Version 2.78

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-AR Spanish (Argentina) procedimiento:tipo:punto en el tiempo:^paciente:Nominal:
es-ES Spanish (Spain) Procedimiento:Tipo:Punto temporal:^paciente:Nom:
es-MX Spanish (Mexico) Procedimiento:Tipo:Punto temporal:^ Paciente:Nominal:
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