 | Primary Diagnosis at Assessment | |||
| Indent Indent52465-2 | Other Diagnoses, Comorbidities, and Complications | |||
| Indent Indent Indent29308-4 | Diagnosis | 0..* | ||
| Indent Indent52466-0 | Major Procedures (Diagnostic, Surgical, and Therapeutic Interventions) | |||
| Indent Indent Indent52558-4 | Did the patient have one or more major procedures (e.g., G-tube placement, EEG, abdominal, cat scans; do not include x-rays, EKGs, ultrasounds) during this admission? | |||
| Indent Indent Indent52467-8 | Procedure [CARE] | |||
| Indent Indent Indent Indent29300-1 | Procedure type | |||
| Indent Indent Indent Indent52560-0 | Procedure.left [CARE] | 0..* | ||
| Indent Indent Indent Indent52561-8 | Procedure.right [CARE] | 0..* | ||
| Indent Indent Indent Indent52562-6 | Procedure.side not applicable [CARE] | 0..* | ||
| Indent Indent52468-6 | Which of the following treatments did the patient receive during the 2-day assessment period? | |||
| Indent Indent Indent52803-4 | Major treatments discharged with panel | |||
| Indent Indent Indent Indent52804-2 | Major treatments discharged with [CARE] | 1..30 | ||
| Indent Indent Indent Indent52565-9 | Specify reason for continuous monitoring: | |||
| Indent Indent Indent Indent52566-7 | Specify most intensive frequency of suctioning during stay: Every____ hours | |||
| Indent Indent Indent Indent55613-4 | If patient is completely independent of the ventilator, specify the number of days it took to wean patient: | d | ||
| Indent Indent Indent Indent52567-5 | Specify reason for 24-hour supervision | |||
| Indent Indent Indent Indent52568-3 | Specify | |||
| Indent Indent Indent52470-2 | Major treatments used at any time during stay panel | |||
| Indent Indent Indent Indent52569-1 | Major treatments used at any time during stay [CARE] | |||
| Indent Indent Indent Indent52565-9 | Specify reason for continuous monitoring: | |||
| Indent Indent Indent Indent52566-7 | Specify most intensive frequency of suctioning during stay: Every____ hours | |||
| Indent Indent Indent Indent55613-4 | If patient is completely independent of the ventilator, specify the number of days it took to wean patient: | d | ||
| Indent Indent Indent Indent52567-5 | Specify reason for 24-hour supervision | |||
| Indent Indent Indent Indent52568-3 | Specify | |||
| Indent Indent52471-0 | Medications (Optional) | |||
| Indent Indent Indent52418-1 | Medication Name | |||
| Indent Indent Indent52809-1 | Dose form Current medication | |||
| Indent Indent Indent18609-8 | Current medication, Route | |||
| Indent Indent Indent52810-9 | Current medication, Frequency | |||
| Indent Indent Indent52796-0 | Planned Stop Date (if applicable) | |||
| Indent Indent52472-8 | Allergies and Adverse Drug Reactions | |||
| Indent Indent Indent52571-7 | Does patient have allergies or any known adverse drug reactions? | |||
| Indent Indent Indent52473-6 | Allergies/Causes of Reaction | 0..* | ||
| Indent Indent Indent31044-1 | Patient Reaction | 0..* | ||
| Indent Indent52474-4 | Skin integrity panel | |||
| Indent Indent Indent69349-9 | Presence of pressure ulcers | |||
| Indent Indent Indent Indent52573-3 | Is this patient at risk of developing pressure ulcers? | |||
| Indent Indent Indent Indent52574-1 | Does this patient have one or more unhealed pressure ulcer(s) at stage 2 or higher? | |||
| Indent Indent Indent Indent52476-9 | IF THE PATIENT HAS ONE OR MORE STAGE 2-4 PRESSURE ULCERS, indicate the number of unhealed pressure ulcers at each stage | |||
| Indent Indent Indent Indent Indent52575-8 | Number of pressure ulcers at assessment - stage 2 [CARE] | |||
| Indent Indent Indent Indent Indent52576-6 | Number of pressure ulcers at assessment - stage 3 [CARE] | |||
| Indent Indent Indent Indent Indent52577-4 | Number of pressure ulcers at assessment - stage 4 [CARE] | |||
| Indent Indent Indent Indent Indent52578-2 | Number of pressure ulcers at assessment - unstageable [CARE] | |||
| Indent Indent Indent Indent Indent52579-0 | Number of pressure ulcers onset during this service - stage 2 [CARE] | |||
| Indent Indent Indent Indent Indent52580-8 | Number of pressure ulcers onset during this service - stage 3 [CARE] | |||
| Indent Indent Indent Indent Indent52581-6 | Number of pressure ulcers onset during this service - stage 4 [CARE] | |||
| Indent Indent Indent Indent Indent52582-4 | Number of pressure ulcers onset during this service - unstageable [CARE] | |||
| Indent Indent Indent Indent Indent52583-2 | Number of unhealed stage 2 ulcers known to be present for more than 1 month [CARE] | {#} | ||
| Indent Indent Indent52477-7 | If any pressure ulcer is stage 3 or 4 (or if eschar is present), please record the most recent measurements for the LARGEST ulcer (or eschar): | |||
| Indent Indent Indent Indent52728-3 | Longest length in any direction | cm | ||
| Indent Indent Indent Indent52729-1 | Pressure Ulcer Width: | cm | ||
| Indent Indent Indent Indent52584-0 | Date of measurement | |||
| Indent Indent Indent52730-9 | Indicate if any unhealed stage 3 or stage 4 pressure ulcer(s) has undermining and/or tunneling (sinus tract) present. | |||
| Indent Indent Indent52585-7 | Major wound (excluding pressure ulcers). Does the patient have one or more major wound(s) that require ongoing care because of draining, infection, or delayed healing? | |||
| Indent Indent Indent52478-5 | Number of Major Wounds | |||
| Indent Indent Indent Indent52586-5 | Delayed healing of surgical wound # [CARE] | {#} | ||
| Indent Indent Indent Indent52587-3 | Trauma-related wound # | {#} | ||
| Indent Indent Indent Indent52588-1 | Diabetic foot ulcer(s) # | {#} | ||
| Indent Indent Indent Indent52589-9 | Vascular ulcer (arterial or venous including diabetic ulcers not located on the foot) # [CARE] | {#} | ||
| Indent Indent Indent Indent52590-7 | Other | {#} | ||
| Indent Indent Indent Indent52591-5 | Please specify: | |||
| Indent Indent Indent52592-3 | Turning surfaces not intact [CARE] | 1..5 | ||
| Indent Indent52479-3 | Physiologic Factors | |||
| Indent Indent Indent52480-1 | Anthropometric Measures | |||
| Indent Indent Indent Indent3137-7 | Height (inches) OR | [in_us];cm;m | ||
| Indent Indent Indent Indent8301-4 | Height (cm) | [in_us];cm;m | ||
| Indent Indent Indent Indent3141-9 | Weight (pounds) OR | [lb_av];kg | ||
| Indent Indent Indent Indent8335-2 | Weight (kg) | [lb_av];kg | ||
| Indent Indent Indent52481-9 | Vital Signs | |||
| Indent Indent Indent Indent8310-5 | Temperature (deg F) OR | Cel | ||
| Indent Indent Indent Indent8867-4 | Heart Rate (beats/min) | {beats}/min;{counts/min} | ||
| Indent Indent Indent Indent9279-1 | Respiratory Rate (breaths/min) | {breaths}/min;{counts/min} | ||
| Indent Indent Indent Indent8480-6 | Systolic Blood Pressure (mm/Hg) | mm[Hg] | ||
| Indent Indent Indent Indent8462-4 | Diastolic Blood Pressure (mm/Hg) | mm[Hg] | ||
| Indent Indent Indent69344-0 | Laboratory | |||
| Indent Indent Indent Indent718-7 | Hemogloblin (gm/dL) | g/dL | ||
| Indent Indent Indent Indent20570-8 | Hematocrit (%) | % | ||
| Indent Indent Indent Indent26464-8 | WBC (K/mm3) | 10*3/uL | ||
| Indent Indent Indent Indent4548-4 | HbA1c (%) | % | ||
| Indent Indent Indent52483-5 | Other | |||
| Indent Indent Indent Indent10230-1 | Left Ventricular Ejection Fraction (%) | % | ||
| Indent Indent Indent52484-3 | Arterial Blood Gases (ABGs) | |||
| Indent Indent Indent Indent52593-1 | Please specify source and amount of supplemental O2 | |||
| Indent Indent Indent Indent2744-1 | pH of Arterial blood | [pH] | ||
| Indent Indent Indent Indent2019-8 | PaCO2 (mm/Hg) | mm[Hg] | ||
| Indent Indent Indent Indent1960-4 | HCO3 (mEq/L) | mmol/L | ||
| Indent Indent Indent Indent2703-7 | PaO2 (mm/Hg) | mm[Hg] | ||
| Indent Indent Indent Indent2708-6 | SaO2 (%) | % | ||
| Indent Indent Indent Indent1925-7 | B.E. (base excess) (mEq/dL) | mmol/L | ||
| Indent Indent Indent52485-0 | Pulmonary Function Tests | |||
| Indent Indent Indent Indent19870-5 | FVC (liters) | L | ||
| Indent Indent Indent Indent19926-5 | FEV1% or FEV1/FVC (%) | % | ||
| Indent Indent Indent Indent20150-9 | FEV1 (liters) | L | ||
| Indent Indent Indent Indent33452-4 | PEF (liters per minute) | L/min | ||
| Indent Indent Indent Indent20159-0 | MVV (liters per minute) | L/min | ||
| Indent Indent Indent Indent19862-2 | TLC (liters) | mL;L | ||
| Indent Indent Indent Indent19843-2 | FRC (liters) | L | ||
| Indent Indent Indent Indent20146-7 | RV (liters) | L | ||
| Indent Indent Indent Indent19924-0 | ERV (liters) | L | ||
| Indent Indent69339-0 | Influenza vaccine during assessment period [CMS Assessment] | |||
| Indent Indent Indent55019-4 | Influenza virus vaccine received in facility during assessment period [CMS Assessment] | |||
| Indent Indent Indent58131-4 | Date of influenza vaccination | {mm/dd/yyyy} | ||
| Indent Indent Indent55020-2 | If influenza vaccine not received, state reason: | |||
| Indent Indent55021-0 | Pneumococcal vaccine | |||
| Indent Indent Indent55022-8 | Is the resident's Pneumococcal Vaccination up to date? | |||
| Indent Indent Indent45956-0 | Reason pneumococcal vaccine not received during assessment period [CMS Assessment] | |||
| Indent69375-4 | Cognitive status, mood, pain | |||
| Indent Indent55762-9 | Comatose | |||
| Indent Indent Indent45482-7 | Persistent vegetative state/no discrenible consciousness at the time of admission | |||
| Indent Indent69350-7 | Temporal orientation &or mental status | |||
| Indent Indent Indent52489-2 | Interview Attempted | |||
| Indent Indent Indent Indent52594-9 | Interview attempted | |||
| Indent Indent Indent Indent52595-6 | Indicate reason that the interview was not attempted | |||
| Indent Indent Indent55759-5 | Temporal Orientation - CARE Acute Care | |||
| Indent Indent Indent Indent52732-5 | Temporal orientation - current year [BIMS] | |||
| Indent Indent Indent Indent52733-3 | Temporal orientation - current month [BIMS] | |||
| Indent Indent52494-2 | Observational Assessment of Cognitive Status | |||
| Indent Indent Indent52596-4 | Memory/recall ability | 1..6 | ||
| Indent Indent Indent52597-2 | Specify reason | |||
| Indent Indent52495-9 | Confusion Assessment Method (CAM) | |||
| Indent Indent Indent52738-2 | Inattention | |||
| Indent Indent Indent52739-0 | Disorganized thinking | |||
| Indent Indent Indent52740-8 | Altered level of consciousness/alertness | |||
| Indent Indent Indent52741-6 | Psychomotor retardation | |||
| Indent Indent52500-6 | Pain | |||
| Indent Indent Indent52603-8 | Pain Interview Attempted? | |||
| Indent Indent Indent52604-6 | Pain Presence. Ask patient: "Have you had pain or hurting at any time during the last 2 days?" | |||
| Indent Indent Indent52742-4 | 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." | |||
| Indent Indent Indent52605-3 | Pain Effect on Sleep. Ask patient: "During the past 2 days, has pain made it hard for you to sleep?" | |||
| Indent Indent Indent52606-1 | Pain Effect on Activities. Ask patient: "During the past 2 days, have you limited your activities because of pain?" | |||
| Indent Indent Indent52607-9 | Pain Observational Assessment. If the patient could not be interviewed for pain assessment, check all indicators of of pain or possible pain | 0..5 | ||
| Indent52502-2 | Impairments | |||
| Indent Indent52503-0 | Bladder and Bowel Management - Use of Device(s) and Incontinence | |||
| Indent Indent Indent52608-7 | Does the patient have any impairments with bladder or bowel management (e.g., use of a device or incontinence)? | |||
| Indent Indent Indent52609-5 | Bladder - Does this patient use an external or indwelling device or require intermittent catheterization? | |||
| Indent Indent Indent52610-3 | Bowel - Does this patient use an external or indwelling device or require intermittent catheterization? | |||
| Indent Indent Indent52611-1 | Bladder - Indicate the frequency of incontinence. | |||
| Indent Indent Indent52612-9 | Bowel - Indicate the frequency of incontinence. | |||
| Indent Indent Indent52613-7 | Bladder - Does the patient need assistance to manage equipment or devices related to bladder or bowel care (e.g., urinal, bedpan, indwelling catheter, intermittent catheterization, ostomy, incontinence pads/undergarments)? | |||
| Indent Indent Indent52614-5 | Bowel - Does the patient need assistance to manage equipment or devices related to bladder or bowel care (e.g., urinal, bedpan, indwelling catheter, intermittent catheterization, ostomy, incontinence pads/undergarments)? | |||
| Indent Indent Indent52615-2 | Bladder - If the patient is incontinent or has an indwelling device, was the patient incontinent (excluding stress incontinence) immediately prior to the current illness, exacerbation, or injury? | |||
| Indent Indent Indent52616-0 | Bowel - If the patient is incontinent or has an indwelling device, was the patient incontinent (excluding stress incontinence) immediately prior to the current illness, exacerbation, or injury? | |||
| Indent Indent52504-8 | Swallowing | |||
| Indent Indent Indent52618-6 | Does the patient have any signs or symptoms of a possible swallowing disorder? | 1..7 | ||
| Indent Indent Indent52619-4 | Other (specify) | |||
| Indent Indent Indent52620-2 | Describe the patient's usual ability with swallowing. | |||
| Indent Indent52505-5 | Hearing, Vision, and Communication | |||
| Indent Indent Indent52621-0 | Does the patient have any impairments with hearing, vision, or communication? | |||
| Indent Indent Indent52622-8 | Understanding verbal content - excluding language barriers [CARE] | |||
| Indent Indent Indent52623-6 | Expression of ideas and wants [CARE] | |||
| Indent Indent Indent52624-4 | Ability to see in adequate light (with glasses or other visual appliances) | |||
| Indent Indent Indent52625-1 | Ability to hear (with hearing aid or hearing appliance, if normally used) | |||
| Indent Indent Indent52677-2 | Medication management-oral medications during two day assessment period [CARE] | |||
| Indent Indent Indent52679-8 | Medication management-injectable medications during two day assessment period [CARE] | |||
| Indent Indent52506-3 | Weight-bearing | |||
| Indent Indent Indent52626-9 | Does the patient have any clinician-ordered weight-bearing or limb/spinal loading restrictions( including upper body lift, push, pull, or carry restrictions)? | |||
| Indent Indent Indent52507-1 | Weight-bearing restrictions panel | |||
| Indent Indent Indent Indent52627-7 | Upper Extremity - Left | |||
| Indent Indent Indent Indent52628-5 | Upper Extremity - Right | |||
| Indent Indent Indent Indent52629-3 | Lower Extremity - Left | |||
| Indent Indent Indent Indent52630-1 | Lower Extremity - Right | |||
| Indent Indent52508-9 | Grip strength | |||
| Indent Indent Indent52631-9 | Does the patient have any impairments with grip strength (e.g. reduced/limited or absent)? | |||
| Indent Indent Indent52509-7 | Grip strength panel | |||
| Indent Indent Indent Indent52632-7 | Left Hand | |||
| Indent Indent Indent Indent52633-5 | Right Hand | |||
| Indent Indent52510-5 | Respiratory status | |||
| Indent Indent Indent52634-3 | Does the patient have any impairments with respiratory status? | |||
| Indent Indent Indent52635-0 | Respiratory status with supplemental oxygen | |||
| Indent Indent Indent52636-8 | Respiratory status without supplemental oxygen | |||
| Indent Indent52511-3 | Endurance | |||
| Indent Indent Indent52637-6 | Does the patient have any impairments with endurance? | |||
| Indent Indent Indent52638-4 | Mobility Endurance: Was the patient able to walk or wheel 50 feet (15 meters)? | |||
| Indent Indent Indent52639-2 | Sitting Endurance: Was the patient able to tolerate sitting for 15 minutes? | |||
| Indent Indent52512-1 | Mobility Devices and Aids Needed | |||
| Indent Indent Indent52640-0 | Indicate all mobility devices and aids needed at time of assessment. | 1..8 | ||
| Indent Indent Indent52641-8 | Other (specify) | |||
| Indent52513-9 | Functional Status - Usual Performance | |||
| Indent Indent52514-7 | Core Self Care | |||
| Indent Indent Indent52642-6 | Eating | |||
| Indent Indent Indent52643-4 | Tube feeding | |||
| Indent Indent Indent52644-2 | Oral hygiene | |||
| Indent Indent Indent52645-9 | Toilet hygiene | |||
| Indent Indent Indent52646-7 | Upper body dressing | |||
| Indent Indent Indent52647-5 | Lower body dressing | |||
| Indent Indent52515-4 | Core Functional Mobility | |||
| Indent Indent Indent52648-3 | Lying to Sitting on Side of Bed | |||
| Indent Indent Indent52649-1 | Sit to Stand | |||
| Indent Indent Indent52650-9 | Chair/Bed-to-Chair Transfer | |||
| Indent Indent Indent52651-7 | Toilet Transfer | |||
| Indent Indent Indent52516-2 | Mode of Mobility - All Patients | |||
| Indent Indent Indent Indent52652-5 | Does this patient primarily use a wheelchair for mobility? | |||
| Indent Indent Indent Indent52517-0 | Select the longest distance the patient walks and code his/her level of independence (Level 1-6) on that distance. Observe performance. (Select only one.) | |||
| Indent Indent Indent Indent Indent52653-3 | Walk 150 ft (45 m) | |||
| Indent Indent Indent Indent Indent52654-1 | Walk 100 ft (30 m) | |||
| Indent Indent Indent Indent Indent52655-8 | Walk 50 ft (15m) | |||
| Indent Indent Indent Indent Indent52656-6 | Walk in Room Once Standing | |||
| Indent Indent Indent Indent52518-8 | Select the longest distance the patient wheels and code his/her level of independence (Level 1-6). Observe performance. (Select only one.) | |||
| Indent Indent Indent Indent Indent52657-4 | Wheel 150 ft (45 m) | |||
| Indent Indent Indent Indent Indent52658-2 | Wheel 100 ft (30 m) | |||
| Indent Indent Indent Indent Indent52659-0 | Wheel 50 ft (15 m) | |||
| Indent Indent Indent Indent Indent52660-8 | Wheel in Room Once Seated | |||
| Indent Indent52519-6 | Supplemental Functional Ability | |||
| Indent Indent Indent54066-6 | Following discharge, is it anticipated that the patient will need post-acute care to improve their functional ability or other types of personal assistance? | |||
| Indent Indent Indent52661-6 | Wash Upper Body | |||
| Indent Indent Indent52662-4 | Shower/bathe self | |||
| Indent Indent Indent52663-2 | Roll left and right | |||
| Indent Indent Indent52664-0 | Sit to lying | |||
| Indent Indent Indent52665-7 | Picking up object | |||
| Indent Indent Indent52666-5 | Putting on/taking off footwear during 2 day assessment period [CARE] | |||
| Indent Indent Indent52520-4 | Mode of Mobility - PAC Patients | |||
| Indent Indent Indent Indent52652-5 | Does this patient primarily use a wheelchair for mobility? | |||
| Indent Indent Indent Indent52667-3 | 1 step (curb) | |||
| Indent Indent Indent Indent52668-1 | Walk 50 feet with two turns | |||
| Indent Indent Indent Indent52669-9 | 12 steps-interior | |||
| Indent Indent Indent Indent52670-7 | Four steps-exterior | |||
| Indent Indent Indent Indent52671-5 | Walking 10 feet on uneven surfaces | |||
| Indent Indent Indent Indent52672-3 | Car transfer | |||
| Indent Indent Indent Indent52673-1 | Wheel short ramp | |||
| Indent Indent Indent Indent52674-9 | Wheel long ramp | |||
| Indent Indent Indent Indent52675-6 | Telephone answering | |||
| Indent Indent Indent Indent52676-4 | Telephone-placing call | |||
| Indent Indent Indent Indent52677-2 | Medication management-oral medications | |||
| Indent Indent Indent Indent52678-0 | Medication management-inhalant/mist | |||
| Indent Indent Indent Indent52679-8 | Medication management-injectable medications | |||
| Indent Indent Indent Indent52680-6 | Make light meal | |||
| Indent Indent Indent Indent52681-4 | Wipe down surface | |||
| Indent Indent Indent Indent52682-2 | Light shopping | |||
| Indent Indent Indent Indent52683-0 | Laundry | |||
| Indent Indent Indent Indent52684-8 | Use public transportation | |||
| Indent81957-3 | Overall Plan of Care/Advance Care Directives panel | |||
| Indent Indent52522-0 | Overall Plan of Care/Advance Care Directives | |||
| Indent Indent Indent52685-5 | Have the patient (or representative) and the care team (or physician) documented agreed-upon care goals and expected dates of completion or re-evaluation? | |||
| Indent Indent Indent52686-3 | Which description best fits the patient's overall status? | |||
| Indent Indent Indent52687-1 | In anticipation of serious clinical complications, has the patient made care decisions which are documented in the medical record? | 1..2 | ||
| Indent52523-8 | Discharge Status | |||
| Indent Indent52524-6 | Discharge Information | |||
| Indent Indent Indent52525-3 | Discharge date | {mm/dd/yyyy} | ||
| Indent Indent Indent52526-1 | Attending Physician (at this location) | |||
| Indent Indent Indent52688-9 | Discharge Location. Where will the patient be discharged to? | |||
| Indent Indent Indent52689-7 | Frequency of Assistance at Discharge (or admission for HH). How often will the patient require assistance (physical care or supervision) from a caregiver(s) or provider(s)? | |||
| Indent Indent Indent52690-5 | Caregiver(s) Availability. Was the discharge destination decision influenced by the availability of a family member or friend to provide assistance? | |||
| Indent Indent Indent52691-3 | Willing Caregiver(s). Does the patient have one or more willing caregiver(s)? | |||
| Indent Indent Indent52692-1 | Types of Caregiver(s). What is the relationship of the caregiver(s) to the patient? | 1..4 | ||
| Indent Indent52527-9 | Residential Information | |||
| Indent Indent Indent52693-9 | Patient Lives With at Discharge (or admission for HH). Upon discharge (admission), who will the patient live with? | 1..4 | ||
| Indent Indent52528-7 | Support Needs/Caregiver Assistance | |||
| Indent Indent Indent52694-7 | ADL assistance (e.g., transfer/ambulation, bathing, dressing, toileting, eating/feeding) | |||
| Indent Indent Indent52695-4 | IADL assistance (e.g., meals, housekeeping, laundry, telephone, shopping, finances) | |||
| Indent Indent Indent52696-2 | Medication administration (e.g., oral, inhaled, or injectable) | |||
| Indent Indent Indent52697-0 | Medical procedures/treatments (e.g., changing wound dressing) | |||
| Indent Indent Indent52698-8 | Management of equipment (includes oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment, or supplies) | |||
| Indent Indent Indent52699-6 | Supervision and safety | |||
| Indent Indent Indent52700-2 | Advocacy or facilitation of patient's participation in appropriate medical care (includes transportation to or from appointments) | |||
| Indent Indent Indent52701-0 | None of the above or non-residential setting | |||
| Indent Indent52529-5 | Discharge Care Options | |||
| Indent Indent Indent52702-8 | Home Health Care (HHA) | |||
| Indent Indent Indent52703-6 | Skilled Nursing Facility (SNF/TCU) | |||
| Indent Indent Indent52704-4 | Inpatient Rehabilitation Hospital or Unit (IRF) | |||
| Indent Indent Indent52705-1 | Long-Term Care Hospital (LTCH) | |||
| Indent Indent Indent52706-9 | Psychiatric Hospital or Unit | |||
| Indent Indent Indent52707-7 | Outpatient Services | |||
| Indent Indent Indent52708-5 | Acute Hospital Admission | |||
| Indent Indent Indent52709-3 | Hospice | |||
| Indent Indent Indent52710-1 | Long-term Personal Care Services | |||
| Indent Indent Indent52711-9 | Long-Term Nursing Facility | |||
| Indent Indent Indent52712-7 | Other (specify) | |||
| Indent Indent Indent55760-3 | Other service considered appropriate.other specified [CARE] | |||
| Indent Indent Indent55761-1 | No services needed after discharge [CARE] | |||
| Indent Indent52530-3 | Discharge Location Information | |||
| Indent Indent Indent52713-5 | Is the patient being discharged with referral for additional services? | |||
| Indent Indent Indent52458-7 | Name Provider | |||
| Indent Indent Indent52714-3 | Provider type [CARE] | |||
| Indent Indent Indent52715-0 | Other (specify) | |||
| Indent Indent Indent52531-1 | Provider city | |||
| Indent Indent Indent52532-9 | Provider state | |||
| Indent Indent Indent45952-9 | National provider ID | |||
| Indent Indent Indent52716-8 | Was the patient's discharge delayed for at least 24 hours? | |||
| Indent Indent Indent52717-6 | Reason for discharge delay | |||
| Indent Indent Indent52718-4 | Other (specify) | |||
| Indent Indent Indent52719-2 | In the situation that the patient or an authorized representative has requested this information not be shared with the next provider, check here: | |||
| Indent52533-7 | Medical Coding Information | |||
| Indent Indent52534-5 | Principal Diagnosis | |||
| Indent Indent Indent46584-9 | ICD-9 CM for Principal Diagnosis at Assessment | |||
| Indent Indent Indent86255-7 | Primary diagnosis ICD code | |||
| Indent Indent Indent18630-4 | Primary Diagnosis at Assessment | |||
| Indent Indent Indent29308-4 | Diagnosis | 0..* | ||
| Indent Indent52807-5 | Other Diagnoses, Comorbidities, and Complications | |||
| Indent Indent Indent52797-8 | Diagnosis ICD code [Identifier] | 0..* | ||
| Indent Indent Indent29308-4 | Diagnosis | 0..* | ||
| Indent Indent52808-3 | Major Procedures (Diagnostic, Surgical, and Therapeutic Interventions) | |||
| Indent Indent Indent52558-4 | Did the patient have one or more major procedures (e.g., G-tube placement, EEG, abdominal, cat scans; do not include x-rays, EKGs, ultrasounds) during this admission? | |||
| Indent Indent Indent69967-8 | Procedure ICD code | |||
| Indent Indent Indent29300-1 | Procedure | 0..* | ||
| Indent52535-2 | Other useful information | |||
| Indent Indent52720-0 | Is there other useful information about this patient that you want to add? |
Fully-Specified Name
- Component
- Continuity assessment record and evaluation tool - Acute care
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- -
- Method
- CARE
Basic Attributes
- Class
- PANEL.SURVEY.CARE
- Type
- Surveys
- First Released
- Version 2.27
- Last Updated
- Version 2.77
- 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=52743-2 - Questionnaire definition
- https:
//fhir.loinc.org/Questionnaire/?url=http: //loinc.org/q/52743-2
LOINC Copyright
Copyright © 2024 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright