54564-0 Shortness of Breath (dyspnea)

Observation ID in Form

J1100

Form Coding Instructions

Check all that apply.

Fully-Specified Name

Component

Shortness of breath

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Long Common Name

Shortness of breath

Basic Attributes

Class

PANEL.SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.68 (MIN)

Panel Type

Panel

Member of these Panels

Related Names

• Pan
• Panel
• Panl
• Pnl
• Point in time
• Random
• Survey
• SURVEY.MDS

54841-2 Shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring).

Term Description

e.g. walking, bathing, transferring
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

J1100A

Fully-Specified Name

Component

Shortness of breath or trouble breathing with exertion in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Ord

Method

MDSv3

Long Common Name

Shortness of breath or trouble breathing with exertion in last 7 days [MDSv3]

Basic Attributes

Class

SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.54 (MAJ)

Normative Answer List LL251-0

Member of these Panels

Related Names

• Finding
• Findings
• MDS version 3
• Ordinal
• PAINAD.breathing
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey
• SURVEY.MDS

Third Party Copyright

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

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

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

54842-0 Shortness of breath or trouble breathing when sitting at rest

Observation ID in Form

J1100B

Fully-Specified Name

Component

Shortness of breath or trouble breathing when sitting at rest in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Ord

Method

MDSv3

Long Common Name

Shortness of breath or trouble breathing when sitting at rest in last 7 days [MDSv3]

Basic Attributes

Class

SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.54 (MAJ)

Normative Answer List LL251-0

Member of these Panels

Related Names

• Finding
• Findings
• MDS version 3
• Ordinal
• PAINAD.breathing
• Past
• QL
• Qual
• Qualitative
• Resting
• Screen
• Survey
• SURVEY.MDS

Third Party Copyright

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

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

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

54843-8 Shortness of breath or trouble breathing when lying flat

Observation ID in Form

J1100C

Fully-Specified Name

Component

Shortness of breath or trouble breathing when lying flat in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Ord

Method

MDSv3

Long Common Name

Shortness of breath or trouble breathing when lying flat in last 7 days [MDSv3]

Basic Attributes

Class

SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.54 (MAJ)

Normative Answer List LL251-0

Member of these Panels

Related Names

• Finding
• Findings
• MDS version 3
• Ordinal
• PAINAD.breathing
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey
• SURVEY.MDS

Third Party Copyright

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

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

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

54844-6 None of the above

Observation ID in Form

J1100Z

Fully-Specified Name

Component

None of the above shortness of breath symptoms in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Ord

Method

MDSv3

Long Common Name

None of the above shortness of breath symptoms in last 7 days [MDSv3]

Basic Attributes

Class

SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.54 (MAJ)

Normative Answer List LL251-0

Member of these Panels

Related Names

• Finding
• Findings
• MDS version 3
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey
• SURVEY.MDS
• Sx

Third Party Copyright

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

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

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

54845-3 Tobacco Use

Observation ID in Form

J1300

Fully-Specified Name

Component

Tobacco use

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Tobacco use during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.70 (NAM)

Change Reason

Release 2.70: TIME_ASPCT: Updated Timing to align with the new model representing various reporting periods across CMS assessment.; COMPONENT: Removed "in last 7D"; Previous Releases: Removed "Current" from Component because it is does not match Timing of 7D. Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee.

Order vs. Observation

Observation

Normative Answer List LL251-0

Member of these Panels

Member of these Groups Get Info

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

Third Party Copyright

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

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

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

54846-1 Prognosis

Observation ID in Form

J1400

Fully-Specified Name

Component

Life expectancy of less than 6M

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Life expectancy of less than 6 months during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77 (MAJ)

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 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. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL251-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

Third Party Copyright

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

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

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

54847-9 Problem conditions [MDSv3]

Observation ID in Form

J1550

Form Coding Instructions

Check all that apply.

