Version 2.78

52452-0 Administrative Items

Observation ID in Form

I

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Administrative Items
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.67
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52453-8 Assessment Type

Observation ID in Form

A

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Assessment Type
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.73
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

70160-7 Reason for assessment

Observation ID in Form

A1

Fully-Specified Name

Component
Reason for assessment - acute
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.40
Last Updated
Version 2.64

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

54593-9 Assessment reference date - observation end date during assessment period [CMS Assessment]

Term Description

The end-point of the assessment period for the CMS assessment instrument.
Source: Regenstrief LOINC

Observation ID in Form

A3

Fully-Specified Name

Component
Assessment reference date - observation end date
Property
Date
Time
RptPeriod
System
^Patient
Scale
Qn
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Release 2.74: PanelType: made subset organizer - contains children; CLASS: Class must include panel because made subset organizer - contains children; Previous Releases: Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee. Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
45981-8 Deprecated MDS full assessment form - version 2.0
46102-0 Deprecated MDS quarterly assessment form - version 2.0
46103-8 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III
46104-6 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III 1997 update
86870-3 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
86874-5 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA start of therapy (NS/SS) item set [CMS Assessment]
86875-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed tracking (NT/ST) item set [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86877-8 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88279-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88280-3 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88281-1 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88286-0 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88952-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88953-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88948-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87506-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 4.00 during assessment period [CMS Assessment]
93219-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.00 during assessment period [CMS Assessment]
103948-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 during assessment period [CMS Assessment]
93220-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.00 during assessment period [CMS Assessment]
103947-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90479-7 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home and Swing bed tracking (NT and ST) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90481-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Optional State Assessment (OSA) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101111-3 MDS v3.0 - RAI v1.18.11 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
101108-9 MDS v3.0 - RAI v1.18.11 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
104608-5 MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
105008-7 MDS v3.0 - RAI v1.19.1 - Nursing home and Swing bed tracking (NT ST) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
62863-6 PhenX domain - Infectious diseases and immunity

Example Units

Unit Source
{mm/dd/yyyy} Example UCUM Units

52457-9 Provider Information

Observation ID in Form

B

Fully-Specified Name

Component
Provider Information
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

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52458-7 Name Provider

Observation ID in Form

B1

Fully-Specified Name

Component
Name
Property
Pn
Time
Pt
System
Provider
Scale
Nom
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.27

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
62400-7 PhenX - arrhythmia protocol 041101
97029-3 Spine Tango surgery follow-up 2017 Spine Tango

69326-7 Patient information

Observation ID in Form

C

Fully-Specified Name

Component
Patient information - acute
Property
-
Time
Pt
System
^Patient
Scale
-
Method
CARE

Basic Attributes

Class
PANEL.SURVEY.OASIS
Type
Surveys
First Released
Version 2.38
Last Updated
Version 2.67
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

45392-8 Patient's First Name

Observation ID in Form

C1

Fully-Specified Name

Component
First name
Property
Pn
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Patient First name

Basic Attributes

Class
ADMIN.PATIENT
Type
Clinical
First Released
Version 2.17
Last Updated
Version 2.70
Change Reason
Release 2.70: LONG_COMMON_NAME: Added "Patient" to distinguish from the general "First name" term that does not distinguish between various subjects (patient, provider, contact, etc.).; SHORTNAME: Added "Patient" to distinguish from the general "First name" term that does not distinguish between various subjects (patient, provider, contact, etc.).;
Order vs. Observation
Both

HL7® Attributes

HL7® Field ID
PID-5.2

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
45963-6 Deprecated MDS basic assessment tracking form - version 2.0
45981-8 Deprecated MDS full assessment form - version 2.0
46102-0 Deprecated MDS quarterly assessment form - version 2.0
46103-8 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III
46104-6 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III 1997 update
86870-3 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
86874-5 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA start of therapy (NS/SS) item set [CMS Assessment]
86875-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed tracking (NT/ST) item set [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86877-8 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88279-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88280-3 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88281-1 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88286-0 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88952-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88953-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88948-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
46462-8 Deprecated Outcome and assessment information set (OASIS) form - version B1
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57190-1 Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care
85907-4 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
68359-9 End Stage Renal Disease (ESRD) Death Notification - OMB CMS form 2746
67868-0 End Stage Renal Disease (ESRD) Medical Evidence Report, Medicare Entitlement AndOr Patient Registration - OMB CMS form 2728
70297-7 ESRD patient information panel
47245-6 HIV treatment form Document
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87506-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 4.00 during assessment period [CMS Assessment]
93219-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.00 during assessment period [CMS Assessment]
103948-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 during assessment period [CMS Assessment]
93220-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.00 during assessment period [CMS Assessment]
103947-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90479-7 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home and Swing bed tracking (NT and ST) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90481-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Optional State Assessment (OSA) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101111-3 MDS v3.0 - RAI v1.18.11 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
101108-9 MDS v3.0 - RAI v1.18.11 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
104608-5 MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
105008-7 MDS v3.0 - RAI v1.19.1 - Nursing home and Swing bed tracking (NT ST) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
46611-0 Mental residual functional capacity (RFC) assessment form
80399-9 Occupational exposure information panel
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
79191-3 Patient demographics panel
62812-3 PhenX domain - Physical activity and physical fitness
46637-5 Residual physical functional capacity (RFC) assessment form [RFC]
55140-8 Vaccine Adverse Event Reporting System (VAERS) panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Nombre de pila:Pn:Punto temporal:^ Paciente:Nominal:
es-ES Spanish (Spain) Nombre:Pn:Punto temporal:^paciente:Nom:
it-IT Italian (Italy) Primo nome:Pn:Pt:^Paziente:Nom:
Synonyms: Amministrativo Nome di persona Paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) voornaam:persoonsnaam:moment:^patiënt:nominaal:
tr-TR Turkish (Turkey) Ad:KişiAdı:Zmlı:^Hasta:Snf:
Synonyms: İsim
zh-CN Chinese (China) 名字:人员姓名:时间点:^患者:名义型:
Synonyms: 人名 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 名字(不包括姓氏);教名;名;西方人名的第一个字 姓名;名字;名 时刻;随机;随意;瞬间 行政;管理;施行;执行;经营 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员)

52461-1 Patient's Middle Initial or Name

Observation ID in Form

C2

Fully-Specified Name

Component
Middle name
Property
Pn
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Patient middle name

Basic Attributes

Class
ADMIN.PATIENT
Type
Clinical
First Released
Version 2.26
Last Updated
Version 2.70
Change Reason
Release 2.70: LONG_COMMON_NAME: Added "Patient" to distinguish from the general "Middle name" term that does not distinguish between various subjects (patient, provider, contact, etc.).;

HL7® Attributes

HL7® Field ID
PID-5.3

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
55140-8 Vaccine Adverse Event Reporting System (VAERS) panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Segundo nombre:Pn:Punto temporal:^ Paciente:Nominal:
it-IT Italian (Italy) Secondo nome:Pn:Pt:^Paziente:Nom:
Synonyms: Amministrativo Nome di persona Paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 中间名:人员姓名:时间点:^患者:名义型:
Synonyms: 中名;教名;中間名字;中间名字;名和姓之间的名字 人名 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 姓名;名字;名 时刻;随机;随意;瞬间 行政;管理;施行;执行;经营 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员)

45394-4 Patient's Last Name

Observation ID in Form

C3

Fully-Specified Name

Component
Last name
Property
Pn
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Patient Last name

Basic Attributes

Class
ADMIN.PATIENT
Type
Clinical
First Released
Version 2.17
Last Updated
Version 2.70
Change Reason
Release 2.70: LONG_COMMON_NAME: Added "Patient" to distinguish from the general "Last name" term that does not distinguish between various subjects (patient, provider, contact, etc.).; SHORTNAME: Added "Patient" to distinguish from the general "Last name" term that does not distinguish between various subjects (patient, provider, contact, etc.).;
Order vs. Observation
Both

HL7® Attributes

HL7® Field ID
PID-5.1

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
45963-6 Deprecated MDS basic assessment tracking form - version 2.0
45981-8 Deprecated MDS full assessment form - version 2.0
46102-0 Deprecated MDS quarterly assessment form - version 2.0
46103-8 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III
46104-6 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III 1997 update
86870-3 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
86874-5 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA start of therapy (NS/SS) item set [CMS Assessment]
86875-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed tracking (NT/ST) item set [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86877-8 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88279-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88280-3 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88281-1 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88286-0 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88952-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88953-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88948-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
46462-8 Deprecated Outcome and assessment information set (OASIS) form - version B1
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57190-1 Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care
85907-4 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
68359-9 End Stage Renal Disease (ESRD) Death Notification - OMB CMS form 2746
67868-0 End Stage Renal Disease (ESRD) Medical Evidence Report, Medicare Entitlement AndOr Patient Registration - OMB CMS form 2728
70297-7 ESRD patient information panel
47245-6 HIV treatment form Document
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87506-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 4.00 during assessment period [CMS Assessment]
93219-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.00 during assessment period [CMS Assessment]
103948-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 during assessment period [CMS Assessment]
93220-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.00 during assessment period [CMS Assessment]
103947-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90479-7 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home and Swing bed tracking (NT and ST) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90481-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Optional State Assessment (OSA) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101111-3 MDS v3.0 - RAI v1.18.11 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
101108-9 MDS v3.0 - RAI v1.18.11 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
104608-5 MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
105008-7 MDS v3.0 - RAI v1.19.1 - Nursing home and Swing bed tracking (NT ST) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
46611-0 Mental residual functional capacity (RFC) assessment form
80399-9 Occupational exposure information panel
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
79191-3 Patient demographics panel
62812-3 PhenX domain - Physical activity and physical fitness
46637-5 Residual physical functional capacity (RFC) assessment form [RFC]
55140-8 Vaccine Adverse Event Reporting System (VAERS) panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Apellido:Pn:Punto temporal:^ Paciente:Nominal:
es-ES Spanish (Spain) Apellido:Pn:Punto temporal:^paciente:Nom:
it-IT Italian (Italy) Cognome:Pn:Pt:^Paziente:Nom:
Synonyms: Amministrativo Nome di persona Paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) achternaam:persoonsnaam:moment:^patiënt:nominaal:
tr-TR Turkish (Turkey) Soyad:KişiAdı:Zmlı:^Hasta:Snf:
zh-CN Chinese (China) 姓氏:人员姓名:时间点:^患者:名义型:
Synonyms: 人名 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 姓 姓名;名字;名 时刻;随机;随意;瞬间 行政;管理;施行;执行;经营 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员)

52462-9 Patient's Nickname (optional)

Observation ID in Form

C4

Fully-Specified Name

Component
Nickname
Property
Pn
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Nickname

Basic Attributes

Class
ADMIN.PATIENT
Type
Clinical
First Released
Version 2.26
Last Updated
Version 2.66
Change Reason
Changed Class from SURVEY.MDS to ADMIN
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
86870-3 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
86874-5 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA start of therapy (NS/SS) item set [CMS Assessment]
86875-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed tracking (NT/ST) item set [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86877-8 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88279-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88280-3 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88281-1 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88286-0 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88952-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88953-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88948-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90479-7 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home and Swing bed tracking (NT and ST) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90481-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Optional State Assessment (OSA) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101111-3 MDS v3.0 - RAI v1.18.11 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
101108-9 MDS v3.0 - RAI v1.18.11 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
104608-5 MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
105008-7 MDS v3.0 - RAI v1.19.1 - Nursing home and Swing bed tracking (NT ST) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Apodo:Pn:Punto temporal:^ Paciente:Nominal:
it-IT Italian (Italy) Nickname:Pn:Pt:^Paziente:Nom:
Synonyms: Amministrativo Nome di persona Paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 昵称:人员姓名:时间点:^患者:名义型:
Synonyms: 人名 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 时刻;随机;随意;瞬间 绰号;诨名;爱称;外号;俗称 行政;管理;施行;执行;经营 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员)

45397-7 Medicare or comparable number

Observation ID in Form

C5

Fully-Specified Name

Component
Medicare or comparable number
Property
ID
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Medicare or comparable #

Basic Attributes

Class
ADMIN.PATIENT.ID
Type
Clinical
First Released
Version 2.17
Last Updated
Version 2.66
Change Reason
Changed CLASS to ADMIN
Order vs. Observation
Both

HL7® Attributes

HL7® Field ID
PID-3

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
84908-3 Cancer pathology panel - Prostate cancer
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
45963-6 Deprecated MDS basic assessment tracking form - version 2.0
86870-3 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
86874-5 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA start of therapy (NS/SS) item set [CMS Assessment]
86875-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed tracking (NT/ST) item set [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86877-8 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88279-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88280-3 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88281-1 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88286-0 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88952-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88953-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88948-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
46462-8 Deprecated Outcome and assessment information set (OASIS) form - version B1
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57190-1 Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care
85907-4 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
68359-9 End Stage Renal Disease (ESRD) Death Notification - OMB CMS form 2746
67868-0 End Stage Renal Disease (ESRD) Medical Evidence Report, Medicare Entitlement AndOr Patient Registration - OMB CMS form 2728
70297-7 ESRD patient information panel
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87506-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 4.00 during assessment period [CMS Assessment]
93219-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.00 during assessment period [CMS Assessment]
103948-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 during assessment period [CMS Assessment]
93220-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.00 during assessment period [CMS Assessment]
103947-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90479-7 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home and Swing bed tracking (NT and ST) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90481-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Optional State Assessment (OSA) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101111-3 MDS v3.0 - RAI v1.18.11 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
101108-9 MDS v3.0 - RAI v1.18.11 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
104608-5 MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
105008-7 MDS v3.0 - RAI v1.19.1 - Nursing home and Swing bed tracking (NT ST) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Medicare o número comparable:ID:Punto temporal:^ Paciente:Nominal:
it-IT Italian (Italy) Medicare o numero equivalente:ID:Pt:^Paziente:Nom:
Synonyms: Amministrativo Assistenza medica o numero equivalente Identificatore Numero di identificazione del paziente paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 医疗保险或类似编号:标识符:时间点:^患者:名义型:
Synonyms: 个数;数目 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗保险或类似(同类、可比)编号;医疗保险或类似号码;Medicare 或类似编号 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 时刻;随机;随意;瞬间 标志 标志符 标识 标识;身份标识符;身份标识 标识符 标识符(Identifier,ID) 皮下 皮下的 皮内 皮内(Intradermal,ID) 皮内的 皮层内 皮层内的 真皮下 真皮下的 真皮内的 行政;管理;施行;执行;经营 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员) 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员).标识号(ID、身份标识符、身份标识) 识别 识别符

45400-9 Patient's Medicaid Number

Observation ID in Form

C6

Fully-Specified Name

Component
Medicaid number
Property
ID
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Medicaid #

Basic Attributes

Class
ADMIN.PATIENT.ID
Type
Clinical
First Released
Version 2.17
Last Updated
Version 2.66
Change Reason
Changed CLASS to ADMIN
Order vs. Observation
Both

HL7® Attributes

HL7® Field ID
PID-3

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
45963-6 Deprecated MDS basic assessment tracking form - version 2.0
86870-3 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
86874-5 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA start of therapy (NS/SS) item set [CMS Assessment]
86875-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed tracking (NT/ST) item set [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86877-8 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88279-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88280-3 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88281-1 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88286-0 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88952-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88953-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88948-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
46462-8 Deprecated Outcome and assessment information set (OASIS) form - version B1
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57190-1 Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care
85907-4 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87506-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 4.00 during assessment period [CMS Assessment]
93219-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.00 during assessment period [CMS Assessment]
103948-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 during assessment period [CMS Assessment]
93220-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.00 during assessment period [CMS Assessment]
103947-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90479-7 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home and Swing bed tracking (NT and ST) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90481-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Optional State Assessment (OSA) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101111-3 MDS v3.0 - RAI v1.18.11 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
101108-9 MDS v3.0 - RAI v1.18.11 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
104608-5 MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
105008-7 MDS v3.0 - RAI v1.19.1 - Nursing home and Swing bed tracking (NT ST) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Número de Medicaid:ID:Punto temporal:^ Paciente:Nominal:
it-IT Italian (Italy) Medicaid, numero:ID:Pt:^Paziente:Nom:
Synonyms: Amministrativo Identificatore Numero di identificazione del paziente Numero Medicaid Paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 医疗补助计划编号:标识符:时间点:^患者:名义型:
Synonyms: Medicaid编号 个数;数目 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 时刻;随机;随意;瞬间 标志 标志符 标识 标识;身份标识符;身份标识 标识符 标识符(Identifier,ID) 皮下 皮下的 皮内 皮内(Intradermal,ID) 皮内的 皮层内 皮层内的 真皮下 真皮下的 真皮内的 行政;管理;施行;执行;经营 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员) 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员).标识号(ID、身份标识符、身份标识) 识别 识别符

52463-7 Patient's Facility/Agency Identification Number (for internal tracking)

Observation ID in Form

C7

Fully-Specified Name

Component
Patient Identification Number or Provider Account Number
Property
ID
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Patient ID # or Provider Acct #

Basic Attributes

Class
ADMIN.PATIENT.ID
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.66
Order vs. Observation
Both

HL7® Attributes

HL7® Field ID
PID-3.1

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Número de identificación del paciente o número de cuenta del proveedor:ID:Punto temporal:^ Paciente:Nominal:
it-IT Italian (Italy) Numero di Identificazione del Paziente o Numero di Account del Provider:ID:Pt:^Paziente:Nom:
Synonyms: Amministrativo Identificatore Numero di identificazione del paziente paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 患者身份标识编号或服务提供者账号:标识符:时间点:^患者:名义型:
Synonyms: 个数;数目 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 患者身份标识号或服务提供者账号;患者(病人)身份标识编号(标识编号、身份标识号、标识号)或服务提供者(服务提供方、服务提供人员、服务人员、服务工作人员)账号(帐号) 时刻;随机;随意;瞬间 标志 标志符 标识 标识;身份标识符;身份标识 标识符 标识符(Identifier,ID) 皮下 皮下的 皮内 皮内(Intradermal,ID) 皮内的 皮层内 皮层内的 真皮下 真皮下的 真皮内的 行政;管理;施行;执行;经营 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员) 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员).标识号(ID、身份标识符、身份标识) 识别 识别符 账户编号;帐目编号;帐号 鉴定;识别;验明;身份证明;确认;认出;核实;认同;身份证件

52455-3 Admission date

Observation ID in Form

C8a

Fully-Specified Name

Component
Admission date
Property
TmStp
Time
Pt
System
^Patient
Scale
Qn
Method

Additional Names

Short Name
Admission date

Basic Attributes

Class
ADMIN
Type
Clinical
First Released
Version 2.26
Last Updated
Version 2.63
Change Reason
Updated Class from SURVEY.CARE to ADMIN
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
89070-7 ADAPTABLE patient reported item set [ADAPTABLE]
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
86870-3 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
86874-5 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA start of therapy (NS/SS) item set [CMS Assessment]
86875-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed tracking (NT/ST) item set [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86877-8 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88279-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88280-3 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88281-1 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88286-0 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88952-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88953-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88948-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87506-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 4.00 during assessment period [CMS Assessment]
93219-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.00 during assessment period [CMS Assessment]
103948-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 during assessment period [CMS Assessment]
93220-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.00 during assessment period [CMS Assessment]
103947-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment]
90479-7 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home and Swing bed tracking (NT and ST) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90481-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Optional State Assessment (OSA) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101108-9 MDS v3.0 - RAI v1.18.11 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
105008-7 MDS v3.0 - RAI v1.19.1 - Nursing home and Swing bed tracking (NT ST) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
75854-0 PCORnet common data model set - version 1.0 [PCORnet]
85057-8 PCORnet Common Data Model set - version 3.0 [PCORnet]
97782-7 Spine Tango Surgery 2017

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Fecha de admisión:TmStp:Punto temporal:^ Paciente:Cuantitativo:
it-IT Italian (Italy) Ricovero, data:TmStp:Pt:^Paziente:Qn:
Synonyms: Amministrativo Data del ricovero paziente Punto nel tempo (episodio) Time stamp (Data e Ora)
ru-RU Russian (Russian Federation) Госпитализация дата:TmStp:ТчкВрм:^Пациент:Колич:
Synonyms: Time Stamp (Дата и Время) Количественный Точка во времени;Момент
zh-CN Chinese (China) 入院日期:时间戳:时间点:^患者:定量型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印时戳;时标;时间戳(日期与时间);时间标记;计时标记 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 日子;几号 时刻;随机;随意;瞬间 行政;管理;施行;执行;经营

Example Units

Unit Source
{mm/dd/yyyy} Example UCUM Units

21112-8 Birth date

Observation ID in Form

C8b

Fully-Specified Name

Component
Birth date
Property
TmStp
Time
Pt
System
^Patient
Scale
Qn
Method

Additional Names

Short Name
Birth date
Display Name
Birth date [Date/time]
Consumer Name Alpha Get Info
Birth date

Basic Attributes

Class
MISC
Type
Laboratory
First Released
Version 1.0m
Last Updated
Version 2.73
Order vs. Observation
Observation
Common Test Rank Get Info
1746

HL7® Attributes

HL7® Field ID
PID-7.1

Member of these Panels

LOINC Long Common Name
89070-7 ADAPTABLE patient reported item set [ADAPTABLE]
58735-2 Alpha-1-Fetoprotein panel - Amniotic fluid
48802-3 Alpha-1-Fetoprotein panel - Serum or Plasma
76464-7 American Physical Therapy Association registry panel
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
75199-0 Congenital syphilis case investigation and report panel [CDC.CS]
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
45963-6 Deprecated MDS basic assessment tracking form - version 2.0
86870-3 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
86874-5 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA start of therapy (NS/SS) item set [CMS Assessment]
86875-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed tracking (NT/ST) item set [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86877-8 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88279-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88280-3 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88281-1 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88286-0 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88952-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88953-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88948-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
46462-8 Deprecated Outcome and assessment information set (OASIS) form - version B1
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57190-1 Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care
85907-4 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
68359-9 End Stage Renal Disease (ESRD) Death Notification - OMB CMS form 2746
67868-0 End Stage Renal Disease (ESRD) Medical Evidence Report, Medicare Entitlement AndOr Patient Registration - OMB CMS form 2728
70297-7 ESRD patient information panel
86636-8 Family planning report - FPAR 2.0 set
49085-4 First and Second trimester integrated maternal screen panel
48798-3 First trimester maternal screen panel - Serum or Plasma
49086-2 First trimester maternal screen with nuchal translucency panel
47245-6 HIV treatment form Document
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
100203-9 Knee Society Score post-op panel [Knee Society Score]
100159-3 Knee Society Score pre-op panel [Knee Society Score]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87506-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 4.00 during assessment period [CMS Assessment]
93219-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.00 during assessment period [CMS Assessment]
103948-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 during assessment period [CMS Assessment]
93220-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.00 during assessment period [CMS Assessment]
103947-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment]
49087-0 Maternal screen clinical predictors panel
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90479-7 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home and Swing bed tracking (NT and ST) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90481-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Optional State Assessment (OSA) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101111-3 MDS v3.0 - RAI v1.18.11 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
101108-9 MDS v3.0 - RAI v1.18.11 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
104608-5 MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
105008-7 MDS v3.0 - RAI v1.19.1 - Nursing home and Swing bed tracking (NT ST) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
70182-1 NIH Stroke Scale
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
74495-3 Patient safety event report - hospital - healthcare event reporting form (HERF) - version 1.2 [AHRQ]
75854-0 PCORnet common data model set - version 1.0 [PCORnet]
85057-8 PCORnet Common Data Model set - version 3.0 [PCORnet]
62293-6 PhenX - current age protocol 010101
62263-9 PhenX domain - Nutrition and dietary supplements
62812-3 PhenX domain - Physical activity and physical fitness
62611-9 PhenX domain - Respiratory
48799-1 Second trimester penta maternal screen panel - Serum or Plasma
48800-7 Second trimester quad maternal screen panel - Serum or Plasma
35086-8 Second trimester triple maternal screen panel - Serum or Plasma
60687-1 Test of Infant Motor Performance Version 5.1
54127-6 US Surgeon General family health portrait [USSG-FHT]
55140-8 Vaccine Adverse Event Reporting System (VAERS) panel

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Geburtsdatum:Zeitstempel:Zeitpunkt:^Patient:Quantitativ:
es-MX Spanish (Mexico) Fecha de nacimiento:Sello de hora (fecha y hora):Punto temporal:^ Paciente:Cuantitativo:
es-AR Spanish (Argentina) fecha de nacimiento:marca de tiempo:fecha y hora:punto en el tiempo:^paciente:cuantitativo:
es-ES Spanish (Spain) Fecha de nacimiento:Certificado de tiempo (Dia y Hora):Punto temporal:^paciente:Qn:
Synonyms: Cuantitativo
fr-FR French (France) Date de naissance:Horodatage:Ponctuel:Patient:Numérique:
it-IT Italian (Italy) Data di nascita:TmStp:Pt:^Paziente:Qn:
Synonyms: Miscellanea paziente Punto nel tempo (episodio) Time stamp (Data e Ora)
nl-NL Dutch (Netherlands) geboortedatum:tijdstempel:moment:^patiënt:kwantitatief:
pt-BR Portuguese (Brazil) Data de nascimento:TmStp:Pt:^Paciente:Qn:
Synonyms: Dob; Date of birth; Birthdate; Time stamp; Date and time; Timestamp; Point in time; Random; Quantitative; QNT; Quant; Quan
ru-RU Russian (Russian Federation) Рождения дата:TmStp:ТчкВрм:^Пациент:Колич:
Synonyms: Time Stamp (Дата и Время) Дата рождения Количественный Точка во времени;Момент
tr-TR Turkish (Turkey) Doğum tarihi:ZBel:Zmlı:^Hasta:Kant:
zh-CN Chinese (China) 出生日期:时间戳:时间点:^患者:定量型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印时戳;时标;时间戳(日期与时间);时间标记;计时标记 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 日子;几号 时刻;随机;随意;瞬间 杂项;杂项类;杂项试验 生日

Example Units

Unit Source
{mm/dd/yyyy} Example UCUM Units

45396-9 Social Security number [Identifier]

Observation ID in Form

C9

Fully-Specified Name

Component
Social Security number
Property
ID
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Social Security #

Basic Attributes

Class
ADMIN.PATIENT.ID
Type
Clinical
First Released
Version 2.17
Last Updated
Version 2.73
Change Reason
Updated Class from SURVEY.MDS to ADMIN; Capitalized Security in Component
Order vs. Observation
Both
Common Test Rank Get Info
6170

HL7® Attributes

HL7® Field ID
PID-19

Member of these Panels

LOINC Long Common Name
89070-7 ADAPTABLE patient reported item set [ADAPTABLE]
76464-7 American Physical Therapy Association registry panel
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
45963-6 Deprecated MDS basic assessment tracking form - version 2.0
86870-3 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
86874-5 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA start of therapy (NS/SS) item set [CMS Assessment]
86875-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed tracking (NT/ST) item set [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86877-8 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88279-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88280-3 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88281-1 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88286-0 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88952-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88953-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88948-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
46462-8 Deprecated Outcome and assessment information set (OASIS) form - version B1
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57190-1 Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care
85907-4 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
68359-9 End Stage Renal Disease (ESRD) Death Notification - OMB CMS form 2746
67868-0 End Stage Renal Disease (ESRD) Medical Evidence Report, Medicare Entitlement AndOr Patient Registration - OMB CMS form 2728
70297-7 ESRD patient information panel
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87506-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 4.00 during assessment period [CMS Assessment]
93219-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.00 during assessment period [CMS Assessment]
103948-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 during assessment period [CMS Assessment]
93220-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.00 during assessment period [CMS Assessment]
103947-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90479-7 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home and Swing bed tracking (NT and ST) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90481-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Optional State Assessment (OSA) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101111-3 MDS v3.0 - RAI v1.18.11 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
101108-9 MDS v3.0 - RAI v1.18.11 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
104608-5 MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
105008-7 MDS v3.0 - RAI v1.19.1 - Nursing home and Swing bed tracking (NT ST) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
46611-0 Mental residual functional capacity (RFC) assessment form
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
62812-3 PhenX domain - Physical activity and physical fitness
46637-5 Residual physical functional capacity (RFC) assessment form [RFC]

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Número de seguro social:ID:Punto temporal:^ Paciente:Nominal:
it-IT Italian (Italy) Previdenza Sociale, numero:ID:Pt:^Paziente:Nom:
Synonyms: Amministrativo Identificatore Numero di identificazione del paziente Numero di Previdenza Sociale paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 社会安全号码:标识符:时间点:^患者:名义型:
Synonyms: Social Security number;SSN;社会保险号码;社会保障号码;社会保障号 个数;数目 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 时刻;随机;随意;瞬间 标志 标志符 标识 标识;身份标识符;身份标识 标识符 标识符(Identifier,ID) 皮下 皮下的 皮内 皮内(Intradermal,ID) 皮内的 皮层内 皮层内的 真皮下 真皮下的 真皮内的 行政;管理;施行;执行;经营 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员) 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员).标识号(ID、身份标识符、身份标识) 识别 识别符

46098-0 Gender

Part Descriptions

LP101395-4   Sex
In LOINC, sex refers to the biological sex of an organism, which is most commonly determined based on anatomy and physiology or genetic (chromosome) analysis. Our definition is based on the World Health Organization's definition of sex and gender: sex (male, female) refers to biological and physiological characteristics, and gender (masculine, feminine) refers to socially constructed roles, behaviors, activities, and attributes. (http://www.who.int/gender/whatisgender/en) Source: Regenstrief LOINC, WHO: gender

Observation ID in Form

C10

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Sex
Property
Type
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Sex

Basic Attributes

Class
ADMIN.PATIENT.DEMOG
Type
Clinical
First Released
Version 2.17
Last Updated
Version 2.73
Change Reason
Changed Component from 'Gender' to 'Sex' to align with the World Health Organization (WHO) definition of this concept.
Order vs. Observation
Both
Common Test Rank Get Info
2086

HL7® Attributes

HL7® Field ID
PID-8

Example Answer List LL1-9

Answer Code Score Answer ID
Male 1 LA2-8
Female 2 LA3-6

Member of these Panels

LOINC Long Common Name
89070-7 ADAPTABLE patient reported item set [ADAPTABLE]
95556-7 Adrenal cancer risk assessment and urine steroid fractions panel
72110-0 Alcohol Use Disorder Identification Test [AUDIT]
95405-7 Assay related variables panel [PhenX]
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
45963-6 Deprecated MDS basic assessment tracking form - version 2.0
86870-3 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
86874-5 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA start of therapy (NS/SS) item set [CMS Assessment]
86875-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed tracking (NT/ST) item set [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86877-8 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88279-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88280-3 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88281-1 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88286-0 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88952-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88953-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88948-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
46462-8 Deprecated Outcome and assessment information set (OASIS) form - version B1
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57190-1 Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care
85907-4 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
68359-9 End Stage Renal Disease (ESRD) Death Notification - OMB CMS form 2746
67868-0 End Stage Renal Disease (ESRD) Medical Evidence Report, Medicare Entitlement AndOr Patient Registration - OMB CMS form 2728
70297-7 ESRD patient information panel
86636-8 Family planning report - FPAR 2.0 set
96452-8 Hepatocellular carcinoma risk panel - Serum or Plasma
47245-6 HIV treatment form Document
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
85626-0 Kidney failure 2-year and 5-year risk panel by KFRE
100203-9 Knee Society Score post-op panel [Knee Society Score]
100159-3 Knee Society Score pre-op panel [Knee Society Score]
78699-6 Liver fibrosis score panel - Serum or Plasma Calculated by FibroMeter
78698-8 Liver fibrosis score panel - Serum or Plasma Calculated by HepaScore
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87506-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 4.00 during assessment period [CMS Assessment]
93219-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.00 during assessment period [CMS Assessment]
103948-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 during assessment period [CMS Assessment]
93220-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.00 during assessment period [CMS Assessment]
103947-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90479-7 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home and Swing bed tracking (NT and ST) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90481-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Optional State Assessment (OSA) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101111-3 MDS v3.0 - RAI v1.18.11 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
101108-9 MDS v3.0 - RAI v1.18.11 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
104608-5 MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
105008-7 MDS v3.0 - RAI v1.19.1 - Nursing home and Swing bed tracking (NT ST) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
82259-3 Metabolic equivalent of task and Resting metabolic rate panel
89724-9 Minimum Data Set (MDS) for Public Health Emergency Operations Centers (EOC) [CDC Emergency Operations Centers]
91393-9 Opioid risk tool panel
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]
69723-5 Patient Health Questionnaire (PHQ) [Reported]
93149-3 PhenX - bone age protocol 220301
62787-7 PhenX domain - Diabetes
62863-6 PhenX domain - Infectious diseases and immunity
62755-4 PhenX domain - Neurology
62263-9 PhenX domain - Nutrition and dietary supplements
62812-3 PhenX domain - Physical activity and physical fitness
62611-9 PhenX domain - Respiratory
63009-5 PhenX domain - Social environments
63067-3 PhenX domain - Speech and hearing
82287-4 Physical activity panel
69919-9 Race, ethnicity, sex, primary language, disability - Health and Human Services (HHS) panel [HHS.ACA Section 4302]
55140-8 Vaccine Adverse Event Reporting System (VAERS) panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Sexo:Tipo:Punto temporal:^ Paciente:Nominal:
es-ES Spanish (Spain) Sexo:Tipo:Punto temporal:^paciente:Nom:
et-EE Estonian (Estonia) Sugu:Tüüp:Pt:^patsient:Nom:
Synonyms: Juhuslik
fr-CA French (Canada) Sexe:Type:Temps ponctuel:^Patient:Nominal:
fr-BE French (Belgium) Sexe:Type:Temps ponctuel:^Patient:Nominal:
it-IT Italian (Italy) Sesso:Tipo:Pt:^Paziente:Nom:
Synonyms: Amministrativo Dati demografici del paziente Paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) geslacht:type:moment:^patiënt:nominaal:
ru-RU Russian (Russian Federation) Пол:Тип:ТчкВрм:^Пациент:Ном:
Synonyms: Номинальный;Именной Точка во времени;Момент
tr-TR Turkish (Turkey) Cinsiyet:Tip:Zmlı:^Hasta:Snf:
Synonyms: Seks Tür
zh-CN Chinese (China) 性别:类型:时间点:^患者:名义型:
Synonyms: 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 型 性;性别特征;性行为;性交;性活动 时刻;随机;随意;瞬间 行政;管理;施行;执行;经营 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员) 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员).人口统计学信息(人口统计学、人口统计、人口统计数据、人口统计学数据、人口统计特征、人口统计学特征、个人基本信息、人员基本信息、个人基本资料、个人基本数据)

46463-6 Race or ethnicity

Term Description

The groups or populations to which the patient is affiliated, as identified by the patient or caregiver.
Source: Regenstrief LOINC

Observation ID in Form

C11

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Race or ethnicity
Property
Type
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Race or ethnicity

Basic Attributes

Class
ADMIN.DEMOG
Type
Clinical
First Released
Version 2.19
Last Updated
Version 2.69
Change Reason
Release 2.69: ANSWER_LIST_TYPE: Answer list type changed from Normative to Example for the base term; override Normative lists added in the context of the panels in which this term is a member.; METHOD_TYP: The Method was removed because this is a generic concept that can be used across many contexts;

HL7® Attributes

HL7® Field ID
PID-10;PID-22

Normative Answer List LL247-8

Answer Code Score Answer ID
American Indian or Alaska Native 1 LA6155-1
Asian 2 LA6156-9
Black or African-American 3 LA6162-7
Hispanic or Latino 4 LA6214-6
Native Hawaiian or Pacific Islander 5 LA6266-6
White 6 LA4457-3
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) UK LA4489-6

Member of these Panels

LOINC Long Common Name
96749-7 Association of Asian Pacific Community Health Organizations enabling services and social intervention panel AAPCHO
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
46462-8 Deprecated Outcome and assessment information set (OASIS) form - version B1
100203-9 Knee Society Score post-op panel [Knee Society Score]
100159-3 Knee Society Score pre-op panel [Knee Society Score]

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Raza o etnia:Tipo:Punto temporal:^ Paciente:Nominal:
it-IT Italian (Italy) Razza o etnia:Tipo:Pt:^Paziente:Nom:
Synonyms: Amministrativo Demografia paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) ras of etniciteit:type:moment:^patiënt:nominaal:
ru-RU Russian (Russian Federation) Раса или этническая принадлежность:Тип:ТчкВрм:^Пациент:Ном:
Synonyms: Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 种族或民族:类型:时间点:^患者:名义型:
Synonyms: 人种;族;民族;种 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 型 时刻;随机;随意;瞬间 种族关系;种族性;种族 行政;管理;施行;执行;经营 行政管理(行政、管理、施行、执行、经营).人口统计学信息(人口统计学、人口统计、人口统计数据、人口统计学数据、人口统计特征、人口统计学特征、个人基本信息、人员基本信息、个人基本资料、个人基本数据)

52553-5 Is English the patient's primary language?

Observation ID in Form

C12

Skip Logic

If Yes, skip to C13.

Fully-Specified Name

Component
Language.primary is English
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64
Change Reason
Method removed and Answer List Type changed to Example because this generic term can be used across contexts

Survey Question

Text
Is English the patient's primary language?
Source
CARE I.c12

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

Member of these Groups Get Info

LOINC Group Group Name
LG51306-5 SDOH

52554-3 If English is not the patient's primary language, what is the patient's primary language?

Observation ID in Form

C12a

Fully-Specified Name

Component
Language.primary not English
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
CARE

Basic Attributes

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

Survey Question

Text
If English is not the patient's primary language, what is the patient's primary language?
Source
CARE I.c12a

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

54588-9 Interpreter needed

Term Description

Patient/resident's need or want an interpreter to communicate with a doctor or health care staff
Source: Regenstrief LOINC

Observation ID in Form

C13

Fully-Specified Name

Component
Interpreter needed
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Additional Names

Short Name
Interpreter needed

Basic Attributes

Class
ADMIN.PATIENT
Type
Clinical
First Released
Version 2.27
Last Updated
Version 2.66
Change Reason
Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Updated CLASS from SURVEY.MDS to ADMIN; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms; Method removed because this generic term can be used across contexts
Order vs. Observation
Observation

Example Answer List LL633-9

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Unable to determine 2 LA11137-9

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
86870-3 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86877-8 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88279-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88286-0 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88948-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
90481-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Optional State Assessment (OSA) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101111-3 MDS v3.0 - RAI v1.18.11 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
104608-5 MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Se necesita intérprete:Tipo:Punto temporal:^ Paciente:Ordinal:
it-IT Italian (Italy) Interprete necessario:Osservazione:Pt:^Paziente:Ord:
Synonyms: Amministrativo Osservazione Paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) tolk nodig:bevinding:moment:^patiënt:ordinaal:
zh-CN Chinese (China) 需要口译员:发现:时间点:^患者:序数型:
Synonyms: 依次型;分类顺序型;定性的;序数型(或称等级型);性质上的;有序型;有序性分类应答;有序性分类结果;秩次型;等级型;筛查;顺序型 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 时刻;随机;随意;瞬间 行政;管理;施行;执行;经营 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员) 需要口译者;需要口译;需要翻译;需要口头翻译人员

52556-8 Current Payment Source (s)

Observation ID in Form

D

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Payment sources
Property
Type
Time
Pt
System
^Patient
Scale
Nom
Method

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.63
Change Reason
Changed METHOD to methodless - generic term that does not orginate from just one method; Removed "Current" from component because it is conveyed by TIMING = Pt;Updated PROPERTY from Find to Type
Order vs. Observation
Both

Normative Answer List LL544-8

Answer Code Score Answer ID
None (no charge for current services) D1 LA10028-1
Medicare (traditional fee-for-service) D2 LA6259-1
Medicare (HMO/managed care) D3 LA6258-3
Medicaid (traditional fee-for-service) D4 LA6257-5
Medicaid (HMO/managed care) D5 LA6256-7
Workers’ compensation D6 LA10123-0
Title programs (e.g., Title III, V, or XX) D7 LA6398-7
Other government (e.g., TRICARE, VA, etc.) D8 LA10049-7
Private insurance/Medigap D9 LA10061-2
Private HMO/managed care D10 LA6349-0
Self-pay D11 LA6369-8
Other (specify) D12 LA6310-2
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) D13 LA4489-6

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
67868-0 End Stage Renal Disease (ESRD) Medical Evidence Report, Medicare Entitlement AndOr Patient Registration - OMB CMS form 2728
86636-8 Family planning report - FPAR 2.0 set
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
87506-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 4.00 during assessment period [CMS Assessment]
93219-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.00 during assessment period [CMS Assessment]
103948-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 during assessment period [CMS Assessment]
93220-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.00 during assessment period [CMS Assessment]
103947-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment]

Member of these Groups Get Info

LOINC Group Group Name
LG51306-5 SDOH

52721-8 Other (specify)

Observation ID in Form

D12

Fully-Specified Name

Component
Current payment source.other specified
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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52536-0 Admission Information

Observation ID in Form

II

Fully-Specified Name

Component
Admission Information
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

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52537-8 Pre-admission Service Use

Observation ID in Form

A

Fully-Specified Name

Component
Pre-admission Service Use
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

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52722-6 Admitted From. Immediately preceding this admission, where was the patient?