Fully-Specified Name

Component

Problem conditions

Property

-

Time

Pt

System

^Patient

Scale

-

Method

MDSv3

Basic Attributes

Class

PANEL.SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.68 (MIN)

Panel Type

Panel

Member of these Panels

Related Names

• MDS version 3
• Pan
• Panel
• Panl
• Pnl
• Point in time
• Random
• Survey
• SURVEY.MDS

45701-0 Fever [Minimum Data Set]

Observation ID in Form

J1550A

Fully-Specified Name

Component

Fever

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

MDS

Basic Attributes

Class

SURVEY.MDS

Type

Surveys

First Released

Version 2.17

Last Updated

Version 2.50 (MIN)

Normative Answer List LL251-0

Member of these Panels

Related Names

• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.MDS

Copyright

Organization

interRAI

Copyright

InterRAI holds the copyright to Version 2.0 of the RAI for long term care outside of the US. Supplemental help and contextual information for MDS items in LOINC was derived from Version 2.0 of the RAI/MDS manual, and should not be reproduced outside of the United States without permission of InterRAI. Within the US, Version 2.0 is in the public domain.

Terms of Use

As a not for profit corporation under the US Tax Code, interRAI holds the copyright to a number of assessment systems, including the Resident Assessment Instrument (RAI) for long term care facilities outside of the US (the RAI is in the public domain within the US), as well as the assessment systems for Home Care (HC), Assisted Living (AL), Palliative Care (PC), Mental Health (MH) (outside of Canada), and Acute Care (RAI-AC). The scales, algorithms, and case-mix measures based on these assessment instruments cannot be copyrighted and are thus available to everyone (although the individual items on which they are based are usually copyrighted). The major clauses of our royalty-free licenses follow: * the instrument is not to be changed substantially (excepting individual identifiers and demographics); * the license is limited to non-commercial use (i.e., the instrument will not be not incorporated into products to be sold to others); * no royalties will be charged; * the organization will make appropriate efforts to inform others of the copyright status of the instrument; * interRAI's logo and copyright notice are to appear on the form; * authors, author institutions, and translators (as appropriate) are to be acknowledged in any document where authors would regularly be indicated (e.g., publication of a training manual); * publication of any training manual is limited to the period until a commercially-published version is available; * data from use of the instrument are to be shared with interRAI, subject to existing laws on confidentiality. Commercial use usually requires royalties. In this instance, interRAI may omit the data requirement, but retains the other requirements for a logo, attribution, etc. We will be pleased in any contract negotiations to acknowledge the participation of individuals or organizations which have played a substantial role in getting the instrument to the point of implementation. For more information on licensing with interRAI, please contact the president of the Board: Brant E. Fries, Ph.D. Institute of Gerontology University of Michigan 300 North Ingalls Ann Arbor, Michigan USA 48109 Email: bfries@umich.edu

URL

http://www.interrai.org

Third Party Copyright

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

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

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

45708-5 Vomiting [Minimum Data Set]

Observation ID in Form

J1550B

Fully-Specified Name

Component

Vomiting

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

MDS

Basic Attributes

Class

SURVEY.MDS

Type

Surveys

First Released

Version 2.17

Last Updated

Version 2.50 (MIN)

Normative Answer List LL251-0

Member of these Panels

Related Names

• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.MDS

Copyright

Organization

interRAI

Copyright

InterRAI holds the copyright to Version 2.0 of the RAI for long term care outside of the US. Supplemental help and contextual information for MDS items in LOINC was derived from Version 2.0 of the RAI/MDS manual, and should not be reproduced outside of the United States without permission of InterRAI. Within the US, Version 2.0 is in the public domain.

Terms of Use

As a not for profit corporation under the US Tax Code, interRAI holds the copyright to a number of assessment systems, including the Resident Assessment Instrument (RAI) for long term care facilities outside of the US (the RAI is in the public domain within the US), as well as the assessment systems for Home Care (HC), Assisted Living (AL), Palliative Care (PC), Mental Health (MH) (outside of Canada), and Acute Care (RAI-AC). The scales, algorithms, and case-mix measures based on these assessment instruments cannot be copyrighted and are thus available to everyone (although the individual items on which they are based are usually copyrighted). The major clauses of our royalty-free licenses follow: * the instrument is not to be changed substantially (excepting individual identifiers and demographics); * the license is limited to non-commercial use (i.e., the instrument will not be not incorporated into products to be sold to others); * no royalties will be charged; * the organization will make appropriate efforts to inform others of the copyright status of the instrument; * interRAI's logo and copyright notice are to appear on the form; * authors, author institutions, and translators (as appropriate) are to be acknowledged in any document where authors would regularly be indicated (e.g., publication of a training manual); * publication of any training manual is limited to the period until a commercially-published version is available; * data from use of the instrument are to be shared with interRAI, subject to existing laws on confidentiality. Commercial use usually requires royalties. In this instance, interRAI may omit the data requirement, but retains the other requirements for a logo, attribution, etc. We will be pleased in any contract negotiations to acknowledge the participation of individuals or organizations which have played a substantial role in getting the instrument to the point of implementation. For more information on licensing with interRAI, please contact the president of the Board: Brant E. Fries, Ph.D. Institute of Gerontology University of Michigan 300 North Ingalls Ann Arbor, Michigan USA 48109 Email: bfries@umich.edu

URL

http://www.interrai.org

Third Party Copyright

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

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

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

45696-2 Dehydrated

Observation ID in Form

J1550C

Fully-Specified Name

Component

Dehydrated

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

MDS

Long Common Name

Dehydrated [Minimum Data Set]

Basic Attributes

Class

SURVEY.MDS

Type

Surveys

First Released

Version 2.17

Last Updated

Version 2.50 (MIN)

Normative Answer List LL251-0

Member of these Panels

Related Names

• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.MDS

Copyright

Organization

interRAI

Copyright

InterRAI holds the copyright to Version 2.0 of the RAI for long term care outside of the US. Supplemental help and contextual information for MDS items in LOINC was derived from Version 2.0 of the RAI/MDS manual, and should not be reproduced outside of the United States without permission of InterRAI. Within the US, Version 2.0 is in the public domain.

Terms of Use

As a not for profit corporation under the US Tax Code, interRAI holds the copyright to a number of assessment systems, including the Resident Assessment Instrument (RAI) for long term care facilities outside of the US (the RAI is in the public domain within the US), as well as the assessment systems for Home Care (HC), Assisted Living (AL), Palliative Care (PC), Mental Health (MH) (outside of Canada), and Acute Care (RAI-AC). The scales, algorithms, and case-mix measures based on these assessment instruments cannot be copyrighted and are thus available to everyone (although the individual items on which they are based are usually copyrighted). The major clauses of our royalty-free licenses follow: * the instrument is not to be changed substantially (excepting individual identifiers and demographics); * the license is limited to non-commercial use (i.e., the instrument will not be not incorporated into products to be sold to others); * no royalties will be charged; * the organization will make appropriate efforts to inform others of the copyright status of the instrument; * interRAI's logo and copyright notice are to appear on the form; * authors, author institutions, and translators (as appropriate) are to be acknowledged in any document where authors would regularly be indicated (e.g., publication of a training manual); * publication of any training manual is limited to the period until a commercially-published version is available; * data from use of the instrument are to be shared with interRAI, subject to existing laws on confidentiality. Commercial use usually requires royalties. In this instance, interRAI may omit the data requirement, but retains the other requirements for a logo, attribution, etc. We will be pleased in any contract negotiations to acknowledge the participation of individuals or organizations which have played a substantial role in getting the instrument to the point of implementation. For more information on licensing with interRAI, please contact the president of the Board: Brant E. Fries, Ph.D. Institute of Gerontology University of Michigan 300 North Ingalls Ann Arbor, Michigan USA 48109 Email: bfries@umich.edu

URL

http://www.interrai.org

Third Party Copyright

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

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

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

45703-6 Internal bleeding [Minimum Data Set]

Observation ID in Form

J1550D

Fully-Specified Name

Component

Internal bleeding

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

MDS

Basic Attributes

Class

SURVEY.MDS

Type

Surveys

First Released

Version 2.17

Last Updated

Version 2.50 (MIN)

Normative Answer List LL251-0

Member of these Panels

Related Names

• Finding
• Findings
• Int bleeding
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.MDS

Copyright

Organization

interRAI

Copyright

InterRAI holds the copyright to Version 2.0 of the RAI for long term care outside of the US. Supplemental help and contextual information for MDS items in LOINC was derived from Version 2.0 of the RAI/MDS manual, and should not be reproduced outside of the United States without permission of InterRAI. Within the US, Version 2.0 is in the public domain.

Terms of Use

As a not for profit corporation under the US Tax Code, interRAI holds the copyright to a number of assessment systems, including the Resident Assessment Instrument (RAI) for long term care facilities outside of the US (the RAI is in the public domain within the US), as well as the assessment systems for Home Care (HC), Assisted Living (AL), Palliative Care (PC), Mental Health (MH) (outside of Canada), and Acute Care (RAI-AC). The scales, algorithms, and case-mix measures based on these assessment instruments cannot be copyrighted and are thus available to everyone (although the individual items on which they are based are usually copyrighted). The major clauses of our royalty-free licenses follow: * the instrument is not to be changed substantially (excepting individual identifiers and demographics); * the license is limited to non-commercial use (i.e., the instrument will not be not incorporated into products to be sold to others); * no royalties will be charged; * the organization will make appropriate efforts to inform others of the copyright status of the instrument; * interRAI's logo and copyright notice are to appear on the form; * authors, author institutions, and translators (as appropriate) are to be acknowledged in any document where authors would regularly be indicated (e.g., publication of a training manual); * publication of any training manual is limited to the period until a commercially-published version is available; * data from use of the instrument are to be shared with interRAI, subject to existing laws on confidentiality. Commercial use usually requires royalties. In this instance, interRAI may omit the data requirement, but retains the other requirements for a logo, attribution, etc. We will be pleased in any contract negotiations to acknowledge the participation of individuals or organizations which have played a substantial role in getting the instrument to the point of implementation. For more information on licensing with interRAI, please contact the president of the Board: Brant E. Fries, Ph.D. Institute of Gerontology University of Michigan 300 North Ingalls Ann Arbor, Michigan USA 48109 Email: bfries@umich.edu

URL

http://www.interrai.org

Third Party Copyright

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

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

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

54848-7 None of the above

Observation ID in Form

J1550Z

Fully-Specified Name

Component

Problem conditions - none of above

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

MDSv3

Long Common Name

Problem conditions - none of above [MDSv3]

Basic Attributes

Class

SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.44 (MIN)

Normative Answer List LL251-0

Member of these Panels

Related Names

• Finding
• Findings
• MDS version 3
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.MDS

Third Party Copyright

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

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

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

54849-5 Fall history on admission during assessment period [CMS Assessment]

Observation ID in Form

J1700

Skip Logic

Complete only if A0310A = 01 or A0310E = 1

Fully-Specified Name

Component

Fall history on admission

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.78 (PANEL)

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 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.

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Fall Hx on admission
• Hx
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

Related Codes

54850-3 Did the resident fall one or more times in the last month prior to admission?

Observation ID in Form

J1700A

Fully-Specified Name

Component

Fall one or more times in the last Mo prior to admission

Property

Find

Time

1Mo

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Fall one or more times in the last month prior to admission [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63 (MIN)

Change Reason

Changed month to Mo in component based on current LOINC model. 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. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL1502-5

Member of these Panels

Related Names

• 1 month
• 1 month (30 days)
• 30 days
• Centers for Medicare and Medicaid Assessment
• Fall one or more times in the last month prior to admission
• Finding
• Findings
• month
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey

Related Codes

Third Party Copyright

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

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

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

54851-1 Did the resident fall one or more times in the last 2 - 6 months prior to admission?

Observation ID in Form

J1700B

Fully-Specified Name

Component

Fall one or more times in the last 2 to 6Mo prior to admission

Property

Find

Time

6Mo

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Fall one or more times in the last 2 to 6 months prior to admission [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63 (MIN)

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. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL1502-5

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Fall one or more times in the last 2 to 6 months prior to admission
• Finding
• Findings
• II
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey

Related Codes

Third Party Copyright

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

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

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

54852-9 Did the resident have any fracture related to a fall in the 6 months prior to admission?

Observation ID in Form

J1700C

Fully-Specified Name

Component

Any fracture related to a fall in the 6Mo prior to admission

Property

Find

Time

6Mo

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Any fracture related to a fall in the 6 months prior to admission [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63 (MIN)

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. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL1502-5

Member of these Panels

Related Names

• Any fracture related to a fall in the 6 months prior to admission
• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Screen
• Survey

Related Codes

Third Party Copyright

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

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

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

54853-7 Has the resident had any falls since admission or the prior assessment (OBRA or PPS), whichever is more recent?

Observation ID in Form

J1800

Skip Logic

If No, Skip to K0100, Swallowing Disorder. If Yes, Continue to J1900, Number of Falls Since Admission or Prior Assessment (OBRA, PPS, or Discharge).

Fully-Specified Name

Component

Has the patient had any falls since admission or prior assessment

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Has the patient had any falls since admission or prior assessment [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63 (MIN)

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. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Normative Answer List LL251-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

Third Party Copyright

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

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

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

54854-5 Number of Falls Since Admission or Prior Assessment (OBRA or PPS), Whichever is More Recent

Observation ID in Form

J1900

Form Coding Instructions

Enter Codes in Boxes

Fully-Specified Name

Component

Number of falls since admission or prior assessment

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Long Common Name

Number of falls since admission or prior assessment [CMS Assessment]

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.67 (PANEL)

Change Reason

Updated METHOD from MDSv3 to CMS Assessment to use term across CMS assessments as approved by the Clinical LOINC committee; TIMING was changed from Pt to RptPeriod to accurately reflect the time interval addressed.

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• # falls since admission or prior assessment
• Centers for Medicare and Medicaid Assessment
• No
• Num
• Num of falls
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

Related Codes

54855-2 No injury

Term Description

Number of falls the patient/resident has experienced in which no evidence of any injury is noted on physical assessment by the nurse or primary care clinician, no complaints of pain or injury by the patient/resident, and no change in the patient/resident's behavior is noted after the fall.

Observation ID in Form

J1900A

Form Context

No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the resident; no change in the resident's behavior is noted after the fall

Fully-Specified Name

Component

Number of falls since admission or prior assessment - no injury

Property

Num

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Number of falls since admission or prior assessment - no injury [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.67 (MIN)

Change Reason

Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Timing was changed from Pt to RptPeriod to accurately reflect the time interval addressed.

Order vs. Observation

Observation

Normative Answer List LL670-1

Member of these Panels

Related Names

• # falls since admission or prior assessment
• # falls since admission or prior assessment - no injury
• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Num of falls
• Number
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey
• Ulcer

Related Codes

Third Party Copyright

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

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

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

54856-0 Injury (except major)

Term Description

Number of falls the patient/resident has experienced that resulted in skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain.

Observation ID in Form

J1900B

Form Context

Skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the resident to complain of pain

Fully-Specified Name

Component

Number of falls since admission or prior assessment - injury except major

Property

Num

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Number of falls since admission or prior assessment - injury except major [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.61 (MIN)

Change Reason

Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Timing was changed from Pt to RptPeriod to accurately reflect the time interval addressed.

Order vs. Observation

Observation

Normative Answer List LL670-1

Member of these Panels

Related Names

• # falls since admission or prior assessment
• # falls since admission or prior assessment - injury except major
• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Num of falls
• Number
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey
• Ulcer

Related Codes

Third Party Copyright

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

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

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

54857-8 Major injury

Term Description

Number of falls the patient has experienced that resulted in bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma.

Observation ID in Form

J1900C

Form Context

Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma

Fully-Specified Name

Component

Number of falls since admission or prior assessment - major injury

Property

Num

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Number of falls since admission or prior assessment - major injury [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.61 (MIN)

Change Reason

Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Timing was changed from Pt to RptPeriod to accurately reflect the time interval addressed.

Order vs. Observation

Observation

Normative Answer List LL670-1

Member of these Panels

Related Names

• # falls since admission or prior assessment
• # falls since admission or prior assessment - major injury
• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Num of falls
• Number
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey
• Ulcer

Related Codes

Third Party Copyright

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

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

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