Observation ID in Form

A1

Form Coding Instructions

If transferring within units of an acute setting, choose Other and indicate if transferring to ICU, stepdown, med/surg, or other unit

Source: Regenstrief Help

Fully-Specified Name

Component
Admitted from
Property
Type
Time
Pt
System
Facility
Scale
Nom
Method
CARE

Basic Attributes

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

Survey Question

Text
Admitted From. Immediately preceding this admission, where was the patient?
Source
CARE I.a02

Normative Answer List LL730-3

Answer Code Score Answer ID
Community residential setting (e.g., private home, assisted living, group home, adult foster care) 1 LA11501-6
Long-term nursing facility 2 LA11502-4
Skilled nursing facility (SNF/TCU) 3 LA10080-2
Hospital emergency department 4 LA11504-0
Short-stay acute hospital (IPPS) 5 LA10078-6
Long-Term Care Hospital (LTCH) 6 LA10000-0
Inpatient rehabilitation hospital or unit (IRF) 7 LA9986-6
Psychiatric hospital or unit 8 LA10065-3
Other (specify) 9 LA6310-2

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52723-4 Other (specify)

Observation ID in Form

A19

Fully-Specified Name

Component
Admitted from.other specified
Property
Type
Time
Pt
System
Facility
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

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52724-2 If admitted from a medical setting, what was the primary diagnosis being treated in the previous setting?

Observation ID in Form

A2a

Fully-Specified Name

Component
Primary diagnosis code from previous setting
Property
Prid
Time
Pt
System
^Patient
Scale
Nom
Method
CARE

Basic Attributes

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

Survey Question

Text
If admitted from a medical setting, what was the primary diagnosis being treated in the previous setting?
Source
CARE I.a03

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52725-9 In the last 2 months, what medical services other than those identified in A1. has the patient received?

Observation ID in Form

A3

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Medical services received in the last 2Mo
Property
Find
Time
2Mo
System
^Patient
Scale
Nom
Method
CARE

Basic Attributes

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

Survey Question

Text
In the last 2 months, what medical services other than those identified in A1. has the patient received?
Source
CARE I.A4

Normative Answer List LL722-0

Answer Code Score Answer ID
Skilled nursing facility (SNF/TCU) a LA10080-2
Short-stay acute hospital (IPPS) b LA10078-6
Long-Term Care Hospital (LTCH) c LA10000-0
Inpatient rehabilitation hospital or unit (IRF) d LA9986-6
Psychiatric hospital or unit e LA10065-3
Home Health Care (HHA) f LA9978-3
Hospice g LA6216-1
Outpatient Services h LA10053-9
None Copyright http://snomed.info/sct ID:260413007 None (qualifier value) i LA137-2

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

70129-2 Within this acute care hospital stay, on what other units has the patient been treated prior to coming to this unit?

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Within this acute care hospital stay, on what other units has the patient been treated prior to coming to this unit
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.40
Last Updated
Version 2.64

Survey Question

Text
Within this acute care hospital stay, on what other units has the patient been treated prior to coming to this unit?
Source
A4

Normative Answer List LL2016-5

Answer Code Score Answer ID
Critical care/intensive care unit - 1-2 pts per nurse a LA18414-5
Step-down/intermediate unit - 3-6 pts per nurse b LA18415-2
General/medical unit or floor - 6 or more pts per nurse c LA18416-0
No previous units or not applicable d LA18417-8

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52538-6 Patient History Prior to this Current Illness, Exacerbation, or Injury

Observation ID in Form

B

Fully-Specified Name

Component
Patient History Prior to this Current Illness, Exacerbation, or Injury
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

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52726-7 Prior to this recent illness, where did the patient live?

Observation ID in Form

B1

Skip Logic

If permanently in long-term care, skip to B5. Prior Functioning. If Other, skip to B5. Prior Functioning. If Unknown, skip to B5. Prior Functioning.

Fully-Specified Name

Component
Prior residence
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
CARE

Basic Attributes

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

Survey Question

Text
Prior to this recent illness, where did the patient live?
Source
CARE I.b01

Normative Answer List LL545-5

Answer Code Score Answer ID
Private residence 1 LA10062-0
Community based residence (e.g., assisted living residence, group home, adult foster care) 2 LA9951-0
Long-term care facility (e.g., nursing home) 3 LA11521-4
Other (e.g., shelter, jail, no known address) 4 LA10047-1
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52539-4 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.).

Observation ID in Form

B2

Fully-Specified Name

Component
Prior postal code
Property
Loc
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Prior postal code

Basic Attributes

Class
ADMIN.PATIENT.DEMOG
Type
Clinical
First Released
Version 2.26
Last Updated
Version 2.66
Change Reason
Updated Class from SURVEY.CARE to ADMIN; Updated "ZIP code" in Component name to "Postal code", the more universal nomenclature for this concept.
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
45969-3 Deprecated MDS background information at admission form - version 2.0
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Código postal anterior:Loc:Punto temporal:^ Paciente:Nominal:
it-IT Italian (Italy) Codice postale precedente:Loc:Pt:^Paziente:Nom:
Synonyms: Amministrativo CAP Dati demografici del paziente Paziente Posizione Punto nel tempo (episodio)
zh-CN Chinese (China) 既往邮政编码:位置:时间点:^患者:名义型:
Synonyms: 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 地点;场所 既往(过去的、曾用的)邮政编码(邮政区号、邮递区号、邮编);既往邮政区号;既往邮递区号;既往邮编;之前的邮政编码 时刻;随机;随意;瞬间 行政;管理;施行;执行;经营 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员) 行政管理(行政、管理、施行、执行、经营).患者(病人、病患、病号、伤病员).人口统计学信息(人口统计学、人口统计、人口统计数据、人口统计学数据、人口统计特征、人口统计学特征、个人基本信息、人员基本信息、个人基本资料、个人基本数据) 邮政区号;邮递区号;邮编

52727-5 Lives outside U.S.

Observation ID in Form

B2a

Fully-Specified Name

Component
Lives outside U.S.
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64
Change Reason
Method removed and Answer List Type changed to Example because this generic term can be used across contexts

Example Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52540-2 ZIP Code unknown

Observation ID in Form

B2b

Fully-Specified Name

Component
ZIP Code unknown
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64
Change Reason
Release 2.73: COMPONENT: Z-I-P and C in code should be capitalized; Previous Releases: Method removed and Answer List Type changed to Example because this generic term can be used across contexts

Example Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52541-0 If the patient lived in the community prior to this illness, what help was used?

Observation ID in Form

B3

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Prior help
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
CARE

Basic Attributes

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

Survey Question

Text
If the patient lived in the community prior to this illness, what help was used?
Source
CARE I.B3

Normative Answer List LL548-9

Answer Code Score Answer ID
No help received or no help necessary a LA10022-4
Unpaid Assistance b LA10111-5
Paid Assistance c LA10054-7
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) d LA4489-6

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52542-8 If the patient lived in the community prior to this illness, who did the patient live with?

Observation ID in Form

B3a

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Patient lived with prior to this illness
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
CARE

Basic Attributes

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

Survey Question

Text
If the patient lived in the community prior to this illness, who did the patient live with?
Source
CARE I.B3a

Normative Answer List LL549-7

Answer Code Score Answer ID
Lives alone a LA6255-9
Lives with paid helper b LA9997-3
Lives with other(s) c LA9996-5
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) d LA4489-6

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52543-6 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?

Observation ID in Form

B4

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Structural barriers in prior residence that could interfere with the patient's discharge
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64
Change Reason
Method removed and Answer List Type changed to Example because this generic term can be used across contexts

Survey Question

Text
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?
Source
CARE I.B4

Example Answer List LL550-5

Answer Code Score Answer ID
Structural barriers are not an issue. a LA10089-3
Stairs inside the living setting that must be used by patient (e.g., to get to toileting, sleeping, eating areas). b LA10086-9
Stairs leading from inside to outside of living setting. c LA10087-7
Narrow or obstructed doorways for patients using wheelchairs or walkers. d LA10016-6
Insufficient space to accommodate extra equipment (e.g., hospital bed, vent equipment). e LA9987-4
Other (specify) f LA6310-2
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) g LA4489-6

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52544-4 Other (specify)

Observation ID in Form

B4f

Fully-Specified Name

Component
Structural barrier.other specified
Property
Find
Time
Pt
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

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52449-6 Prior Functioning. Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.

Observation ID in Form

B5

Form Coding Instructions

Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury. Check only one box in each row

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Prior Functioning
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
Prior Functioning. Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury.
Source
CARE I.B5

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52545-1 Self Care: Did the patient need help bathing, dressing, using the toilet, or eating?

Observation ID in Form

B5a

Fully-Specified Name

Component
Prior functioning.self care
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
Change Reason
Edits made and then reverted

Survey Question

Text
Self Care: Did the patient need help bathing, dressing, using the toilet, or eating?
Source
CARE I.b05a

Normative Answer List LL546-3

Answer Code Score Answer ID
Independent – Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper. 3 LA9982-5
Needed partial assistance – Patient needed partial assistance from another person to complete activities. 2 LA10018-2
Dependent – A helper completed the activity for the patient. 1 LA9963-5
Not applicable 8 LA4720-4
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52546-9 Indoor Mobility (Ambulation): Did the patient need assistance with walking from room to room (with or without devices such as cane, crutch, or walker)?

Observation ID in Form

B5b

Fully-Specified Name

Component
Prior functioning.mobility - ambulation
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
Change Reason
Made edits and then reverted back

Survey Question

Text
Indoor Mobility (Ambulation): Did the patient need assistance with walking from room to room (with or without devices such as cane, crutch, or walker)?
Source
CARE I.b05b

Normative Answer List LL546-3

Answer Code Score Answer ID
Independent – Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper. 3 LA9982-5
Needed partial assistance – Patient needed partial assistance from another person to complete activities. 2 LA10018-2
Dependent – A helper completed the activity for the patient. 1 LA9963-5
Not applicable 8 LA4720-4
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52547-7 Stairs (Ambulation): Did the patient need assistance with internal or external stairs (with or without devices such as cane, crutch, or walker)?

Observation ID in Form

B5c

Fully-Specified Name

Component
Prior functioning.stairs - ambulation
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
Change Reason
Made edits and then reverted back

Survey Question

Text
Stairs (Ambulation): Did the patient need assistance with internal or external stairs (with or without devices such as cane, crutch, or walker)?
Source
CARE I.b05c

Normative Answer List LL546-3

Answer Code Score Answer ID
Independent – Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper. 3 LA9982-5
Needed partial assistance – Patient needed partial assistance from another person to complete activities. 2 LA10018-2
Dependent – A helper completed the activity for the patient. 1 LA9963-5
Not applicable 8 LA4720-4
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52548-5 Indoor Mobility (Wheelchair): Did the patient need assistance with moving from room to room using a wheelchair, scooter, or other wheeled mobility device?

Observation ID in Form

B5d

Fully-Specified Name

Component
Prior functioning.mobility - wheelchair
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
Indoor Mobility (Wheelchair): Did the patient need assistance with moving from room to room using a wheelchair, scooter, or other wheeled mobility device?
Source
CARE I.b05d

Normative Answer List LL546-3

Answer Code Score Answer ID
Independent – Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper. 3 LA9982-5
Needed partial assistance – Patient needed partial assistance from another person to complete activities. 2 LA10018-2
Dependent – A helper completed the activity for the patient. 1 LA9963-5
Not applicable 8 LA4720-4
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52549-3 Functional Cognition: Did the patient need help planning regular tasks, such as shopping or remembering to take medication?

Observation ID in Form

B5e

Fully-Specified Name

Component
Prior functioning.functional cognition
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
Change Reason
Made edits and then reverted back

Survey Question

Text
Functional Cognition: Did the patient need help planning regular tasks, such as shopping or remembering to take medication?
Source
CARE I.b05e

Normative Answer List LL546-3

Answer Code Score Answer ID
Independent – Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper. 3 LA9982-5
Needed partial assistance – Patient needed partial assistance from another person to complete activities. 2 LA10018-2
Dependent – A helper completed the activity for the patient. 1 LA9963-5
Not applicable 8 LA4720-4
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52550-1 Mobility devices and aids used prior to current illness, exacerbation, or injury [CARE]

Observation ID in Form

B6

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Mobility devices and aids used prior to current illness, exacerbation, or injury
Property
Find
Time
Pt
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 LL551-3

Answer Code Score Answer ID
Cane/crutch a LA9941-1
Walker b LA10117-2
Orthotics/Prosthetics c LA10046-3
Wheelchair/scooter full time d LA10119-8
Wheelchair/scooter part time e LA10120-6
Mechanical lift required f LA10003-4
Other (specify) g LA6310-2
None apply h LA10029-9
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) i LA4489-6

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52551-9 Other (specify)

Observation ID in Form

B6g

Fully-Specified Name

Component
Prior mobility device.other specified
Property
Find
Time
Pt
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

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52552-7 Falls in the past year

Observation ID in Form

B7

Fully-Specified Name

Component
Falls in the past Y
Property
Hx
Time
1Y
System
^Patient
Scale
Ord
Method

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.70
Change Reason
Release 2.70: METHOD_TYP: General concept not specific to CMS; Previous Releases: Changed Component from "History of falls in the past year" to "Falls in the past Y" and Property from "Find" to "Hx" based on current LOINC model.
Order vs. Observation
Observation

Normative Answer List LL208-0

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
97874-2 Stay Independent panel [Stay Independent]

52450-4 Current Medical Information

Observation ID in Form

III

Type of Entry

Question expects user entry - requires response [Q]

Form Coding Instructions

Clinicians: For this section, please provide a listing of medical diagnoses, comorbid diseases and complications, and procedures based on a review of the patient's clinical records available at the time of assessment. This information is intended to enhance continuity of care. For discharge only, these can be added to throughout the stay and will be specific to each setting

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Current Medical Information
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52464-5 Primary and Other Diagnoses, Comorbidities, and Complications

Observation ID in Form

A

Type of Entry

Question expects user entry - requires response [Q]

Form Coding Instructions

Indicate the primary diagnosis and up to 14 other diagnoses being treated, managed, or monitored in this setting. Please include all diagnoses (e.g., depression, schizophrenia, dementia, protein calorie malnutrition)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Primary and Other Diagnoses, Comorbidities, and Complications
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

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

18630-4 Primary Diagnosis at Assessment

Observation ID in Form

A1

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Diagnosis.primary
Property
Imp
Time
Pt
System
^Patient
Scale
Nom
Method

Basic Attributes

Class
ATTACH.REHAB
Type
Claims Attachments
First Released
Version 1.0l
Last Updated
Version 2.70
Change Reason
Release 2.70: AnswerListId: Added example answer list;
Order vs. Observation
Observation

Example Answer List LL4747-3

Answer Code Score Answer ID
Other LA46-8
Alcoholism LA20350-7
Bleeding disorder LA20352-3
Currently receiving chemotherapy for cancer LA20353-1
Congenital anomalies LA20354-9
Congestive heart failure (CHF) LA12740-9
Current smoker LA20356-4
Chronic renal failure LA20357-2
Cerebrovascular accident LA22244-0
Diabetes mellitus LA14291-1
Disseminated cancer LA20360-6
Advanced directive limiting care LA20361-4
Functionally dependent health status LA20363-0
Hypertension LA7444-8
Prematurity LA20368-9
Chronic obstructive pulmonary disease LA28200-6
Steroid use LA20370-5
Cirrhosis LA9639-1
Dementia LA20372-1
Attention deficit disorder/Attention deficit hyperactivity disorder (ADD/ADHD) LA28412-7
Anticoagulant therapy LA28199-0
Angina pectoris Copyright http://snomed.info/sct ID:194828000 Angina (disorder) LA14275-4
Mental/personality disorder LA28198-2
Myocardial infarction Copyright http://snomed.info/sct ID:22298006 Myocardial infarction (disorder) LA14274-7
Peripheral arterial disease Copyright http://snomed.info/sct ID:399957001 Peripheral arterial occlusive disease (disorder) LA28197-4
Substance abuse disorder Copyright http://snomed.info/sct ID:66214007 Substance abuse (disorder) LA28195-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
97782-7 Spine Tango Surgery 2017

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) diagnóstico.primario:impresión/interpretación del estudio:punto en el tiempo:^paciente:Nominal:
it-IT Italian (Italy) Diagnosi.primaria:Imp:Pt:^Paziente:Nom:
Synonyms: Allegato Allegato riabilitazione Impressione/interpretazione di studio paziente Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Диагноз.основной:Впчт:ТчкВрм:^Пациент:Ном:
Synonyms: Впечатление/интерпретация исследования Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 诊断.主要:印象:时间点:^患者:名义型:
Synonyms: Health Insurance Portability and Accountability Act of 1996;HIPAA;健康保險可攜與責任法;HIPAA法案;健康保险可移植性和问责法1996年;美国健康保险携带和责任法案;医疗保险便携性和责任法案;医疗保险便携性与责任法案;醫療保險可攜性與責任法;HIPAA 信息附件.康复治疗;健康保险便携与责任法案信息附件.康复;健康保险便携与责任法案信息附件.康复治疗;康复信息附件;康复治疗HIPAA信息附件;康复治疗信息附件;康复治疗健康保险便携与责任法 主要诊断 信息附件;健康保险便携与责任法案信息附件;附件 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述,始终是对其他某种观察指标的解释或抽象(一系列检验项目结果、一幅图像或者整个某位病人),而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 时刻;随机;随意;瞬间 诊断结论;判断;结论

52465-2 Other Diagnoses, Comorbidities, and Complications

Observation ID in Form

B

Type of Entry

Question expects user entry - requires response [Q]

Form Coding Instructions

List other diagnoses being treated, managed, or monitored in this setting. Include all diagnoses (e.g., depression, schizophrenia, dementia, protein calorie malnutrition)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Other Diagnoses, Comorbidities, and Complications
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

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

29308-4 Diagnosis

Part Descriptions

LP72437-4   Diagnosis
The end result of a diagnostic process that identifies a disease. Source: Regenstrief LOINC

Observation ID in Form

B1a

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Diagnosis
Property
Imp
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Dx

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.03
Last Updated
Version 2.73
Order vs. Observation
Observation
Common Test Rank Get Info
4809

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
74293-2 Oncology plan of care and summary - recommended CDA set
93149-3 PhenX - bone age protocol 220301
62863-6 PhenX domain - Infectious diseases and immunity
62896-6 PhenX domain - Skin, bone, muscle and joint

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Diagnose:Interpretation:Zeitpunkt:^Patient:Nominal:
es-AR Spanish (Argentina) diagnóstico:impresión/interpretación del estudio:punto en el tiempo:^paciente:Nominal:
es-ES Spanish (Spain) Diagnóstico:Impresión/interpretación del estudio:Punto temporal:^paciente:Nom:
es-MX Spanish (Mexico) Diagnóstico:Interpretación:Punto temporal:^ Paciente:Nominal:
fr-CA French (Canada) Diagnostic:Impression:Temps ponctuel:^Patient:Nominal:
fr-BE French (Belgium) Diagnostic:Impression/interprétation d'étude:Temps ponctuel:^Patient:Nominal:
it-IT Italian (Italy) Diagnosi:Imp:Pt:^Paziente:Nom:
Synonyms: Esame obbiettivo Impressione/interpretazione di studio paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Diagnóstico:Imp:Pt:^Paciente:Nom:
Synonyms: ; Dx; Interpretation; Interp; Impression; Impressions; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Диагноз:Впчт:ТчкВрм:^Пациент:Ном:
Synonyms: Впечатление/интерпретация исследования Номинальный;Именной Точка во времени;Момент
uk-UA Ukrainian (Ukraine) Діагноз:Інтерпретація:МоментЧасу:^Пацієнт:Категорійно:
Synonyms: Dx; H+P; H+P.PX; Impression; Impression/interpretation of study; Impressions; Interp; Interpretation; Nominal; P prime; Point in time; Random
zh-CN Chinese (China) 诊断:印象:时间点:^患者:名义型:
Synonyms: 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述,始终是对其他某种观察指标的解释或抽象(一系列检验项目结果、一幅图像或者整个某位病人),而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 历史纪录与体格检查 历史纪录与体格检查小节 时刻;随机;随意;瞬间 病史与体格检查 诊断结论;判断;结论

52466-0 Major Procedures (Diagnostic, Surgical, and Therapeutic Interventions)

Observation ID in Form

C

Fully-Specified Name

Component
Major Procedures (Diagnostic, Surgical, and Therapeutic Interventions)
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

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim

52558-4 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?

Observation ID in Form

C1

Skip Logic

If No, skip to Section D. Major Treatments.

Form Coding Instructions

List up to 15 procedures (diagnostic, surgical and therapeutic interventions). Indicate if a procedure was left, right, or not applicable (N/A). If procedure was bilateral (e.g., bilateral knee replacement), check both left and right boxes

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Procedure this admission
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
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?
Source
CARE I.c01

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim

52467-8 Procedure [CARE]

Form Coding Instructions

List up to 15 procedures (diagnostic, surgical and therapeutic interventions). Indicate if a procedure was left, right, or not applicable (N/A). If procedure was bilateral (e.g., bilateral knee replacement), check both left and right boxes

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Procedure
Property
-
Time
Pt
System
^Patient
Scale
-
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim

29300-1 Procedure type

Observation ID in Form

C1a

Fully-Specified Name

Component
Procedure
Property
Type
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Procedure type

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.03
Last Updated
Version 2.73
Common Test Rank Get Info
2979

Member of these Panels

LOINC Long Common Name
84907-5 Cancer pathology panel - Colorectal cancer specimen
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
74028-2 Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Procedimiento:Tipo:Punto temporal:^ Paciente:Nominal:
es-AR Spanish (Argentina) procedimiento:tipo:punto en el tiempo:^paciente:Nominal:
es-ES Spanish (Spain) Procedimiento:Tipo:Punto temporal:^paciente:Nom:
it-IT Italian (Italy) Procedura:Tipo:Pt:^Paziente:Nom:
Synonyms: Esame obbiettivo paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) verrichting:type:moment:^patiënt:nominaal:
pt-BR Portuguese (Brazil) Procedimento:Tipo:Pt:^Paciente:Nom:
Synonyms: Typ; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Вмешательство:Тип:ТчкВрм:^Пациент:Ном:
Synonyms: Номинальный;Именной Процедура Точка во времени;Момент
zh-CN Chinese (China) 操作项目:类型:时间点:^患者:名义型:
Synonyms: 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 型 操作;程序;手续;步骤;规程;程序流程 时刻;随机;随意;瞬间 病史与体格检查

52560-0 Procedure.left [CARE]

Fully-Specified Name

Component
Procedure.left
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

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim

52561-8 Procedure.right [CARE]

Fully-Specified Name

Component
Procedure.right
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

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim

52562-6 Procedure.side not applicable [CARE]

Fully-Specified Name

Component
Procedure.side not applicable
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

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim

52468-6 Which of the following treatments did the patient receive during the 2-day assessment period?

Observation ID in Form

D

Type of Entry

Question expects user entry - requires response [Q]

Form Coding Instructions

"Discharged With" refers to the 2-day discharge assessment period. Which of the following treatments did the patient receive a) at the time of discharge or b) at any time during their admission?

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Major Treatments
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

Survey Question

Text
Which of the following treatments did the patient receive during the 2-day assessment period?

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52803-4 Major treatments discharged with panel

Fully-Specified Name

Component
Major treatments discharged with panel
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
PANEL.SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52804-2 Major treatments discharged with [CARE]

Observation ID in Form

D1a

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Major treatments discharged with
Property
Find
Time
Pt
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 LL552-1

Answer Code Score Answer ID
None Copyright http://snomed.info/sct ID:260413007 None (qualifier value) D1 LA137-2
Insulin Drip D2 LA9988-2
Total parenteral nutrition D3 LA10101-6
Central Line Management D4 LA9943-7
Blood Transfusion(s) D5 LA9940-3
Controlled Parenteral Analgesia – Peripheral D6 LA9959-3
Controlled Parenteral Analgesia – Epidural D7 LA9958-5
Left Ventricular Assistive Device (LVAD) D8 LA9994-0
Continuous Cardiac Monitoring D9 LA9957-7
Chest Tube(s) D10 LA9948-6
Trach Tube with Suctioning D11 LA10102-4
High O2 Concentration Delivery System with FiO2 > 40% D12 LA9976-7
Non-invasive ventilation (CPAP) D13 LA10033-1
Ventilator – Weaning D14 LA10115-6
Ventilator – Non-Weaning D16 LA10114-9
Hemodialysis D17 LA9975-9
Peritoneal Dialysis D18 LA10059-6
Fistula or Other Drain Management D19 LA9971-8
Negative Pressure Wound Therapy D20 LA10019-0
Complex Wound Management with positioning and skin separation/traction that requires at least two persons or extensive & complex wound management by one person D21 LA9954-4
Halo D22 LA9974-2
Complex External Fixators (e.g., Ilizarov) D23 LA9953-6
One-on-One 24-Hour Staff Supervision D24 LA11601-4
Specialty Surface or Bed (i.e., air fluidized, bariatric, low air loss, or rotation bed) D25 LA10084-4
Multiple Types of IV Antibiotic Administration D26 LA11603-0
IV Vaso-actors (e.g., pressors, dilators, medication for pulmonary edema) D27 LA9992-4
IV Anti-coagulants D28 LA9990-8
IV Chemotherapy D28 LA9991-6
Indwelling Bowel Catheter Management System D29 LA9984-1
Other Major Treatments, e.g. isolation, hypothermia blanket D30 LA10050-5

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52565-9 Specify reason for continuous monitoring:

Observation ID in Form

D9c

Fully-Specified Name

Component
Reason for continuous cardiac monitoring
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Change Reason
Method removed because this generic term can be used across contexts

Survey Question

Text
Specify reason for continuous monitoring:
Source
CARE I.d09c

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52566-7 Specify most intensive frequency of suctioning during stay: Every____ hours

Observation ID in Form

D11c

Fully-Specified Name

Component
Suctioning frequency per H during stay.max
Property
NRat
Time
Pt
System
^Patient
Scale
Qn
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Survey Question

Text
Specify most intensive frequency of suctioning during stay: Every____ hours
Source
CARE I.d11c

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

55613-4 If patient is completely independent of the ventilator, specify the number of days it took to wean patient:

Observation ID in Form

D14c

Fully-Specified Name

Component
Number of D to wean patient who is now independent from ventilator
Property
Num
Time
Pt
System
^Patient
Scale
Qn
Method
CARE

Basic Attributes

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

Survey Question

Text
If patient is completely independent of the ventilator, specify the number of days it took to wean patient:
Source
CARE_D14c

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

Example Units

Unit Source
d Example UCUM Units

52567-5 Specify reason for 24-hour supervision

Observation ID in Form

D23c

Fully-Specified Name

Component
Reason for one on one 24H supervision
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Change Reason
Method removed because this generic term can be used across contexts

Survey Question

Text
Specify reason for 24-hour supervision
Source
CARE I.d23c

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52568-3 Specify

Observation ID in Form

D30c

Fully-Specified Name

Component
Other major treatments received.other specified
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

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52470-2 Major treatments used at any time during stay panel

Fully-Specified Name

Component
Major treatments used at any time during stay panel
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
PANEL.SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52569-1 Major treatments used at any time during stay [CARE]

Observation ID in Form

D1b

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Major treatments used at any time during stay
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 LL552-1

Answer Code Score Answer ID
None Copyright http://snomed.info/sct ID:260413007 None (qualifier value) D1 LA137-2
Insulin Drip D2 LA9988-2
Total parenteral nutrition D3 LA10101-6
Central Line Management D4 LA9943-7
Blood Transfusion(s) D5 LA9940-3
Controlled Parenteral Analgesia – Peripheral D6 LA9959-3
Controlled Parenteral Analgesia – Epidural D7 LA9958-5
Left Ventricular Assistive Device (LVAD) D8 LA9994-0
Continuous Cardiac Monitoring D9 LA9957-7
Chest Tube(s) D10 LA9948-6
Trach Tube with Suctioning D11 LA10102-4
High O2 Concentration Delivery System with FiO2 > 40% D12 LA9976-7
Non-invasive ventilation (CPAP) D13 LA10033-1
Ventilator – Weaning D14 LA10115-6
Ventilator – Non-Weaning D16 LA10114-9
Hemodialysis D17 LA9975-9
Peritoneal Dialysis D18 LA10059-6
Fistula or Other Drain Management D19 LA9971-8
Negative Pressure Wound Therapy D20 LA10019-0
Complex Wound Management with positioning and skin separation/traction that requires at least two persons or extensive & complex wound management by one person D21 LA9954-4
Halo D22 LA9974-2
Complex External Fixators (e.g., Ilizarov) D23 LA9953-6
One-on-One 24-Hour Staff Supervision D24 LA11601-4
Specialty Surface or Bed (i.e., air fluidized, bariatric, low air loss, or rotation bed) D25 LA10084-4
Multiple Types of IV Antibiotic Administration D26 LA11603-0
IV Vaso-actors (e.g., pressors, dilators, medication for pulmonary edema) D27 LA9992-4
IV Anti-coagulants D28 LA9990-8
IV Chemotherapy D28 LA9991-6
Indwelling Bowel Catheter Management System D29 LA9984-1
Other Major Treatments, e.g. isolation, hypothermia blanket D30 LA10050-5

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52565-9 Specify reason for continuous monitoring:

Observation ID in Form

D9c

Fully-Specified Name

Component
Reason for continuous cardiac monitoring
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Change Reason
Method removed because this generic term can be used across contexts

Survey Question

Text
Specify reason for continuous monitoring:
Source
CARE I.d09c

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52566-7 Specify most intensive frequency of suctioning during stay: Every____ hours

Observation ID in Form

D11c

Fully-Specified Name

Component
Suctioning frequency per H during stay.max
Property
NRat
Time
Pt
System
^Patient
Scale
Qn
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Survey Question

Text
Specify most intensive frequency of suctioning during stay: Every____ hours
Source
CARE I.d11c

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

55613-4 If patient is completely independent of the ventilator, specify the number of days it took to wean patient:

Observation ID in Form

D14c

Fully-Specified Name

Component
Number of D to wean patient who is now independent from ventilator
Property
Num
Time
Pt
System
^Patient
Scale
Qn
Method
CARE

Basic Attributes

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

Survey Question

Text
If patient is completely independent of the ventilator, specify the number of days it took to wean patient:
Source
CARE_D14c

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

Example Units

Unit Source
d Example UCUM Units

52567-5 Specify reason for 24-hour supervision

Observation ID in Form

D23c

Fully-Specified Name

Component
Reason for one on one 24H supervision
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Change Reason
Method removed because this generic term can be used across contexts

Survey Question

Text
Specify reason for 24-hour supervision
Source
CARE I.d23c

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52568-3 Specify

Observation ID in Form

D30c

Fully-Specified Name

Component
Other major treatments received.other specified
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

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52471-0 Medications (Optional)

Type of Entry

Question expects user entry - requires response [Q]

Form Coding Instructions

List all current medications for the patient

Source: Centers for Medicare & Medicaid Services

Form Coding Instructions

List the ten most clinically relevant medications

Source: Regenstrief Help

Fully-Specified Name

Component
Medications
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
PANEL.SURVEY.MDS
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.68
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57192-7 Deprecated Outcome and assessment information set (OASIS) form - version C - Follow-Up
57191-9 Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care
57190-1 Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Dokumente der e-Medikation

52418-1 Medication Name

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Name
Property
ID
Time
Pt
System
Medication.current
Scale
Nom
Method

Basic Attributes

Class
ATTACH.MEDS
Type
Claims Attachments
First Released
Version 2.26
Last Updated
Version 2.27

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
18605-6 Medication current Set
62611-9 PhenX domain - Respiratory
63067-3 PhenX domain - Speech and hearing

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Medikation
fr-FR French (France) Nom:Identifiant:Ponctuel:Traitement courant:Résultat nominal:
it-IT Italian (Italy) Nome:ID:Pt:Farmaco.attuale:Nom:
Synonyms: Allegato Allegato farmaci Farmaco attuale Identificatore Medicazione Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Nome:ID:Pt:Medicação.atual:Nom:
Synonyms: Identifier; Ident; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Фамилия:ID:ТчкВрм:Лекарственный препарат.текущий:Ном:
Synonyms: Идентификатор Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 名称:标识符:时间点:药物.当前:名义型:
Synonyms: Health Insurance Portability and Accountability Act of 1996;HIPAA;健康保險可攜與責任法;HIPAA法案;健康保险可移植性和问责法1996年;美国健康保险携带和责任法案;医疗保险便携性和责任法案;医疗保险便携性与责任法案;醫療保險可攜性與責任法;HIPAA 信息附件.药物处理;健康保险便携与责任法案信息附件.药物处理;健康保险便携与责任法案信息附件.药物治疗;药物处理HIPAA信息附件;药物处理信息附件;药物处理健康保险便携与责任法案信息附件 信息附件;健康保险便携与责任法案信息附件;附件 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 处理用药.当前;处理用药物.当前;处理药物.当前;当前的处理用药;当前的处理用药物;当前的处理药物;当前的治疗用药;当前的治疗用药物;当前的治疗药物;当前的药物;治疗用药.当前;治疗用药物.当前;治疗药物.当前 处理用药;处理用药物;处理药物;治疗用药;治疗用药物;用药;药物处理;药物治疗;治疗药物 姓名;名字;名 时刻;随机;随意;瞬间 标识;身份标识符;身份标识 药物;药物处理;用药;使用药物

52809-1 Dose form Current medication

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Dose form
Property
Type
Time
Pt
System
Medication.current
Scale
Nom
Method

Additional Names

Short Name
Dose form Medication.current

Basic Attributes

Class
MEDS
Type
Clinical
First Released
Version 2.26
Last Updated
Version 2.73
Order vs. Observation
Observation
Common Test Rank Get Info
2249

Example Answer List LL3146-9

Answer Code Score Answer ID
Pill LA16247-1
Tablet LA21908-1
Capsule LA21907-3
Extended-release capsule LA21911-5
Granules LA21912-3
Suspension LA21913-1
Elixir LA21914-9
Cream LA21915-6
Ointment LA21916-4
Injectable solution LA21917-2
Patch LA21918-0
Spray LA21919-8

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Forma de dosis:Tipo:Punto temporal:Medicación actual:Nominal:
fr-FR French (France) Forme posologique:Type:Ponctuel:Traitement courant:Résultat nominal:
it-IT Italian (Italy) Dose, forma:Tipo:Pt:Farmaco.attuale:Nom:
Synonyms: Farmaco attuale Medicazione Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Forma de apresentação:Ident:Pt:Medicação.atual:Nom:
Synonyms: Identity or presence; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Доза форма:Тип:ТчкВрм:Лекарственный препарат.текущий:Ном:
Synonyms: Номинальный;Именной Точка во времени;Момент Форма выпуска
zh-CN Chinese (China) 剂型:类型:时间点:药物.当前:名义型:
Synonyms: 一剂物质 一剂药物 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 剂量物质 型 处理用药.当前;处理用药物.当前;处理药物.当前;当前的处理用药;当前的处理用药物;当前的处理药物;当前的治疗用药;当前的治疗用药物;当前的治疗药物;当前的药物;治疗用药.当前;治疗用药物.当前;治疗药物.当前 处理用药;处理用药物;处理药物;治疗用药;治疗用药物;用药;药物处理;药物治疗;治疗药物 时刻;随机;随意;瞬间 药剂形式 药物;药物处理;用药;使用药物 表格;表;窗体

18609-8 Current medication, Route

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Route
Property
Prid
Time
Pt
System
Medication.current
Scale
Nom
Method

Basic Attributes

Class
ATTACH.MEDS
Type
Claims Attachments
First Released
Version 1.0l
Last Updated
Version 2.27

Normative Answer List LL696-6

Answer Code Score Answer ID
Chew, oral CHEW LA11235-1
Diffusion, extracorporeal EXTCORPDIF LA11236-9
Diffusion, hemodialysis HEMODIFF LA11237-7
Diffusion, transdermal TRNSDERMD LA11238-5
Dissolve, oral DISSOLVE LA11239-3
Dissolve, sublingual SL LA11240-1
Douche, vaginal DOUCHE LA11241-9
Electro-osmosis ELECTOSMOS LA11242-7
Enema, rectal ENEMA LA11243-5
Enema, rectal retention RETENEMA LA11244-3
Flush, intravenous catheter IVFLUSH LA11245-0
Gargle GARGLE LA11246-8
Immersion (soak) SOAK LA11247-6
Implantation, intradermal IDIMPLNT LA11248-4
Implantation, intravitreal IVITIMPLNT LA11249-2
Implantation, subcutaneous SQIMPLNT LA11250-0
Infusion, epidural EPI LA11251-8
Infusion, intraarterial catheter IA LA11252-6
Infusion, intracardiac IC LA11253-4
Infusion, intracoronary ICOR LA11254-2
Infusion, intraosseous, continuous IOSSC LA11255-9
Infusion, intrathecal IT LA11256-7
Infusion, intravascular IVASCINFUS LA11257-5
Infusion, intravenous IV LA11258-3
Infusion, intravenous catheter IVC LA11259-1
Infusion, intravenous catheter, continuous IVCC LA11260-9
Infusion, intravenous catheter, intermittent IVCI LA11261-7
Infusion, intravenous catheter, pca pump PCA LA11262-5
Infusion, subcutaneous SQINFUS LA11263-3
Inhalation, intermittent positive pressure breathing (ippb) IPPB LA11264-1
Inhalation, nasal NASINHL LA11265-8
Inhalation, nasal cannula NASINHLC LA11266-6
Inhalation, nebulization NEB LA11268-2
Inhalation, nebulization, nasal NASNEB LA11269-0
Inhalation, nebulization, oral ORNEB LA11270-8
Inhalation, oral intermittent flow ORIFINHL LA11271-6
Inhalation, oral rebreather mask REBREATH LA11272-4
Inhalation, respiratory ORINHL LA11273-2
Inhalation, tracheostomy TRACH LA11274-0
Inhalation, ventilator VENT LA11275-7
Inhalation, ventimask VENTMASK LA11276-5
Injection, amniotic fluid AMNINJ LA11277-3
Injection, biliary tract BILINJ LA11278-1
Injection, cervical CERVINJ LA11279-9
Injection, endosinusial ENDOSININJ LA11280-7
Injection, epidural EPIDURINJ LA11281-5
Injection, epidural, push EPIINJ LA11282-3
Injection, epidural, slow push EPINJSP LA11283-1
Injection, extra-amniotic EXTRAMNINJ LA11284-9
Injection, extracorporeal EXTCORPINJ LA11285-6
Injection, for cholangiography CHOLINJ LA11286-4
Injection, gastric button GBINJ LA11287-2
Injection, gingival GINGINJ LA11288-0
Injection, hemodialysis port HEMOPORT LA11289-8
Injection, insulin pump IPUMPINJ LA11290-6
Injection, interameningeal INTERMENINJ LA11291-4
Injection, interstitial INTERSTITINJ LA11292-2
Injection, intra-abdominal IABDINJ LA11293-0
Injection, intraarterial IAINJ LA11294-8
Injection, intraarterial, push IAINJP LA11295-5
Injection, intraarterial, slow push IAINJSP LA11296-3
Injection, intraarticular IARTINJ LA11297-1
Injection, intrabursal IBURSINJ LA11298-9
Injection, intracardiac ICARDINJ LA11299-7
Injection, intracardiac, push ICARINJP LA11300-3
Injection, intracardiac, rapid push ICARDINJRP LA11301-1
Injection, intracardiac, slow push ICARDINJSP LA11302-9
Injection, intracartilaginous ICARTINJ LA11303-7
Injection, intracaudal ICAUDINJ LA11304-5
Injection, intracavernous ICAVINJ LA11305-2
Injection, intracavitary ICAVITINJ LA11306-0
Injection, intracerebral ICEREBINJ LA11307-8
Injection, intracervical (uterus) IUINJC LA11308-6
Injection, intracisternal ICISTERNINJ LA11309-4
Injection, intracoronary ICORONINJ LA11310-2
Injection, intracoronary, push ICORONINJP LA11311-0
Injection, intracorpus cavernosum ICORPCAVINJ LA11312-8
Injection, intradermal IDINJ LA11313-6
Injection, intradiscal IDISCINJ LA11314-4
Injection, intraductal IDUCTINJ LA11315-1
Injection, intradural IDURINJ LA11316-9
Injection, intraepidermal IEPIDINJ LA11317-7
Injection, intraepithelial IEPITHINJ LA11318-5
Injection, intralesional ILESINJ LA11319-3
Injection, intraluminal ILUMINJ LA11320-1
Injection, intralymphatic ILYMPJINJ LA11321-9
Injection, intramedullary IMEDULINJ LA11322-7
Injection, intramuscular IM LA11323-5
Injection, intramuscular, deep IMD LA11324-3
Injection, intramuscular, z track IMZ LA11325-0
Injection, intraocular IOINJ LA11326-8
Injection, intraosseous IOSSINJ LA11327-6
Injection, intraovarian IOVARINJ LA11328-4
Injection, intrapericardial IPCARDINJ LA11329-2
Injection, intraperitoneal IPERINJ LA11330-0
Injection, intrapleural IPLRINJ LA11331-8
Injection, intraprostatic IPROSTINJ LA11332-6
Injection, intrapulmonary IPINJ LA11333-4
Injection, intraspinal ISINJ LA11334-2
Injection, intrasternal ISTERINJ LA11335-9
Injection, intrasynovial ISYNINJ LA11336-7
Injection, intratendinous ITENDINJ LA11337-5
Injection, intratesticular ITESTINJ LA11338-3
Injection, intrathecal ITINJ LA11339-1
Injection, intrathoracic ITHORINJ LA11340-9
Injection, intratubular ITUBINJ LA11341-7
Injection, intratumor ITUMINJ LA11342-5
Injection, intratympanic ITYMPINJ LA11343-3
Injection, intraureteral, retrograde IURETINJ LA11344-1
Injection, intrauterine IUINJ LA11345-8
Injection, intravascular IVASCINJ LA11346-6
Injection, intravenous IVINJ LA11347-4
Injection, intravenous, bolus IVINJBOL LA11348-2
Injection, intravenous, push IVPUSH LA11349-0
Injection, intravenous, rapid push IVRPUSH LA11350-8
Injection, intravenous, slow push IVSPUSH LA11351-6
Injection, intraventricular (heart) IVENTINJ LA11352-4
Injection, intravesicle IVESINJ LA11353-2
Injection, intravitreal IVITINJ LA11354-0
Injection, paranasal sinuses PNSINJ LA11355-7
Injection, parenteral PARENTINJ LA11356-5
Injection, periarticular PAINJ LA11357-3
Injection, peridural PDURINJ LA11358-1
Injection, perineural PNINJ LA11359-9
Injection, periodontal PDONTINJ LA11360-7
Injection, peritoneal dialysis port PDPINJ LA11361-5
Injection, retrobulbar RBINJ LA11362-3
Injection, soft tissue SOFTISINJ LA11363-1
Injection, subarachnoid SUBARACHINJ LA11364-9
Injection, subconjunctival SCINJ LA11365-6
Injection, subcutaneous SQ LA11366-4
Injection, sublesional SLESINJ LA11367-2
Injection, submucosal SUBMUCINJ LA11368-0
Injection, transplacental TRPLACINJ LA11369-8
Injection, transtracheal TRTRACHINJ LA11370-6
Injection, ureteral URETINJ LA11371-4
Injection, urethral URETHINJ LA11372-2
Injection, urinary bladder BLADINJ LA11373-0
Insertion, cervical (uterine) CERVINS LA11374-8
Insertion, intraocular, surgical IOSURGINS LA11375-5
Insertion, intrauterine IU LA11376-3
Insertion, lacrimal puncta LPINS LA11377-1
Insertion, rectal PR LA11378-9
Insertion, subcutaneous, surgical SQSURGINS LA11379-7
Insertion, urethral URETHINS LA11380-5
Insertion, vaginal VAGINSI LA11381-3
Instillation, cecostomy CECINSTL LA11382-1
Instillation, chest tube CTINSTL LA11383-9
Instillation, continuous ambulatory peritoneal dialysis port CAPDINSTL LA11384-7
Instillation, endotracheal tube ETINSTL LA11385-4
Instillation, enteral ENTINSTL LA11386-2
Instillation, enteral feeding tube EFT LA11387-0
Instillation, gastro-jejunostomy tube GJT LA11388-8
Instillation, gastrostomy tube GT LA11389-6
Instillation, intrabronchial IBRONCHINSTIL LA11390-4
Instillation, intraduodenal IDUODINSTIL LA11391-2
Instillation, intraesophageal IESOPHINSTIL LA11392-0
Instillation, intragastric IGASTINSTIL LA11393-8
Instillation, intraileal IILEALINJ LA11394-6
Instillation, intraocular IOINSTL LA11395-3
Instillation, intrasinal ISININSTIL LA11396-1
Instillation, intratracheal ITRACHINSTIL LA11397-9
Instillation, intrauterine IUINSTL LA11398-7
Instillation, jejunostomy tube JJTINSTL LA11399-5
Instillation, laryngeal LARYNGINSTIL LA11400-1
Instillation, nasal NASALINSTIL LA11401-9
Instillation, nasogastric NASOGASINSTIL LA11402-7
Instillation, nasogastric tube NGT LA11403-5
Instillation, nasotracheal tube NTT LA11404-3
Instillation, orogastric tube OGT LA11405-0
Instillation, orojejunum tube OJJ LA11406-8
Instillation, otic OT LA11407-6
Instillation, paranasal sinuses PNSINSTL LA11408-4
Instillation, peritoneal dialysis port PDPINSTL LA11409-2
Instillation, rectal RECINSTL LA11410-0
Instillation, rectal tube RECTINSTL LA11411-8
Instillation, sinus, unspecified SININSTIL LA11412-6
Instillation, soft tissue SOFTISINSTIL LA11413-4
Instillation, tracheostomy TRACHINSTL LA11414-2
Instillation, transtympanic TRTYMPINSTIL LA11415-9
instillation, urethral URETHINSTL LA11416-7
Instillation, urinary catheter BLADINSTL LA11417-5
Insufflation INSUF LA11418-3
Irrigation, genitourinary GUIRR LA11419-1
Irrigation, intragastric IGASTIRR LA11420-9
Irrigation, intralesional ILESIRR LA11421-7
Irrigation, intraocular IOIRR LA11422-5
Irrigation, rectal RECIRR LA11423-3
Irrigation, urinary bladder BLADIRR LA11424-1
Irrigation, urinary bladder, continuous BLADIRRC LA11425-8
Irrigation, urinary bladder, tidal BLADIRRT LA11426-6
Lavage, intragastric IGASTLAV LA11427-4
Mucosal absorption, intraduodenal IDOUDMAB LA11428-2
Mucosal absorption, intratracheal ITRACHMAB LA11429-0
Mucosal absorption, submucosal SMUCMAB LA11430-8
Nebulization, endotracheal tube ETNEB LA11431-6
Occlusive dressing technique OCDRESTA LA11432-4
Rinse, dental DENRINSE LA11433-2
Rinse, oral ORRINSE LA11434-0
Shampoo SHAMPOO LA11435-7
Subconjunctival SUBCONJTA LA11436-5
Suck, oromucosal SUCK LA11437-3
Suppository, urethral URETHSUP LA11438-1
Swallow, oral PO LA11439-9
Swish and spit out, oromucosal SWISHSPIT LA11440-7
Swish and swallow, oromucosal SWISHSWAL LA11441-5
Topical TOPICAL LA9456-0
Topical absorption, transtympanic TTYMPTABSORP LA11443-1
Topical application, buccal BUC LA11444-9
Topical application, cervical CERV LA11445-6
Topical application, dental DEN LA11446-4
Topical application, gingival GIN LA11447-2
Topical application, hair HAIR LA11448-0
Topical application, intracorneal ICORNTA LA11449-8
Topical application, intracoronal (dental) ICORONTA LA11450-6
Topical application, intraesophageal IESOPHTA LA11451-4
Topical application, intraileal IILEALTA LA11452-2
Topical application, intralesional ILTOP LA11453-0
Topical application, intraluminal ILUMTA LA11454-8
Topical application, intraocular IOTOP LA11455-5
Topical application, iontophoresis IONTO LA11456-3
Topical application, laryngeal LARYNGTA LA11457-1
Topical application, mucous membrane MUC LA11458-9
Topical application, nail NAIL LA11459-7
Topical application, nasal NASAL LA11460-5
Topical application, ophthalmic OPTHALTA LA11461-3
Topical application, oral ORALTA LA11462-1
Topical application, oromucosal ORMUC LA11463-9
Topical application, oropharyngeal OROPHARTA LA11464-7
Topical application, perianal PERIANAL LA11465-4
Topical application, perineal PERINEAL LA11466-2
Topical application, periodontal PDONTTA LA11467-0
Topical application, rectal RECTAL LA11468-8
Topical application, scalp SCALP LA11469-6
Topical application, skin SKIN LA11470-4
Topical application, soaked dressing DRESS LA11471-2
Topical application, swab SWAB LA11472-0
Topical application, transmucosal TMUCTA LA11473-8
Topical application, vaginal VAGINS LA11474-6
Transdermal TRNSDERM LA9454-5
Translingual TRNSLING LA9455-2

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
18605-6 Medication current Set

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) vía:presencia o identidad:punto en el tiempo:medicación.actual:Nominal:
fr-FR French (France) Voie d'administration:Identification:Ponctuel:Traitement courant:Résultat nominal:
it-IT Italian (Italy) Via:Prid:Pt:Farmaco.attuale:Nom:
Synonyms: Allegato Allegato farmaci Farmaco attuale Medicazione Presenza o Identità Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Путь:ПрИд:ТчкВрм:Лекарственный препарат.текущий:Ном:
Synonyms: Номинальный;Именной Присутствие или Идентификация Точка во времени;Момент
zh-CN Chinese (China) 途径:存在与否或特征标识:时间点:药物.当前:名义型:
Synonyms: Health Insurance Portability and Accountability Act of 1996;HIPAA;健康保險可攜與責任法;HIPAA法案;健康保险可移植性和问责法1996年;美国健康保险携带和责任法案;医疗保险便携性和责任法案;医疗保险便携性与责任法案;醫療保險可攜性與責任法;HIPAA 信息附件.药物处理;健康保险便携与责任法案信息附件.药物处理;健康保险便携与责任法案信息附件.药物治疗;药物处理HIPAA信息附件;药物处理信息附件;药物处理健康保险便携与责任法案信息附件 信息附件;健康保险便携与责任法案信息附件;附件 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 处理用药.当前;处理用药物.当前;处理药物.当前;当前的处理用药;当前的处理用药物;当前的处理药物;当前的治疗用药;当前的治疗用药物;当前的治疗药物;当前的药物;治疗用药.当前;治疗用药物.当前;治疗药物.当前 处理用药;处理用药物;处理药物;治疗用药;治疗用药物;用药;药物处理;药物治疗;治疗药物 存在;存在与否;特征标识;身份;身份标识 时刻;随机;随意;瞬间 药物;药物处理;用药;使用药物 路径;通道;通路

52810-9 Current medication, Frequency

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Frequency
Property
NRat
Time
Pt
System
Medication.current
Scale
Qn
Method

Basic Attributes

Class
ATTACH.MEDS
Type
Claims Attachments
First Released
Version 2.26
Last Updated
Version 2.73
Common Test Rank Get Info
8478

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

Language Variants Get Info

Tag Language Translation
fr-FR French (France) Fréquence:Nombre/Temps:Ponctuel:Traitement courant:Numérique:
it-IT Italian (Italy) Frequenza:NRat:Pt:Farmaco.attuale:Qn:
Synonyms: Allegato Allegato farmaci Farmaco attuale Indice numerico Medicazione Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Frequência:NRat:Pt:Medicação.atual:Qn:
Synonyms: ; nRate; Number rate; Count/time; Point in time; Random; Quantitative; QNT; Quant; Quan
ru-RU Russian (Russian Federation) Частота:КолСкор:ТчкВрм:Лекарственный препарат.текущий:Колич:
Synonyms: Количественный Количество скорость Точка во времени;Момент
zh-CN Chinese (China) 频率:计数型速率:时间点:药物.当前:定量型:
Synonyms: Health Insurance Portability and Accountability Act of 1996;HIPAA;健康保險可攜與責任法;HIPAA法案;健康保险可移植性和问责法1996年;美国健康保险携带和责任法案;医疗保险便携性和责任法案;医疗保险便携性与责任法案;醫療保險可攜性與責任法;HIPAA 信息附件.药物处理;健康保险便携与责任法案信息附件.药物处理;健康保险便携与责任法案信息附件.药物治疗;药物处理HIPAA信息附件;药物处理信息附件;药物处理健康保险便携与责任法案信息附件 信息附件;健康保险便携与责任法案信息附件;附件 单位时间内的数量或计数;数量/时间;数量型速率;数量型速率或计数型速率;数量型速率或计数型速率(单位时间);数量或计数型速率;计数/时间;计数型速率(单位时间);数量或计数型速率(单位时间) 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 处理用药.当前;处理用药物.当前;处理药物.当前;当前的处理用药;当前的处理用药物;当前的处理药物;当前的治疗用药;当前的治疗用药物;当前的治疗药物;当前的药物;治疗用药.当前;治疗用药物.当前;治疗药物.当前 处理用药;处理用药物;处理药物;治疗用药;治疗用药物;用药;药物处理;药物治疗;治疗药物 时刻;随机;随意;瞬间 药物;药物处理;用药;使用药物 频次;频度;频繁性;次数;频率分布;发生次数;周率;频繁程度

52796-0 Planned Stop Date (if applicable)

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Planned stop date
Property
Date
Time
Pt
System
Medication.current
Scale
Qn
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52472-8 Allergies and Adverse Drug Reactions

Fully-Specified Name

Component
Allergies & Adverse Drug Reactions
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

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52571-7 Does patient have allergies or any known adverse drug reactions?

Skip Logic

If None Known, skip to Section G. Skin Integrity. If Yes, list all allergies/causes of reaction [e.g., food, medications, other] and describe the adverse reactions.)

Fully-Specified Name

Component
Known allergies or adverse drug reactions
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
Does patient have allergies or any known adverse drug reactions?
Source
CARE I.f01

Normative Answer List LL553-9

Answer Code Score Answer ID
None known 0 LA10030-7
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52473-6 Allergies/Causes of Reaction

Fully-Specified Name

Component
Allergy or cause of reaction
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.27

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
62863-6 PhenX domain - Infectious diseases and immunity

31044-1 Patient Reaction

Fully-Specified Name

Component
Immunization reaction
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Immunization reaction

Basic Attributes

Class
VACCIN
Type
Clinical
First Released
Version 2.05
Last Updated
Version 2.52
Order vs. Observation
Observation

Example Answer List LL3209-5

Answer Code Score Answer ID
Pain 7 LA7460-4
Hypotonic LA22435-4
Fever LA7435-6
Encephalopathy, disorder of the brain LA22437-0
Anaphylaxis within 24 hours LA22438-8
Redness LA22439-6
Swelling 6 LA22440-4

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
62863-6 PhenX domain - Infectious diseases and immunity

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Reacción de inmunización:Tipo:Punto temporal:^ Paciente:Nominal:
es-AR Spanish (Argentina) reacción:hallazgo:punto en el tiempo:^paciente:Nominal:
fr-FR French (France) Réaction d'immunisation:Recherche:Ponctuel:Patient:Résultat nominal:
it-IT Italian (Italy) Immunizzazione, reazione:Osservazione:Pt:^Paziente:Nom:
Synonyms: Osservazione paziente Punto nel tempo (episodio) Vaccinazioni
pt-BR Portuguese (Brazil) Reação:Achado:Pt:^Paciente:Nom:
Synonyms: Finding; Findings; Point in time; Random; Nominal; Rxn; React; VACCINE
zh-CN Chinese (China) 疫苗接种反应:发现:时间点:^患者:名义型:
Synonyms: React Rxn 免疫接种历史;免疫史;接种史;免疫接种史 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 发现是一个原子型临床观察指标,并不是作为印象的概括陈述。体格检查、病史、系统检查及其他此类观察指标的属性均为发现。它们的标尺对于编码型发现可能是名义型,而对于叙述型文本之中所报告的发现,则可能是叙述型。;发现物;所见;结果;结论 响应 接种;接种记录;疫苗;疫苗接种 时刻;随机;随意;瞬间 疫苗接种(免疫接种、预防接种、接种)反应

52474-4 Skin integrity panel

Form Coding Instructions

Complete during the 2-day assessment period

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Skin integrity panel
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
PANEL.SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

69349-9 Presence of pressure ulcers

Observation ID in Form

G1-2

Fully-Specified Name

Component
Presence of pressure ulcers - acute
Property
-
Time
Pt
System
^Patient
Scale
-
Method
CARE

Basic Attributes

Class
PANEL.SURVEY.CARE
Type
Surveys
First Released
Version 2.38
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52573-3 Is this patient at risk of developing pressure ulcers?

Observation ID in Form

G1

Fully-Specified Name

Component
Risk of developing pressure ulcers
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
Is this patient at risk of developing pressure ulcers?
Source
CARE I.g01

Normative Answer List LL723-8

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes, indicated by clinical judgement 1 LA11612-1
Yes, indicated by high risk by formal assessment (e.g., on Braden or Norton tools) or the patient has a stage I or greater ulcer, a scar over a bony prominence, or a non-removable dressing, device, or cast. 2 LA11613-9

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52574-1 Does this patient have one or more unhealed pressure ulcer(s) at stage 2 or higher?

Observation ID in Form

G2

Skip Logic

If No, skip to G5. Major Wounds.

Fully-Specified Name

Component
One or more unhealed pressure ulcer(s) at stage 2 or higher
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
Does this patient have one or more unhealed pressure ulcer(s) at stage 2 or higher?
Source
CARE I.g02

Normative Answer List LL361-7

Answer Code Score Answer ID
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) LA33-6
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) LA32-8

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52476-9 IF THE PATIENT HAS ONE OR MORE STAGE 2-4 PRESSURE ULCERS, indicate the number of unhealed pressure ulcers at each stage

Term Description

Pressure ulcer at stage 2, stage 3, or stage 4 only:
Source: Regenstrief LOINC

Form Coding Instructions

CODING: Please specify the number of ulcers at each stage:

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Number of unhealed pressure ulcers at each stage - at assessment and onset during this service
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim

52575-8 Number of pressure ulcers at assessment - stage 2 [CARE]

Term Description

Stage 2 - Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister (excludes those resulting from skin tears, tape stripping, or incontinence associated dermatitis).
Source: Regenstrief LOINC

Observation ID in Form

G2a1

Form Coding Instructions

If the patient has one or more stage 2-4 pressure ulcers, indicate the number of unhealed pressure ulcers at each stage

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Number of pressure ulcers at assessment - stage 2
Property
Num
Time
Pt
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.63

Normative Answer List LL555-4

Answer Code Score Answer ID
0 ulcers 0 LA9916-3
1 ulcer 1 LA9917-1
2 ulcers 2 LA9918-9
3 ulcers 3 LA9920-5
4 ulcers 4 LA9921-3
5 ulcers 5 LA9922-1
6 ulcers 6 LA9923-9
7 ulcers 7 LA9924-7
8 or more ulcers 8 LA9925-4
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52576-6 Number of pressure ulcers at assessment - stage 3 [CARE]

Term Description

Stage 3 - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Source: Regenstrief LOINC

Observation ID in Form

G2b1

Form Coding Instructions

If the patient has one or more stage 2-4 pressure ulcers, indicate the number of unhealed pressure ulcers at each stage

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Number of pressure ulcers at assessment - stage 3
Property
Num
Time
Pt
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.63

Normative Answer List LL555-4

Answer Code Score Answer ID
0 ulcers 0 LA9916-3
1 ulcer 1 LA9917-1
2 ulcers 2 LA9918-9
3 ulcers 3 LA9920-5
4 ulcers 4 LA9921-3
5 ulcers 5 LA9922-1
6 ulcers 6 LA9923-9
7 ulcers 7 LA9924-7
8 or more ulcers 8 LA9925-4
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52577-4 Number of pressure ulcers at assessment - stage 4 [CARE]

Term Description

Stage 4 - Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
Source: Regenstrief LOINC

Observation ID in Form

G2c1

Form Coding Instructions

If the patient has one or more stage 2-4 pressure ulcers, indicate the number of unhealed pressure ulcers at each stage

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Number of pressure ulcers at assessment - stage 4
Property
Num
Time
Pt
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.63

Normative Answer List LL555-4

Answer Code Score Answer ID
0 ulcers 0 LA9916-3
1 ulcer 1 LA9917-1
2 ulcers 2 LA9918-9
3 ulcers 3 LA9920-5
4 ulcers 4 LA9921-3
5 ulcers 5 LA9922-1
6 ulcers 6 LA9923-9
7 ulcers 7 LA9924-7
8 or more ulcers 8 LA9925-4
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52578-2 Number of pressure ulcers at assessment - unstageable [CARE]

Term Description

Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, gray, green, or brown) or eschar (tan, brown, or black) in the wound bed. Include ulcers that are known or likely, but are not stageable due to non-removable dressing, device, cast or suspected deep tissue injury in evolution.
Source: Regenstrief LOINC

Observation ID in Form

G2d1

Fully-Specified Name

Component
Number of pressure ulcers at assessment - unstageable
Property
Num
Time
Pt
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.63

Normative Answer List LL555-4

Answer Code Score Answer ID
0 ulcers 0 LA9916-3
1 ulcer 1 LA9917-1
2 ulcers 2 LA9918-9
3 ulcers 3 LA9920-5
4 ulcers 4 LA9921-3
5 ulcers 5 LA9922-1
6 ulcers 6 LA9923-9
7 ulcers 7 LA9924-7
8 or more ulcers 8 LA9925-4
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52579-0 Number of pressure ulcers onset during this service - stage 2 [CARE]

Term Description

Stage 2 - Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister (excludes those resulting from skin tears, tape stripping, or incontinence associated dermatitis).
Source: Regenstrief LOINC

Observation ID in Form

G2a2

Form Coding Instructions

If the patient has one or more stage 2-4 pressure ulcers, indicate the number of unhealed pressure ulcers at each stage

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Number of pressure ulcers onset during this service - stage 2
Property
Num
Time
Pt
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.63

Normative Answer List LL555-4

Answer Code Score Answer ID
0 ulcers 0 LA9916-3
1 ulcer 1 LA9917-1
2 ulcers 2 LA9918-9
3 ulcers 3 LA9920-5
4 ulcers 4 LA9921-3
5 ulcers 5 LA9922-1
6 ulcers 6 LA9923-9
7 ulcers 7 LA9924-7
8 or more ulcers 8 LA9925-4
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim

52580-8 Number of pressure ulcers onset during this service - stage 3 [CARE]

Term Description

Stage 3 - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Source: Regenstrief LOINC

Observation ID in Form

G2b2

Form Coding Instructions

If the patient has one or more stage 2-4 pressure ulcers, indicate the number of unhealed pressure ulcers at each stage

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Number of pressure ulcers onset during this service - stage 3
Property
Num
Time
Pt
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.63

Normative Answer List LL555-4

Answer Code Score Answer ID
0 ulcers 0 LA9916-3
1 ulcer 1 LA9917-1
2 ulcers 2 LA9918-9
3 ulcers 3 LA9920-5
4 ulcers 4 LA9921-3
5 ulcers 5 LA9922-1
6 ulcers 6 LA9923-9
7 ulcers 7 LA9924-7
8 or more ulcers 8 LA9925-4
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim

52581-6 Number of pressure ulcers onset during this service - stage 4 [CARE]

Term Description

Stage 4 - Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
Source: Regenstrief LOINC

Observation ID in Form

G2c2

Form Coding Instructions

If the patient has one or more stage 2-4 pressure ulcers, indicate the number of unhealed pressure ulcers at each stage

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Number of pressure ulcers onset during this service - stage 4
Property
Num
Time
Pt
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.63

Normative Answer List LL555-4

Answer Code Score Answer ID
0 ulcers 0 LA9916-3
1 ulcer 1 LA9917-1
2 ulcers 2 LA9918-9
3 ulcers 3 LA9920-5
4 ulcers 4 LA9921-3
5 ulcers 5 LA9922-1
6 ulcers 6 LA9923-9
7 ulcers 7 LA9924-7
8 or more ulcers 8 LA9925-4
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim

52582-4 Number of pressure ulcers onset during this service - unstageable [CARE]

Term Description

Unstageable - Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, gray, green, or brown) or eschar (tan, brown, or black) in the wound bed. Include ulcers that are known or likely, but are not stageable due to non-removable dressing, device, cast or suspected deep tissue injury in evolution.
Source: Regenstrief LOINC

Observation ID in Form

G2d2

Fully-Specified Name

Component
Number of pressure ulcers onset during this service - unstageable
Property
Num
Time
Pt
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.63

Normative Answer List LL555-4

Answer Code Score Answer ID
0 ulcers 0 LA9916-3
1 ulcer 1 LA9917-1
2 ulcers 2 LA9918-9
3 ulcers 3 LA9920-5
4 ulcers 4 LA9921-3
5 ulcers 5 LA9922-1
6 ulcers 6 LA9923-9
7 ulcers 7 LA9924-7
8 or more ulcers 8 LA9925-4
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim

52583-2 Number of unhealed stage 2 ulcers known to be present for more than 1 month [CARE]

Observation ID in Form

G2e

Form Coding Instructions

If the patient has one or more unhealed stage 2 pressure ulcers, record the number present today that were first observed more than 1 month ago, according to the best available records. If the patient has no unhealed stage 2 pressure ulcers, record "0."

Source: Centers for Medicare & Medicaid Services

Form Coding Instructions

If the patient has one or more unhealed stage 2 pressure ulcers, record the number present today that were first observed more than 1 month ago, according to the best available records. If the patient has no unhealed stage 2 pressure ulcers, record "0"

Source: Centers for Medicare & Medicaid Services

Form Coding Instructions

If the resident has one or more unhealed Stage 2 pressure ulcers, record the number present today that were first observed more than one month ago

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Number of unhealed stage 2 ulcers known to be present for more than 1 month
Property
Num
Time
Pt
System
^Patient
Scale
Qn
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL555-4

Answer Code Score Answer ID
0 ulcers 0 LA9916-3
1 ulcer 1 LA9917-1
2 ulcers 2 LA9918-9
3 ulcers 3 LA9920-5
4 ulcers 4 LA9921-3
5 ulcers 5 LA9922-1
6 ulcers 6 LA9923-9
7 ulcers 7 LA9924-7
8 or more ulcers 8 LA9925-4
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

Example Units

Unit Source
{#} Example UCUM Units

52477-7 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):

Observation ID in Form

G3

Form Coding Instructions

If the patient has one or more unhealed (non-epithelialized) Stage 3 or 4 pressure ulcers or an unstageable pressure ulcer due to slough or eschar, identify the pressure ulcer with the largest surface area (length x width) and record in centimeters

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Largest pressure ulcer measurements
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
PANEL.SURVEY.MDS
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.73
Change Reason
Release 2.73: COMPONENT: update older "ulcer" terms in panels;
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
54580-6 Deprecated Minimum Data Set - version 3.0

52728-3 Longest length in any direction

Observation ID in Form

G3a

Fully-Specified Name

Component
Diameter.any.max
Property
Len
Time
Pt
System
Pressure injury.largest stage 3 or 4
Scale
Qn
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.63
Change Reason
Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee. Changed CLASS from SURVEY.CARE to SURVEY.CMS because term is used across CMS assessments.; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
54580-6 Deprecated Minimum Data Set - version 3.0

Example Units

Unit Source
cm Example UCUM Units

52729-1 Pressure Ulcer Width:

Observation ID in Form

G3b

Fully-Specified Name

Component
Diameter.transverse
Property
Len
Time
Pt
System
Pressure injury.largest stage 3 or 4
Scale
Qn
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.63
Change Reason
Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments.; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
54580-6 Deprecated Minimum Data Set - version 3.0
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57192-7 Deprecated Outcome and assessment information set (OASIS) form - version C - Follow-Up
57191-9 Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care
57190-1 Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care

Example Units

Unit Source
cm Example UCUM Units

52584-0 Date of measurement

Fully-Specified Name

Component
Date of ulcer measurement
Property
Date
Time
Pt
System
^Patient
Scale
Qn
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52730-9 Indicate if any unhealed stage 3 or stage 4 pressure ulcer(s) has undermining and/or tunneling (sinus tract) present.

Observation ID in Form

G3c

Fully-Specified Name

Component
Undermining or tunneling present
Property
Find
Time
Pt
System
Pressure injury.stage 3 or 4
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Change Reason
"Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Survey Question

Text
Indicate if any unhealed stage 3 or stage 4 pressure ulcer(s) has undermining and/or tunneling (sinus tract) present.
Source
CARE I.g04

Normative Answer List LL556-2

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Unable to assess 8 LA10105-7

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52585-7 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?

Observation ID in Form

G5

Form Coding Instructions

e.g., burns

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Major wound (excluding pressure ulcers)
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
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?
Source
CARE I.g05

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52478-5 Number of Major Wounds

Observation ID in Form

G5a-e

Form Coding Instructions

Must fill in all choices

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Number of Major Wounds
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52586-5 Delayed healing of surgical wound # [CARE]

Observation ID in Form

G5a

Fully-Specified Name

Component
Delayed healing of surgical wound
Property
Num
Time
Pt
System
^Patient
Scale
Qn
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

Example Units

Unit Source
{#} Example UCUM Units

52587-3 Trauma-related wound #

Term Description

e.g., burns
Source: Regenstrief LOINC

Observation ID in Form

G5b

Fully-Specified Name

Component
Trauma-related wound
Property
Num
Time
Pt
System
^Patient
Scale
Qn
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Change Reason
Method removed because this generic term can be used across contexts

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

Example Units

Unit Source
{#} Example UCUM Units

52588-1 Diabetic foot ulcer(s) #

Observation ID in Form

G5c

Fully-Specified Name

Component
Diabetic foot ulcer(s)
Property
Num
Time
Pt
System
^Patient
Scale
Qn
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Change Reason
Method removed because this generic term can be used across contexts

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

Example Units

Unit Source
{#} Example UCUM Units

52589-9 Vascular ulcer (arterial or venous including diabetic ulcers not located on the foot) # [CARE]

Observation ID in Form

G5d

Fully-Specified Name

Component
Vascular ulcer (arterial or venous including diabetic ulcers not located on the foot)
Property
Num
Time
Pt
System
^Patient
Scale
Qn
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

Example Units

Unit Source
{#} Example UCUM Units

52590-7 Other

Term Description

(e.g., incontinence associated dermatitis, normal surgical wound healing).
Source: Regenstrief LOINC

Observation ID in Form

G5e

Fully-Specified Name

Component
Major wound.other
Property
Num
Time
Pt
System
^Patient
Scale
Qn
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

Example Units

Unit Source
{#} Example UCUM Units

52591-5 Please specify:

Observation ID in Form

G5e.1

Fully-Specified Name

Component
Major wound.other
Property
Type
Time
Pt
System
^Patient
Scale
Qn
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Survey Question

Text
Please specify:
Source
CARE G5e.1

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52592-3 Turning surfaces not intact [CARE]

Observation ID in Form

G6

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Form Coding Instructions

Indicate which of the following turning surfaces have either a pressure ulcer or major wound

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Turning surfaces not intact
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

Survey Question

Source
CARE I.G6

Normative Answer List LL557-0

Answer Code Score Answer ID
Skin for all turning surfaces is intact a LA10081-0
Right hip not intact b LA10071-1
Left hip not intact c LA9993-2
Back/buttocks not intact d LA9935-3
Other turning surface(s) not intact e LA10051-3

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52479-3 Physiologic Factors

Observation ID in Form

H

Form Coding Instructions

Complete during the 2-day assessment period. Record the most recent value for each of the following physiologic factors tested during this admission. Indicate the date (MM/DD/YYYY) that the value was collected. If the test was not provided during this admission, check "not tested." If it is not possible to measure the height and weight, check box if value is estimated (actual measurement is preferred)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Physiologic Factors
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52480-1 Anthropometric Measures

Fully-Specified Name

Component
Anthropometric Measures
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

3137-7 Height (inches) OR

Observation ID in Form

H2b

Fully-Specified Name

Component
Body height
Property
Len
Time
Pt
System
^Patient
Scale
Qn
Method
Measured

Additional Names

Short Name
Body height Measured

Basic Attributes

Class
BDYHGT.ATOM
Type
Clinical
First Released
Version 1.0
Last Updated
Version 2.73
Order vs. Observation
Both
Common Test Rank Get Info
372

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
39294-4 Children's preventive health services attachment Set
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
45981-8 Deprecated MDS full assessment form - version 2.0
46103-8 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III
46104-6 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III 1997 update
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
86189-8 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
85907-4 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
43142-9 Height measurement device panel
47245-6 HIV treatment form Document
75885-4 IEEE 11073 Rosetta panel
62611-9 PhenX domain - Respiratory
81232-1 Supersaturation panel - 24 hour Urine
86347-2 U.S. standard certificate of live birth - recommended 2003 revision set
86346-4 U.S. standard report of fetal death - recommended 2003 revision set
43143-7 Weighing device panel

Member of these Groups Get Info

LOINC Group Group Name
LG34373-7 Body height|Len|Pt|^Patient

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Körpergröße:Länge:Zeitpunkt:^Patient:Quantitativ:Gemessen
es-MX Spanish (Mexico) Peso corporal:Len:Punto temporal:^ Paciente:Cuantitativo:Measured
es-AR Spanish (Argentina) altura corporal:longitud:punto en el tiempo:^paciente:cuantitativo:medido
fr-CA French (Canada) Taille:Longueur:Temps ponctuel:^Patient:Quantitatif:Mesuré
fr-FR French (France) Taille du patient:Longueur:Ponctuel:Patient:Numérique:Résultat mesuré
fr-BE French (Belgium) Taille corporelle:Longueur:Temps ponctuel:^Patient:Quantitatif:Mesuré
it-IT Italian (Italy) Altezza corporea:Len:Pt:^Paziente:Qn:Misurato
Synonyms: Altezza del corpo - atomica Lunghezza paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) lichaamslengte:afmeting:moment:^patiënt:kwantitatief:meting
Synonyms: lengte
pt-BR Portuguese (Brazil) Estatura:Comprimento:Pt:^Paciente:Qn:Mensurado
Synonyms: ; Bdy height; Body length; Axial length; Length; Point in time; Random; Quantitative; QNT; Quant; Quan; bod; Bodies; BODY HEIGHT(LENGTH).ATOM; BODY HEIGHT(LENGTH).ATOM
ru-RU Russian (Russian Federation) Рост:Дл:ТчкВрм:^Пациент:Колич:Измеренный
Synonyms: Длина Количественный Тело высота Точка во времени;Момент
zh-CN Chinese (China) 身高:长度:时间点:^患者:定量型:测量法
Synonyms: 一般体长;一般身高;一般身高(长度);体长.原子型;身高(长度).原子型 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 时刻;随机;随意;瞬间 测定法;量度法;量测法 物体 身体长度;身体高度;身长 身高;身长;身体高度 长;长短

Example Units

Unit Source
[in_us];cm;m Example UCUM Units

8301-4 Height (cm)

Observation ID in Form

H2b

Fully-Specified Name

Component
Body height
Property
Len
Time
Pt
System
^Patient
Scale
Qn
Method
Estimated

Additional Names

Short Name
Body height Est

Basic Attributes

Class
BDYHGT.ATOM
Type
Clinical
First Released
Version 1.0h(2)
Last Updated
Version 2.73
Common Test Rank Get Info
12391

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Peso corporal:Len:Punto temporal:^ Paciente:Cuantitativo:Estimated
es-AR Spanish (Argentina) altura corporal:longitud:punto en el tiempo:^paciente:cuantitativo:estimativo
fr-CA French (Canada) Taille:Longueur:Temps ponctuel:^Patient:Quantitatif:Estimé
fr-FR French (France) Taille du patient:Longueur:Ponctuel:Patient:Numérique:Résultat estimé
fr-BE French (Belgium) Taille corporelle:Longueur:Temps ponctuel:^Patient:Quantitatif:Estimé
it-IT Italian (Italy) Altezza corporea:Len:Pt:^Paziente:Qn:Stimato
Synonyms: Altezza del corpo - atomica Lunghezza paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) lichaamslengte:afmeting:moment:^patiënt:kwantitatief:schatting
Synonyms: lengte
pt-BR Portuguese (Brazil) Estatura:Comprimento:Pt:^Paciente:Qn:Estimado
Synonyms: ; Bdy height; Body length; Axial length; Length; Point in time; Random; Quantitative; QNT; Quant; Quan; Est; estimation; bod; Bodies; BODY HEIGHT(LENGTH).ATOM; BODY HEIGHT(LENGTH).ATOM
zh-CN Chinese (China) 身高:长度:时间点:^患者:定量型:估计法
Synonyms: 一般体长;一般身高;一般身高(长度);体长.原子型;身高(长度).原子型 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 时刻;随机;随意;瞬间 物体 胎龄估计法;孕龄估计法 身体长度;身体高度;身长 身高;身长;身体高度 长;长短

Example Units

Unit Source
[in_us];cm;m Example UCUM Units

3141-9 Weight (pounds) OR

Observation ID in Form

H3b

Fully-Specified Name

Component
Body weight
Property
Mass
Time
Pt
System
^Patient
Scale
Qn
Method
Measured

Additional Names

Short Name
Weight Measured

Basic Attributes

Class
BDYWGT.ATOM
Type
Clinical
First Released
Version 1.0
Last Updated
Version 2.73
Order vs. Observation
Both
Common Test Rank Get Info
115

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
18584-3 Body weight at ambulance transport Set
52416-5 Body weight Set
39294-4 Children's preventive health services attachment Set
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
45981-8 Deprecated MDS full assessment form - version 2.0
46103-8 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III
46104-6 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III 1997 update
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
86189-8 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
85907-4 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
75885-4 IEEE 11073 Rosetta panel
74293-2 Oncology plan of care and summary - recommended CDA set
75854-0 PCORnet common data model set - version 1.0 [PCORnet]
85057-8 PCORnet Common Data Model set - version 3.0 [PCORnet]
62297-7 PhenX - weight - measured weight protocol 021501
62263-9 PhenX domain - Nutrition and dietary supplements
62611-9 PhenX domain - Respiratory
100230-2 Routine prenatal assessment panel
34566-0 Vital signs with method details panel
72513-5 Vital signs with smoking status and pain scale [VSP]
34565-2 Vital signs, weight and height panel
67795-5 Vital signs, weight, height, head circumference and oximetry panel HITSP
74728-7 Vital signs, weight, height, head circumference, oximetry, BMI, and BSA panel
43143-7 Weighing device panel

Member of these Groups Get Info

LOINC Group Group Name
LG34372-9 Body weight|Mass|Pt|^Patient

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Körpergewicht
de-DE German (Germany) Körpergewicht:Masse:Zeitpunkt:^Patient:Quantitativ:Gemessen
es-MX Spanish (Mexico) Peso corporal:Masa:Punto temporal:^ Paciente:Cuantitativo:Measured
es-AR Spanish (Argentina) peso corporal:masa:punto en el tiempo:^paciente:cuantitativo:medido
fr-CA French (Canada) Poids:Masse:Temps ponctuel:^Patient:Quantitatif:Mesuré
fr-FR French (France) Poids corporel:Masse:Ponctuel:Patient:Numérique:Résultat mesuré
fr-BE French (Belgium) Poids corporel:Masse:Temps ponctuel:^Patient:Quantitatif:Mesuré
Synonyms: Poids
it-IT Italian (Italy) Peso corporeo:Massa:Pt:^Paziente:Qn:Misurato
Synonyms: paziente Peso del corpo - atomico Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) lichaamsgewicht:massa:moment:^patiënt:kwantitatief:meting
pt-BR Portuguese (Brazil) Peso corpóreo:Massa:Pt:^Paciente:Qn:Mensurado
Synonyms: ; Wt; Bdy weight; Point in time; Random; Quantitative; QNT; Quant; Quan; bod; Bodies; BODY WEIGHT.ATOM; BODY WEIGHT.ATOM
ru-RU Russian (Russian Federation) Масса тела:Масса:ТчкВрм:^Пациент:Колич:Измеренный
Synonyms: Количественный Точка во времени;Момент
tr-TR Turkish (Turkey) Vücut ağırlığı:Kütle:Zmlı:^Hasta:Kant:Ölçülmüş
zh-CN Chinese (China) 体重:质量:时间点:^患者:定量型:测量法
Synonyms: 一般体重;一般身体重量;身体重量.原子型 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 时刻;随机;随意;瞬间 标本重量;重 测定法;量度法;量测法 物体 身体重量 重量

Example Units

Unit Source
[lb_av];kg Example UCUM Units
lb REGENSTRIEF

8335-2 Weight (kg)

Observation ID in Form

H3b

Fully-Specified Name

Component
Body weight
Property
Mass
Time
Pt
System
^Patient
Scale
Qn
Method
Estimated

Additional Names

Short Name
Weight Est

Basic Attributes

Class
BDYWGT.ATOM
Type
Clinical
First Released
Version 1.0h(2)
Last Updated
Version 2.73
Common Test Rank Get Info
11753

Member of these Panels

LOINC Long Common Name
18584-3 Body weight at ambulance transport Set
52416-5 Body weight Set
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
84428-2 National EMS Information System - version 3 set

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Peso corporal:Masa:Punto temporal:^ Paciente:Cuantitativo:Estimated
es-AR Spanish (Argentina) peso corporal:masa:punto en el tiempo:^paciente:cuantitativo:estimativo
es-ES Spanish (Spain) Peso corporal:Masa:Punto temporal:^paciente:Qn:Estimado
Synonyms: Cuantitativo
fr-CA French (Canada) Poids:Masse:Temps ponctuel:^Patient:Quantitatif:Estimé
fr-FR French (France) Poids corporel:Masse:Ponctuel:Patient:Numérique:Résultat estimé
fr-BE French (Belgium) Poids corporel:Masse:Temps ponctuel:^Patient:Quantitatif:Estimé
Synonyms: Poids
it-IT Italian (Italy) Peso corporeo:Massa:Pt:^Paziente:Qn:Stimato
Synonyms: paziente Peso del corpo - atomico Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) lichaamsgewicht:massa:moment:^patiënt:kwantitatief:schatting
pl-PL Polish (Poland) Masa ciała:masa:punkt w czasie:^pacjent:ilościowy:szacowany
Synonyms: Ciężar Masa ciała
pt-BR Portuguese (Brazil) Peso corpóreo:Massa:Pt:^Paciente:Qn:Estimado
Synonyms: ; Wt; Bdy weight; Point in time; Random; Quantitative; QNT; Quant; Quan; Est; estimation; bod; Bodies; BODY WEIGHT.ATOM; BODY WEIGHT.ATOM
tr-TR Turkish (Turkey) Vücut ağırlığı:Kütle:Zmlı:^Hasta:Kant:Hesaplanmış
zh-CN Chinese (China) 体重:质量:时间点:^患者:定量型:估计法
Synonyms: 一般体重;一般身体重量;身体重量.原子型 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 时刻;随机;随意;瞬间 标本重量;重 物体 胎龄估计法;孕龄估计法 身体重量 重量

Example Units

Unit Source
[lb_av];kg Example UCUM Units

52481-9 Vital Signs

Fully-Specified Name

Component
Vital signs - acute
Property
-
Time
Pt
System
^Patient
Scale
-
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

8310-5 Temperature (deg F) OR

Observation ID in Form

H5b

Fully-Specified Name

Component
Body temperature
Property
Temp
Time
Pt
System
^Patient
Scale
Qn
Method

Additional Names

Short Name
Body temperature
Consumer Name Alpha Get Info
Body Temperature

Basic Attributes

Class
BDYTMP.ATOM
Type
Clinical
First Released
Version 1.0h(2)
Last Updated
Version 2.73
Common Test Rank Get Info
49

Member of these Panels

LOINC Long Common Name
35095-9 Body temperature panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
100847-3 Gas and ammonia panel - Arterial blood
93685-6 Gas and Carbon monoxide and Electrolytes panel - Arterial blood
24341-0 Gas and Carbon monoxide panel - Arterial blood
24343-6 Gas and Carbon monoxide panel - Blood
24342-8 Gas and Carbon monoxide panel - Capillary blood
24344-4 Gas and Carbon monoxide panel - Venous blood
99548-0 Gas and electrolytes panel - Arterial blood
24336-0 Gas panel - Arterial blood
51974-4 Gas panel - Arterial cord blood
24338-6 Gas panel - Blood
24337-8 Gas panel - Capillary blood
51973-6 Gas panel - Mixed venous blood
24339-4 Gas panel - Venous blood
51972-8 Gas panel - Venous cord blood
75885-4 IEEE 11073 Rosetta panel
84428-2 National EMS Information System - version 3 set
87825-6 National Trauma Data Standard - version 2018 set
74293-2 Oncology plan of care and summary - recommended CDA set
62611-9 PhenX domain - Respiratory
89694-4 Pulmonary Embolism Severity Index panel [PESI]
74028-2 Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS
34566-0 Vital signs with method details panel
72513-5 Vital signs with smoking status and pain scale [VSP]
34565-2 Vital signs, weight and height panel
67795-5 Vital signs, weight, height, head circumference and oximetry panel HITSP
74728-7 Vital signs, weight, height, head circumference, oximetry, BMI, and BSA panel
85353-1 Vital signs, weight, height, head circumference, oxygen saturation and BMI panel
82611-5 Wearable device external physiologic monitoring panel

Member of these Groups Get Info

LOINC Group Group Name
LG33052-8 Body temperature|Temp|Pt|Chal:None

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Körpertemperatur:Temperatur:Zeitpunkt:^Patient:Quantitativ:
de-AT German (Austria) Synonyms: Körpertemperatur
es-MX Spanish (Mexico) Temperatura corporal:Temperatura:Punto temporal:^ Paciente:Cuantitativo:
es-AR Spanish (Argentina) temperatura corporal:temperatura:punto en el tiempo:^paciente:cuantitativo:
fr-CA French (Canada) Température corporelle:Température:Temps ponctuel:^Patient:Quantitatif:
fr-FR French (France) Température corporelle:Température:Ponctuel:Patient:Numérique:
fr-BE French (Belgium) Température corporelle:Température:Temps ponctuel:^Patient:Quantitatif:
it-IT Italian (Italy) Temperatura corporea:Temp:Pt:^Paziente:Qn:
Synonyms: paziente Punto nel tempo (episodio) Temperatura Temperatura del corpo - atomica
nl-NL Dutch (Netherlands) lichaamstemperatuur:temperatuur:moment:^patiënt:kwantitatief:
pt-BR Portuguese (Brazil) Temperatura corpórea:Temp:Pt:^Paciente:Qn:
Synonyms: ; Bdy temp; Point in time; Random; Quantitative; QNT; Quant; Quan; bod; Bodies; BODY TEMPERATURE.ATOM; BODY TEMPERATURE.ATOM
ru-RU Russian (Russian Federation) Температура тела:Темп:ТчкВрм:^Пациент:Колич:
Synonyms: Количественный Температура Точка во времени;Момент
tr-TR Turkish (Turkey) Vücut sıcaklığı:Scklk:Zmlı:^Hasta:Kant:
zh-CN Chinese (China) 体温:温度:时间点:^患者:定量型:
Synonyms: 一般体温 体温 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 时刻;随机;随意;瞬间 物体 身体温度

Example Units

Unit Source
Cel Example UCUM Units
Deg C REGENSTRIEF

8867-4 Heart Rate (beats/min)

Observation ID in Form

H7b

Fully-Specified Name

Component
Heart rate
Property
NRat
Time
Pt
System
XXX
Scale
Qn
Method

Additional Names

Short Name
Heart rate
Consumer Name Alpha Get Info
Heart rate

Basic Attributes

Class
HRTRATE.ATOM
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.73
Common Test Rank Get Info
18

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
84428-2 National EMS Information System - version 3 set
87825-6 National Trauma Data Standard - version 2018 set
74293-2 Oncology plan of care and summary - recommended CDA set
62611-9 PhenX domain - Respiratory
89544-1 Pulmonary Embolism Rule-out Criteria panel PERC
89694-4 Pulmonary Embolism Severity Index panel [PESI]
89549-0 Revised Geneva Score panel
55417-0 Short blood pressure panel
74028-2 Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS
34566-0 Vital signs with method details panel
72513-5 Vital signs with smoking status and pain scale [VSP]
34565-2 Vital signs, weight and height panel
67795-5 Vital signs, weight, height, head circumference and oximetry panel HITSP
74728-7 Vital signs, weight, height, head circumference, oximetry, BMI, and BSA panel
85353-1 Vital signs, weight, height, head circumference, oxygen saturation and BMI panel
82611-5 Wearable device external physiologic monitoring panel
89546-6 Wells pulmonary embolism risk calculator panel

Member of these Groups Get Info

LOINC Group Group Name
LG33055-1 Heart rate|NRat|Pt|Chal:None

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Puls
de-DE German (Germany) Herzfrequenz:Anzahl pro Zeit:Zeitpunkt:XXX:Quantitativ:
es-MX Spanish (Mexico) Ritmo cardiaco:NRat:Punto temporal:No especificado:Cuantitativo:
es-AR Spanish (Argentina) latido cardíaco:índice numérico:punto en el tiempo:XXX:cuantitativo:
it-IT Italian (Italy) Frequenza cardiaca:NRat:Pt:XXX:Qn:
Synonyms: Frequenza cardiaca - atomica Indice numerico Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) hartslagfrequentie:aantal/tijd:moment:XXX:kwantitatief:
pt-BR Portuguese (Brazil) Frequência cardíaca:NRat:Pt:XXX:Qn:
Synonyms: ; nRate; Number rate; Count/time; Point in time; Random; Misc; Miscellaneous; Unspecified; Other; Quantitative; QNT; Quant; Quan; Pulse; Heart beat; HEART RATE.ATOM; HEART RATE.ATOM
ru-RU Russian (Russian Federation) Частота сердечных сокращений:КолСкор:ТчкВрм:XXX:Колич:
Synonyms: Количественный Количество скорость Точка во времени;Момент
zh-CN Chinese (China) 心率:计数型速率:时间点:XXX:定量型:
Synonyms: 一般心率 不明的;其他;将在相应消息内其他部分之中加以详细说明;未作详细说明的;未作说明的;未做说明的标本;未加规定的;未加说明的标本;杂项 单位时间内的数量或计数;数量/时间;数量型速率;数量型速率或计数型速率;数量型速率或计数型速率(单位时间);数量或计数型速率;计数/时间;计数型速率(单位时间);数量或计数型速率(单位时间) 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 心搏率;心跳速率 时刻;随机;随意;瞬间 速度

Example Units

Unit Source
{beats}/min;{counts/min} Example UCUM Units
bpm REGENSTRIEF

9279-1 Respiratory Rate (breaths/min)

Observation ID in Form

H8b

Fully-Specified Name

Component
Breaths
Property
NRat
Time
Pt
System
Respiratory system
Scale
Qn
Method

Additional Names

Short Name
Resp rate

Basic Attributes

Class
RESP.ATOM
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.73
Common Test Rank Get Info
12

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
55169-7 Data Elements for Emergency Department Systems (DEEDS) Release 1.0
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
75885-4 IEEE 11073 Rosetta panel
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
84428-2 National EMS Information System - version 3 set
87825-6 National Trauma Data Standard - version 2018 set
80346-0 Nursing physiologic assessment panel
74293-2 Oncology plan of care and summary - recommended CDA set
62611-9 PhenX domain - Respiratory
89694-4 Pulmonary Embolism Severity Index panel [PESI]
74028-2 Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS
34566-0 Vital signs with method details panel
72513-5 Vital signs with smoking status and pain scale [VSP]
34565-2 Vital signs, weight and height panel
67795-5 Vital signs, weight, height, head circumference and oximetry panel HITSP
74728-7 Vital signs, weight, height, head circumference, oximetry, BMI, and BSA panel
85353-1 Vital signs, weight, height, head circumference, oxygen saturation and BMI panel

Member of these Groups Get Info

LOINC Group Group Name
LG33054-4 Breaths|NRat|Pt|Chal:None

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Atemfrequenz
de-DE German (Germany) Atemfrequenz:Anzahl pro Zeit:Zeitpunkt:Respiratorisches System:Quantitativ:
es-MX Spanish (Mexico) Respiraciones:NRat:Punto temporal:Sistema respiratorio:Cuantitativo:
es-AR Spanish (Argentina) respiraciones:índice numérico:punto en el tiempo:aparato respiratorio:cuantitativo:
it-IT Italian (Italy) Respiri:NRat:Pt:Apparato respiratorio:Qn:
Synonyms: Indice numerico Punto nel tempo (episodio) Respiratorio - atomico
pt-BR Portuguese (Brazil) Respirações:NRat:Pt:Sistema Respiratório:Qn:
Synonyms: ; nRate; Number rate; Count/time; Point in time; Random; Lungs; Breathing; RS; Quantitative; QNT; Quant; Quan; Respiratory rate
ru-RU Russian (Russian Federation) Дыхание:КолСкор:ТчкВрм:Дыхательная система:Колич:
Synonyms: Количественный Количество скорость Точка во времени;Момент
zh-CN Chinese (China) 呼吸:计数型速率:时间点:呼吸系统:定量型:
Synonyms: 一般呼吸类指标;一般呼吸系统类指标;呼吸类指标.原子型 单位时间内的数量或计数;数量/时间;数量型速率;数量型速率或计数型速率;数量型速率或计数型速率(单位时间);数量或计数型速率;计数/时间;计数型速率(单位时间);数量或计数型速率(单位时间) 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 呼吸 呼吸类 呼吸类指标 呼吸系统 呼吸系统类 呼吸道标本(样品、样本);呼吸系统标本(样品、样本) 时刻;随机;随意;瞬间

Example Units

Unit Source
{breaths}/min;{counts/min} Example UCUM Units
/MIN REGENSTRIEF

8480-6 Systolic Blood Pressure (mm/Hg)

Observation ID in Form

H9b

Fully-Specified Name

Component
Intravascular systolic
Property
Pres
Time
Pt
System
Arterial system
Scale
Qn
Method

Additional Names

Short Name
BP sys

Basic Attributes

Class
BP.ATOM
Type
Clinical
First Released
Version 1.0h(3)
Last Updated
Version 2.73
Common Test Rank Get Info
3

Member of these Panels

LOINC Long Common Name
35094-2 Blood pressure panel
39294-4 Children's preventive health services attachment Set
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
86636-8 Family planning report - FPAR 2.0 set
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
94137-7 HEDIS 2020 Value Sets
96068-2 HEDIS MY 2020 Value Sets
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
84428-2 National EMS Information System - version 3 set
87825-6 National Trauma Data Standard - version 2018 set
74293-2 Oncology plan of care and summary - recommended CDA set
75854-0 PCORnet common data model set - version 1.0 [PCORnet]
85057-8 PCORnet Common Data Model set - version 3.0 [PCORnet]
62611-9 PhenX domain - Respiratory
89694-4 Pulmonary Embolism Severity Index panel [PESI]
100230-2 Routine prenatal assessment panel
55417-0 Short blood pressure panel
81671-0 Tissue perfusion assessment panel
74028-2 Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS
34566-0 Vital signs with method details panel
72513-5 Vital signs with smoking status and pain scale [VSP]
34565-2 Vital signs, weight and height panel
67795-5 Vital signs, weight, height, head circumference and oximetry panel HITSP
74728-7 Vital signs, weight, height, head circumference, oximetry, BMI, and BSA panel
85353-1 Vital signs, weight, height, head circumference, oxygen saturation and BMI panel
82611-5 Wearable device external physiologic monitoring panel

Member of these Groups Get Info

LOINC Group Group Name
LG33053-6 Intravascular systolic|Pres|Pt|Chal:None

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Blutdruck systolisch
de-DE German (Germany) Intravaskulär systolisch:Druck:Zeitpunkt:Arterielles System:Quantitativ:
es-AR Spanish (Argentina) sistólico intravascular:presión:punto en el tiempo:sistema arterial:cuantitativo:
es-MX Spanish (Mexico) Sistólica intravascular:Pres:Punto temporal:Sistema arterial:Cuantitativo:
fr-CA French (Canada) Intravasculaire systolique:Pression:Temps ponctuel:Système artériel:Quantitatif:
it-IT Italian (Italy) Sistolica intravascolare:Pres:Pt:Sistema arterioso:Qn:
Synonyms: Pressione Pressione arteriosa - atomica Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) intravasculaire systolische bloeddruk:druk:moment:arterieel vaatstelsel:kwantitatief:
pt-BR Portuguese (Brazil) Intravascular sistólica:Pres:Pt:Sistema arterial:Qn:
Synonyms: ; BP sys; Pressure; Point in time; Random; Art sys; Quantitative; QNT; Quant; Quan; IV; Intravenous; BLOOD PRESSURE MEASUREMENTS.ATOM; BLOOD PRESSURE MEASUREMENTS.ATOM; BP systolic; Blood pressure systolic; Sys BP; SBP
ru-RU Russian (Russian Federation) Интраваскулярный систолический:Давл:ТчкВрм:Артериальная система:Колич:
Synonyms: Давление Количественный Точка во времени;Момент
zh-CN Chinese (China) 血管内心脏收缩期:压力或压强:时间点:动脉系统:定量型:
Synonyms: 一般血压;血压.原子型;血压指标.原子型 压力;压强 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 时刻;随机;随意;瞬间 血管内收缩期;血管内心缩期 血管内的

Example Units

Unit Source
mm[Hg] Example UCUM Units
mm Hg REGENSTRIEF

8462-4 Diastolic Blood Pressure (mm/Hg)

Observation ID in Form

H9b

Fully-Specified Name

Component
Intravascular diastolic
Property
Pres
Time
Pt
System
Arterial system
Scale
Qn
Method

Additional Names

Short Name
BP dias

Basic Attributes

Class
BP.ATOM
Type
Clinical
First Released
Version 1.0h(2)
Last Updated
Version 2.73
Change Reason
Release 2.69: UnitsAndRange: Added missing delimiter;
Common Test Rank Get Info
2

Member of these Panels

LOINC Long Common Name
43152-8 Blood pressure device panel
35094-2 Blood pressure panel
39294-4 Children's preventive health services attachment Set
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
86636-8 Family planning report - FPAR 2.0 set
88677-0 German Interdisciplinary Association of Intensive Care and Emergency Care Medicine - recommended MIND protocol set
94137-7 HEDIS 2020 Value Sets
96068-2 HEDIS MY 2020 Value Sets
84429-0 Level 3 emergency medical services patient care report - recommended CDA R1 and R2 set
84428-2 National EMS Information System - version 3 set
74293-2 Oncology plan of care and summary - recommended CDA set
75854-0 PCORnet common data model set - version 1.0 [PCORnet]
85057-8 PCORnet Common Data Model set - version 3.0 [PCORnet]
62611-9 PhenX domain - Respiratory
100230-2 Routine prenatal assessment panel
55417-0 Short blood pressure panel
81671-0 Tissue perfusion assessment panel
74028-2 Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS
34566-0 Vital signs with method details panel
72513-5 Vital signs with smoking status and pain scale [VSP]
34565-2 Vital signs, weight and height panel
67795-5 Vital signs, weight, height, head circumference and oximetry panel HITSP
74728-7 Vital signs, weight, height, head circumference, oximetry, BMI, and BSA panel
85353-1 Vital signs, weight, height, head circumference, oxygen saturation and BMI panel
82611-5 Wearable device external physiologic monitoring panel

Member of these Groups Get Info

LOINC Group Group Name
LG33056-9 Intravascular diastolic|Pres|Pt|Chal:None

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Blutdruck diastolisch
de-DE German (Germany) Intravaskulär diastolisch:Druck:Zeitpunkt:Arterielles System:Quantitativ:
es-AR Spanish (Argentina) diastólico intravascular:presión:punto en el tiempo:sistema arterial:cuantitativo:
es-MX Spanish (Mexico) Diastólica intravascular:Pres:Punto temporal:Sistema arterial:Cuantitativo:
fr-CA French (Canada) Intravasculaire diastolique:Pression:Temps ponctuel:Système artériel:Quantitatif:
it-IT Italian (Italy) Diastolica intravascolare:Pres:Pt:Sistema arterioso:Qn:
Synonyms: Pressione Pressione arteriosa - atomica Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) intravasculaire diastolische bloeddruk:druk:moment:arterieel vaatstelsel:kwantitatief:
pt-BR Portuguese (Brazil) Intravascular diastólica:Pres:Pt:Sistema arterial:Qn:
Synonyms: ; BP dias; Dias; Diast; Pressure; Point in time; Random; Art sys; Quantitative; QNT; Quant; Quan; IV; Intravenous; Diastoli; BLOOD PRESSURE MEASUREMENTS.ATOM; BLOOD PRESSURE MEASUREMENTS.ATOM; Blood pressure diastolic; BP diastolic; Dias BP; DBP
ru-RU Russian (Russian Federation) Интраваскулярный диастолический:Давл:ТчкВрм:Артериальная система:Колич:
Synonyms: Внутрисосудистый диастолический Давление Количественный Точка во времени;Момент
zh-CN Chinese (China) 血管内心脏舒张期:压力或压强:时间点:动脉系统:定量型:
Synonyms: 一般血压;血压.原子型;血压指标.原子型 压力;压强 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 时刻;随机;随意;瞬间 血管内心舒期;血管内舒张期 血管内的

Example Units

Unit Source
mm[Hg] Example UCUM Units
mm Hg REGENSTRIEF

69344-0 Laboratory

Fully-Specified Name

Component
Laboratory - acute
Property
-
Time
Pt
System
^Patient
Scale
-
Method
CARE

Basic Attributes

Class
PANEL.SURVEY.CARE
Type
Surveys
First Released
Version 2.38
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

718-7 Hemogloblin (gm/dL)

Reference Information

Type Source Reference
Mapping Guidance Regenstrief Help This is the the code included in the CBC auto. It is NOT obtained via the automated counting but uses a chemistry method just like most other hemoglobins. Mapper’s Guide for the Top 2000 plus LOINC Laboratory Observations
Webcontent Lab Tests Online®Copyright Copyright © 2021 Lab Tests Online. All rights reserved. Hemoglobin

Observation ID in Form

H11b

Fully-Specified Name

Component
Hemoglobin
Property
MCnc
Time
Pt
System
Bld
Scale
Qn
Method

Additional Names

Short Name
Hgb Bld-mCnc
Display Name
Hemoglobin (Bld) [Mass/Vol]
Consumer Name Alpha Get Info
Hemoglobin, Blood

Basic Attributes

Class
HEM/BC
Type
Laboratory
First Released
Version 1.0
Last Updated
Version 2.73
Order vs. Observation
Both
Common Test Rank Get Info
17

Member of these Panels

LOINC Long Common Name
104076-5 Basic metabolic with hemoglobin and hematocrit panel - Blood
58410-2 CBC panel - Blood by Automated count
57021-8 CBC W Auto Differential panel - Blood
69742-5 CBC W Differential panel, method unspecified - Blood
57782-5 CBC W Ordered Manual Differential panel - Blood
57022-6 CBC W Reflex Manual Differential panel - Blood
39294-4 Children's preventive health services attachment Set
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
24361-8 Deprecated Hemogram, platelets & Differential panel in Blood
34527-2 Deprecated Hemogram, Platelets, Differential & Reticulocyte panel in Blood
67868-0 End Stage Renal Disease (ESRD) Medical Evidence Report, Medicare Entitlement AndOr Patient Registration - OMB CMS form 2728
48809-8 Erythrogram panel - Blood
70299-3 ESRD anemia management panel
24343-6 Gas and Carbon monoxide panel - Blood
24338-6 Gas panel - Blood
24360-0 Hemoglobin and Hematocrit panel - Blood
24317-0 Hemogram and platelets WO differential panel - Blood
24359-2 Hemogram without Platelets and with Manual Differential panel - Blood
24358-4 Hemogram without Platelets panel - Blood
24364-2 Obstetric 1996 panel - Serum and Blood
93340-8 PhenX - complete blood count protocol 220501
62611-9 PhenX domain - Respiratory
55429-5 Short blood count panel - Blood

Member of these Groups Get Info

LOINC Group Group Name
LG44868-4 Hemoglobin|Pt|Bld

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Hämoglobin:Massenkonzentration:Zeitpunkt:Blut:Quantitativ:
de-AT German (Austria) Synonyms: Hämoglobin
el-GR Greek (Greece) Αιμοσφαιρίνη:Συγκέντρωση μάζας:Χρονική στιγμή:Αίμα:Ποσοτική:
es-MX Spanish (Mexico) Hemoglobina:Concentración de masa:Punto temporal:Sangre:Cuantitativo:
es-AR Spanish (Argentina) hemoglobina:concentración de masa:punto en el tiempo:sangre:cuantitativo:
es-ES Spanish (Spain) Hemoglobina:Concentración de masa:Punto temporal:Sangre:Qn:
Synonyms: Cuantitativo
et-EE Estonian (Estonia) Hemoglobiin:MCnc:Pt:B:Qn:
Synonyms: Juhuslik Kvantitatiivne Veri
fr-CA French (Canada) Hémoglobine:Concentration de masse:Temps ponctuel:Sang:Quantitatif:
fr-FR French (France) Hémoglobine:Masse/Volume:Ponctuel:Sang:Numérique:
fr-BE French (Belgium) Hémoglobine:Concentration de masse:Temps ponctuel:Sang:Quantitatif:
Synonyms: Hb
it-IT Italian (Italy) Emoglobina:MCnc:Pt:Sangue:Qn:
Synonyms: Concentrazione di Massa Ematologia (coagulazione) conta differenziale Punto nel tempo (episodio) Sangue
ko-KR Korean (Korea, Republic Of) 혈색소:질량농도:검사시점:전혈:정량:
nl-NL Dutch (Netherlands) hemoglobine:massa/volume:moment:bloed:kwantitatief:
pl-PL Polish (Poland) Hemoglobina:stężenie masowe:punkt w czasie:krew:ilościowy:
pt-BR Portuguese (Brazil) Hemoglobina:MCnc:Pt:SgTotal:Qn:
Synonyms: ; Hgb; Hb; Haemoglobin; Mass concentration; Level; Point in time; Random; Blood; WB; Whole blood; Quantitative; QNT; Quant; Quan; HEMATOLOGY/CELL COUNTS; HEMATOLOGY/CELL COUNTS
ru-RU Russian (Russian Federation) Гемоглобин:МассКонц:ТчкВрм:Кр:Колич:
Synonyms: Количественный Кровь Массовая концентрация Точка во времени;Момент
tr-TR Turkish (Turkey) Hemoglobin:KütlKons:Zmlı:Kan:Kant:
uk-UA Ukrainian (Ukraine) Гемоглобін:Масова Концентрація:МоментЧасу:Кров:Кількісно:
Synonyms: Blood; Haemoglobin; Hb; HEMATOLOGY/CELL COUNTS; Hgb; Level; Mass concentration; Point in time; QNT; Quan; Quant; Quantitative; Random; UniversalLabOrders; WB; Whole blood
zh-CN Chinese (China) 血红蛋白:质量浓度:时间点:全血:定量型:
Synonyms: 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 时刻;随机;随意;瞬间 氧血红蛋白;血红朊;血红素;血色素 水平;浓度;质量浓度(单位体积) 血;血液 血液学/细胞计数;血液学与细胞计数

Example Units

Unit Source
g/dL Example UCUM Units
g/L REGENSTRIEF

20570-8 Hematocrit (%)

Part Descriptions

LP15101-6   Hematocrit
The volume of packed red blood cells in a blood sample. The volume is measured by centrifugation in a tube with graduated markings, or with automated blood cell counters. It is an indicator of erythrocyte status in disease. For example, in anemia the volume is low and in polycythemia it is high. Source: National Library of Medicine, MeSH 2006

Reference Information

Type Source Reference
Webcontent Lab Tests Online®Copyright Copyright © 2021 Lab Tests Online. All rights reserved. Hematocrit

Observation ID in Form

H12b

Fully-Specified Name

Component
Hematocrit
Property
VFr
Time
Pt
System
Bld
Scale
Qn
Method

Additional Names

Short Name
Hct VFr Bld
Display Name
Hematocrit (Bld) [Volume fraction]
Consumer Name Alpha Get Info
Hematocrit, Blood

Basic Attributes

Class
HEM/BC
Type
Laboratory
First Released
Version 1.0m
Last Updated
Version 2.73
Order vs. Observation
Both
Common Test Rank Get Info
40

Member of these Panels

LOINC Long Common Name
101655-9 Basic metabolic and hematocrit panel - Blood
104076-5 Basic metabolic with hemoglobin and hematocrit panel - Blood
69742-5 CBC W Differential panel, method unspecified - Blood
39294-4 Children's preventive health services attachment Set
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
24361-8 Deprecated Hemogram, platelets & Differential panel in Blood
34527-2 Deprecated Hemogram, Platelets, Differential & Reticulocyte panel in Blood
48809-8 Erythrogram panel - Blood
101866-2 Gas and electrolytes point of care panel - Venous blood
24360-0 Hemoglobin and Hematocrit panel - Blood
24317-0 Hemogram and platelets WO differential panel - Blood
24359-2 Hemogram without Platelets and with Manual Differential panel - Blood
24358-4 Hemogram without Platelets panel - Blood
75885-4 IEEE 11073 Rosetta panel
55429-5 Short blood count panel - Blood

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Hämatokrit
de-DE German (Germany) Hämatokrit:Volumenfraktion:Zeitpunkt:Blut:Quantitativ:
el-GR Greek (Greece) Αιματοκρίτης:Κλάσμα όγκου:Χρονική στιγμή:Αίμα:Ποσοτική:
es-MX Spanish (Mexico) Hematocrito:Fracción de volumen:Punto temporal:Sangre:Cuantitativo:
es-AR Spanish (Argentina) hematócrito:fracción de volumen:punto en el tiempo:sangre:cuantitativo:
es-ES Spanish (Spain) Hematocrito:Fracción de volumen:Punto temporal:Sangre:Qn:
Synonyms: Cuantitativo
et-EE Estonian (Estonia) Hematokrit:VFr:Pt:B:Qn:
Synonyms: Juhuslik Kvantitatiivne Mahu fraktsioon Veri
fr-CA French (Canada) Hématocrite:Fraction volumique:Temps ponctuel:Sang:Quantitatif:
fr-FR French (France) Hématocrite:Fraction volumique:Ponctuel:Sang:Numérique:
fr-BE French (Belgium) Hématocrite:Fraction volumique:Temps ponctuel:Sang:Quantitatif:
it-IT Italian (Italy) Ematocrito:VFr:Pt:Sangue:Qn:
Synonyms: Ematologia (coagulazione) conta differenziale Frazione di Volume Punto nel tempo (episodio) Sangue
ko-KR Korean (Korea, Republic Of) 적혈구용적률:부피 분획:검사시점:전혈:정량:
nl-NL Dutch (Netherlands) hematocriet:volumefractie:moment:bloed:kwantitatief:
pt-BR Portuguese (Brazil) Hematócrito:VFr:Pt:SgTotal:Qn:
Synonyms: ; Hct; PCV; Fr; Volume fraction; Volfr; Percent; Point in time; Random; Blood; WB; Whole blood; Quantitative; QNT; Quant; Quan; HEMATOLOGY/CELL COUNTS; HEMATOLOGY/CELL COUNTS
ru-RU Russian (Russian Federation) Гематокрит:ОбФр:ТчкВрм:Кр:Колич:
Synonyms: Количественный Кровь Объемная фракция Точка во времени;Момент
tr-TR Turkish (Turkey) Hematokrit:HcmFr:Zmlı:Kan:Kant:
uk-UA Ukrainian (Ukraine) Гематокрит:Об'ємна Фракція:МоментЧасу:Кров:Кількісно:
Synonyms: Blood; Hct; HEMATOLOGY/CELL COUNTS; PCV; Percent; Point in time; QNT; Quan; Quant; Quantitative; Random; UniversalLabOrders; Volfr; Volume fraction; WB; Whole blood
zh-CN Chinese (China) 血细胞压积:体积分数:时间点:全血:定量型:
Synonyms: HCT;红细胞压积;红细胞容量;红细胞比容;红细胞比率;红细胞比积;血球比率;血细胞容量;血细胞比容;血细胞比积 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 容积分数 时刻;随机;随意;瞬间 血;血液 血液学/细胞计数;血液学与细胞计数

Example Units

Unit Source
% Example UCUM Units
% REGENSTRIEF

26464-8 WBC (K/mm3)

Part Descriptions

LP14419-3   Leukocytes
Leukocytes or white blood cells (WBCs) are immune cells that fight infection, neoplasms and other inflammatory conditions, and mediate allergic responses. There are five types of WBCs normally present in the circulation that are all derived from a similar stem cell in the bone marrow. The five type of WBCs are divided into two groups based on the presence or absence of granules in the cytoplasm. The granulocytes include the neutrophils, basophils and eosinophils. The non-granulocytes include the lymphocytes and the monocytes. The neutrophils fight infection by ingesting and digesting bacteria. Eosinophils and basophils respond to allergic reactions and are capable of ingesting antigen-antibody complexes. Monocytes phagocytose bacteria and release interferon to stimulate the immune system. Lymphocytes are divided into T-cells and B-cells. T-cell immunity is cellular and involves the activation of phagocytes and B-cell immunity uses antibodies to fight infection. Both elevated and low leukocyte counts can be markers of infection and malignancy, and low leukocyte counts are associated with a variety of primary and secondary immunodeficiencies, depending on the WBC type(s) that are out of range. (Mosby's manual of diagnostic and laboratory tests, Kathleen Deska Pagana; Timothy James Pagana, Elsevier St. Louis, Mo ©2010) Source: Regenstrief LOINC

Reference Information

Type Source Reference
Mapping Guidance Regenstrief Help Most leukocyte counts will be done by an automated counter and will be reported under [LOINC: 6690-2]. This term should be used only rarely. Mapper’s Guide for the Top 2000 plus LOINC Laboratory Observations
Webcontent Lab Tests Online®Copyright Copyright © 2021 Lab Tests Online. All rights reserved. White Blood Cell Count (WBC)

Observation ID in Form

H13b

Fully-Specified Name

Component
Leukocytes
Property
NCnc
Time
Pt
System
Bld
Scale
Qn
Method

Additional Names

Short Name
WBC # Bld
Display Name
WBC (Bld) [#/Vol]
Consumer Name Alpha Get Info
White blood cell (WBC) count, Blood

Basic Attributes

Class
HEM/BC
Type
Laboratory
First Released
Version 2.00
Last Updated
Version 2.73
Change Reason
Changed Order_Obs from 'Observation Only' to fit the current order use cases.
Order vs. Observation
Both
Common Test Rank Get Info
68

Member of these Panels

LOINC Long Common Name
69742-5 CBC W Differential panel, method unspecified - Blood
57782-5 CBC W Ordered Manual Differential panel - Blood
57022-6 CBC W Reflex Manual Differential panel - Blood
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
24361-8 Deprecated Hemogram, platelets & Differential panel in Blood
34527-2 Deprecated Hemogram, Platelets, Differential & Reticulocyte panel in Blood
69738-3 Differential panel, method unspecified - Blood
24317-0 Hemogram and platelets WO differential panel - Blood
24359-2 Hemogram without Platelets and with Manual Differential panel - Blood
24358-4 Hemogram without Platelets panel - Blood
48808-0 Leukogram panel - Blood
24318-8 Manual Differential panel - Blood
55429-5 Short blood count panel - Blood

Member of these Groups Get Info

LOINC Group Group Name
LG32857-1 Leukocytes|NCnc|Pt|Bld

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Leukozyten
de-DE German (Germany) Leukozyten:Anzahl pro Volumen:Zeitpunkt:Blut:Quantitativ:
el-GR Greek (Greece) Λευκοκύτταρα:Αριθμητική συγκέντρωση:Χρονική στιγμή:Αίμα:Ποσοτική:
es-MX Spanish (Mexico) Leucocitos:Concentración numérica:Punto temporal:Sangre:Cuantitativo:
es-AR Spanish (Argentina) leucocitos:concentración de número:punto en el tiempo:sangre:cuantitativo:
es-ES Spanish (Spain) Leucocitos:Concentración de número:Punto temporal:Sangre:Qn:
Synonyms: Cuantitativo
et-EE Estonian (Estonia) Leukotsüüdid:NCnc:Pt:B:Qn:
Synonyms: Juhuslik Kvantitatiivne Veri
fr-CA French (Canada) Leucocytes:Concentration numérique:Temps ponctuel:Sang:Quantitatif:
fr-FR French (France) Leucocytes:Nombre/Volume:Ponctuel:Sang:Numérique:
fr-BE French (Belgium) Leucocytes:Concentration numérique:Temps ponctuel:Sang:Quantitatif:
it-IT Italian (Italy) Leucociti:NCnc:Pt:Sangue:Qn:
Synonyms: Concentrazione Numerica Ematologia (coagulazione) conta differenziale Punto nel tempo (episodio) Sangue
ko-KR Korean (Korea, Republic Of) 백혈구:계수/부피:검사시점:전혈:정량:
nl-NL Dutch (Netherlands) leukocyten:aantal/volume:moment:bloed:kwantitatief:
pl-PL Polish (Poland) Leukocyty:stężenie liczbowe:punkt w czasie:krew:ilościowy:
Synonyms: koncentracja Leukocyty
pt-BR Portuguese (Brazil) Leucócitos:NCnc:Pt:SgTotal:Qn:
Synonyms: ; Leucoc; White blood cell; Leuc; Leuk; Leukocyte; Lkcs; White blood cells; Leucocs; #; Number concentration; Count/mass; Count; AcS; CT; Acsolute; Acsolutes; Cnt; Point in time; Random; Blood; WB; Whole blood; Quantitative; QNT; Quant; Quan; HEMATOLOGY/CELL COUNTS; HEMATOLOGY/CELL COUNTS
ru-RU Russian (Russian Federation) Лейкоциты:КолОб:ТчкВрм:Кр:Колич:
Synonyms: Количественный Количество в объеме Кровь Точка во времени;Момент
tr-TR Turkish (Turkey) Lökositler:SayKons:Zmlı:Kan:Kant:
uk-UA Ukrainian (Ukraine) Лейкоцити:Чисельна Концентрація:МоментЧасу:Кров:Кількісно:
Synonyms: #; ABS; absolute; absolutes; Blood; Cnt; Count; Count/volume; CT; HEMATOLOGY/CELL COUNTS; Leuc; Leuk; Leukocyte; Lkcs; Number concentration; Number Concentration (count/vol); Point in time; QNT; Quan; Quant; Quantitative; Random; UniversalLabOrders; WB; WBC; WBCs; White blood cell; White blood cells; Whole blood
zh-CN Chinese (China) 白细胞:计数型浓度:时间点:全血:定量型:
Synonyms: Leuc;Leuk;Lkcs;WBC;WBCs;白细胞;White blood cell;WBC;白细胞类;白细胞类髓系细胞;白血球;白血细胞;白细胞数 单位体积内的数量或计数;数量型浓度(单位体积);数量或计数型浓度(计数/体积);数量或计数型浓度(单位体积);计数型浓度(单位体积) 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 时刻;随机;随意;瞬间 血;血液 血液学/细胞计数;血液学与细胞计数

Example Units

Unit Source
10*3/uL Example UCUM Units
k/cumm REGENSTRIEF

4548-4 HbA1c (%)

Part Descriptions

LP16413-4   Hemoglobin A1c
Currently (2010), four standardization protocols exist for measuring Hgb A1c:

1. IFCC - designated as a Reference Method or RM (http://www.ifcchba1c.net/)
2. NGSP - the long standing protocol used in the US and most other countries since the DCCT study (http://www.ngsp.org/factors.asp)
3.JDS/JSCC - a protocol used in Japan, Spain and possibly other countries
4. Swedish - used in Sweden at least

Protocols 2-4 are known as Designated Comparison Methods (DCM) and have been connected to the Reference Method and each other through various regression equations.

Because of the high degrees of standardization within protocol it should no longer be necessary to specify a LOINC code with a method such as "HPLC", "electrophoresis" or anything else. Analytical instruments will be designed so that an Hgb A1c result can be traced back to a specific standardization protocol, so the important distinction will be the standardization protocol as described above and which will be carried in the method field.

A meeting of instrument manufacturers (presumably including Japanese) in Milan, Italy, December 12, 2007, agreed (among other items) that:

-All manufacturers should implement worldwide the traceability to the IFCC reference system for Hgb -A1c.
-All new instruments sold after January 1st, 2011 will report (as a result of an Hgb A1c test) both SI (mmol/mol - no decimals) and NGSP derived units (percentage - one decimal), in agreement with the Consensus Statement.
-Note they only committed to supporting protocol (1) and (2)

Different countries are adopting the international harmonization recommendations in different ways. We have information from the NGSP that the US will continue to report only Hgb A1c/NGSP, with the unit percent - i.e., no change. In Great Britain, labs have already started to report all results both as Hgb A1c (NGSP) in % and Hgb A1c (IFCC) in mmol/mol. In Canada, they are awaiting a recommendation from an expert panel. Any of these measures could be reported in the same units, but the convention for the reporting Hgb A1c under the new IFCC protocol will be to use units of mmol/mol to avoid confusion between the DCCT/NGSP and the IFFCC protocol.

LOINC has defined 59261-8 (Hemoglobin A1c/Hemoglobin.total in Blood) by IFCC protocol.

These protocols produce different results when expressed in the same units. For example, the equivalent of Hgb A1c (NGSP) of 6.5% is Hgb A1c (IFCC) is 4.8%.

The NGSP web site (http://www.ngsp.org/factors.asp) suggests the use of alternate measures, such as glycated albumen, for patients with severe iron deficiency, dialysis patients, and those with SS SC CC because of over or under reading that can occur with these interferences. It also describes the effect of abnormal hemoglobins on results of HbA1c by instrument.

Studies have demonstrated racial and ethnic differences in the relationship between glucose levels and hemoglobin A1C [22238408], and it has been suggested that some descendants of sub-Saharan Africa may have higher levels of measured hemoglobin A1C compared to glucose levels due to hemoglobin variants PMID: 31675503. Source: Regenstrief Help

Reference Information

Type Source Reference
Mapping Guidance Regenstrief Help Today, all US HbA1c measurements reported in the US and many other countries are standardized to the NGSP protocol and that has been true for years. This code [LOINC: 4548-4] should be used for reporting the HbA1c in the US. Other countries may report HbA1c measured by the IFCC protocol [LOINC: 59261-8], a protocol with results reported in units of mmol/mol. In Japan and parts of Spain it may be measured using the Japanese protocol. All three protocols produce different numeric values. Mapper’s Guide for the Top 2000 plus LOINC Laboratory Observations
Webcontent Lab Tests Online®Copyright Copyright © 2021 Lab Tests Online. All rights reserved. Hemoglobin A1c

Observation ID in Form

H14b

Fully-Specified Name

Component
Hemoglobin A1c/Hemoglobin.total
Property
MFr
Time
Pt
System
Bld
Scale
Qn
Method

Additional Names

Short Name
HbA1c MFr Bld
Display Name
HbA1c (Bld) [Mass fraction]
Consumer Name Alpha Get Info
HbA1c/Total Hgb, Blood

Basic Attributes

Class
CHEM
Type
Laboratory
First Released
Version 1.0
Last Updated
Version 2.73
Change Reason
Release 2.70: CLASS: Changed Class from HEM/BC to CHEM as A1C tests are more correctly classified in CHEM.; Previous Releases: Changing from the property from Mass fraction to substance fraction has not effect on the meaning when the molecular weight of the numerator and the denominator are the same (for practical purposes). These terms had had a property of MFR in the past and we changed to SFR because we thought the LOINC community preferred SFR for HbA1c. But we mis understood the preference is to use the MFR variant- so we have changed back.
Order vs. Observation
Both
Common Test Rank Get Info
88

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
55399-0 Diabetes tracking panel
67868-0 End Stage Renal Disease (ESRD) Medical Evidence Report, Medicare Entitlement AndOr Patient Registration - OMB CMS form 2728
54037-7 HEDIS 2009 panel
57820-3 HEDIS 2010 panel
60442-1 HEDIS 2011 panel
67767-4 HEDIS 2012 panel
72199-3 HEDIS 2013 panel
74234-6 HEDIS 2014 Value Sets
75868-0 HEDIS 2015 Value Sets
79544-3 HEDIS 2016 Value Sets
82955-6 HEDIS 2017 Value Sets
87625-0 HEDIS 2018 Value Sets
90766-7 HEDIS 2019 Value Sets
94137-7 HEDIS 2020 Value Sets
96068-2 HEDIS MY 2020 Value Sets
43150-2 Hemoglobin A1c measurement device panel

Member of these Groups Get Info

LOINC Group Group Name
LG51070-7 Hemoglobin A1c/Hemoglobin.total|MFr|Pt|ANYBldSerPl

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Hämoglobin A1c/Hämoglobin.gesamt:Massenfraktion:Zeitpunkt:Blut:Quantitativ:
Synonyms: HbA1c
de-AT German (Austria) Synonyms: Hämoglobin A1c
es-MX Spanish (Mexico) Hemoglobina A1c / Hemoglobina total:Fracción de masa:Punto temporal:Sangre:Cuantitativo:
es-AR Spanish (Argentina) hemoglobina A1c/hemoglobina.total:fracción de masa:punto en el tiempo:sangre:cuantitativo:
es-ES Spanish (Spain) Hemoglobina A1c (Hemoglobina glicosilada)/Hemoglobina.total:Fracción de masa:Punto temporal:Sangre:Qn:
Synonyms: Cuantitativo
et-EE Estonian (Estonia) Hemoglobiin A1c/hemoglobiin.üld:MFr:Pt:B:Qn:
Synonyms: Glükohemoglobiin Juhuslik Kvantitatiivne Veri
fr-CA French (Canada) Hémoglobine A1c/Hémoglobine.totale:Fraction de masse:Temps ponctuel:Sang:Quantitatif:
fr-FR French (France) Hémoglobine A1c/hémoglobine totale:Fraction massique:Ponctuel:Sang:Numérique:
fr-BE French (Belgium) Hémoglobine A1c/Hémoglobine.totale:Fraction de masse:Temps ponctuel:Sang:Quantitatif:
Synonyms: Hb Hb.totale HbA1c
it-IT Italian (Italy) Emoglobina A1c/Emoglobina.totale:MFr:Pt:Sangue:Qn:
Synonyms: Chimica Emoglobina A1c (HgB glicata ) Frazione di massa Punto nel tempo (episodio) Sangue
ko-KR Korean (Korea, Republic Of) 혈색소 A1C/총혈색소:질량분획:검사시점:전혈:정량:
nl-NL Dutch (Netherlands) hemoglobine A1c/hemoglobine.totaal:massafractie:moment:bloed:kwantitatief:
pl-PL Polish (Poland) Hemoglobina A1c/hemoglobina całkowita:frakcja masowa:punkt w czasie:krew:ilościowy:
Synonyms: Hemoglobina A1c/Hemoglobina całkowita
pt-BR Portuguese (Brazil) Hemoglobina A1c/Hemoglobina.total:SFr:Pt:SgTotal:Qn:
Synonyms: ; Hgb A1c; Glycohemogolobin; Glycohaemogolobin; GHb; HA1c; HBA1c; Glycated hemoglobin; Glycosylated hemoglobin; Hb; Haemoglobin; Substance fraction; Percent; Point in time; Random; Blood; WB; Whole blood; Quantitative; QNT; Quant; Quan; Tot; Totl; HEMATOLOGY/CELL COUNTS; HEMATOLOGY/CELL COUNTS
ru-RU Russian (Russian Federation) Гемоглобин А1с/Гемоглобин.общий:МассДол:ТчкВрм:Кр:Колич:
Synonyms: Количественный Кровь Массовая доля Точка во времени;Момент
tr-TR Turkish (Turkey) Hemoglobin A1c/Hemoglobin.total:KütlFr:Zmlı:Kan:Kant:
uk-UA Ukrainian (Ukraine) Гемоглобін A1c/Гемоглобін загальний:Масова Фракція:МоментЧасу:Кров:Кількісно:
Synonyms: Blood; Chemistry; Endocrine; Endocrinology; GHb; Glycated hemoglobin; Glycohaemogolobin; Glycohemogolobin; Glycosylated hemoglobin; HA1c; Haemoglobin; Hb; HbA1c; Hgb; Hgb A1c; Mass fraction; Percent; Point in time; QNT; Quan; Quant; Quantitative; Random; Tot; Totl; WB; Whole blood
zh-CN Chinese (China) 血红蛋白 A1c/血红蛋白.总计:质量分数:时间点:全血:定量型:
Synonyms: GHb;HA1c;HBA1c;Hgb A1c;糖化血红蛋白;糖基化血红蛋白;血红蛋白 A1c (糖化血红蛋白) MFr 全体数量 全部 共计 化学;化学检验项目;化学检验项目类;化学类;化学试验;非刺激耐受型化学检验项目;非刺激耐受型化学检验项目类;非刺激耐受型化学试验;非刺激耐受型化学试验类 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 总 总和 总数 总血红蛋白 总量 总额 时刻;随机;随意;瞬间 氧血红蛋白;血红朊;血红素;血色素 汇总 血;血液

Example Units

Unit Source
% Example UCUM Units
% Hgb REGENSTRIEF

52483-5 Other

Fully-Specified Name

Component
Other
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

10230-1 Left Ventricular Ejection Fraction (%)

Part Descriptions

LP35012-1   Ejection fraction
In cardiovascular physiology, ejection fraction (Ef) is the fraction of blood pumped out of a ventricle with each heart beat. The term ejection fraction applies to both the right and left ventricles; one can speak equally of the left ventricular ejection fraction (LVEF) and the right ventricular ejection fraction (RVEF). Without a qualifier, the term ejection fraction refers specifically to that of the left ventricle. Copyright Text is available under the Creative Commons Attribution/Share-Alike License. See http://creativecommons.org/licenses/by-sa/3.0/ for details. Source: Wikipedia, Ejection fraction (Wikipedia)

Observation ID in Form

H22b

Form Coding Instructions

This or prior setting acceptable

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Ejection fraction
Property
VFr
Time
Pt
System
Heart.ventricle.left
Scale
Qn
Method

Additional Names

Short Name
LV EF

Basic Attributes

Class
HEMODYN.MOLEC
Type
Clinical
First Released
Version 1.0i
Last Updated
Version 2.73
Common Test Rank Get Info
1325

Formula (Readable)

Ejection fraction=[(LV end-diastolic volume-LV end-systolic volume)/LV end-diastolic volume]*100

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
55405-5 Heart failure tracking panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Fracción de eyección:VFr:Punto temporal:Corazón.ventrículo.izquierdo:Cuantitativo:
es-AR Spanish (Argentina) fracción de eyección:relación de volumen:punto en el tiempo:corazón.ventrículo.izquierdo:cuantitativo:
fr-FR French (France) Fraction d'éjection:Fraction volumique:Ponctuel:Ventricule gauche:Numérique:
it-IT Italian (Italy) Frazione di eiezione:VFr:Pt:Cuore.ventricolo.sinistro:Qn:
Synonyms: Emodinamica - molecolare FE Frazione di Volume Punto nel tempo (episodio) Ventricolo cardiaco Ventricolo cardiaco Sinistro
pt-BR Portuguese (Brazil) Fração de ejeção:VFr:Pt:Coração.ventrículo.esquerdo:Qn:
Synonyms: ; EF; Fr; Volume fraction; Volfr; Percent; Point in time; Random; LV; Vent; Ventricular; Hrt; Cardiac; Quantitative; QNT; Quant; Quan; Frac; Fract; Fractionation; Fractions; HEMODYNAMICS.MOLEC; HEMODYNAMICS.MOLEC; LVEF
ru-RU Russian (Russian Federation) Выброса фракция:ОбФр:ТчкВрм:Сердце.желудочек.левый:Колич:
Synonyms: Количественный Объемная фракция Точка во времени;Момент Фракция выброса
zh-CN Chinese (China) 射血分数:体积分数:时间点:心脏.心室.左侧:定量型:
Synonyms: EF;喷血分数 L LT 分数 分数类 分级 分级分离 分部分离 分馏 分馏(Fractionation) 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 向左 向左侧 容积分数 左 左侧(Left,LT,L) 左向 左心室;心.室.左侧;心.心室.左侧;心脏.室.左侧 左边 心 心.室;心.心室;心室;心脏.室 时刻;随机;随意;瞬间 特殊血流动力学;特殊血液动力学;血液动力学.分子型 精馏 组份(Fraction) 组份类 组份类(Fractions) 组分 组分类 血液动力学 部分 部分类 馏分 馏分类

Example Units

Unit Source
% Example UCUM Units

52484-3 Arterial Blood Gases (ABGs)

Fully-Specified Name

Component
Arterial Blood Gases (ABGs)
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52593-1 Please specify source and amount of supplemental O2

Term Description

e.g. room air, nasal cannula, trach collar
Source: Regenstrief LOINC

Observation ID in Form

H23d

Fully-Specified Name

Component
Oxygen therapy source and amount
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

Survey Question

Text
Please specify source and amount of supplemental O2
Source
CARE I.h23d

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

2744-1 pH of Arterial blood

Part Descriptions

LP14752-7   pH
pH is a measure of the acidity or basicity of a solution. It is defined as the cologarithm of dissolved hydrogen ions (H+). Hydrogen ion activity coefficients cannot be measured experimentally, so they are based on theoretical calculations. The pH scale is not an absolute one, it is relative to a set of internationally established standard solutions. pH 7.0 is considered neutral. Copyright Text is available under the Creative Commons Attribution/Share-Alike License. See http://creativecommons.org/licenses/by-sa/3.0/ for details. Source: Wikipedia, pH

LP14752-7   pH
Potentia Hydrogenii, commonly known as pH, is a quantitative measurement of the acidity or basicity of a substance. A substance's pH value is based on a relative scale from 1-14 depending on the substance's proton ion concentration (H+). A higher proton ion concentration results in a lower pH value. Therefore, a pH value between 0 and 7 is an acidic substance whereas a pH value between 7 and 14 is an alkaline/basic substance. A pH value of exactly 7 is a neutral substance. [https://labtestsonline.org/understanding/analytes/SearchForm?Search=pH&action_ProcessSphinxSearchForm=Go] The specific pH value of the blood is crucial in maintaining bodily functions. When the blood pH value is below normal range it is called acidosis. When the blood pH value is above normal range, it is called alkadosis. Acidosis/alkadosis can be divided into two categories: metabolic and respiratory. [https://labtestsonline.org/understanding/analytes/blood-gases/tab/test/] Source: Regenstrief LOINC

Observation ID in Form

H24b

Fully-Specified Name

Component
pH
Property
LsCnc
Time
Pt
System
BldA
Scale
SemiQn
Method

Additional Names

Short Name
pH BldA
Display Name
pH (BldA)
Consumer Name Alpha Get Info
pH, Blood

Basic Attributes

Class
CHEM
Type
Laboratory
First Released
Version 1.0
Last Updated
Version 2.75
Order vs. Observation
Both
Common Test Rank Get Info
184

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
100847-3 Gas and ammonia panel - Arterial blood
93685-6 Gas and Carbon monoxide and Electrolytes panel - Arterial blood
24341-0 Gas and Carbon monoxide panel - Arterial blood
99548-0 Gas and electrolytes panel - Arterial blood
104074-0 Gas and Lactate panel - Arterial blood
24336-0 Gas panel - Arterial blood
75885-4 IEEE 11073 Rosetta panel
62611-9 PhenX domain - Respiratory

Member of these Groups Get Info

LOINC Group Group Name
LG345-5 pH|LsCnc|Pt|ANYBldSerPl

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) pH:Logarithmische Stoffmengenkonzentration:Zeitpunkt:Blut arteriell:Semiquantitativ:
Synonyms: pH-Wert
de-AT German (Austria) Synonyms: pH art.
es-MX Spanish (Mexico) pH:Concentración logarítmica molar:Punto temporal:Sangre arterial:Cuantitativo:
es-AR Spanish (Argentina) pH:concentración de sustancia:punto en el tiempo:sangre arterial:cuantitativo:
es-ES Spanish (Spain) pH:LsCnc:Punto temporal:Sangre arterial:Semicuantitativo:
Synonyms: Semicuantitativo
fr-FR French (France) pH:Log de concentration:Ponctuel:Sang artériel:Semi-Quantitatif:
fr-CA French (Canada) pH:LsCnc:Temps ponctuel:Sang artériel:SemiQn:
it-IT Italian (Italy) pH:LsCnc:Pt:Sangue art:SemiQn:
Synonyms: Chimica Logaritmo della concentrazione molare Punto nel tempo (episodio) Sangue arterioso
ko-KR Korean (Korea, Republic Of) pH:물질농도:검사시점:동맥혈:정량:
nl-NL Dutch (Netherlands) pH:logaritmische molaire concentratie:moment:arterieel bloed:semikwantitatief:
pl-PL Polish (Poland) PH:stężenie logarytmowo-molowe:punkt w czasie:krew tętnicza:półilościowy:
pt-BR Portuguese (Brazil) pH:LsCnc:Pt:SgArt:Qn:
Synonyms: Log molar concentration; Point in time; Random; Blood; Blood arterial; ART; Bld art; Bld arterial; Blood art; Art blood; Art bld; AcG; Quantitative; QNT; Quant; Quan; Chemistry
zh-CN Chinese (China) pH:对数型物质的量浓度:时间点:动脉全血:半定量型:
Synonyms: 动脉血 化学;化学检验项目;化学检验项目类;化学类;化学试验;非刺激耐受型化学检验项目;非刺激耐受型化学检验项目类;非刺激耐受型化学试验;非刺激耐受型化学试验类 对数型克分子浓度;对数型克分子浓度(单位体积);对数型摩尔浓度;对数型摩尔浓度(单位体积);对数型物质的量浓度(单位体积) 时刻;随机;随意;瞬间 氢指数;氢离子指数;氢离子浓度;氢离子浓度倒数的对数;酸度;酸碱值;酸碱度

Example Units

Unit Source
[pH] Example UCUM Units

2019-8 PaCO2 (mm/Hg)

Part Descriptions

LP15150-3   Carbon dioxide
CO2 content is a measurement of total CO2 in the blood. Most of it is in the form of bicarbonate (HCO3) controlled by the kidney. A small amount (5%) of CO2 is dissolved in the blood as insoluble carbonic acid (H2CO3). Changes in CO2 content generally relate to metabolic issues, renal function and unusual losses (diarrhea). Respiratory disease can ultimately effect CO2 content, but only slightly and only if prolonged. (Operational Medicine 2001, Arterial Blood Gas, Brookside Associates Medical Education Division) Source: Regenstrief Institute

Observation ID in Form

H25b

Fully-Specified Name

Component
Carbon dioxide
Property
PPres
Time
Pt
System
BldA
Scale
Qn
Method

Additional Names

Short Name
pCO2 BldA
Display Name
CO2 (BldA) [Partial pressure]
Consumer Name Alpha Get Info
Carbon Dioxide (CO2), Blood

Basic Attributes

Class
CHEM
Type
Laboratory
First Released
Version 1.0
Last Updated
Version 2.73
Order vs. Observation
Both
Common Test Rank Get Info
179

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
100847-3 Gas and ammonia panel - Arterial blood
93685-6 Gas and Carbon monoxide and Electrolytes panel - Arterial blood
24341-0 Gas and Carbon monoxide panel - Arterial blood
99548-0 Gas and electrolytes panel - Arterial blood
104074-0 Gas and Lactate panel - Arterial blood
24336-0 Gas panel - Arterial blood
75885-4 IEEE 11073 Rosetta panel
62611-9 PhenX domain - Respiratory

Member of these Groups Get Info

LOINC Group Group Name
LG344-8 Carbon dioxide|PPres|Pt|ANYBldSerPl

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: pCO2 art.
de-DE German (Germany) Kohlenstoffdioxid:Partialdruck:Zeitpunkt:Blut arteriell:Quantitativ:
es-MX Spanish (Mexico) Dióxido de carbono:Presión parcial:Punto temporal:Sangre arterial:Cuantitativo:
es-AR Spanish (Argentina) dióxido de carbono:presión (parcial):punto en el tiempo:sangre arterial:cuantitativo:
es-ES Spanish (Spain) Dioxido de carbono:Presión parcial:Punto temporal:Sangre arterial:Qn:
Synonyms: Cuantitativo
et-EE Estonian (Estonia) Süsinikdioksiid:PPres:Pt:aB:Qn:
Synonyms: Arteriaalne veri Juhuslik Kvantitatiivne Osarõhk
fr-CA French (Canada) Dioxyde de carbone:Pression partielle:Temps ponctuel:Sang artériel:Quantitatif:
fr-FR French (France) Carbone dioxyde:Pression partielle:Ponctuel:Sang artériel:Numérique:
fr-BE French (Belgium) Dioxyde de carbone:Pression partielle:Temps ponctuel:Sang artériel:Quantitatif:
Synonyms: CO2
it-IT Italian (Italy) Diossido di carbonio:PPres:Pt:Sangue art:Qn:
Synonyms: Biossido di carbonio Chimica Pressione parziale Punto nel tempo (episodio) Sangue arterioso
ko-KR Korean (Korea, Republic Of) 이산화 탄소:분압:검사시점:동맥혈:정량:
nl-NL Dutch (Netherlands) koolstofdioxide:partiële druk:moment:arterieel bloed:kwantitatief:
pt-BR Portuguese (Brazil) Dióxido de carbono:PPres:Pt:SgArt:Qn:
Synonyms: ; CO2; Carbonic anhydride; Partial pressure; Point in time; Random; Blood; Blood arterial; ART; Bld art; Bld arterial; Blood art; Art blood; Art bld; AcG; Quantitative; QNT; Quant; Quan; Chemistry; PCO2; PaCO2
ru-RU Russian (Russian Federation) Углерода диоксид:ПарцД:ТчкВрм:КрА:Колич:
Synonyms: Количественный Кровь артериальная Парциальное давление Точка во времени;Момент Углекислый газ
tr-TR Turkish (Turkey) Karbon dioksit:PBsnç:Zmlı:KanArt:Kant:
zh-CN Chinese (China) 二氧化碳:分压:时间点:动脉全血:定量型:
Synonyms: cCO2;CO2;CO2CT;ctCO2;tCO2;TOTAL CO2;总 CO2;总二氧化碳;碳酐;碳酸酐 CO2分压 PaCO2 PCO2 分压力;分压强;局部压力;气体分压;部分压力;局部压应力;压力(局部性);压力(部分的);压力或压强(局部性);压力或压强(部分的);压强(局部性);压强(部分的) 动脉血 动脉血CO2分压 化学;化学检验项目;化学检验项目类;化学类;化学试验;非刺激耐受型化学检验项目;非刺激耐受型化学检验项目类;非刺激耐受型化学试验;非刺激耐受型化学试验类 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 时刻;随机;随意;瞬间

Example Units

Unit Source
mm[Hg] Example UCUM Units
mm Hg REGENSTRIEF

1960-4 HCO3 (mEq/L)

Part Descriptions

LP15441-6   Bicarbonate
Bicarbonate is an electrolyte and typically measured along with other electrolytes (e.g. sodium, potassium, and chloride) to detect, evaluate, and monitor electrolyte imbalances. Low bicarbonate levels may occur in patients with Addison's disease, chronic diarrhea, diabetic ketoacidosis, and kidney disease. Increased levels may be seen in patients with severe vomiting, cushing syndrome, and metabolic alkalosis. Various drugs may also increase or decrease biocarbonate levels.[Lab Tests Online: co2]
Bicarbonate and total CO2 are not synonyms. Total CO2 = bicarbonate + CO2 + carbonic acid. Under normal circumstances, bicarbonate is the primary constituent of total CO2, however, in certain pathologic conditions, CO2 and/or carbonic acid contribute a clinically significant fraction of the total. Source: Regenstrief LOINC

Observation ID in Form

H26b

Fully-Specified Name

Component
Bicarbonate
Property
SCnc
Time
Pt
System
BldA
Scale
Qn
Method

Additional Names

Short Name
HCO3 BldA-sCnc
Display Name
HCO3 (BldA) [Moles/Vol]
Consumer Name Alpha Get Info
Bicarbonate, Blood

Basic Attributes

Class
CHEM
Type
Laboratory
First Released
Version 1.0
Last Updated
Version 2.73
Order vs. Observation
Both
Common Test Rank Get Info
198

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
100847-3 Gas and ammonia panel - Arterial blood
93685-6 Gas and Carbon monoxide and Electrolytes panel - Arterial blood
24341-0 Gas and Carbon monoxide panel - Arterial blood
99548-0 Gas and electrolytes panel - Arterial blood
104074-0 Gas and Lactate panel - Arterial blood
24336-0 Gas panel - Arterial blood
75885-4 IEEE 11073 Rosetta panel

Member of these Groups Get Info

LOINC Group Group Name
LG2807-8 Bicarbonate|SCnc|Pt|ANYBldSerPl

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Bikarbonat art.
de-DE German (Germany) Bicarbonat:Stoffmengenkonzentration:Zeitpunkt:Blut arteriell:Quantitativ:
Synonyms: HCO3
es-MX Spanish (Mexico) Bicarbonato:Concentración de sustancias:Punto temporal:Sangre arterial:Cuantitativo:
es-AR Spanish (Argentina) bicarbonato:concentración de sustancia:punto en el tiempo:sangre arterial:cuantitativo:
es-ES Spanish (Spain) Bicarbonato:Concentración de sustancia:Punto temporal:Sangre arterial:Qn:
Synonyms: Cuantitativo
et-EE Estonian (Estonia) Vesinikkarbonaat:SCnc:Pt:aB:Qn:
Synonyms: Aine kontsentratsioon Arteriaalne veri Bikarbonaat Juhuslik Kvantitatiivne
fr-CA French (Canada) Bicarbonates:Concentration de substance:Temps ponctuel:Sang artériel:Quantitatif:
fr-FR French (France) Bicarbonate:Moles/Volume:Ponctuel:Sang artériel:Numérique:
fr-BE French (Belgium) Bicarbonates:Concentration de substance:Temps ponctuel:Sang artériel:Quantitatif:
Synonyms: HCO3-
it-IT Italian (Italy) Bicarbonato:SCnc:Pt:Sangue art:Qn:
Synonyms: Chimica Concentrazione di Sostanza Punto nel tempo (episodio) Sangue arterioso
ko-KR Korean (Korea, Republic Of) 중탄산염:물질농도:검사시점:동맥혈:정량:
nl-NL Dutch (Netherlands) bicarbonaat:mol/volume:moment:arterieel bloed:kwantitatief:
pt-BR Portuguese (Brazil) Bicarbonato:SCnc:Pt:SgArt:Qn:
Synonyms: ; HCO3; BIC; Bicarb; bicar; Substance concentration; Level; Point in time; Random; Blood; Blood arterial; ART; Bld art; Bld arterial; Blood art; Art blood; Art bld; AcG; Quantitative; QNT; Quant; Quan; Chemistry
ru-RU Russian (Russian Federation) Бикарбонат:МолКонц:ТчкВрм:КрА:Колич:
Synonyms: Количественный Кровь артериальная Молярность;Молярная объёмная концентрация Точка во времени;Момент
tr-TR Turkish (Turkey) Bikarbonat:SubKons:Zmlı:KanArt:Kant:
zh-CN Chinese (China) 碳酸氢盐:物质的量浓度:时间点:动脉全血:定量型:
Synonyms: BIC;bicar;Bicarb;HCO3;HCO3-;碳酸氢根;酸式碳酸根;酸式碳酸盐;重碳酸根;重碳酸盐 克分子浓度;克分子浓度(单位体积);摩尔浓度;摩尔浓度(单位体积);物质的量浓度(单位体积) 动脉血 化学;化学检验项目;化学检验项目类;化学类;化学试验;非刺激耐受型化学检验项目;非刺激耐受型化学检验项目类;非刺激耐受型化学试验;非刺激耐受型化学试验类 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 时刻;随机;随意;瞬间

Example Units

Unit Source
mmol/L Example UCUM Units
mmol/L REGENSTRIEF

2703-7 PaO2 (mm/Hg)

Observation ID in Form

H27b

Fully-Specified Name

Component
Oxygen
Property
PPres
Time
Pt
System
BldA
Scale
Qn
Method

Additional Names

Short Name
pO2 BldA
Display Name
Oxygen (BldA) [Partial pressure]
Consumer Name Alpha Get Info
Oxygen, Blood

Basic Attributes

Class
CHEM
Type
Laboratory
First Released
Version 1.0
Last Updated
Version 2.73
Order vs. Observation
Both
Common Test Rank Get Info
196

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
100847-3 Gas and ammonia panel - Arterial blood
93685-6 Gas and Carbon monoxide and Electrolytes panel - Arterial blood
24341-0 Gas and Carbon monoxide panel - Arterial blood
99548-0 Gas and electrolytes panel - Arterial blood
104074-0 Gas and Lactate panel - Arterial blood
24336-0 Gas panel - Arterial blood
75885-4 IEEE 11073 Rosetta panel
62611-9 PhenX domain - Respiratory

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Sauerstoff:Partialdruck:Zeitpunkt:Blut arteriell:Quantitativ:
de-AT German (Austria) Synonyms: pO2 art.
es-MX Spanish (Mexico) Oxígeno:Presión parcial:Punto temporal:Sangre arterial:Cuantitativo:
es-AR Spanish (Argentina) oxígeno:presión (parcial):punto en el tiempo:sangre arterial:cuantitativo:
es-ES Spanish (Spain) Oxígeno:Presión parcial:Punto temporal:Sangre arterial:Qn:
Synonyms: Cuantitativo
et-EE Estonian (Estonia) Hapnik:PPres:Pt:aB:Qn:
Synonyms: Arteriaalne veri Juhuslik Kvantitatiivne Osarõhk
fr-CA French (Canada) Oxygène:Pression partielle:Temps ponctuel:Sang artériel:Quantitatif:
fr-FR French (France) Oxygène:Pression partielle:Ponctuel:Sang artériel:Numérique:
fr-BE French (Belgium) Oxygène:Pression partielle:Temps ponctuel:Sang artériel:Quantitatif:
Synonyms: O2
it-IT Italian (Italy) Ossigeno:PPres:Pt:Sangue art:Qn:
Synonyms: Chimica Pressione parziale Punto nel tempo (episodio) Sangue arterioso
ko-KR Korean (Korea, Republic Of) 산소:분압:검사시점:동맥혈:정량:
nl-NL Dutch (Netherlands) zuurstof:partiële druk:moment:arterieel bloed:kwantitatief:
pl-PL Polish (Poland) Tlen:ciśnienie parcjalne:punkt w czasie:krew tętnicza:ilościowy:
pt-BR Portuguese (Brazil) Oxigênio:PPres:Pt:SgArt:Qn:
Synonyms: ; O2; tO2; Partial pressure; Point in time; Random; Blood; Blood arterial; ART; Bld art; Bld arterial; Blood art; Art blood; Art bld; AcG; Quantitative; QNT; Quant; Quan; Chemistry; O2 partial pressure; PO2; PaO2
ru-RU Russian (Russian Federation) Кислород:ПарцД:ТчкВрм:КрА:Колич:
Synonyms: Количественный Кровь артериальная Парциальное давление Точка во времени;Момент
tr-TR Turkish (Turkey) Oksijen:PBsnç:Zmlı:KanArt:Kant:
zh-CN Chinese (China) 氧:分压:时间点:动脉全血:定量型:
Synonyms: O2;tO2;总氧;氧气 O2分压 PaO2 PO2 分压力;分压强;局部压力;气体分压;部分压力;局部压应力;压力(局部性);压力(部分的);压力或压强(局部性);压力或压强(部分的);压强(局部性);压强(部分的) 动脉血 动脉血O2分压 化学;化学检验项目;化学检验项目类;化学类;化学试验;非刺激耐受型化学检验项目;非刺激耐受型化学检验项目类;非刺激耐受型化学试验;非刺激耐受型化学试验类 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 时刻;随机;随意;瞬间

Example Units

Unit Source
mm[Hg] Example UCUM Units
mm Hg REGENSTRIEF

2708-6 SaO2 (%)

Part Descriptions

LP21258-6   Oxygen saturation
Oxygen saturation (sO2) is defined as the ratio of oxyhemoglobin to "active" hemoglobin (oxyhemoglobin + deoxyhemoglobin). Some say the term oxygen saturation has been erroneously redefined with a denominator of "total" instead of "active" hemoglobin, an ambiguity that can sometimes create confusion when viewing reported values from different instruments (Anesth Analg. 2007 Dec;105(6 Suppl):S5-9.) Oxygen saturation is commonly measured by blood gas analyzers and pulse oximetry. Source: Regenstrief LOINC

Reference Information

Type Source Reference
Mapping Guidance Regenstrief Help Functional oxygen saturation (SO2) Mapper’s Guide for the Top 2000 plus LOINC Laboratory Observations

Observation ID in Form

H28b

Fully-Specified Name

Component
Oxygen saturation
Property
MFr
Time
Pt
System
BldA
Scale
Qn
Method

Additional Names

Short Name
SaO2 % BldA
Display Name
SaO2% (BldA) [Mass fraction]
Consumer Name Alpha Get Info
SaO2%, Blood

Basic Attributes

Class
CHEM
Type
Laboratory
First Released
Version 1.0
Last Updated
Version 2.73
Order vs. Observation
Both
Common Test Rank Get Info
248

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
100847-3 Gas and ammonia panel - Arterial blood
93685-6 Gas and Carbon monoxide and Electrolytes panel - Arterial blood
24341-0 Gas and Carbon monoxide panel - Arterial blood
99548-0 Gas and electrolytes panel - Arterial blood
24336-0 Gas panel - Arterial blood
75885-4 IEEE 11073 Rosetta panel
84428-2 National EMS Information System - version 3 set
87825-6 National Trauma Data Standard - version 2018 set
89544-1 Pulmonary Embolism Rule-out Criteria panel PERC
89694-4 Pulmonary Embolism Severity Index panel [PESI]

Member of these Groups Get Info

LOINC Group Group Name
LG33051-0 Oxygen saturation|MFr|Pt|Chal:None

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Sauerstoffsättigung:Massenfraktion:Zeitpunkt:Blut arteriell:Quantitativ:
Synonyms: O2-Sättigung
de-AT German (Austria) Synonyms: O2-Sättigung art.
es-MX Spanish (Mexico) Saturación de oxígeno:Fracción de masa:Punto temporal:Sangre arterial:Cuantitativo:
es-AR Spanish (Argentina) saturación de oxígeno:fracción de sustancia:punto en el tiempo:sangre arterial:cuantitativo:
es-ES Spanish (Spain) Saturación de Oxígeno:Fracción de masa:Punto temporal:Sangre arterial:Qn:
Synonyms: Cuantitativo
et-EE Estonian (Estonia) Hapnikuga küllastatus:MFr:Pt:aB:Qn:
Synonyms: Arteriaalne veri Juhuslik Kvantitatiivne
fr-CA French (Canada) Saturation en oxygène:Fraction de masse:Temps ponctuel:Sang artériel:Quantitatif:
fr-FR French (France) Oxygène saturation:Fraction massique:Ponctuel:Sang artériel:Numérique:
fr-BE French (Belgium) Saturation en oxygène:Fraction de masse:Temps ponctuel:Sang artériel:Quantitatif:
Synonyms: O2 SatO2
it-IT Italian (Italy) Saturazione dell'ossigeno:MFr:Pt:Sangue art:Qn:
Synonyms: Chimica Frazione di massa Punto nel tempo (episodio) Sangue arterioso
nl-NL Dutch (Netherlands) zuurstofverzadiging:massafractie:moment:arterieel bloed:kwantitatief:
pl-PL Polish (Poland) Wysycenie tlenem:frakcja masowa:punkt w czasie:krew tętnicza:ilościowy:
pt-BR Portuguese (Brazil) Saturação de Oxigênio:MFr:Pt:SgArt:Qn:
Synonyms: ; O2 %; SO2; tO2; Mass fraction; Percent; Point in time; Random; Blood; Blood arterial; ART; Bld art; Bld arterial; Blood art; Art blood; Art bld; AcG; Quantitative; QNT; Quant; Quan; Satn; SAT; HEMODYNAMICS.MOLEC; HEMODYNAMICS.MOLEC; SaO2
ru-RU Russian (Russian Federation) Кислородом сатурация:МассДол:ТчкВрм:КрА:Колич:
Synonyms: Количественный Кровь артериальная Массовая доля Насыщение кислородом Точка во времени;Момент
tr-TR Turkish (Turkey) Oksijen satürasyonu:KütlFr:Zmlı:KanArt:Kant:
Synonyms: Oksijen doymuşluğu
zh-CN Chinese (China) 氧饱和度:质量分数:时间点:动脉全血:定量型:
Synonyms: MFr O2;tO2;总氧;氧气 SaO2 动脉血 动脉血O2饱和度 化学;化学检验项目;化学检验项目类;化学类;化学试验;非刺激耐受型化学检验项目;非刺激耐受型化学检验项目类;非刺激耐受型化学试验;非刺激耐受型化学试验类 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 时刻;随机;随意;瞬间 饱和 饱和状态 饱和程度

Example Units

Unit Source
% Example UCUM Units
% REGENSTRIEF

1925-7 B.E. (base excess) (mEq/dL)

Part Descriptions

LP15429-1   Base excess
Base excess refers to the amount of a strong acid required to bring back the blood pH to the normal value of 7.4. The term and concept were first introduced by Astrup and Siggaard-Andersen in 1958 as a way to measure the metabolic component of an acid-base disturbance.

Actual versus standard:
In vivo, acid-base homeostasis takes place throughout the extracellular fluid (ECF), not just the blood compartment that is in a patient specimen. The concept of "standard" base excess attempts to adjust for the base excess of the entire extracellular compartment by calculating the base excess for blood diluted as if the entire extracellular compartment were sampled (approx Hgb of 5g/l). So the ACTUAL base excess (ABE) is the dose of acid to return PLASMA to normal pH, whereas the STANDARD base excess (SBE) is the dose to return ECF to normal pH.

Adjusting for oxygen saturation:
Base excess normally assumes 100% oxygen saturation, which is valid for many arterial specimens. However, it is possible to add additional terms to the calculation which account for the actual oxygen saturation of the patient sample. The terms in LOINC indicating 'Base excess.100% oxygenated' are intended to encode base excess terms adjusted for oxygen saturation (i.e. do not assume 100% oxygenation). Source: Regenstrief LOINC

Observation ID in Form

H29b

Fully-Specified Name

Component
Base excess
Property
SCnc
Time
Pt
System
BldA
Scale
Qn
Method
Calculated

Additional Names

Short Name
Base excess BldA Calc-sCnc
Display Name
Base excess Calc (BldA) [Moles/Vol]
Consumer Name Alpha Get Info
Base excess, Blood

Basic Attributes

Class
CHEM
Type
Laboratory
First Released
Version 1.0
Last Updated
Version 2.73
Order vs. Observation
Observation
Common Test Rank Get Info
360

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
100847-3 Gas and ammonia panel - Arterial blood
93685-6 Gas and Carbon monoxide and Electrolytes panel - Arterial blood
24341-0 Gas and Carbon monoxide panel - Arterial blood
99548-0 Gas and electrolytes panel - Arterial blood
104074-0 Gas and Lactate panel - Arterial blood
24336-0 Gas panel - Arterial blood

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Base excess art.
de-DE German (Germany) Basenüberschuss:Stoffmengenkonzentration:Zeitpunkt:Blut arteriell:Quantitativ:Berechnet
es-MX Spanish (Mexico) Exceso de base:Concentración de sustancias:Punto temporal:Sangre arterial:Cuantitativo:Calculado
es-AR Spanish (Argentina) exceso de bases:concentración de sustancia:punto en el tiempo:sangre arterial:cuantitativo:
es-ES Spanish (Spain) Exceso de base:Concentración de sustancia:Punto temporal:Sangre arterial:Qn:Calculado
Synonyms: Cuantitativo
et-EE Estonian (Estonia) Aluste liig:SCnc:Pt:aB:Qn:Arvutuslik
Synonyms: Aine kontsentratsioon Arteriaalne veri Juhuslik Kvantitatiivne
fr-CA French (Canada) Excès de base:Concentration de substance:Temps ponctuel:Sang artériel:Quantitatif:Calculé
fr-FR French (France) Base excès:Moles/Volume:Ponctuel:Sang artériel:Numérique:Résultat calculé
fr-BE French (Belgium) Excès de base:Concentration de substance:Temps ponctuel:Sang artériel:Quantitatif:Calculé
it-IT Italian (Italy) Basi, eccesso:SCnc:Pt:Sangue art:Qn:Calcolato
Synonyms: Chimica Concentrazione di Sostanza Eccesso di basi Punto nel tempo (episodio) Sangue arterioso
ko-KR Korean (Korea, Republic Of) 염기 과잉:물질농도:검사시점:동맥혈:정량:
nl-NL Dutch (Netherlands) base-overschot:mol/volume:moment:arterieel bloed:kwantitatief:berekend
pt-BR Portuguese (Brazil) Excesso de base:SCnc:Pt:SgArt:Qn:
Synonyms: Base ex; BSE; BE; Substance concentration; Level; Point in time; Random; Blood; Blood arterial; ART; Bld art; Bld arterial; Blood art; Art blood; Art bld; AcG; Quantitative; QNT; Quant; Quan; EXS; Chemistry; AcE
ru-RU Russian (Russian Federation) Оснований избыток:МолКонц:ТчкВрм:КрА:Колич:Вычисленный
Synonyms: Количественный Кровь артериальная Молярность;Молярная объёмная концентрация Точка во времени;Момент
tr-TR Turkish (Turkey) Baz fazlalığı:SubKons:Zmlı:KanArt:Kant:Hesaplanmış
zh-CN Chinese (China) 碱剩余:物质的量浓度:时间点:动脉全血:定量型:计算法
Synonyms: ABE BE;BSE;碱超;碱过剩;过剩碱 克分子浓度;克分子浓度(单位体积);摩尔浓度;摩尔浓度(单位体积);物质的量浓度(单位体积) 动脉血 动脉血碱剩余 化学;化学检验项目;化学检验项目类;化学类;化学试验;非刺激耐受型化学检验项目;非刺激耐受型化学检验项目类;非刺激耐受型化学试验;非刺激耐受型化学试验类 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 时刻;随机;随意;瞬间 计算;计算型方法 过剩

Example Units

Unit Source
mmol/L Example UCUM Units
mmol/L REGENSTRIEF

52485-0 Pulmonary Function Tests

Fully-Specified Name

Component
Pulmonary Function Tests
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

19870-5 FVC (liters)

Part Descriptions

LP72220-4   Forced vital capacity
Forced vital capacity (FVC) is the volume of air that can forcibly be blown out after full inspiration, measured in liters. FVC is the most basic maneuver in spirometry tests. Copyright Text is available under the Creative Commons Attribution/Share-Alike License. See http://creativecommons.org/licenses/by-sa/3.0/ for details. Source: Wikipedia, Wikipedia

Observation ID in Form

H31b

Fully-Specified Name

Component
Forced vital capacity
Property
Vol
Time
Pt
System
Respiratory system
Scale
Qn
Method

Additional Names

Short Name
FVC Vol Respiratory

Basic Attributes

Class
PULM
Type
Clinical
First Released
Version 1.0l
Last Updated
Version 2.73
Common Test Rank Get Info
3755

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Capacidad vital forzada:Volumen:Punto temporal:Sistema respiratorio:Cuantitativo:
es-AR Spanish (Argentina) capacidad.vital.forzada:volumen:punto en el tiempo:aparato respiratorio:cuantitativo:
it-IT Italian (Italy) Capacità vitale forzata:Vol:Pt:Apparato respiratorio:Qn:
Synonyms: Gestione ventilazione polmonare Punto nel tempo (episodio) Volume
pt-BR Portuguese (Brazil) Capacidade.vital.forçada:Volume:Pt:Sistema Respiratório:Qn:
Synonyms: ; FVC; VC; Volume; Point in time; Random; Lungs; Breathing; RS; Quantitative; QNT; Quant; Quan; PULMONARY
ru-RU Russian (Russian Federation) Форсированная жизненная ёмкость:Об:ТчкВрм:Дыхательная система:Колич:
Synonyms: Количественный Объем Точка во времени;Момент
zh-CN Chinese (China) 用力肺活量:体积型属性:时间点:呼吸系统:定量型:
Synonyms: forced vital capacity;FVC;时间肺活量;尽力最大吸气后,尽力尽快呼气所能呼出的最大气量;略小于没有时间限制条件下测得的肺活量;最大肺活量 体积;容积;容量 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 呼吸道标本(样品、样本);呼吸系统标本(样品、样本) 时刻;随机;随意;瞬间 肺部测量指标与呼吸机管理

Example Units

Unit Source
L Example UCUM Units

19926-5 FEV1% or FEV1/FVC (%)

Part Descriptions

LP140652-1   Volume expired during 1.0 s of forced expiration
The forced expiratory volume in one second (FEV1) is the volume of air that can be exhaled in one second. It is usually measured as part of the forced vital capacity (FVC), which is the total amount of air that can be exhaled in a full forced exhalation. The pattern of FVC, FEV1, and the FEV1/FVC ratio can be used together to determine the type of respiratory disease. A normal or low FVC with an FEV1/FVC of <0.7 indicates obstructive pulmonary disease, while low FVC and FEV1/FVC of >0.7 indicates respiratory disease. Normal values for FEV1 and FVC vary based on several factors including age, sex, height, and weight. PMID: 15023009 Source: Regenstrief LOINC

LP91339-9   Volume expired during 1.0 s of forced expiration/Forced vital capacity
FEV1/FVC (FEV1%) is the ratio of FEV1 to FVC. In healthy adults this should be approximately 75-80%. In obstructive diseases (asthma, COPD, chronic bronchitis, emphysema) FEV1 is diminished because of increased airway resistance to expiratory flow; the FVC may be decreased as well, due to the premature closure of airway in expiration, just not in the same proportion as FEV1 (for instance, both FEV1 and FVC are reduced, but the former is more affected because of the increased airway resistance). This generates a reduced value (<80%, often ~45%). In restrictive diseases (such as pulmonary fibrosis) the FEV1 and FVC are both reduced proportionally and the value may be normal or even increased as a result of decreased lung compliance.

A derived value of FEV1% is FEV1% predicted, which is defined as FEV1% of the patient divided by the average FEV1% in the population for any person of similar age, sex and body composition. Copyright Text is available under the Creative Commons Attribution/Share-Alike License. See http://creativecommons.org/licenses/by-sa/3.0/ for details. Source: Wikipedia, Wikipedia

Observation ID in Form

H32b

Fully-Specified Name

Component
Volume expired during 1.0 s of forced expiration/Forced vital capacity
Property
VRto
Time
Pt
System
Respiratory system
Scale
Qn
Method

Additional Names

Short Name
FEV1/FVC

Basic Attributes

Class
PULM
Type
Clinical
First Released
Version 1.0l
Last Updated
Version 2.73
Common Test Rank Get Info
1240

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Volumen expirado durante 1.0 s de espiración forzada / Capacidad vital forzada:VRto:Punto temporal:Sistema respiratorio:Cuantitativo:
es-AR Spanish (Argentina) volumen espiratorio.forzado en el primer segundo/capacidad vital.forzada:relación de volumen:punto en el tiempo:aparato respiratorio:cuantitativo:
it-IT Italian (Italy) Volume espirato durante 1,0Secondi di espirazione forzata/Capacità vitale forzata:Vrto:Pt:Apparato respiratorio:Qn:
Synonyms: CVF FEV1 Gestione ventilazione polmonare Punto nel tempo (episodio) Rapporto di Volume Volume espirato
pt-BR Portuguese (Brazil) Volume expiratório^forçado no 1º seg/Capacidade vital.forçada:VRto:Pt:Sistema Respiratório:Qn:
Synonyms: ; Vol; FEV1/VFC; exp; Exp; FEV1/VFC; FVC; Volume ratio; Point in time; Random; Lungs; Breathing; RS; Quantitative; QNT; Quant; Quan; S prime; PST; After; PULMONARY; FEV1; FEV1/FVC
ru-RU Russian (Russian Federation) FEV1/Форсированная жизненная ёмкость:ОбОтн:ТчкВрм:Дыхательная система:Колич:
Synonyms: Количественный Объём выдоха за 1,0 с форсированный выдох Объём отношение Точка во времени;Момент ФЖЁЛ
zh-CN Chinese (China) 用力呼气 1.0 秒过程中所呼出的体积/用力肺活量:体积比率:时间点:呼吸系统:定量型:
Synonyms: forced vital capacity forced vital capacity;FVC;时间肺活量;尽力最大吸气后,尽力尽快呼气所能呼出的最大气量;略小于没有时间限制条件下测得的肺活量;最大肺活量 S 型 体积.呼气;呼出体积;呼气体积 体积比 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 吐气 呼 呼出 呼出;呼出气体 呼吸道标本(样品、样本);呼吸系统标本(样品、样本) 容积 时刻;随机;随意;瞬间 用力呼气 1.0 s 过程中所呼出的体积 肺部测量指标与呼吸机管理

Example Units

Unit Source
% Example UCUM Units

20150-9 FEV1 (liters)

Part Descriptions

LP140652-1   Volume expired during 1.0 s of forced expiration
The forced expiratory volume in one second (FEV1) is the volume of air that can be exhaled in one second. It is usually measured as part of the forced vital capacity (FVC), which is the total amount of air that can be exhaled in a full forced exhalation. The pattern of FVC, FEV1, and the FEV1/FVC ratio can be used together to determine the type of respiratory disease. A normal or low FVC with an FEV1/FVC of <0.7 indicates obstructive pulmonary disease, while low FVC and FEV1/FVC of >0.7 indicates respiratory disease. Normal values for FEV1 and FVC vary based on several factors including age, sex, height, and weight. PMID: 15023009 Source: Regenstrief LOINC

Observation ID in Form

H33b

Fully-Specified Name

Component
Volume expired during 1.0 s of forced expiration
Property
Vol
Time
Pt
System
Respiratory system
Scale
Qn
Method

Additional Names

Short Name
FEV1

Basic Attributes

Class
PULM
Type
Clinical
First Released
Version 1.0m
Last Updated
Version 2.73
Common Test Rank Get Info
1342

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
62611-9 PhenX domain - Respiratory

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Volumen expirado durante 1.0 s de expiración forzada:Volumen:Punto temporal:Sistema respiratorio:Cuantitativo:
es-AR Spanish (Argentina) volumen^al primer segundo después de la espiración forzada:volumen:punto en el tiempo:aparato respiratorio:cuantitativo:
it-IT Italian (Italy) Volume espirato durante 1,0Secondi di espirazione forzata:Vol:Pt:Apparato respiratorio:Qn:
Synonyms: FEV1 Gestione ventilazione polmonare Punto nel tempo (episodio) Volume Volume espirato
pt-BR Portuguese (Brazil) Volume^expiratório forçado em 1,0 seg:Volume:Pt:Sistema Respiratório:Qn:
Synonyms: ; FEV1; exp; Exp; Point in time; Random; Lungs; Breathing; RS; Quantitative; QNT; Quant; Quan; S prime; PST; After; PULMONARY
ru-RU Russian (Russian Federation) FEV1:Об:ТчкВрм:Дыхательная система:Колич:
Synonyms: Количественный Объем Объём выдоха за 1,0 с форсированный выдох Точка во времени;Момент
zh-CN Chinese (China) 用力呼气 1.0 秒过程中所呼出的体积:体积型属性:时间点:呼吸系统:定量型:
Synonyms: S 型 体积.呼气;呼出体积;呼气体积 体积;容积;容量 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 吐气 呼 呼出 呼出;呼出气体 呼吸道标本(样品、样本);呼吸系统标本(样品、样本) 容积 时刻;随机;随意;瞬间 用力呼气 1.0 s 过程中所呼出的体积 肺部测量指标与呼吸机管理

Example Units

Unit Source
L Example UCUM Units

33452-4 PEF (liters per minute)

Term Description

Peak Expiratory Flow Rate
Source: Regenstrief LOINC

Part Descriptions

LP76210-1   Expiratory gas flow.max
Peak expiratory flow (PEF) is the maximal flow (or speed) achieved during the maximally forced expiration initiated at full expiration, measured in liters per minute. Copyright Text is available under the Creative Commons Attribution/Share-Alike License. See http://creativecommons.org/licenses/by-sa/3.0/ for details. Source: Wikipedia, Wikipedia

Observation ID in Form

H34b

Fully-Specified Name

Component
Expiratory gas flow.max
Property
VRat
Time
Pt
System
Respiratory system.airway
Scale
Qn
Method

Additional Names

Short Name
PEF Airway

Basic Attributes

Class
PULM
Type
Clinical
First Released
Version 2.09
Last Updated
Version 2.73
Common Test Rank Get Info
12775

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
62611-9 PhenX domain - Respiratory

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Caudal de gas espiratorio máx.:VRat:Punto temporal:Sistema respiratorio vía aérea.:Cuantitativo:
es-AR Spanish (Argentina) flujo de gas espiratorio.máximo:índice de volumen:punto en el tiempo:sistema respiratorio.vía aérea:cuantitativo:
it-IT Italian (Italy) Gas espiratori, flusso.massimo:VRat:Pt:Apparato respiratorio.vie aeree:Qn:
Synonyms: Flusso di gas Flusso massimo di gas Flusso massimo di gas espiratori Gestione ventilazione polmonare Massimo Punto nel tempo (episodio) Tasso di Volume Via aeree dell''apparato respiratorio
pt-BR Portuguese (Brazil) Pico de fluxo expiratório máximo:VRat:Pt:Sistema Respiratório.vias aéreas:Qn:
Synonyms: Maximum; Maximal; Largest; Peak; vRate; Volume rate; Point in time; Random; Lungs; Breathing; RS; Quantitative; QNT; Quant; Quan; Gases; Dynamic; PULMONARY
ru-RU Russian (Russian Federation) Выдох газ поток.max:ОбСк:ТчкВрм:Дыхательная система.дыхательные пути:Колич:
Synonyms: Количественный Максимум Объемная скорость Точка во времени;Момент
zh-CN Chinese (China) 呼气气体流量.最大值:体积速率:时间点:呼吸系统.气道:定量型:
Synonyms: 体积速率(单位时间);单位时间内体积的变化速率;流量 动态 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 呼吸系统.导气管;呼吸系统.通气导管;呼吸系统导气管;呼吸系统气道;呼吸系统通气导管 呼吸道标本(样品、样本);呼吸系统标本(样品、样本) 呼气气体流量(流速、气流流量、流量、气体流、气流速度、气体流速) 呼气气体流量(流速、气流流量、流量、气体流、气流速度、气体流速).最大值;呼出气体流量.最大值;呼出气流.最大值 时刻;随机;随意;瞬间 最大;极大值 气 气体流量(流速、气流流量、流量、气体流、气流速度、气体流速).最大值;气体流.最大值;气流速度.最大值;气体流速.最大值 气体类 流 流速;气流流量;流量;气体流;气流速度;气体流速 流量;流速;流体 空气 肺部测量指标与呼吸机管理

Example Units

Unit Source
L/min Example UCUM Units

20159-0 MVV (liters per minute)

Part Descriptions

LP75978-4   Voluntary ventilation.max
Maximum voluntary ventilation (MVV) is a measure of the maximum amount of air that can be inhaled and exhaled within one minute. For the comfort of the patient this is done over a 15 second time period before being extrapolated to a value for one minute expressed as liters/minute. Average values for males and females are 140-180 and 80-120 liters per minute respectively. Copyright Text is available under the Creative Commons Attribution/Share-Alike License. See http://creativecommons.org/licenses/by-sa/3.0/ for details. Source: Wikipedia, Wikipedia

Observation ID in Form

H35b

Fully-Specified Name

Component
Voluntary ventilation.max
Property
VRat
Time
Pt
System
Respiratory system
Scale
Qn
Method

Additional Names

Short Name
MVV

Basic Attributes

Class
PULM
Type
Clinical
First Released
Version 1.0m
Last Updated
Version 2.48

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Ventilación voluntaria máx.:VRat:Punto temporal:Sistema respiratorio:Cuantitativo:
es-AR Spanish (Argentina) ventilación voluntaria.máximo:índice de volumen:punto en el tiempo:aparato respiratorio:cuantitativo:
it-IT Italian (Italy) Ventilazione volontaria.massimo:VRat:Pt:Apparato respiratorio:Qn:
Synonyms: Gestione ventilazione polmonare Massimo Punto nel tempo (episodio) Tasso di Volume Ventilazione volontaria massima
pt-BR Portuguese (Brazil) Ventilação voluntária.máxima:VRat:Pt:Sistema Respiratório:Qn:
Synonyms: ; MVV; Maximum; Maximal; Largest; Peak; vRate; Volume rate; Flow; Point in time; Random; Lungs; Breathing; RS; Quantitative; QNT; Quant; Quan; PULMONARY
ru-RU Russian (Russian Federation) Произвольная вентиляция.max:ОбСк:ТчкВрм:Дыхательная система:Колич:
Synonyms: Количественный Максимум Объемная скорость Точка во времени;Момент
zh-CN Chinese (China) 自主通气.最大值:体积速率:时间点:呼吸系统:定量型:
Synonyms: 体积速率(单位时间);单位时间内体积的变化速率;流量 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 呼吸道标本(样品、样本);呼吸系统标本(样品、样本) 时刻;随机;随意;瞬间 最大;极大值 肺部测量指标与呼吸机管理 自主性通气.最大值;随意性通气.最大值;随意通气.最大值;自主通气.最大

Example Units

Unit Source
L/min Example UCUM Units

19862-2 TLC (liters)

Part Descriptions

LP76186-3   Capacity.total
Total lung capacity (TLC) is the volume of air in the lungs at maximum inflation. TLC can be derived as the sum of the vital capacity (VC), the largest volume a patient can exhale after a full inhalation, and residual volume (RV), the volume of air remaining in the lungs after maximum exhalation). Functional residual capacity (FRC) is the volume of air remaining in the lungs after normal exhalation. Restrictive lung diseases, such as pulmonary fibrosis and neonatal respiratory distress syndrome, generally lead to a decrease in various lung volumes, while obstructive lung diseases, such as asthma, are associated with preserved total volumes. However, obstructive disease may be associated with high RV values, which may also be expressed as RV/TLC, which represents RV as a percentage of TLC. Source: Regenstrief LOINC

Observation ID in Form

H36b

Fully-Specified Name

Component
Capacity.total
Property
Vol
Time
Pt
System
Respiratory system
Scale
Qn
Method

Additional Names

Short Name
TLC

Basic Attributes

Class
PULM
Type
Clinical
First Released
Version 1.0l
Last Updated
Version 2.73
Common Test Rank Get Info
4295

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Capacidad total:Volumen:Punto temporal:Sistema respiratorio:Cuantitativo:
es-AR Spanish (Argentina) capacidad.total:volumen:punto en el tiempo:aparato respiratorio:cuantitativo:
es-ES Spanish (Spain) Capacidad.total:Volumen:Punto temporal:Sistema respiratorio:Qn:
Synonyms: Cuantitativo Muestra respiratoria Tracto respiratorio
it-IT Italian (Italy) Capacità.totale:Vol:Pt:Apparato respiratorio:Qn:
Synonyms: Gestione ventilazione polmonare Punto nel tempo (episodio) Volume
pt-BR Portuguese (Brazil) Capacidade pulmonar.total:Volume:Pt:Sistema Respiratório:Qn:
Synonyms: ; TC; Volume; Point in time; Random; Lungs; Breathing; RS; Quantitative; QNT; Quant; Quan; Tot; Totl; PULMONARY; TLC
ru-RU Russian (Russian Federation) Ёмкость.общий:Об:ТчкВрм:Дыхательная система:Колич:
Synonyms: Количественный Объем Точка во времени;Момент
zh-CN Chinese (China) 容量.总计:体积型属性:时间点:呼吸系统:定量型:
Synonyms: 体积;容积;容量 全体数量 全部 共计 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 呼吸道标本(样品、样本);呼吸系统标本(样品、样本) 总 总和 总容量 总数 总量 总额 时刻;随机;随意;瞬间 汇总 肺部测量指标与呼吸机管理

Example Units

Unit Source
mL;L Example UCUM Units

19843-2 FRC (liters)

Part Descriptions

LP72216-2   Capacity.functional residual
Total lung capacity (TLC) is the volume of air in the lungs at maximum inflation. TLC can be derived as the sum of the vital capacity (VC), the largest volume a patient can exhale after a full inhalation, and residual volume (RV), the volume of air remaining in the lungs after maximum exhalation). Functional residual capacity (FRC) is the volume of air remaining in the lungs after normal exhalation. Restrictive lung diseases, such as pulmonary fibrosis and neonatal respiratory distress syndrome, generally lead to a decrease in various lung volumes, while obstructive lung diseases, such as asthma, are associated with preserved total volumes. However, obstructive disease may be associated with high RV values, which may also be expressed as RV/TLC, which represents RV as a percentage of TLC. Source: Regenstrief LOINC

Observation ID in Form

H37b

Fully-Specified Name

Component
Capacity.functional residual
Property
Vol
Time
Pt
System
Respiratory system
Scale
Qn
Method

Additional Names

Short Name
FRC

Basic Attributes

Class
PULM
Type
Clinical
First Released
Version 1.0l
Last Updated
Version 2.48

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Capacidad residual funcional:Volumen:Punto temporal:Sistema respiratorio:Cuantitativo:
es-AR Spanish (Argentina) capacidad.residual funcional:volumen:punto en el tiempo:aparato respiratorio:cuantitativo:
it-IT Italian (Italy) Capacità.funzionale residua:Vol:Pt:Apparato respiratorio:Qn:
Synonyms: Capacità funzionale residua Gestione ventilazione polmonare Punto nel tempo (episodio) Volume
pt-BR Portuguese (Brazil) Capacidade.residual funcional:Volume:Pt:Sistema Respiratório:Qn:
Synonyms: ; FRC; Volume; Point in time; Random; Lungs; Breathing; RS; Quantitative; QNT; Quant; Quan; PULMONARY
ru-RU Russian (Russian Federation) Ёмкость.функциональная остаточная:Об:ТчкВрм:Дыхательная система:Колич:
Synonyms: Количественный Объем Точка во времени;Момент
zh-CN Chinese (China) 容量.功能性残气:体积型属性:时间点:呼吸系统:定量型:
Synonyms: 体积;容积;容量 功能性残气量;机能性余气量;容量.功能性参与;容量.机能性余气 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 呼吸道标本(样品、样本);呼吸系统标本(样品、样本) 时刻;随机;随意;瞬间 肺部测量指标与呼吸机管理

Example Units

Unit Source
L Example UCUM Units

20146-7 RV (liters)

Part Descriptions

LP73708-7   Volume.residual
Total lung capacity (TLC) is the volume of air in the lungs at maximum inflation. TLC can be derived as the sum of the vital capacity (VC), the largest volume a patient can exhale after a full inhalation, and residual volume (RV), the volume of air remaining in the lungs after maximum exhalation). Functional residual capacity (FRC) is the volume of air remaining in the lungs after normal exhalation. Restrictive lung diseases, such as pulmonary fibrosis and neonatal respiratory distress syndrome, generally lead to a decrease in various lung volumes, while obstructive lung diseases, such as asthma, are associated with preserved total volumes. However, obstructive disease may be associated with high RV values, which may also be expressed as RV/TLC, which represents RV as a percentage of TLC. Source: Regenstrief LOINC

Observation ID in Form

H38b

Fully-Specified Name

Component
Volume.residual
Property
Vol
Time
Pt
System
Respiratory system
Scale
Qn
Method

Additional Names

Short Name
Residual vol

Basic Attributes

Class
PULM
Type
Clinical
First Released
Version 1.0m
Last Updated
Version 2.73
Common Test Rank Get Info
7619

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Volumen.residual:Volumen:Punto temporal:Sistema respiratorio:Cuantitativo:
es-AR Spanish (Argentina) volumen.residual:volumen:punto en el tiempo:aparato respiratorio:cuantitativo:
it-IT Italian (Italy) Volume.residuo:Vol:Pt:Apparato respiratorio:Qn:
Synonyms: Gestione ventilazione polmonare Punto nel tempo (episodio) Volume
pt-BR Portuguese (Brazil) Volume.residual:Volume:Pt:Sistema Respiratório:Qn:
Synonyms: RV; Point in time; Random; Lungs; Breathing; RS; Quantitative; QNT; Quant; Quan; PULMONARY
ru-RU Russian (Russian Federation) Объём.остаточный:Об:ТчкВрм:Дыхательная система:Колич:
Synonyms: Количественный Объем Точка во времени;Момент
zh-CN Chinese (China) 体积.残余:体积型属性:时间点:呼吸系统:定量型:
Synonyms: 体积;容积;容量 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 呼吸道标本(样品、样本);呼吸系统标本(样品、样本) 容积 时刻;随机;随意;瞬间 残气量;余气量;残余气量;餘氣量;体积.残留;体积.残存 肺部测量指标与呼吸机管理

Example Units

Unit Source
L Example UCUM Units

19924-0 ERV (liters)

Part Descriptions

LP75974-3   Expiratory reserve Vol
Expiratory reserve volume (ERV) is the maximal volume of air that can be exhaled from the end-expiratory position Copyright Text is available under the Creative Commons Attribution/Share-Alike License. See http://creativecommons.org/licenses/by-sa/3.0/ for details. Source: Wikipedia, Wikipedia

Observation ID in Form

H39b

Fully-Specified Name

Component
Expiratory reserve
Property
Vol
Time
Pt
System
Respiratory system
Scale
Qn
Method

Additional Names

Short Name
Expiratory reserve

Basic Attributes

Class
PULM
Type
Clinical
First Released
Version 1.0l
Last Updated
Version 2.48

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Reserva espiratoria:Volumen:Punto temporal:Sistema respiratorio:Cuantitativo:
es-AR Spanish (Argentina) reserva espiratoria:volumen:punto en el tiempo:aparato respiratorio:cuantitativo:
it-IT Italian (Italy) Riserva espiratoria:Vol:Pt:Apparato respiratorio:Qn:
Synonyms: Gestione ventilazione polmonare Punto nel tempo (episodio) Volume
pt-BR Portuguese (Brazil) Reserva expiratória:Volume:Pt:Sistema Respiratório:Qn:
Synonyms: ER; Volume; Point in time; Random; Lungs; Breathing; RS; Quantitative; QNT; Quant; Quan; PULMONARY; ERV
ru-RU Russian (Russian Federation) Выдох резерв:Об:ТчкВрм:Дыхательная система:Колич:
Synonyms: Количественный Объем Резерв выдоха Точка во времени;Момент
zh-CN Chinese (China) 呼气储备:体积型属性:时间点:呼吸系统:定量型:
Synonyms: 体积;容积;容量 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 呼出气体储备 呼吸道标本(样品、样本);呼吸系统标本(样品、样本) 时刻;随机;随意;瞬间 肺部测量指标与呼吸机管理

Example Units

Unit Source
L Example UCUM Units

69339-0 Influenza vaccine during assessment period [CMS Assessment]

Fully-Specified Name

Component
Influenza vaccine
Property
-
Time
RptPeriod
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.38
Last Updated
Version 2.78
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from CARE so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
87506-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 4.00 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]

55019-4 Influenza virus vaccine received in facility during assessment period [CMS Assessment]

Fully-Specified Name

Component
Influenza virus vaccine received in facility
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 and removed Survey Question Text and Source so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG
Order vs. Observation
Observation

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
45981-8 Deprecated MDS full assessment form - version 2.0
46104-6 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III 1997 update
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
46076-6 Deprecated Minimum Data Set (MDS) supplemental items section - version 2.0
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
87506-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 4.00 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]

Member of these Groups Get Info

LOINC Group Group Name
LG32757-3 Influenza virus

58131-4 Date of influenza vaccination

Fully-Specified Name

Component
Date of influenza vaccination
Property
Date
Time
Pt
System
^Patient
Scale
Qn
Method

Additional Names

Short Name
Flu vaccine date
Consumer Name Alpha Get Info
Date of influenza vaccination

Basic Attributes

Class
CLIN
Type
Clinical
First Released
Version 2.29
Last Updated
Version 2.63
Change Reason
Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Updated component to follow new vaccination term convention: Date of X vaccination; Removed METHOD because term is generic; Changed CLASS from SURVEY.MDS to CLIN.
Order vs. Observation
Observation

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
87506-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 4.00 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Fecha de vacunación contra la influenza:Fecha:Punto temporal:^ Paciente:Cuantitativo:
it-IT Italian (Italy) Data di vaccinazione influenzale:Data:Pt:^Paziente:Qn:
Synonyms: Clinico paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 流行性感冒疫苗接种日期:日期:时间点:^患者:定量型:
Synonyms: 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 日子;几号 时刻;随机;随意;瞬间 流行性感冒(流感)疫苗接种(预防接种、免疫接种)日期(时间)

Example Units

Unit Source
{mm/dd/yyyy} Example UCUM Units

55020-2 If influenza vaccine not received, state reason:

Fully-Specified Name

Component
Reason influenza virus vaccine not received
Property
Find
Time
RptPeriod
System
^Patient
Scale
Nom
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG
Order vs. Observation
Observation

Normative Answer List LL676-8

Answer Code Score Answer ID
Resident not in facility during this year's flu season 1 LA12666-6
Received outside of this facility 2 LA184-4
Not eligible - medical contraindication 3 LA11091-8
Offered and declined 4 LA186-9
Not offered 5 LA187-7
Inability to obtain vaccine due to declared shortage 6 LA12156-8
None of the above 9 LA9-3

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
45981-8 Deprecated MDS full assessment form - version 2.0
46104-6 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III 1997 update
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
46076-6 Deprecated Minimum Data Set (MDS) supplemental items section - version 2.0
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
87506-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 4.00 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]

55021-0 Pneumococcal vaccine

Fully-Specified Name

Component
Pneumococcal vaccine
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.74
Change Reason
Changed Class from SURVEY.MDS to PANEL.SURVEY.CMS
Order vs. Observation
Subset
Common Test Rank Get Info
6230
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]

55022-8 Is the resident's Pneumococcal Vaccination up to date?

Observation ID in Form

O0300A

Fully-Specified Name

Component
Pneumococcal vaccination up to date
Property
Find
Time
RptPeriod
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.;Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments
Order vs. Observation
Observation

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]

45956-0 Reason pneumococcal vaccine not received during assessment period [CMS Assessment]

Fully-Specified Name

Component
Reason pneumococcal vaccine not received
Property
Find
Time
RptPeriod
System
^Patient
Scale
Nom
Method
CMS Assessment

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.17
Last Updated
Version 2.77
Change Reason
Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from MDS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee
Order vs. Observation
Observation

Normative Answer List LL677-6

Answer Code Score Answer ID
Not eligible - medical contraindication 1 LA11091-8
Offered and declined 2 LA186-9
Not offered 3 LA187-7

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
45981-8 Deprecated MDS full assessment form - version 2.0
46104-6 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III 1997 update
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
46076-6 Deprecated Minimum Data Set (MDS) supplemental items section - version 2.0
86264-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment]
86259-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
88367-8 Outcome and assessment information set (OASIS) form - version D, D1 - Transfer to inpatient facility - patient discharged or not discharged during assessment period [CMS Assessment]

69375-4 Cognitive status, mood, pain

Observation ID in Form

IV

Fully-Specified Name

Component
Cognitive status, mood, pain - acute
Property
-
Time
Pt
System
^Patient
Scale
-
Method
CARE

Basic Attributes

Class
PANEL.SURVEY.CARE
Type
Surveys
First Released
Version 2.38
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

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

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

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

Source: Centers for Medicare & Medicaid Services

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

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

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
46102-0 Deprecated MDS quarterly assessment form - version 2.0
46103-8 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III
46104-6 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III 1997 update

69350-7 Temporal orientation &or mental status

Observation ID in Form

B

Fully-Specified Name

Component
Temporal orientation &or mental status - acute
Property
-
Time
Pt
System
^Patient
Scale
-
Method
CARE

Basic Attributes

Class
PANEL.SURVEY.CARE
Type
Surveys
First Released
Version 2.38
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

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

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

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

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

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

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

Answer Code Score Answer ID
Unresponsive or minimally conscious 1 LA10112-3
Communication disorder 2 LA9950-2
No interpreter available 3 LA10023-2

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

55759-5 Temporal Orientation - CARE Acute Care

Observation ID in Form

B2

Skip Logic

Any score with an asterisk will require the completion of D. Confusion Assessment Method.

Fully-Specified Name

Component
Temporal Orientation - CARE Acute Care
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

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52732-5 Temporal orientation - current year [BIMS]

Observation ID in Form

B2a

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

Answer Code Score Answer ID
Correct 3 LA9960-1
Missed by 1 year 2 LA10008-3
Missed by 2-5 years 1 LA10966-2
Missed by > 5 years or no answer 0 LA10965-4

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
86870-3 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88279-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0

52733-3 Temporal orientation - current month [BIMS]

Observation ID in Form

B2b

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

Answer Code Score Answer ID
Accurate within 5 days 2 LA9927-0
Missed by 6 days to 1 month 1 LA10010-9
Missed by > 1 month or no answer 0 LA10969-6

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
86870-3 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88279-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0

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

Source: Centers for Medicare & Medicaid Services

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

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

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52596-4 Memory/recall ability

Observation ID in Form

C1

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

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

Answer Code Score Answer ID
Current season a LA9962-7
Location of own room b LA9998-1
Staff names and faces c LA10085-1
That he or she is in a hospital, nursing home, or home d LA10093-5
None of the above are recalled e LA10031-5
Unable to assess. Specify reason f LA10106-5

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

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

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52495-9 Confusion Assessment Method (CAM)

Reference Information

Type Source Reference
Article NCBI PubMed 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. Link to PubMed

Observation ID in Form

D

Skip Logic

Complete this section only if patient scored 0 or 1 on B2a. Or B2b. Code the following behaviors during the 2-day assessment period. Indicate the status regardless of cause.

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

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

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

Type Source Reference
Article NCBI PubMed 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. Link to PubMed

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

Answer Code Score Answer ID
Behavior is not present. 0 LA9938-7
Behavior continuously present does not fluctuate. 1 LA9937-9
Behavior present, fluctuates (e.g., comes and goes, changes in severity). 2 LA9939-5

Member of these Panels

LOINC Long Common Name
52495-9 Confusion Assessment Method (CAM)
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

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

Type Source Reference
Article NCBI PubMed 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. Link to PubMed

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

Answer Code Score Answer ID
Behavior is not present. 0 LA9938-7
Behavior continuously present does not fluctuate. 1 LA9937-9
Behavior present, fluctuates (e.g., comes and goes, changes in severity). 2 LA9939-5

Member of these Panels

LOINC Long Common Name
52495-9 Confusion Assessment Method (CAM)
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

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

Type Source Reference
Article NCBI PubMed 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. Link to PubMed

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

Answer Code Score Answer ID
Behavior is not present. 0 LA9938-7
Behavior continuously present does not fluctuate. 1 LA9937-9
Behavior present, fluctuates (e.g., comes and goes, changes in severity). 2 LA9939-5

Member of these Panels

LOINC Long Common Name
52495-9 Confusion Assessment Method (CAM)
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

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

Type Source Reference
Article NCBI PubMed 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. Link to PubMed

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

Answer Code Score Answer ID
Behavior is not present. 0 LA9938-7
Behavior continuously present does not fluctuate. 1 LA9937-9
Behavior present, fluctuates (e.g., comes and goes, changes in severity). 2 LA9939-5

Member of these Panels

LOINC Long Common Name
52495-9 Confusion Assessment Method (CAM)
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52500-6 Pain

Observation ID in Form

G

Form Coding Instructions

Complete during the 2-day assessment period

Source: Centers for Medicare & Medicaid Services

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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

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

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

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

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Unable to answer or no response 8 LA10104-0

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

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

Source: Centers for Medicare & Medicaid Services

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

Answer Code Score Answer ID
0 0 LA6111-4
1 1 LA6112-2
2 or more 2 LA6113-0
3 3 LA6114-8
4 4 LA6115-5
5 5 LA10137-0
6 6 LA10138-8
7 7 LA10139-6
8 8 LA10140-4
9 9 LA10141-2
10 10 LA13942-0
Patient does not answer or is unable to respond 88 LA10056-2

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

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

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Unable to answer or no response 8 LA10104-0

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

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

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Unable to answer or no response 8 LA10104-0

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

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

Source: Centers for Medicare & Medicaid Services

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

Source: Centers for Medicare & Medicaid Services

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

Answer Code Score Answer ID
Non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning) A LA10034-9
Vocal complaints of pain (e.g., that hurts, ouch, stop) B LA10116-4
Facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) C LA9968-4
Protective body movements or postures (e.g., bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement) D LA10063-8
None of these signs observed or documented E LA10032-3

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52502-2 Impairments

Observation ID in Form

V

Fully-Specified Name

Component
Impairments
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52503-0 Bladder and Bowel Management - Use of Device(s) and Incontinence

Observation ID in Form

A

Form Coding Instructions

Complete during the 2-day assessment period

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Bladder and Bowel Management - Use of Device(s) and Incontinence
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52608-7 Does the patient have any impairments with bladder or bowel management (e.g., use of a device or incontinence)?

Observation ID in Form

A1

Skip Logic

If No, skip to Section B. Swallowing. If Yes, please complete this section.

Fully-Specified Name

Component
Impairments with bladder or bowel management
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Change Reason
Method removed and Answer List Type changed to Example because this generic term can be used across contexts

Survey Question

Text
Does the patient have any impairments with bladder or bowel management (e.g., use of a device or incontinence)?
Source
CARE I.a01

Example Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52609-5 Bladder - Does this patient use an external or indwelling device or require intermittent catheterization?

Observation ID in Form

A2a

Fully-Specified Name

Component
Bladder - external or indwelling device or intermittent catheterization
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
Bladder - Does this patient use an external or indwelling device or require intermittent catheterization?
Source
CARE I.a02a

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52610-3 Bowel - Does this patient use an external or indwelling device or require intermittent catheterization?

Observation ID in Form

A2b

Fully-Specified Name

Component
Bowel - external or indwelling device or intermittent catheterization
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
Bowel - Does this patient use an external or indwelling device or require intermittent catheterization?
Source
CARE I.a02b

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52611-1 Bladder - Indicate the frequency of incontinence.

Observation ID in Form

A3a

Fully-Specified Name

Component
Bladder - frequency of incontinence during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Survey Question

Text
Bladder - Indicate the frequency of incontinence.
Source
CARE I.a03a

Normative Answer List LL724-6

Answer Code Score Answer ID
Continent (no documented incontinence) 0 LA9956-9
Stress incontinence only (bladder only) 1 LA10088-5
Incontinence less than daily 2 LA11689-9
Incontinence daily (at least once a day) 3 LA11690-7
Always continent 4 LA11042-1
No urine/bowel output (e.g., renal failure) 5 LA10024-0
Not applicable (e.g., indwelling catheter) 9 LA11693-1

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52612-9 Bowel - Indicate the frequency of incontinence.

Observation ID in Form

A3b

Fully-Specified Name

Component
Bowel - frequency of incontinence during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Survey Question

Text
Bowel - Indicate the frequency of incontinence.
Source
CARE I.a03b

Normative Answer List LL724-6

Answer Code Score Answer ID
Continent (no documented incontinence) 0 LA9956-9
Stress incontinence only (bladder only) 1 LA10088-5
Incontinence less than daily 2 LA11689-9
Incontinence daily (at least once a day) 3 LA11690-7
Always continent 4 LA11042-1
No urine/bowel output (e.g., renal failure) 5 LA10024-0
Not applicable (e.g., indwelling catheter) 9 LA11693-1

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52613-7 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)?

Observation ID in Form

A4a

Fully-Specified Name

Component
Bladder - needs assistance to manage bladder care equipment
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
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)?
Source
CARE I.a04a

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52614-5 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)?

Observation ID in Form

A4b

Fully-Specified Name

Component
Bowel - needs assistance to manage bowel care equipment
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
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)?
Source
CARE I.a05b

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52615-2 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?

Observation ID in Form

A5a

Fully-Specified Name

Component
Bladder - incontinent immediately prior to current illness, exacerbation, or injury
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
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?
Source
CARE I.a05a

Normative Answer List LL208-0

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52616-0 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?

Observation ID in Form

A5b

Fully-Specified Name

Component
Bowel - incontinent immediately prior to current illness, exacerbation, or injury
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
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?
Source
CARE I.a05b

Normative Answer List LL208-0

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52504-8 Swallowing

Observation ID in Form

B

Form Coding Instructions

Complete during the 2-day assessment period

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Swallowing
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52618-6 Does the patient have any signs or symptoms of a possible swallowing disorder?

Observation ID in Form

B1

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Swallowing disorder
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
Does the patient have any signs or symptoms of a possible swallowing disorder?
Source
CARE I.B1

Normative Answer List LL574-5

Answer Code Score Answer ID
Complaints of difficulty or pain with swallowing a LA9952-8
Coughing or choking during meals or when swallowing medications b LA9961-9
Holding food in mouth/cheeks or residual food in mouth after meals c LA9977-5
Loss of liquids/solids from mouth when eating or drinking d LA10001-8
NPO: intake not by mouth e LA10043-0
Other (specify) f LA6310-2
None Copyright http://snomed.info/sct ID:260413007 None (qualifier value) g LA137-2

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52619-4 Other (specify)

Observation ID in Form

B1f

Fully-Specified Name

Component
Swallowing disorder.other specified
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

Survey Question

Text
Other (specify)
Source
CARE I.b01f.1

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52620-2 Describe the patient's usual ability with swallowing.

Observation ID in Form

B2

Form Coding Instructions

Check one option only

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Swallowing usual ability
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
Describe the patient's usual ability with swallowing.
Source
CARE I.B2

Normative Answer List LL575-2

Answer Code Score Answer ID
Regular food: solids and liquids swallowed safely without supervision and without modified food or liquid consistency. A LA10070-3
Modified food consistency/supervision: Patient requires modified food or liquid consistency and/or needs supervision during eating for safety. B LA10013-3
Tube/parenteral feeding: Tube/parenteral feeding used wholly or partially as a means of sustenance. C LA10103-2

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52505-5 Hearing, Vision, and Communication

Observation ID in Form

C

Form Coding Instructions

Complete during the 2-day assessment period

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Hearing, Vision, and Communication
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52621-0 Does the patient have any impairments with hearing, vision, or communication?

Observation ID in Form

C1

Skip Logic

If No impairments, skip to Section D. Weight-bearing. If Yes, please complete this section.

Fully-Specified Name

Component
Any impairments with hearing, vision, or communication
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Change Reason
Method removed and Answer List Type changed to Example because this generic term can be used across contexts

Survey Question

Text
Does the patient have any impairments with hearing, vision, or communication?
Source
CARE I.c01

Example Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52622-8 Understanding verbal content - excluding language barriers [CARE]

Observation ID in Form

C1a

Fully-Specified Name

Component
Understanding verbal content - excluding language barriers
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

Normative Answer List LL576-0

Answer Code Score Answer ID
Understands: clear comprehension without cues or repetitions 4 LA10110-7
Usually understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand 3 LA10113-1
Sometimes understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand 2 LA10083-6
Rarely/never understands 1 LA81-5
Unable to assess 8 LA10105-7
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52623-6 Expression of ideas and wants [CARE]

Observation ID in Form

C1b

Fully-Specified Name

Component
Expression of ideas and wants
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

Normative Answer List LL577-8

Answer Code Score Answer ID
Expresses complex messages without difficulty and with speech that is clear and easy to understand 4 LA9967-6
Exhibits some difficulty with expressing needs and ideas (e.g., some words or finishing thoughts) or speech is not clear 3 LA9966-8
Frequently exhibits difficulty with expressing needs and ideas 2 LA9972-6
Rarely/Never expresses self or speech is very difficult to understand. 1 LA10067-9
Unable to assess 8 LA10105-7
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52624-4 Ability to see in adequate light (with glasses or other visual appliances)

Observation ID in Form

C1c

Fully-Specified Name

Component
Seeing in adequate light - with glasses or other visual appliances
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

Normative Answer List LL578-6

Answer Code Score Answer ID
Adequate: Sees fine detail, including regular print in newspapers/books 3 LA9930-4
Mildly to Moderately Impaired: Can identify objects; may see large print 2 LA10006-7
Severely Impaired: No vision or object identification questionable 1 LA10077-8
Unable to assess 8 LA10105-7
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52625-1 Ability to hear (with hearing aid or hearing appliance, if normally used)

Observation ID in Form

C1d

Fully-Specified Name

Component
Hearing - with hearing aid or hearing appliance if normally used
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

Normative Answer List LL579-4

Answer Code Score Answer ID
Adequate: Hears normal conversation and TV without difficulty 3 LA9929-6
Mildly to Moderately Impaired: Difficulty hearing in some environments or speaker may need to increase volume or speak distinctly 2 LA10007-5
Severely Impaired: Absence of useful hearing 1 LA10076-0
Unable to assess 8 LA10105-7
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) 9 LA4489-6

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52677-2 Medication management-oral medications during two day assessment period [CARE]

Term Description

The ability to prepare and take all prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Medication management-oral medications during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52679-8 Medication management-injectable medications during two day assessment period [CARE]

Term Description

The ability to prepare and take all prescribed injectable medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals.
Source: Regenstrief LOINC

Fully-Specified Name

Component
Medication management-injectable medications during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52506-3 Weight-bearing

Observation ID in Form

D

Form Coding Instructions

Complete during the 2-day assessment period

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Weight-bearing
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52626-9 Does the patient have any clinician-ordered weight-bearing or limb/spinal loading restrictions( including upper body lift, push, pull, or carry restrictions)?

Observation ID in Form

D1

Skip Logic

If No impairments, skip to Section E. Grip Strength. If Yes, please complete this section.

Fully-Specified Name

Component
Any impairments with weight-bearing
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Change Reason
Method removed and Answer List Type changed to Example because this generic term can be used across contexts

Survey Question

Text
Does the patient have any clinician-ordered weight-bearing or limb/spinal loading restrictions( including upper body lift, push, pull, or carry restrictions)?
Source
CARE I.d01

Example Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52507-1 Weight-bearing restrictions panel

Observation ID in Form

CODING

Form Coding Instructions

CODING: Indicate all the patient's weight-bearing restrictions

Source: Centers for Medicare & Medicaid Services

Form Coding Instructions

Indicate all the patient's weight-bearing restrictions

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Weight-bearing restrictions panel
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
PANEL.SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52627-7 Upper Extremity - Left

Observation ID in Form

D1a

Form Coding Instructions

CODING: Indicate all the patient's weight-bearing restrictions

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Weight-bearing restrictions during 2D assessment period
Property
Find
Time
2D
System
Upper extremity.left
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL580-2

Answer Code Score Answer ID
Fully weight-bearing: No clinician ordered restrictions 1 LA9973-4
Not fully weight-bearing: Patient has clinician ordered restrictions 0 LA10042-2

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52628-5 Upper Extremity - Right

Observation ID in Form

D1b

Form Coding Instructions

CODING: Indicate all the patient's weight-bearing restrictions

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Weight-bearing restrictions during 2D assessment period
Property
Find
Time
2D
System
Upper extremity.right
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL580-2

Answer Code Score Answer ID
Fully weight-bearing: No clinician ordered restrictions 1 LA9973-4
Not fully weight-bearing: Patient has clinician ordered restrictions 0 LA10042-2

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52629-3 Lower Extremity - Left

Observation ID in Form

D1c

Form Coding Instructions

CODING: Indicate all the patient's weight-bearing restrictions

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Weight-bearing restrictions during 2D assessment period
Property
Find
Time
2D
System
Lower extremity.left
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL580-2

Answer Code Score Answer ID
Fully weight-bearing: No clinician ordered restrictions 1 LA9973-4
Not fully weight-bearing: Patient has clinician ordered restrictions 0 LA10042-2

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52630-1 Lower Extremity - Right

Observation ID in Form

D1d

Form Coding Instructions

CODING: Indicate all the patient's weight-bearing restrictions

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Weight-bearing restrictions during 2D assessment period
Property
Find
Time
2D
System
Lower extremity.right
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL580-2

Answer Code Score Answer ID
Fully weight-bearing: No clinician ordered restrictions 1 LA9973-4
Not fully weight-bearing: Patient has clinician ordered restrictions 0 LA10042-2

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52508-9 Grip strength

Observation ID in Form

E

Form Coding Instructions

Complete during the 2-day assessment period

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Grip Strength
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52631-9 Does the patient have any impairments with grip strength (e.g. reduced/limited or absent)?

Observation ID in Form

E1

Skip Logic

If No impairments, skip to Section F. Repiratory Status. If Yes, please complete this section.

Fully-Specified Name

Component
Any impairments with grip strength
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Change Reason
Method removed and Answer List Type changed to Example because this generic term can be used across contexts

Survey Question

Text
Does the patient have any impairments with grip strength (e.g. reduced/limited or absent)?
Source
CARE I.e01

Example Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52509-7 Grip strength panel

Observation ID in Form

CODING

Form Coding Instructions

CODING: Indicate the patient's ability to squeeze your hand

Source: Centers for Medicare & Medicaid Services

Form Coding Instructions

Indicate the patient's ability to squeeze your hand

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Grip strength panel
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
PANEL.SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52632-7 Left Hand

Observation ID in Form

E1a

Form Coding Instructions

CODING: Indicate the patient's ability to squeeze your hand

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Grip strength during 2D assessment period
Property
Find
Time
2D
System
Hand.left
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL581-0

Answer Code Score Answer ID
Normal Copyright http://snomed.info/sct ID:17621005 Normal (qualifier value) 2 LA6626-1
Reduced/Limited 1 LA10068-7
Absent Copyright http://snomed.info/sct ID:2667000 Absent (qualifier value) 0 LA9634-2

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52633-5 Right Hand

Observation ID in Form

E1b

Form Coding Instructions

CODING: Indicate the patient's ability to squeeze your hand

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Grip strength during 2D assessment period
Property
Find
Time
2D
System
Hand.right
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL581-0

Answer Code Score Answer ID
Normal Copyright http://snomed.info/sct ID:17621005 Normal (qualifier value) 2 LA6626-1
Reduced/Limited 1 LA10068-7
Absent Copyright http://snomed.info/sct ID:2667000 Absent (qualifier value) 0 LA9634-2

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52510-5 Respiratory status

Observation ID in Form

F

Form Coding Instructions

Complete during the 2-day assessment period

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Respiratory status
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
PANEL.SURVEY.MDS
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.68
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57192-7 Deprecated Outcome and assessment information set (OASIS) form - version C - Follow-Up
57191-9 Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care
57190-1 Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care

Language Variants Get Info

Tag Language Translation
fr-FR French (France) Statut respiratoire:-:Ponctuel:Patient:-:

52634-3 Does the patient have any impairments with respiratory status?

Observation ID in Form

F1

Skip Logic

If No impairments, skip to Section G. Endurance. If Yes, please complete this section.

Fully-Specified Name

Component
Any impairments with respiratory status
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Change Reason
Method removed and Answer List Type changed to Example because this generic term can be used across contexts

Survey Question

Text
Does the patient have any impairments with respiratory status?
Source
CARE I.f01

Example Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52635-0 Respiratory status with supplemental oxygen

Fully-Specified Name

Component
Respiratory status with oxygen therapy during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Survey Question

Text
Respiratory Status With Supplemental O2: Was the patient dyspneic or noticeably short of breath?
Source
CARE I.f01a

Normative Answer List LL582-8

Answer Code Score Answer ID
Severe, with evidence the patient is struggling to breathe at rest 5 LA10075-2
Mild at rest (during day or night) 4 LA10005-9
With minimal exertion (for example, while eating, talking, or performing other ADLs) or with agitation 3 LA6445-6
With moderate exertion (e.g., while dressing, using commode or bedpan, walking between rooms) 2 LA10122-2
When climbing stairs 1 LA10121-4
Never, patient was not short of breath 0 LA10020-8
Not assessed (e.g., on ventilator) 8 LA10035-6
Not applicable 9 LA4720-4

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52636-8 Respiratory status without supplemental oxygen

Observation ID in Form

F1b

Fully-Specified Name

Component
Respiratory status without oxygen therapy during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Survey Question

Text
Respiratory Status Without Supplemental O2: Was the patient dyspneic or noticeably short of breath?
Source
CARE I.f01b

Normative Answer List LL582-8

Answer Code Score Answer ID
Severe, with evidence the patient is struggling to breathe at rest 5 LA10075-2
Mild at rest (during day or night) 4 LA10005-9
With minimal exertion (for example, while eating, talking, or performing other ADLs) or with agitation 3 LA6445-6
With moderate exertion (e.g., while dressing, using commode or bedpan, walking between rooms) 2 LA10122-2
When climbing stairs 1 LA10121-4
Never, patient was not short of breath 0 LA10020-8
Not assessed (e.g., on ventilator) 8 LA10035-6
Not applicable 9 LA4720-4

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52511-3 Endurance

Observation ID in Form

G

Form Coding Instructions

Complete during the 2-day assessment period

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Endurance
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52637-6 Does the patient have any impairments with endurance?

Observation ID in Form

G1

Skip Logic

If No impairments, skip to Section H. Mobility Devices and Aides Needed. If Yes, please complete this section.

Fully-Specified Name

Component
Any impairments with endurance
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Change Reason
Method removed and Answer List Type changed to Example because this generic term can be used across contexts

Survey Question

Text
Does the patient have any impairments with endurance?
Source
CARE I.g01

Example Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52638-4 Mobility Endurance: Was the patient able to walk or wheel 50 feet (15 meters)?

Observation ID in Form

G1a

Fully-Specified Name

Component
Mobility endurance - able to walk or wheel 50 feet during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Survey Question

Text
Mobility Endurance: Was the patient able to walk or wheel 50 feet (15 meters)?
Source
CARE I.g01a

Normative Answer List LL583-6

Answer Code Score Answer ID
No, could not do 0 LA10026-5
Yes, can do with rest 1 LA10128-9
Yes, can do without rest 2 LA10129-7
Not assessed due to medical restriction 8 LA10036-4

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52639-2 Sitting Endurance: Was the patient able to tolerate sitting for 15 minutes?

Observation ID in Form

G1b

Fully-Specified Name

Component
Sitting endurance - able to tolerate sitting for 15M during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Survey Question

Text
Sitting Endurance: Was the patient able to tolerate sitting for 15 minutes?
Source
CARE I.g01b

Normative Answer List LL584-4

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes, with support 1 LA10135-4
Yes, without support 2 LA10136-2
Not assessed due to medical restriction 8 LA10036-4

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52512-1 Mobility Devices and Aids Needed

Observation ID in Form

H

Form Coding Instructions

Complete during the 2-day assessment period

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Mobility devices and aids needed
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52640-0 Indicate all mobility devices and aids needed at time of assessment.

Observation ID in Form

H1

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Mobility devices and aids needed
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
Change Reason
Method removed and Answer List Type changed to Example because this generic term can be used across contexts

Survey Question

Text
Indicate all mobility devices and aids needed at time of assessment.
Source
CARE I.H1

Example Answer List LL585-1

Answer Code Score Answer ID
Canes/crutch a LA9942-9
Walker b LA10117-2
Orthotics/Prosthetics c LA10046-3
Wheelchair/scooter full time d LA10119-8
Wheelchair/scooter part time e LA10120-6
Mechanical lift f LA11549-5
Other (specify) g LA6310-2
None apply h LA10029-9

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52641-8 Other (specify)

Observation ID in Form

H1g

Fully-Specified Name

Component
Mobility device.other specified
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

Survey Question

Text
Other (specify)
Source
CARE I.h01g.1

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52513-9 Functional Status - Usual Performance

Observation ID in Form

VI

Form Coding Instructions

Code the patient's most usual performance using the 6 point scale below

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Functional Status - Usual Performance
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52514-7 Core Self Care

Observation ID in Form

A

Form Coding Instructions

Core Self Core: The core self care items should be completed on ALL patients. (Complete during the 2-day assessment period.) Code the patient's most usual performance using the 6-point scale below. CODING: Safety and Quality of Performance - If helper assistance is required because the patient's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Core Self Care
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52642-6 Eating

Term Description

The ability to use suitable utensils to bring food to the mouth and swallow food once the meal is presented on a table/tray. Includes modified food consistency.
Source: Regenstrief LOINC

Observation ID in Form

A1

Fully-Specified Name

Component
Eating during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52643-4 Tube feeding

Term Description

The ability to manage all equipment/supplies related to obtaining nutrition.
Source: Regenstrief LOINC

Observation ID in Form

A2

Fully-Specified Name

Component
Tube feeding during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52644-2 Oral hygiene

Term Description

The ability to use suitable items to clean teeth. Dentures: The ability to remove and replace dentures from and to mouth, and manage equipment for soaking and rinsing.
Source: Regenstrief LOINC

Observation ID in Form

A3

Fully-Specified Name

Component
Oral hygiene during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52645-9 Toilet hygiene

Term Description

The ability to maintain perineal hygiene, adjust clothes before and after using toilet, commode, bedpan, urinal. If managing ostomy, include wiping opening but not managing equipment.
Source: Regenstrief LOINC

Observation ID in Form

A4

Fully-Specified Name

Component
Toilet hygiene during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52646-7 Upper body dressing

Term Description

The ability to put on and remove shirt or pajama top. Includes buttoning if applicable.
Source: Regenstrief LOINC

Observation ID in Form

A5

Fully-Specified Name

Component
Upper body dressing during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52647-5 Lower body dressing

Term Description

The ability to dress and undress below the waist, including fasteners. Does not include footwear.
Source: Regenstrief LOINC

Observation ID in Form

A6

Fully-Specified Name

Component
Lower body dressing during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52515-4 Core Functional Mobility

Observation ID in Form

B

Form Coding Instructions

Core Functional Mobility: The core functional mobility items should be completed on ALL patients. (Complete during the 2-day assessment period.) Complete for ALL patients: Code the patient's most usual performance using the 6-point scale below. CODING: Safety and Quality of Performance - If helper assistance is required because the patient's performance is unsafe or of poor quality, score according to amount of assistance provided. Activities may be completed with or without assistive devices

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Core Functional Mobility
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52648-3 Lying to Sitting on Side of Bed

Term Description

The ability to safely move from lying on the back to sitting on side of bed with feet flat on the floor, no back support.
Source: Regenstrief LOINC

Observation ID in Form

B1

Fully-Specified Name

Component
Lying to sitting on side of bed during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52649-1 Sit to Stand

Term Description

The ability to safely come to a standing position from sitting in a chair or on the side of a bed.
Source: Regenstrief LOINC

Observation ID in Form

B2

Fully-Specified Name

Component
Sit to stand during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52650-9 Chair/Bed-to-Chair Transfer

Term Description

The ability to safely transfer to and from a chair (or wheelchair). The chairs are placed at right angles to each other.
Source: Regenstrief LOINC

Observation ID in Form

B3

Fully-Specified Name

Component
Chair-bed to chair transfer during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52651-7 Toilet Transfer

Term Description

The ability to safely get on and off a toilet or commode.
Source: Regenstrief LOINC

Observation ID in Form

B4

Fully-Specified Name

Component
Toilet transfer during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52516-2 Mode of Mobility - All Patients

Fully-Specified Name

Component
Mode of Mobility - All Patients
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52652-5 Does this patient primarily use a wheelchair for mobility?

Observation ID in Form

B5

Skip Logic

If No, code B5a for the longest distance completed. If Yes, code B5b for the longest distance completed.

Fully-Specified Name

Component
Primarily uses wheelchair for mobility during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Survey Question

Text
Does this patient primarily use a wheelchair for mobility?
Source
CARE I.b05

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52517-0 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.)

Observation ID in Form

B5a

Fully-Specified Name

Component
Level of independence on longest distance walked
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

Survey Question

Text
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.)
Source
CARE I.b05a

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52653-3 Walk 150 ft (45 m)

Term Description

Once standing, can walk at least 150 feet (45 meters) in corridor or similar space.
Source: Regenstrief LOINC

Observation ID in Form

B5a.1

Fully-Specified Name

Component
Walk 150 ft (45 m) during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52654-1 Walk 100 ft (30 m)

Term Description

Once standing, can walk at least 100 feet (30 meters) in corridor or similar space.
Source: Regenstrief LOINC

Observation ID in Form

B5a.2

Fully-Specified Name

Component
Walk 100 ft (30 m) during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52655-8 Walk 50 ft (15m)

Term Description

Once standing, can walk at least 50 feet (15 meters) in corridor or similar space.
Source: Regenstrief LOINC

Observation ID in Form

B5a.3

Fully-Specified Name

Component
Walk 50 ft (15 m) during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52656-6 Walk in Room Once Standing

Term Description

Once standing, can walk at least 10 feet (3 meters) in room, corridor or similar space.
Source: Regenstrief LOINC

Observation ID in Form

B5a.4

Fully-Specified Name

Component
Walk 10 ft (3 m) during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52518-8 Select the longest distance the patient wheels and code his/her level of independence (Level 1-6). Observe performance. (Select only one.)

Observation ID in Form

B5b

Fully-Specified Name

Component
Level of independence on longest distance wheeled
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

Survey Question

Text
Select the longest distance the patient wheels and code his/her level of independence (Level 1-6). Observe performance. (Select only one.)
Source
CARE I.b05b

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52657-4 Wheel 150 ft (45 m)

Term Description

Once sitting, can wheel at least 150 feet (45 meters) in corridor or similar space.
Source: Regenstrief LOINC

Observation ID in Form

B5b.1

Fully-Specified Name

Component
Wheel 150 ft (45 m) during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52658-2 Wheel 100 ft (30 m)

Term Description

Once sitting, can wheel at least 100 feet (30 meters) in corridor or similar space.
Source: Regenstrief LOINC

Observation ID in Form

B5b.2

Fully-Specified Name

Component
Wheel 100 ft (30 m) during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52659-0 Wheel 50 ft (15 m)

Term Description

Once sitting, can wheel at least 50 feet (15 meters) in corridor or similar space.
Source: Regenstrief LOINC

Observation ID in Form

B5b.3

Fully-Specified Name

Component
Wheel 50 ft (15 m) during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52660-8 Wheel in Room Once Seated

Term Description

Once seated, can wheel at least 10 feet (3 meters) in room, corridor, or similar space.
Source: Regenstrief LOINC

Observation ID in Form

B5b.4

Fully-Specified Name

Component
Wheel 10 ft (3 m) during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL586-9

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52519-6 Supplemental Functional Ability

Observation ID in Form

C

Form Coding Instructions

Supplemental Functional Ability (Complete during the 2-day assessment period.) Please code the patient on all activities they are able to participate in and which you can observe, or have assessed by other means, using the 6-point scale below. Coding: Safety and Quality and Performance - If helper assistance is required because patient's performance is unsafe or poor quality, score according to amount of assistance provided. Code for the most usual performance in the 2-day assessment period. Activities may be completed with or without assistive devices

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Supplemental Functional Ability
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

54066-6 Following discharge, is it anticipated that the patient will need post-acute care to improve their functional ability or other types of personal assistance?

Observation ID in Form

C

Skip Logic

If No, skip to Section VII. Overall Plan of Care/Advance Care Directives.

Form Coding Instructions

Please code the patient on all activities they are able to particiate in and which you can observe, or have assessed by other means, using the 6-point scale below

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Post acute care or personal assistance anticipated following discharge
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
Following discharge, is it anticipated that the patient will need post-acute care to improve their functional ability or other types of personal assistance?
Source
CARE_VI_C_C

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52661-6 Wash Upper Body

Term Description

The ability to wash, rinse, and dry the face, hands, chest, and arms while sitting in a chair or bed.
Source: Regenstrief LOINC

Observation ID in Form

C1

Fully-Specified Name

Component
Wash upper body during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52662-4 Shower/bathe self

Term Description

The ability to bathe self in shower or tub, including washing and drying self. Does not include transferring in/out of tub/shower.
Source: Regenstrief LOINC

Observation ID in Form

C2

Fully-Specified Name

Component
Shower &or bathe self during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52663-2 Roll left and right

Term Description

The ability to roll from lying on back to left and right side, and roll back to back.
Source: Regenstrief LOINC

Observation ID in Form

C3

Fully-Specified Name

Component
Roll left and right during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52664-0 Sit to lying

Term Description

The ability to move from sitting on side of bed to lying flat on the bed.
Source: Regenstrief LOINC

Observation ID in Form

C4

Fully-Specified Name

Component
Sit to lying during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52665-7 Picking up object

Term Description

The ability to bend/stoop from a standing position to pick up small object such as a spoon from the floor.
Source: Regenstrief LOINC

Observation ID in Form

C5

Fully-Specified Name

Component
Picking up objects during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52666-5 Putting on/taking off footwear during 2 day assessment period [CARE]

Term Description

The ability to put on and take off socks and shoes or other footwear that are appropriate for safe mobility.
Source: Regenstrief LOINC

Observation ID in Form

C6

Fully-Specified Name

Component
Putting on &or taking off footwear during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52520-4 Mode of Mobility - PAC Patients

Fully-Specified Name

Component
Mode of Mobility - PAC Patients
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52652-5 Does this patient primarily use a wheelchair for mobility?

Observation ID in Form

C7

Skip Logic

If No, code C7a-C7f. If Yes, code C7f-C7h.

Fully-Specified Name

Component
Primarily uses wheelchair for mobility during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Survey Question

Text
Does this patient primarily use a wheelchair for mobility?
Source
CARE I.b05

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52667-3 1 step (curb)

Term Description

The ability to step over a curb or up and down one step.
Source: Regenstrief LOINC

Observation ID in Form

C7a

Fully-Specified Name

Component
One step (curb) during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52668-1 Walk 50 feet with two turns

Term Description

The ability to walk 50 feet and make two turns.
Source: Regenstrief LOINC

Observation ID in Form

C7b

Fully-Specified Name

Component
Walk 50 feet with two turns during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52669-9 12 steps-interior

Term Description

The ability to go up and down 12 interior steps with a rail.
Source: Regenstrief LOINC

Observation ID in Form

C7c

Fully-Specified Name

Component
12 steps-interior during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52670-7 Four steps-exterior

Term Description

The ability to go up and down 4 exterior steps with a rail.
Source: Regenstrief LOINC

Observation ID in Form

C7d

Fully-Specified Name

Component
Four steps-exterior during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52671-5 Walking 10 feet on uneven surfaces

Term Description

The ability to walk 10 feet on uneven or sloping surfaces, such as grass, gravel, ice or snow.
Source: Regenstrief LOINC

Observation ID in Form

C7e

Fully-Specified Name

Component
Walking 10 feet on uneven surfaces during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52672-3 Car transfer

Term Description

The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt.
Source: Regenstrief LOINC

Observation ID in Form

C7f

Fully-Specified Name

Component
Car transfer during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.54

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52673-1 Wheel short ramp

Term Description

Once seated in wheelchair, goes up and down a ramp of less than 12 feet (4 meters).
Source: Regenstrief LOINC

Observation ID in Form

C7g

Fully-Specified Name

Component
Wheel short ramp during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52674-9 Wheel long ramp

Term Description

Once seated in wheelchair, goes up and down a ramp of more than 12 feet (4 meters).
Source: Regenstrief LOINC

Observation ID in Form

C7h

Fully-Specified Name

Component
Wheel long ramp during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52675-6 Telephone answering

Term Description

The ability to pick up call in patient's customary manner and maintain for 1 minute. Does not include getting to the phone.
Source: Regenstrief LOINC

Observation ID in Form

C8

Fully-Specified Name

Component
Telephone-answering during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52676-4 Telephone-placing call

Term Description

The ability to pick up and place call in patient's customary manner and maintain for 1 minute. Does not include getting to the phone.
Source: Regenstrief LOINC

Observation ID in Form

C9

Fully-Specified Name

Component
Telephone-placing call during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52677-2 Medication management-oral medications

Term Description

The ability to prepare and take all prescribed oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals.
Source: Regenstrief LOINC

Observation ID in Form

C10

Fully-Specified Name

Component
Medication management-oral medications during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52678-0 Medication management-inhalant/mist

Term Description

The ability to prepare and take all prescribed inhalant/mist medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals.
Source: Regenstrief LOINC

Observation ID in Form

C11

Fully-Specified Name

Component
Medication management-inhalant &or mist medications during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52679-8 Medication management-injectable medications

Term Description

The ability to prepare and take all prescribed injectable medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals.
Source: Regenstrief LOINC

Observation ID in Form

C12

Fully-Specified Name

Component
Medication management-injectable medications during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52680-6 Make light meal

Term Description

The ability to plan and prepare all aspects of a light meal such as bowl of cereal or sandwich and cold drink, or reheat a prepared meal.
Source: Regenstrief LOINC

Observation ID in Form

C13

Fully-Specified Name

Component
Make light meal during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52681-4 Wipe down surface

Term Description

The ability to use a damp cloth to wipe down surface such as table top or bench to remove small amounts of liquid or crumbs. Includes ability to clean cloth of debris in patient's customary manner.
Source: Regenstrief LOINC

Observation ID in Form

C14

Fully-Specified Name

Component
Wipe down surface during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52682-2 Light shopping

Term Description

Once at store, can locate and select up to five needed goods, take to check out, and complete purchasing transaction.
Source: Regenstrief LOINC

Observation ID in Form

C15

Fully-Specified Name

Component
Light shopping during 2D assesssment
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

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52683-0 Laundry

Term Description

Includes all aspects of completing a load of laundry using a washer and dryer. Includes sorting, loading and unloading, and adding laundry detergent.
Source: Regenstrief LOINC

Observation ID in Form

C16

Fully-Specified Name

Component
Laundry during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52684-8 Use public transportation

Term Description

The ability to plan and use public transportation. Includes boarding, riding, and alighting from transportation.
Source: Regenstrief LOINC

Observation ID in Form

C17

Fully-Specified Name

Component
Use public transportation during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL587-7

Answer Code Score Answer ID
Independent - Patient completes the activity by themself with no assistance from a helper. 6 LA9983-3
Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity. 5 LA10073-7
Supervision or touching assistance - Helper provides verbal cues or touching/steadying assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently. 4 LA11757-4
Partial/moderate assistance - Helper does less than half the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort. 3 LA10055-4
Substantial/maximal assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. 2 LA10090-1
Dependent - Helper does all of the effort. Patient does none of the effort to complete the task. 1 LA9964-3
Not attempted due to medical condition M LA10039-8
Not attempted due to safety concerns S LA10040-6
Not attempted due to environmental constraints E LA10038-0
Task attempted but not completed A LA10092-7
Not applicable N LA4720-4
Patient refused P LA10058-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

81957-3 Overall Plan of Care/Advance Care Directives panel

Observation ID in Form

VII

Fully-Specified Name

Component
Overall Plan of Care &or Advance Care Directives panel
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
PANEL.SURVEY.CARE
Type
Surveys
First Released
Version 2.56
Last Updated
Version 2.64
Panel Type
Convenience group

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52522-0 Overall Plan of Care/Advance Care Directives

Observation ID in Form

A

Fully-Specified Name

Component
Overall Plan of Care &or Advance Care Directives - Subheading
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52685-5 Have the patient (or representative) and the care team (or physician) documented agreed-upon care goals and expected dates of completion or re-evaluation?

Observation ID in Form

A1

Fully-Specified Name

Component
Care goals documented
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Change Reason
Method removed and Answer List Type changed to Example because this generic term can be used across contexts

Survey Question

Text
Have the patient (or representative) and the care team (or physician) documented agreed-upon care goals and expected dates of completion or re-evaluation?
Source
CARE I.a01

Example Answer List LL588-5

Answer Code Score Answer ID
No, but this work is in process 0 LA10025-7
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Unclear or unknown 9 LA10109-9

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52686-3 Which description best fits the patient's overall status?

Observation ID in Form

A2

Fully-Specified Name

Component
Overall status
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
Which description best fits the patient's overall status?
Source
CARE I.a02

Normative Answer List LL589-3

Answer Code Score Answer ID
The patient is stable with no risk for serious complications and death (beyond those typical of the patient’s age). 1 LA10098-4
The patient is temporarily facing high health risks but likely to return to being stable without risk for serious complications and death (beyond those typical of the patient's age). 2 LA10099-2
The patient is likely to remain in fragile health and have ongoing high risks of serious complications and death. 3 LA10097-6
The patient has serious progressive conditions that could lead to death within a year. 4 LA10096-8
The patient's situation is unknown or unclear to the respondent. 9 LA10100-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52687-1 In anticipation of serious clinical complications, has the patient made care decisions which are documented in the medical record?

Observation ID in Form

A3

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Decision authority documented
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
In anticipation of serious clinical complications, has the patient made care decisions which are documented in the medical record?
Source
CARE I.A3

Normative Answer List LL590-1

Answer Code Score Answer ID
The patient has designated a decision-maker (if the patient is unable to make decisions) which is documented in the medical record. 1 LA11786-3
The patient (or surrogate) has made a decision to forgo resuscitation which is documented in the medical record. 2 LA11787-1

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52523-8 Discharge Status

Observation ID in Form

VIII

Fully-Specified Name

Component
Discharge 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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52524-6 Discharge Information

Observation ID in Form

A

Fully-Specified Name

Component
Discharge Information
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52525-3 Discharge date

Observation ID in Form

A1

Fully-Specified Name

Component
Discharge date
Property
TmStp
Time
Pt
System
^Patient
Scale
Qn
Method

Additional Names

Short Name
Discharge date

Basic Attributes

Class
H&P.HX
Type
Clinical
First Released
Version 2.24
Last Updated
Version 2.63
Order vs. Observation
Both

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
85671-6 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
86870-3 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
86874-5 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA start of therapy (NS/SS) item set [CMS Assessment]
86875-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed tracking (NT/ST) item set [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86877-8 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88279-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88280-3 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88281-1 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88286-0 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88952-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA start of therapy (NS and SS) item set [CMS Assessment]
88953-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88948-5 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home part A PPS discharge (NPE) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87506-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 4.00 during assessment period [CMS Assessment]
93219-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.00 during assessment period [CMS Assessment]
103948-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 during assessment period [CMS Assessment]
93220-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.00 during assessment period [CMS Assessment]
103947-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment]
90479-7 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home and Swing bed tracking (NT and ST) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101108-9 MDS v3.0 - RAI v1.18.11 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
105008-7 MDS v3.0 - RAI v1.19.1 - Nursing home and Swing bed tracking (NT ST) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
75854-0 PCORnet common data model set - version 1.0 [PCORnet]
85057-8 PCORnet Common Data Model set - version 3.0 [PCORnet]

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Fecha de alta:TmStp:Punto temporal:^ Paciente:Cuantitativo:
it-IT Italian (Italy) Data di dimissione:TmStp:Pt:^Paziente:Qn:
Synonyms: Anamnesi paziente Punto nel tempo (episodio) Time stamp (Data e Ora)
pt-BR Portuguese (Brazil) Data de alta médica:TmStp:Pt:^Paciente:Qn:
Synonyms: Time stamp; Date and time; Timestamp; Point in time; Random; Quantitative; QNT; Quant; Quan
ru-RU Russian (Russian Federation) Выбытие дата:TmStp:ТчкВрм:^Пациент:Колич:
Synonyms: Time Stamp (Дата и Время) Выписка Дата выписки Количественный Точка во времени;Момент
zh-CN Chinese (China) 出院日期:时间戳:时间点:^患者:定量型:
Synonyms: 允许...离开(医院、军队);(从监狱)释放 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印时戳;时标;时间戳(日期与时间);时间标记;计时标记 历史纪录与体格检查 历史纪录与体格检查.历史记录;历史纪录与体格检查.历史记录类;历史纪录与体格检查.历史记录类别;历史纪录与体格检查.病史;历史纪录与体格检查.病史类;历史纪录与体格检查.病史类别;历史纪录与体格检查.病史记录;历史纪录与体格检查.病史记录类;历史纪录与体格检查.病史记录类别;历史纪录与体格检查小节.历史记录;历史纪录与体格检查小节.历史记录类;历史纪录与体格检查小节.历史记录类别;历史纪录与体格检查小节.病史;历史纪录与体格检查小节.病史类;历史纪录与体格检查小节.病史类别 历史纪录与体格检查小节 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 日子;几号 时刻;随机;随意;瞬间 病史与体格检查

Example Units

Unit Source
{mm/dd/yyyy} Example UCUM Units

52526-1 Attending Physician (at this location)

Observation ID in Form

A2

Fully-Specified Name

Component
Attending physician name
Property
Pn
Time
Pt
System
Provider
Scale
Nom
Method

Additional Names

Short Name
Attending physician name

Basic Attributes

Class
CLIN
Type
Clinical
First Released
Version 2.24
Last Updated
Version 2.73
Common Test Rank Get Info
7284

Member of these Panels

LOINC Long Common Name
80190-2 Catheterization and angiography procedure details panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
68359-9 End Stage Renal Disease (ESRD) Death Notification - OMB CMS form 2746
67868-0 End Stage Renal Disease (ESRD) Medical Evidence Report, Medicare Entitlement AndOr Patient Registration - OMB CMS form 2728
55140-8 Vaccine Adverse Event Reporting System (VAERS) panel

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Nombre del médico tratante:Pn:Punto temporal:Proveedor:Nominal:
it-IT Italian (Italy) Medico curante, nome:Pn:Pt:Provider:Nom:
Synonyms: Clinico Nome del medico curante Nome di persona Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Nome do médico atendente:Pn:Pt:Provedor:Nom:
Synonyms: Person name; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Штатный лечащий врач фамилия:Фам:ТчкВрм:Провайдер:Ном:
Synonyms: Номинальный;Именной Специалист с высшим медицинским образованием Точка во времени;Момент Фамилия
zh-CN Chinese (China) 主治医师姓名:人员姓名:时间点:服务提供者:名义型:
Synonyms: 主治医生姓名;主治医姓名 人名 内科医师;内科医生;医生 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 姓名;名字;名 提供方;提供者;服务人员;服务提供方;服务方;服务机构;服务者 时刻;随机;随意;瞬间

52688-9 Discharge Location. Where will the patient be discharged to?

Observation ID in Form

A3

Fully-Specified Name

Component
Discharge disposition
Property
Type
Time
Pt
System
^Patient
Scale
Nom
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.66
Change Reason
Updated Component from "Discharge location" to "Discharge disposition" for consistency across LOINC for terms reporting the location/status (disposition) of the patient at discharge.

Survey Question

Text
Discharge Location. Where will the patient be discharged to?
Source
CARE I.a03

Normative Answer List LL591-9

Answer Code Score Answer ID
Private residence 1 LA10062-0
Other community-based residential setting (e.g., assisted living residents, group home, adult foster care) 2 LA10048-9
Long-term care facility/nursing home 3 LA9999-9
Skilled nursing facility (SNF/TCU) 4 LA10080-2
Short-stay acute hospital (IPPS) 5 LA10078-6
Long-Term Care Hospital (LTCH) 6 LA10000-0
Inpatient rehabilitation hospital or unit (IRF) 7 LA9986-6
Psychiatric hospital or unit 8 LA10065-3
Facility-based hospice 9 LA9969-2
Other (e.g., shelter, jail, no known address) 10 LA10047-1
Discharged against medical advice 11 LA9965-0

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0

52689-7 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)?

Observation ID in Form

A4

Skip Logic

If Patient does not require assistance, Skip to Section B. Residential Information.

Fully-Specified Name

Component
Frequency of assistance at discharge
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
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)?
Source
CARE I.a04

Normative Answer List LL592-7

Answer Code Score Answer ID
Patient does not require assistance 1 LA10057-0
Weekly or less (e.g., requires help with grocery shopping or errands, etc.) 2 LA10118-0
Less than daily but more often than weekly 3 LA9995-7
Intermittently and predictably during the day or night 4 LA9989-0
All night but not during the day 5 LA9932-0
All day but not at night 6 LA9931-2
24 hours per day, or standby services 7 LA9919-7

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52690-5 Caregiver(s) Availability. Was the discharge destination decision influenced by the availability of a family member or friend to provide assistance?

Observation ID in Form

A5

Skip Logic

If No, skip to Section B. Residential Information.

Fully-Specified Name

Component
Discharge destination influenced by caregiver availability
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
Caregiver(s) Availability. Was the discharge destination decision influenced by the availability of a family member or friend to provide assistance?
Source
CARE I.a05

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52691-3 Willing Caregiver(s). Does the patient have one or more willing caregiver(s)?

Observation ID in Form

A6

Skip Logic

In NO, skip to Section B. Residential Information. If Unclear, skip to Section B. Residential Infomation.

Fully-Specified Name

Component
Willing caregiver
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
Willing Caregiver(s). Does the patient have one or more willing caregiver(s)?
Source
CARE I.a06

Normative Answer List LL593-5

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes, confirmed by caregiver 1 LA10130-5
Yes, confirmed only by patient 2 LA10131-3
Unclear from patient; no confirmation from caregiver 9 LA10108-1

Member of these Panels

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

52692-1 Types of Caregiver(s). What is the relationship of the caregiver(s) to the patient?

Observation ID in Form

A7

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Types of caregiver
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64
Change Reason
Method removed and Answer List Type changed to Example because this generic term can be used across contexts

Survey Question

Text
Types of Caregiver(s). What is the relationship of the caregiver(s) to the patient?
Source
CARE I.A7

Example Answer List LL594-3

Answer Code Score Answer ID
Spouse or significant other a LA6382-1
Child b LA9949-4
Other unpaid family member or friend c LA10052-1
Paid help d LA6320-1

Member of these Panels

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

52527-9 Residential Information

Observation ID in Form

B

Form Coding Instructions

Complete only if patient is discharged to a private residence or other community-based setting

Source: Centers for Medicare & Medicaid Services

Form Coding Instructions

Complete only if patient lives a private residence or other community-based setting

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Residential Information
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52693-9 Patient Lives With at Discharge (or admission for HH). Upon discharge (admission), who will the patient live with?

Observation ID in Form

B1

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Patient will live with at discharge
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
CARE

Basic Attributes

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

Survey Question

Text
Patient Lives With at Discharge (or admission for HH). Upon discharge (admission), who will the patient live with?
Source
CARE I.B1

Normative Answer List LL549-7

Answer Code Score Answer ID
Lives alone a LA6255-9
Lives with paid helper b LA9997-3
Lives with other(s) c LA9996-5
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) d LA4489-6

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52528-7 Support Needs/Caregiver Assistance

Observation ID in Form

C

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

Fully-Specified Name

Component
Support Needs &or Caregiver Assistance
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

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

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

Basic Attributes

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

Normative Answer List LL595-0

Answer Code Score Answer ID
CG able 1 LA9945-2
CG will need training and/or other supportive services 2 LA9947-8
CG not likely to be able 3 LA9946-0
CG ability unclear 4 LA9944-5

Member of these Panels

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

Basic Attributes

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

Normative Answer List LL595-0

Answer Code Score Answer ID
CG able 1 LA9945-2
CG will need training and/or other supportive services 2 LA9947-8
CG not likely to be able 3 LA9946-0
CG ability unclear 4 LA9944-5

Member of these Panels

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

Basic Attributes

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

Normative Answer List LL595-0

Answer Code Score Answer ID
CG able 1 LA9945-2
CG will need training and/or other supportive services 2 LA9947-8
CG not likely to be able 3 LA9946-0
CG ability unclear 4 LA9944-5

Member of these Panels

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

Basic Attributes

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

Normative Answer List LL595-0

Answer Code Score Answer ID
CG able 1 LA9945-2
CG will need training and/or other supportive services 2 LA9947-8
CG not likely to be able 3 LA9946-0
CG ability unclear 4 LA9944-5

Member of these Panels

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

Basic Attributes

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

Normative Answer List LL595-0

Answer Code Score Answer ID
CG able 1 LA9945-2
CG will need training and/or other supportive services 2 LA9947-8
CG not likely to be able 3 LA9946-0
CG ability unclear 4 LA9944-5

Member of these Panels

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

Basic Attributes

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

Normative Answer List LL595-0

Answer Code Score Answer ID
CG able 1 LA9945-2
CG will need training and/or other supportive services 2 LA9947-8
CG not likely to be able 3 LA9946-0
CG ability unclear 4 LA9944-5

Member of these Panels

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

Basic Attributes

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

Normative Answer List LL595-0

Answer Code Score Answer ID
CG able 1 LA9945-2
CG will need training and/or other supportive services 2 LA9947-8
CG not likely to be able 3 LA9946-0
CG ability unclear 4 LA9944-5

Member of these Panels

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

Basic Attributes

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

Normative Answer List LL251-0

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

Member of these Panels

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

52529-5 Discharge Care Options

Form Coding Instructions

Please indicate whether the team considered the following services appropriate for the patient at discharge; for those identified as potentially appropriate, were they: unavailable, refused by family, or not covered by insurance. (Check all that apply.)

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Discharge Care Options
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52702-8 Home Health Care (HHA)

Observation ID in Form

Da

Fully-Specified Name

Component
Home health care considered appropriate
Property
Find
Time
Pt
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 LL596-8

Answer Code Score Answer ID
Considered Appropriate by the Provider 1 LA9955-1
No Bed/Services Available 2 LA11804-4
Refused by Patient/Family 3 LA10069-5
Not Covered by Insurance 4 LA10041-4

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52703-6 Skilled Nursing Facility (SNF/TCU)

Fully-Specified Name

Component
Skilled nursing facility considered appropriate
Property
Find
Time
Pt
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 LL596-8

Answer Code Score Answer ID
Considered Appropriate by the Provider 1 LA9955-1
No Bed/Services Available 2 LA11804-4
Refused by Patient/Family 3 LA10069-5
Not Covered by Insurance 4 LA10041-4

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52704-4 Inpatient Rehabilitation Hospital or Unit (IRF)

Fully-Specified Name

Component
Inpatient rehabilitation hospital considered appropriate
Property
Find
Time
Pt
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 LL596-8

Answer Code Score Answer ID
Considered Appropriate by the Provider 1 LA9955-1
No Bed/Services Available 2 LA11804-4
Refused by Patient/Family 3 LA10069-5
Not Covered by Insurance 4 LA10041-4

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52705-1 Long-Term Care Hospital (LTCH)

Fully-Specified Name

Component
Long term care hospital considered appropriate
Property
Find
Time
Pt
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 LL596-8

Answer Code Score Answer ID
Considered Appropriate by the Provider 1 LA9955-1
No Bed/Services Available 2 LA11804-4
Refused by Patient/Family 3 LA10069-5
Not Covered by Insurance 4 LA10041-4

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52706-9 Psychiatric Hospital or Unit

Fully-Specified Name

Component
Psychiatric hospital considered appropriate
Property
Find
Time
Pt
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 LL596-8

Answer Code Score Answer ID
Considered Appropriate by the Provider 1 LA9955-1
No Bed/Services Available 2 LA11804-4
Refused by Patient/Family 3 LA10069-5
Not Covered by Insurance 4 LA10041-4

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52707-7 Outpatient Services

Fully-Specified Name

Component
Outpatient services considered appropriate
Property
Find
Time
Pt
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 LL596-8

Answer Code Score Answer ID
Considered Appropriate by the Provider 1 LA9955-1
No Bed/Services Available 2 LA11804-4
Refused by Patient/Family 3 LA10069-5
Not Covered by Insurance 4 LA10041-4

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52708-5 Acute Hospital Admission

Fully-Specified Name

Component
Acute hospital admission considered appropriate
Property
Find
Time
Pt
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 LL596-8

Answer Code Score Answer ID
Considered Appropriate by the Provider 1 LA9955-1
No Bed/Services Available 2 LA11804-4
Refused by Patient/Family 3 LA10069-5
Not Covered by Insurance 4 LA10041-4

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52709-3 Hospice

Fully-Specified Name

Component
Hospice considered appropriate
Property
Find
Time
Pt
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 LL596-8

Answer Code Score Answer ID
Considered Appropriate by the Provider 1 LA9955-1
No Bed/Services Available 2 LA11804-4
Refused by Patient/Family 3 LA10069-5
Not Covered by Insurance 4 LA10041-4

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52710-1 Long-term Personal Care Services

Fully-Specified Name

Component
Long-term personal care services considered appropriate
Property
Find
Time
Pt
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 LL596-8

Answer Code Score Answer ID
Considered Appropriate by the Provider 1 LA9955-1
No Bed/Services Available 2 LA11804-4
Refused by Patient/Family 3 LA10069-5
Not Covered by Insurance 4 LA10041-4

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52711-9 Long-Term Nursing Facility

Fully-Specified Name

Component
Long term care nursing facility considered appropriate
Property
Find
Time
Pt
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 LL596-8

Answer Code Score Answer ID
Considered Appropriate by the Provider 1 LA9955-1
No Bed/Services Available 2 LA11804-4
Refused by Patient/Family 3 LA10069-5
Not Covered by Insurance 4 LA10041-4

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52712-7 Other (specify)

Fully-Specified Name

Component
Other service considered appropriate
Property
Find
Time
Pt
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 LL596-8

Answer Code Score Answer ID
Considered Appropriate by the Provider 1 LA9955-1
No Bed/Services Available 2 LA11804-4
Refused by Patient/Family 3 LA10069-5
Not Covered by Insurance 4 LA10041-4

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

55760-3 Other service considered appropriate.other specified [CARE]

Fully-Specified Name

Component
Other service considered appropriate.other specified
Property
Type
Time
Pt
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

55761-1 No services needed after discharge [CARE]

Fully-Specified Name

Component
No services needed after discharge
Property
Find
Time
Pt
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52530-3 Discharge Location Information

Fully-Specified Name

Component
Discharge Location Information
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52713-5 Is the patient being discharged with referral for additional services?

Skip Logic

If No, skip to E7. Discharge Delay. If Yes, please identify the name, location, and type, of service to which the patient is discharged.

Fully-Specified Name

Component
Discharged with referral for additional services
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
Is the patient being discharged with referral for additional services?
Source
CARE I.e01

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52458-7 Name Provider

Fully-Specified Name

Component
Name
Property
Pn
Time
Pt
System
Provider
Scale
Nom
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.27

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
62400-7 PhenX - arrhythmia protocol 041101
97029-3 Spine Tango surgery follow-up 2017 Spine Tango

52714-3 Provider type [CARE]

Fully-Specified Name

Component
Provider type
Property
Type
Time
Pt
System
Provider
Scale
Nom
Method
CARE

Basic Attributes

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

Normative Answer List LL729-5

Answer Code Score Answer ID
Home Health Care (HHA) 1 LA9978-3
Skilled nursing facility (SNF/TCU) 2 LA10080-2
Inpatient rehabilitation hospital or unit (IRF) 3 LA9986-6
Long-Term Care Hospital (LTCH) 4 LA10000-0
Psychiatric hospital or unit 5 LA10065-3
Outpatient Services 6 LA10053-9
Short-stay acute hospital (IPPS) 7 LA10078-6
Hospice 8 LA6216-1
Long-term nursing facility 9 LA11502-4
Other (specify) 10 LA6310-2

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0

52715-0 Other (specify)

Observation ID in Form

E3_10

Fully-Specified Name

Component
Provider type.other specified
Property
Type
Time
Pt
System
Provider
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52531-1 Provider city

Fully-Specified Name

Component
Provider city
Property
Loc
Time
Pt
System
Provider
Scale
Nom
Method

Additional Names

Short Name
Provider city

Basic Attributes

Class
CLIN
Type
Clinical
First Released
Version 2.24
Last Updated
Version 2.73
Common Test Rank Get Info
8342

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Ciudad proveedora:Loc:Punto temporal:Proveedor:Nominal:
it-IT Italian (Italy) Provider, città:Loc:Pt:Provider:Nom:
Synonyms: Città del provider Clinico Posizione Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Cidade provedora:Loc:Pt:Provedor:Nom:
Synonyms: Location; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Провайдер город:Лок:ТчкВрм:Провайдер:Ном:
Synonyms: Локализация Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 服务提供者 城市:位置:时间点:服务提供者:名义型:
Synonyms: 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 地点;场所 提供方;提供者;服务人员;服务提供方;服务方;服务机构;服务者 时刻;随机;随意;瞬间 服务提供者(提供方、提供者、服务人员、服务提供方、服务方、服务机构、服务者) 城市

52532-9 Provider state

Fully-Specified Name

Component
Provider state
Property
Loc
Time
Pt
System
Provider
Scale
Nom
Method

Additional Names

Short Name
Provider state

Basic Attributes

Class
CLIN
Type
Clinical
First Released
Version 2.24
Last Updated
Version 2.73
Common Test Rank Get Info
8154

Example Answer List LL3178-2

Answer Code Score Answer ID
AL LA21991-7
AK LA21992-5
AZ LA21993-3
AR LA21994-1
CA LA21995-8
CO LA21996-6
CT LA21997-4
DC LA21998-2
DE LA21999-0
FL LA22000-6
GA LA22001-4
HI LA22002-2
ID LA19256-9
IL LA22003-0
IN LA22004-8
IA LA22005-5
KS LA22006-3
KY LA22007-1
LA LA22008-9
ME LA22009-7
MD LA20036-2
MA LA22010-5
MI LA22011-3
MN LA22012-1
MS LA22013-9
MO LA22014-7
MT LA22015-4
NE LA22016-2
NV LA22017-0
NH LA21453-8
NJ LA22018-8
NM LA22019-6
NY LA22020-4
NC LA22021-2
ND LA22022-0
OH LA22023-8
OK LA22024-6
OR LA22025-3
PA LA22026-1
PR LA21403-3
RI LA22027-9
SC LA22028-7
SD LA22029-5
TN LA22030-3
TX LA3601-7
UT LA22031-1
VT LA22032-9
VA LA18827-8
WA LA22033-7
WV LA22034-5
WI LA22035-2
WY LA22036-0
Other, Please specify: LA46-8

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Estado del proveedor:Loc:Punto temporal:Proveedor:Nominal:
it-IT Italian (Italy) Provider, stato:Loc:Pt:Provider:Nom:
Synonyms: Clinico Posizione Punto nel tempo (episodio) Stato del provider
pt-BR Portuguese (Brazil) Estado provedor:Loc:Pt:Provedor:Nom:
Synonyms: Location; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Провайдер штат:Лок:ТчкВрм:Провайдер:Ном:
Synonyms: Локализация Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 服务提供者州别:位置:时间点:服务提供者:名义型:
Synonyms: 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 地点;场所 州;邦;政府;国家;状况;情况 提供方;提供者;服务人员;服务提供方;服务方;服务机构;服务者 时刻;随机;随意;瞬间 服务提供者(提供方、提供者、服务人员、服务提供方、服务方、服务机构、服务者)州别

45952-9 National provider ID

Fully-Specified Name

Component
National provider ID
Property
ID
Time
Pt
System
Provider
Scale
Nom
Method

Basic Attributes

Class
SURVEY.MDS
Type
Surveys
First Released
Version 2.17
Last Updated
Version 2.50

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
45981-8 Deprecated MDS full assessment form - version 2.0
46104-6 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III 1997 update
46076-6 Deprecated Minimum Data Set (MDS) supplemental items section - version 2.0
71746-2 Personnel contact information panel [ESRD] Personnel

52716-8 Was the patient's discharge delayed for at least 24 hours?

Fully-Specified Name

Component
Discharge delayed at least 24H
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64
Change Reason
Method removed and Answer List Type changed to Example because this generic term can be used across contexts

Survey Question

Text
Was the patient's discharge delayed for at least 24 hours?
Source
CARE I.e07

Example Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0

52717-6 Reason for discharge delay

Fully-Specified Name

Component
Reason for discharge delay
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64
Change Reason
Method removed and Answer List Type changed to Example because this generic term can be used across contexts

Example Answer List LL598-4

Answer Code Score Answer ID
No bed available 1 LA10021-6
Services, equipment or medications not available (e.g., home health care, durable medical equipment, IV medications) 2 LA10072-9
Family/support (e.g., family could not pick patient up) 3 LA9970-0
Medical (patient condition changed) 4 LA10004-2
Other (specify) 5 LA6310-2

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0

52718-4 Other (specify)

Observation ID in Form

E8_5

Fully-Specified Name

Component
Reason for discharge delay.other specified
Property
Find
Time
Pt
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

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0

52719-2 In the situation that the patient or an authorized representative has requested this information not be shared with the next provider, check here:

Fully-Specified Name

Component
Patient requested information not be shared with next provider
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
In the situation that the patient or an authorized representative has requested this information not be shared with the next provider, check here:
Source
CARE I.e09

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52533-7 Medical Coding Information

Observation ID in Form

IX

Type of Entry

Question expects user entry - requires response [Q]

Form Coding Instructions

Coders: For this section, please provide a listing of principal diagnosis, comorbid diseases and complications, and procedures based on a review of the patient's clinical records at the time of discharge or at the time of a significant change in the patient's status affecting Medicare payment

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Medical Coding Information
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.73
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim

52534-5 Principal Diagnosis

Observation ID in Form

A

Type of Entry

Question expects user entry - requires response [Q]

Form Coding Instructions

Indicate the principal diagnosis for billing purposes. Indicate the ICD-9 CM code. For V-codes, also indicate the medical diagnosis and associated ICD-9 CM code. Be as specific as possible

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Principal Diagnosis
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.73
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

46584-9 ICD-9 CM for Principal Diagnosis at Assessment

Term Description

A case mix diagnosis is a primary diagnosis that assigns patients with selected conditions to an orthopedic, diabetes, neurological, or burns/trauma group for Medicare PPS case mix adjustment. A case mix diagnosis may involve manifestation coding.
Source: Regenstrief LOINC

Observation ID in Form

A1

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Payment diagnosis - primary ICD code
Property
Prid
Time
Pt
System
^Patient
Scale
Nom
Method
OASIS

Basic Attributes

Class
SURVEY.OASIS
Type
Surveys
First Released
Version 2.19
Last Updated
Version 2.54

Normative Answer List LL343-5

Externally Defined
Yes
Code System
I9C
Code System OID
1.3.6.1.4.1.12009.10.1.2173
Link to External List

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
46462-8 Deprecated Outcome and assessment information set (OASIS) form - version B1

86255-7 Primary diagnosis ICD code

Term Description

The condition that is the chief reason for providing care.
Source: Regenstrief LOINC

Observation ID in Form

A2

Fully-Specified Name

Component
Primary diagnosis ICD code
Property
Type
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Primary Dx ICD code

Basic Attributes

Class
CLIN
Type
Clinical
First Released
Version 2.63
Last Updated
Version 2.73
Order vs. Observation
Both
Common Test Rank Get Info
17680

Example Answer List LL4547-7

Externally Defined
Yes
Code System
Code System OID
1.3.6.1.4.1.12009.10.1.3459
Link to External List
http://www.cdc.gov/nchs/icd.htm

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
46462-8 Deprecated Outcome and assessment information set (OASIS) form - version B1
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57192-7 Deprecated Outcome and assessment information set (OASIS) form - version C - Follow-Up
57191-9 Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care
57190-1 Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care
86244-1 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment]
86189-8 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
85907-4 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
88369-4 Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
88368-6 Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment]
88373-6 Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment]
93058-6 Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment]
99160-4 Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment]
99131-5 Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment]

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Código ICD de diagnóstico primario:Tipo:Punto temporal:^ Paciente:Nominal:
it-IT Italian (Italy) Diagnosi primaria codice ICD:Tipo:Pt:^Paziente:Nom:
Synonyms: Clinico paziente Punto nel tempo (episodio)
zh-CN Chinese (China) 主要诊断 ICD 代码:类型:时间点:^患者:名义型:
Synonyms: ICD 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 国际疾病分类(International Classification of Diseases,ICD) 国际疾病分类;international Classification of diseases;ICD 国际疾病分类法 国际疾病分类系统 型 时刻;随机;随意;瞬间 诊断 ICD 编码;ICD 诊断代码;ICD 诊断编码;国际疾病分类;international Classification of diseases;ICD 诊断结论;判断;结论

18630-4 Primary Diagnosis at Assessment

Observation ID in Form

A1a

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Diagnosis.primary
Property
Imp
Time
Pt
System
^Patient
Scale
Nom
Method

Basic Attributes

Class
ATTACH.REHAB
Type
Claims Attachments
First Released
Version 1.0l
Last Updated
Version 2.70
Change Reason
Release 2.70: AnswerListId: Added example answer list;
Order vs. Observation
Observation

Example Answer List LL4747-3

Answer Code Score Answer ID
Other LA46-8
Alcoholism LA20350-7
Bleeding disorder LA20352-3
Currently receiving chemotherapy for cancer LA20353-1
Congenital anomalies LA20354-9
Congestive heart failure (CHF) LA12740-9
Current smoker LA20356-4
Chronic renal failure LA20357-2
Cerebrovascular accident LA22244-0
Diabetes mellitus LA14291-1
Disseminated cancer LA20360-6
Advanced directive limiting care LA20361-4
Functionally dependent health status LA20363-0
Hypertension LA7444-8
Prematurity LA20368-9
Chronic obstructive pulmonary disease LA28200-6
Steroid use LA20370-5
Cirrhosis LA9639-1
Dementia LA20372-1
Attention deficit disorder/Attention deficit hyperactivity disorder (ADD/ADHD) LA28412-7
Anticoagulant therapy LA28199-0
Angina pectoris Copyright http://snomed.info/sct ID:194828000 Angina (disorder) LA14275-4
Mental/personality disorder LA28198-2
Myocardial infarction Copyright http://snomed.info/sct ID:22298006 Myocardial infarction (disorder) LA14274-7
Peripheral arterial disease Copyright http://snomed.info/sct ID:399957001 Peripheral arterial occlusive disease (disorder) LA28197-4
Substance abuse disorder Copyright http://snomed.info/sct ID:66214007 Substance abuse (disorder) LA28195-8

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
97782-7 Spine Tango Surgery 2017

Language Variants Get Info

Tag Language Translation
es-AR Spanish (Argentina) diagnóstico.primario:impresión/interpretación del estudio:punto en el tiempo:^paciente:Nominal:
it-IT Italian (Italy) Diagnosi.primaria:Imp:Pt:^Paziente:Nom:
Synonyms: Allegato Allegato riabilitazione Impressione/interpretazione di studio paziente Punto nel tempo (episodio)
ru-RU Russian (Russian Federation) Диагноз.основной:Впчт:ТчкВрм:^Пациент:Ном:
Synonyms: Впечатление/интерпретация исследования Номинальный;Именной Точка во времени;Момент
zh-CN Chinese (China) 诊断.主要:印象:时间点:^患者:名义型:
Synonyms: Health Insurance Portability and Accountability Act of 1996;HIPAA;健康保險可攜與責任法;HIPAA法案;健康保险可移植性和问责法1996年;美国健康保险携带和责任法案;医疗保险便携性和责任法案;医疗保险便携性与责任法案;醫療保險可攜性與責任法;HIPAA 信息附件.康复治疗;健康保险便携与责任法案信息附件.康复;健康保险便携与责任法案信息附件.康复治疗;康复信息附件;康复治疗HIPAA信息附件;康复治疗信息附件;康复治疗健康保险便携与责任法 主要诊断 信息附件;健康保险便携与责任法案信息附件;附件 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述,始终是对其他某种观察指标的解释或抽象(一系列检验项目结果、一幅图像或者整个某位病人),而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 时刻;随机;随意;瞬间 诊断结论;判断;结论

29308-4 Diagnosis

Part Descriptions

LP72437-4   Diagnosis
The end result of a diagnostic process that identifies a disease. Source: Regenstrief LOINC

Observation ID in Form

A2a

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Diagnosis
Property
Imp
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Dx

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.03
Last Updated
Version 2.73
Order vs. Observation
Observation
Common Test Rank Get Info
4809

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
74293-2 Oncology plan of care and summary - recommended CDA set
93149-3 PhenX - bone age protocol 220301
62863-6 PhenX domain - Infectious diseases and immunity
62896-6 PhenX domain - Skin, bone, muscle and joint

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Diagnose:Interpretation:Zeitpunkt:^Patient:Nominal:
es-AR Spanish (Argentina) diagnóstico:impresión/interpretación del estudio:punto en el tiempo:^paciente:Nominal:
es-ES Spanish (Spain) Diagnóstico:Impresión/interpretación del estudio:Punto temporal:^paciente:Nom:
es-MX Spanish (Mexico) Diagnóstico:Interpretación:Punto temporal:^ Paciente:Nominal:
fr-CA French (Canada) Diagnostic:Impression:Temps ponctuel:^Patient:Nominal:
fr-BE French (Belgium) Diagnostic:Impression/interprétation d'étude:Temps ponctuel:^Patient:Nominal:
it-IT Italian (Italy) Diagnosi:Imp:Pt:^Paziente:Nom:
Synonyms: Esame obbiettivo Impressione/interpretazione di studio paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Diagnóstico:Imp:Pt:^Paciente:Nom:
Synonyms: ; Dx; Interpretation; Interp; Impression; Impressions; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Диагноз:Впчт:ТчкВрм:^Пациент:Ном:
Synonyms: Впечатление/интерпретация исследования Номинальный;Именной Точка во времени;Момент
uk-UA Ukrainian (Ukraine) Діагноз:Інтерпретація:МоментЧасу:^Пацієнт:Категорійно:
Synonyms: Dx; H+P; H+P.PX; Impression; Impression/interpretation of study; Impressions; Interp; Interpretation; Nominal; P prime; Point in time; Random
zh-CN Chinese (China) 诊断:印象:时间点:^患者:名义型:
Synonyms: 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述,始终是对其他某种观察指标的解释或抽象(一系列检验项目结果、一幅图像或者整个某位病人),而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 历史纪录与体格检查 历史纪录与体格检查小节 时刻;随机;随意;瞬间 病史与体格检查 诊断结论;判断;结论

52807-5 Other Diagnoses, Comorbidities, and Complications

Observation ID in Form

B

Type of Entry

Question expects user entry - requires response [Q]

Form Coding Instructions

List other diagnoses being treated, managed, or monitored in this setting. Include all diagnoses (e.g., depression, schizophrenia, dementia, protein calorie malnutrition)

Source: Centers for Medicare & Medicaid Services

Form Coding Instructions

List up to 15 ICD-9 CM codes and associated diagnoses being treated, managed, or monitored in this setting. Include all diagnoses ( e.g. depression, schizophrenia, dementia, protein calorie malnutrition). If a V-code is listed, also provide the ICD-9 CM code for the medical diagnosis being treated

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Medical Coding Other Diagnoses, Comorbidities, and Complications
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

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52797-8 Diagnosis ICD code [Identifier]

Observation ID in Form

B1a

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Diagnosis ICD code
Property
Prid
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Dx ICD code

Basic Attributes

Class
CLIN
Type
Clinical
First Released
Version 2.26
Last Updated
Version 2.73
Change Reason
Changed CLASS from SURVEY.MDS to CLIN
Order vs. Observation
Both
Common Test Rank Get Info
743

Example Answer List LL4547-7

Externally Defined
Yes
Code System
Code System OID
1.3.6.1.4.1.12009.10.1.3459
Link to External List
http://www.cdc.gov/nchs/icd.htm

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
93222-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.00 during assessment period [CMS Assessment]
103949-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
90480-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101111-3 MDS v3.0 - RAI v1.18.11 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
104608-5 MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
89724-9 Minimum Data Set (MDS) for Public Health Emergency Operations Centers (EOC) [CDC Emergency Operations Centers]
87825-6 National Trauma Data Standard - version 2018 set
74502-6 Patient safety event report - hospital - patient information form (PIF) - version 1.2 [AHRQ]
62949-3 PhenX domain - Gastrointestinal

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Código ICD de diagnóstico:Tipo:Punto temporal:^ Paciente:Nominal:
es-ES Spanish (Spain) Código CIE del diagnóstico:Presencia o identidad:Punto temporal:^paciente:Nom:
it-IT Italian (Italy) Diagnosi, codice ICD:Prid:Pt:^Paziente:Nom:
Synonyms: Clinico paziente Presenza o Identità Punto nel tempo (episodio)
zh-CN Chinese (China) 诊断 ICD 代码:存在与否或特征标识:时间点:^患者:名义型:
Synonyms: ICD 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 国际疾病分类(International Classification of Diseases,ICD) 国际疾病分类法 国际疾病分类系统 存在;存在与否;特征标识;身份;身份标识 时刻;随机;随意;瞬间 诊断 ICD 编码;ICD 诊断代码;ICD 诊断编码;国际疾病分类;international Classification of diseases;ICD 诊断结论;判断;结论

29308-4 Diagnosis

Part Descriptions

LP72437-4   Diagnosis
The end result of a diagnostic process that identifies a disease. Source: Regenstrief LOINC

Observation ID in Form

B1b

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Diagnosis
Property
Imp
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Dx

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.03
Last Updated
Version 2.73
Order vs. Observation
Observation
Common Test Rank Get Info
4809

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
55168-9 Data Elements for Emergency Department Systems (DEEDS) Release 1.1
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
74293-2 Oncology plan of care and summary - recommended CDA set
93149-3 PhenX - bone age protocol 220301
62863-6 PhenX domain - Infectious diseases and immunity
62896-6 PhenX domain - Skin, bone, muscle and joint

Language Variants Get Info

Tag Language Translation
de-DE German (Germany) Diagnose:Interpretation:Zeitpunkt:^Patient:Nominal:
es-AR Spanish (Argentina) diagnóstico:impresión/interpretación del estudio:punto en el tiempo:^paciente:Nominal:
es-ES Spanish (Spain) Diagnóstico:Impresión/interpretación del estudio:Punto temporal:^paciente:Nom:
es-MX Spanish (Mexico) Diagnóstico:Interpretación:Punto temporal:^ Paciente:Nominal:
fr-CA French (Canada) Diagnostic:Impression:Temps ponctuel:^Patient:Nominal:
fr-BE French (Belgium) Diagnostic:Impression/interprétation d'étude:Temps ponctuel:^Patient:Nominal:
it-IT Italian (Italy) Diagnosi:Imp:Pt:^Paziente:Nom:
Synonyms: Esame obbiettivo Impressione/interpretazione di studio paziente Punto nel tempo (episodio)
pt-BR Portuguese (Brazil) Diagnóstico:Imp:Pt:^Paciente:Nom:
Synonyms: ; Dx; Interpretation; Interp; Impression; Impressions; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Диагноз:Впчт:ТчкВрм:^Пациент:Ном:
Synonyms: Впечатление/интерпретация исследования Номинальный;Именной Точка во времени;Момент
uk-UA Ukrainian (Ukraine) Діагноз:Інтерпретація:МоментЧасу:^Пацієнт:Категорійно:
Synonyms: Dx; H+P; H+P.PX; Impression; Impression/interpretation of study; Impressions; Interp; Interpretation; Nominal; P prime; Point in time; Random
zh-CN Chinese (China) 诊断:印象:时间点:^患者:名义型:
Synonyms: 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 印象是一种诊断陈述,始终是对其他某种观察指标的解释或抽象(一系列检验项目结果、一幅图像或者整个某位病人),而且几乎总是由某位专业人员产生。;检查印象;检查印象/解释;检查的印象/解释;检查解释;解释;阐释 历史纪录与体格检查 历史纪录与体格检查小节 时刻;随机;随意;瞬间 病史与体格检查 诊断结论;判断;结论

52808-3 Major Procedures (Diagnostic, Surgical, and Therapeutic Interventions)

Observation ID in Form

C

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Medical Coding Major Procedures (Diagnostic, Surgical, and Therapeutic Interventions)
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

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim

52558-4 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?

Observation ID in Form

C1

Type of Entry

Question expects user entry - requires response [Q]

Skip Logic

If No, skip to Section X.

Form Coding Instructions

List up to 15 procedures (diagnostic, surgical and therapeutic interventions). Indicate if a procedure was left, right, or not applicable (N/A). If procedure was bilateral (e.g., bilateral knee replacement), check both left and right boxes

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Procedure this admission
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
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?
Source
CARE I.c01

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim

69967-8 Procedure ICD code

Term Description

Diagnostic, surgical and therapeutic interventions
Source: Regenstrief LOINC

Observation ID in Form

C2a

Fully-Specified Name

Component
Procedure ICD code
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.40
Last Updated
Version 2.42

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim

29300-1 Procedure

Observation ID in Form

C2b

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Procedure
Property
Type
Time
Pt
System
^Patient
Scale
Nom
Method

Additional Names

Short Name
Procedure type

Basic Attributes

Class
H&P.PX
Type
Clinical
First Released
Version 2.03
Last Updated
Version 2.73
Common Test Rank Get Info
2979

Member of these Panels

LOINC Long Common Name
84907-5 Cancer pathology panel - Colorectal cancer specimen
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
74028-2 Virtual Medical Record for Clinical Decision Support panel HL7.VMR-CDS

Language Variants Get Info

Tag Language Translation
es-MX Spanish (Mexico) Procedimiento:Tipo:Punto temporal:^ Paciente:Nominal:
es-AR Spanish (Argentina) procedimiento:tipo:punto en el tiempo:^paciente:Nominal:
es-ES Spanish (Spain) Procedimiento:Tipo:Punto temporal:^paciente:Nom:
it-IT Italian (Italy) Procedura:Tipo:Pt:^Paziente:Nom:
Synonyms: Esame obbiettivo paziente Punto nel tempo (episodio)
nl-NL Dutch (Netherlands) verrichting:type:moment:^patiënt:nominaal:
pt-BR Portuguese (Brazil) Procedimento:Tipo:Pt:^Paciente:Nom:
Synonyms: Typ; Point in time; Random; Nominal
ru-RU Russian (Russian Federation) Вмешательство:Тип:ТчкВрм:^Пациент:Ном:
Synonyms: Номинальный;Именной Процедура Точка во времени;Момент
zh-CN Chinese (China) 操作项目:类型:时间点:^患者:名义型:
Synonyms: 体格检查小节与指标;体格检查小节与测量指标;历史纪录与体格检查.体格检查小节与指标;历史纪录与体格检查.体格检查小节与测量指标;历史纪录与体格检查小节.体格检查小节与指标;历史纪录与体格检查小节.体格检查小节与测量指标;病史与体格检查.体格检查小节与指标;病史与体格检查.体格检查小节与测量指标;病史与体格检查小节.体格检查小节与指标 分类型应答;分类型结果;名义性;名称型;名词型;名词性;标称性;没有自然次序的名义型或分类型应答 医疗服务对象;客户;病人;病患;病号;超系统 - 病人 历史纪录与体格检查 历史纪录与体格检查小节 型 操作;程序;手续;步骤;规程;程序流程 时刻;随机;随意;瞬间 病史与体格检查

52535-2 Other useful information

Observation ID in Form

X

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Other useful information
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.73
Common Test Rank Get Info
7460
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52720-0 Is there other useful information about this patient that you want to add?

Observation ID in Form

A

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component
Other useful information
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

Survey Question

Text
Is there other useful information about this patient that you want to add?
Source
CARE I.a01

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission