LOINC
Version 2.67

54580-6Minimum Data Set - version 3.0Active

Term Description

Recognizing the care implication and program importance of an improved Minimim Data Set (MDS), CMS initiated a national project to create a version of 3.0 of the MDS. The revision aimed to improve the clinical relevance and accuracy of MDS assessments, increase the voice of residents in assessments, improve user satisfaction, and increase the efficiency of reports.
Source: Centers for Medicare & Medicaid Services, Centers for Medicare and Medicaid Services

Panel Hierarchy
Details for each LOINC in Panel LHC-Forms

LOINC Name R/O/C Cardinality Example UCUM Units
54580-6 Minimum Data Set - version 3.0
Indent54501-2 Identification information
IndentIndent58198-3 Type of record [CMS Assessment]
IndentIndent54581-4 Facility provider numbers
IndentIndentIndent76468-8 National Provider Identifier (NPI)
IndentIndentIndent69417-4 CMS Certification Number (CCN)
IndentIndentIndent45398-5 State provider number for Facility
IndentIndent54582-2 Type of Provider
IndentIndent54502-0 Type of Assessment
IndentIndentIndent54583-0 Federal OBRA reason for assessment [CMS Assessment]
IndentIndentIndent54584-8 PPS Assessment [CMS Assessment]
IndentIndentIndent54585-5 PPS Other Medicare Required Assessment - OMRA [CMS Assessment]
IndentIndentIndent58107-4 Is this a Swing Bed clinical change assessment?
IndentIndentIndent54587-1 Is this assessment the first assessment (OBRA, PPS, or Discharge) since the most recent admission?
IndentIndentIndent58108-2 Entry/discharge reporting
IndentIndentIndent71440-2 Type of discharge
IndentIndent54896-6 Submission requirement [MDSv3]
IndentIndent54503-8 Legal name of resident
IndentIndentIndent45392-8 First name
IndentIndentIndent45393-6 Middle initial
IndentIndentIndent45394-4 Last name
IndentIndentIndent45395-1 Suffix
IndentIndent45966-9 Social Security and Medicare numbers
IndentIndentIndent45396-9 Social Security number [Identifier]
IndentIndentIndent45397-7 Medicare number (or comparable railroad insurance number)
IndentIndent45400-9 Medicaid number
IndentIndent46098-0 Gender
IndentIndent21112-8 Birth date {mm/dd/yyyy}
IndentIndent59362-4 Race/Ethnicity 1..6
IndentIndent54505-3 Language
IndentIndentIndent54588-9 Does the resident need or want an interpreter to communicate with a doctor or health care staff?
IndentIndentIndent54899-0 Preferred Language
IndentIndent45404-1 Marital status
IndentIndent54506-1 Optional resident items
IndentIndentIndent46106-1 Medical record number
IndentIndentIndent45403-3 Room number [Location]
IndentIndentIndent52462-9 Name by which resident prefers to be addressed
IndentIndentIndent21843-8 History of Usual occupation
IndentIndent54589-7 Preadmission Screening and Resident Review (PASRR). Has the resident been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition?
IndentIndent71441-0 Level II Preadmission Screening and Resident Review (PASRR) [CMS Assessment]
IndentIndent71454-3 Conditions related to ID/DD
IndentIndentIndent71452-7 ID/DD with organic condition
IndentIndentIndentIndent45422-3 Down's syndrome [Minimum Data Set]
IndentIndentIndentIndent45423-1 Autism [Minimum Data Set]
IndentIndentIndentIndent45424-9 Epilepsy [Minimum Data Set]
IndentIndentIndentIndent71455-0 Other organic condition related to ID/DD
IndentIndentIndentIndent71453-5 ID/DD with no organic condition
IndentIndent50786-3 Entry Date (date of this admission/reentry into the facility) {mm/dd/yyyy}
IndentIndent54590-5 Type of Entry
IndentIndent54591-3 Entered from
IndentIndent52525-3 Discharge date {mm/dd/yyyy}
IndentIndent55128-3 Discharge disposition
IndentIndent54592-1 Previous assessment reference date for significant correction [CMS Assessment] {mm/dd/yyyy}
IndentIndent54593-9 Assessment reference date - observation end date [CMS Assessment] {mm/dd/yyyy}
IndentIndent54507-9 Medicare stay [CMS Assessment]
IndentIndentIndent54594-7 Has resident had Medicare-covered stay since the most recent entry?
IndentIndentIndent54595-4 Start date of most recent Medicare stay [CMS Assessment] {mm/dd/yyyy}
IndentIndentIndent54596-2 End date of most recent Medicare stay [CMS Assessment] {mm/dd/yyyy}
Indent54508-7 Hearing, speech, and vision [CMS Assessment]
IndentIndent54597-0 Comatose
IndentIndent54598-8 Hearing
IndentIndent54599-6 Hearing Aid
IndentIndent54600-2 Speech Clarity
IndentIndent54601-0 Makes Self Understood
IndentIndent54602-8 Ability to understand others
IndentIndent54603-6 Vision
IndentIndent54604-4 Corrective Lenses
Indent54509-5 Cognitive patterns
IndentIndent54605-1 Brief Interview for Mental Status (BIMS) should be conducted [CMS Assessment]
IndentIndent52491-8 Brief interview for mental status [BIMS]
IndentIndentIndent52731-7 Repetition of three words # [BIMS]
IndentIndentIndent54510-3 Temporal orientation (orientation to year, month, and day) [BIMS]
IndentIndentIndentIndent52732-5 Temporal orientation - current year [BIMS]
IndentIndentIndentIndent52733-3 Temporal orientation - current month [BIMS]
IndentIndentIndentIndent54609-3 Temporal orientation - current day of the week [BIMS]
IndentIndentIndent52493-4 Recall [BIMS]
IndentIndentIndentIndent52735-8 Able to recall "sock"
IndentIndentIndentIndent52736-6 Able to recall "blue"
IndentIndentIndentIndent52737-4 Able to recall "bed"
IndentIndentIndent54614-3 Summary Score {score}
IndentIndent54615-0 Should the Staff Assessment for Mental Status C0700-C1000 be conducted?
IndentIndent54895-8 Staff assessment for mental status [MDSv3]
IndentIndentIndent54616-8 Short-term Memory OK
IndentIndentIndent54617-6 Long-term memory OK
IndentIndentIndent54618-4 Memory/Recall Ability
IndentIndentIndentIndent54619-2 Current season
IndentIndentIndentIndent54620-0 Location of own room
IndentIndentIndentIndent54621-8 Staff names and faces
IndentIndentIndentIndent54622-6 That he or she is in a nursing home
IndentIndentIndentIndent54623-4 None of the above were recalled
IndentIndentIndent54624-2 Cognitive skills for daily decision making
IndentIndent54626-7 Delirium [MDSv3]
IndentIndentIndent54627-5 Signs and symptoms of delirium (from CAM) [CAM.MDSv3]
IndentIndentIndentIndent54628-3 Inattention. Did the resident have difficulty focusing attention (easily distracted, out of touch or difficulty following what was said)?
IndentIndentIndentIndent54629-1 Disorganized thinking. Was the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?
IndentIndentIndentIndent54630-9 Altered level of consciousness. Did the resident have altered level of consciousness?
IndentIndentIndentIndent54631-7 Psychomotor retardation. Did the resident have an unusually decreased level of ctivity such as sluggishness, staring into space, staying in one position, moving very slowly?
IndentIndentIndent54632-5 Acute Onset Mental Status Change - Is there evidence of an acute change in mental status from the resident's baseline?
Indent54633-3 Mood [CMS Assessment]
IndentIndent54634-1 Should resident mood interview be conducted [CMS Assessment]
IndentIndent54635-8 Resident mood interview (PHQ-9) [Reported PHQ-9 CMS]
IndentIndentIndent86843-0 Symptom Presence
IndentIndentIndentIndent54636-6 Little interest or pleasure in doing things in last 2 weeks.presence [Reported PHQ-9 CMS]
IndentIndentIndentIndent54638-2 Feeling down, depressed or hopeless in last 2 weeks.presence [Reported PHQ-9 CMS]
IndentIndentIndentIndent54640-8 Trouble falling or staying asleep, or sleeping too much in last 2 weeks.presence [Reported PHQ-9 CMS]
IndentIndentIndentIndent54642-4 Feeling tired or having little energy in last 2 weeks.presence [Reported PHQ-9 CMS]
IndentIndentIndentIndent54644-0 Poor appetite or overeating in last 2 weeks.presence [Reported PHQ-9 CMS]
IndentIndentIndentIndent54646-5 Feeling bad about yourself - or that you are a failure or have let yourself or your family down in last 2 weeks.presence [Reported PHQ-9 CMS]
IndentIndentIndentIndent54648-1 Trouble concentrating on things, such as reading the newspaper or watching television in last 2 weeks.presence [Reported PHQ-9 CMS]
IndentIndentIndentIndent54650-7 Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual in last 2 weeks.presence [Reported PHQ-9 CMS]
IndentIndentIndentIndent54652-3 Thoughts that you would be better off dead, or of hurting yourself in some way
IndentIndentIndent86844-8 Symptom Frequency
IndentIndentIndentIndent54637-4 Little interest or pleasure in doing things in last 2 weeks.frequency [Reported PHQ-9 CMS]
IndentIndentIndentIndent54639-0 Feeling down, depressed or hopeless in last 2 weeks.frequency [Reported PHQ-9 CMS]
IndentIndentIndentIndent54641-6 Trouble falling or staying asleep, or sleeping too much in last 2 weeks.frequency [Reported PHQ-9 CMS]
IndentIndentIndentIndent54643-2 Feeling tired or having little energy in last 2 weeks.frequency [Reported PHQ-9 CMS]
IndentIndentIndentIndent54645-7 Poor appetite or overeating in last 2 weeks.frequency [Reported PHQ-9 CMS]
IndentIndentIndentIndent54647-3 Feeling bad about yourself - or that you are a failure or have let yourself or your family down in last 2 weeks.frequency [Reported PHQ-9 CMS]
IndentIndentIndentIndent54649-9 Trouble concentrating on things, such as reading the newspaper or watching television in last 2 weeks.frequency [Reported PHQ-9 CMS]
IndentIndentIndentIndent54651-5 Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual in last 2 weeks.frequency [Reported PHQ-9 CMS]
IndentIndentIndentIndent54653-1 Thoughts that you would be better off dead, or of hurting yourself in some way in last 2 weeks.frequency [Reported PHQ-9 CMS]
IndentIndent54654-9 Total Severity Score {score}
IndentIndent54655-6 Safety Notification. Was a responsible staff or provider informed that there is a potential for resident self harm?
IndentIndent54657-2 Staff assessment of resident mood (PHQ-9-OV) [Observed PHQ-9 CMS]
IndentIndentIndent86833-1 Staff assessment of resident mood (PHQ-9-OV) - symptom presence in the last 2 weeks [CMS Assessment]
IndentIndentIndentIndent54658-0 Little interest or pleasure in doing things
IndentIndentIndentIndent54660-6 Feeling or appearing down, depressed, or hopeless.Presence
IndentIndentIndentIndent54662-2 Trouble falling or staying asleep, or sleeping too much.Presence
IndentIndentIndentIndent54664-8 Feeling tired or having little energy.Presence
IndentIndentIndentIndent54666-3 Poor appetite or overeating.Presence
IndentIndentIndentIndent54668-9 Indicating that s/he feels bad about self, is a failure, or has let self or family down.presence
IndentIndentIndentIndent54670-5 Trouble concentrating on things, such as reading the newspaper or watching television.Presence
IndentIndentIndentIndent54672-1 Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that s/he has been moving around a lot more than usual.presence
IndentIndentIndentIndent54673-9 States that life isn't worth living, wishes for death, or attempts to harm self.Presence
IndentIndentIndentIndent54675-4 Being short-tempered, easily annoyed.Presence
IndentIndentIndent86891-9 Staff assessment of resident mood (PHQ-9-OV) - symptom frequency in the last 2 weeks [CMS Assessment]
IndentIndentIndentIndent54659-8 Little interest or pleasure in doing things.Frequency
IndentIndentIndentIndent54661-4 Feeling or appearing down, depressed, or hopeless.Frequency
IndentIndentIndentIndent54663-0 Trouble falling or staying asleep, or sleeping too much.Frequency
IndentIndentIndentIndent54665-5 Feeling tired or having little energy.Frequency
IndentIndentIndentIndent54667-1 Poor appetite or overeating.Frequency
IndentIndentIndentIndent54669-7 Indicating that s/he feels bad about self, is a failure, or has let self or family down.frequency
IndentIndentIndentIndent54671-3 Trouble concentrating on things, such as reading the newspaper or watching television.Frequency
IndentIndentIndentIndent54904-8 Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that s/he has been moving around a lot more than usual.frequency
IndentIndentIndentIndent54674-7 States that life isn't worth living, wishes for death, or attempts to harm self.Frequency
IndentIndentIndentIndent54676-2 Being short-tempered, easily annoyed.Frequency
IndentIndent54677-0 Total Severity Score {score}
IndentIndent54655-6 Safety Notification. Was a responsible staff or provider informed that there is a potential for resident self harm?
Indent54511-1 Behavior
IndentIndent54512-9 Pyschosis
IndentIndentIndent54678-8 Hallucinations
IndentIndentIndent54680-4 Delusions
IndentIndentIndent54681-2 None of the above
IndentIndent54513-7 Behavioral symptoms
IndentIndentIndent54514-5 Behavioral symptom - presence and frequency [CMS Assessment]
IndentIndentIndentIndent54682-0 Physical behavioral symptoms directed toward others d/(7.d)
IndentIndentIndentIndent54683-8 Verbal behavioral symptoms directed toward others d/(7.d)
IndentIndentIndentIndent54684-6 Other behavioral symptoms not directed toward others d/(7.d)
IndentIndentIndent54685-3 Overall presence of behavioral symptoms. Were any behavioral symptoms in questions E0200 coded 1, 2 or 3?
IndentIndentIndent54515-2 Impact on resident [CMS Assessment]
IndentIndentIndentIndent54686-1 Put the resident at significant risk for physical illness or injury?
IndentIndentIndentIndent54687-9 Significantly interfere with the resident's care?
IndentIndentIndentIndent54688-7 Significantly interfere with the resident's participation in activities or social interactions?
IndentIndentIndent54516-0 Impact on others [CMS Assessment]
IndentIndentIndentIndent54689-5 Put others at significant risk for physical injury?
IndentIndentIndentIndent54690-3 Significantly intrude on the privacy or activity of others?
IndentIndentIndentIndent54691-1 Significantly disrupt care or living environment?
IndentIndentIndent54692-9 Rejection of Care - Presence & Frequency. Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? d/(7.d)
IndentIndentIndent54693-7 Wandering - Presence & Frequency. Has the resident wandered? d/(7.d)
IndentIndentIndent54517-8 Wandering - impact [CMS Assessment]
IndentIndentIndentIndent54694-5 Does the wandering place the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility)?
IndentIndentIndentIndent54695-2 Does wandering significantly intrude on the privacy or activities of others?
IndentIndentIndent54696-0 Change in behavioral or other symptoms - How does resident's current behavior status, care rejection, or wandering compare to prior assessment (OBRA or PPS)?
Indent54518-6 Preferences for customary routine and activities
IndentIndent54697-8 Should Interview for Daily and Activity Preferences be Conducted?
IndentIndent54519-4 Interview for daily preferences [CMS Assessment]
IndentIndentIndent54698-6 How important is it to you to choose what clothes to wear?
IndentIndentIndent54699-4 How important is it to you to take care of your personal belongings or things?
IndentIndentIndent54700-0 How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?
IndentIndentIndent54701-8 How important is it to you to have snacks available between meals?
IndentIndentIndent54702-6 How important is it to choose your own bedtime?
IndentIndentIndent54703-4 How important is it to you to have your family or a close friend involved in discussions about your care?
IndentIndentIndent54704-2 How important is it to you to be able to use the phone in private?
IndentIndentIndent54705-9 How important is it to you to have a place to lock your things to keep them safe?
IndentIndent54520-2 Interview for activity preferences [CMS Assessment]
IndentIndentIndent54706-7 How important is it to you to have books, newspapers, and magazines to read?
IndentIndentIndent54707-5 How important is it to you to listen to music you like?
IndentIndentIndent54708-3 How important is it to you to be around animals such as pets?
IndentIndentIndent54709-1 How important is it to you to keep up with the news?
IndentIndentIndent54710-9 How important is it to you to do things with groups of people?
IndentIndentIndent54711-7 How important is it to you to do your favorite activities?
IndentIndentIndent54712-5 How important is it to you to go outside to get fresh air when the weather is good?
IndentIndentIndent54713-3 How important is it to you to participate in religious services or practices?
IndentIndent54714-1 Primary respondent for daily and activity preferences [CMS Assessment]
IndentIndent54715-8 Should the Staff Assessment of Daily and Activity Preferences be Conducted?
IndentIndent54521-0 Staff assessment of daily and activity preferences
IndentIndentIndent54716-6 Resident prefers choosing clothes to wear [MDSv3]
IndentIndentIndent54717-4 Resident prefers caring for personal belongings [MDSv3]
IndentIndentIndent54718-2 Resident prefers receiving tub bath [MDSv3]
IndentIndentIndent54719-0 Resident prefers receiving shower [MDSv3]
IndentIndentIndent54720-8 Resident prefers receiving bed bath [MDSv3]
IndentIndentIndent54721-6 Resident prefers receiving sponge bath [MDSv3]
IndentIndentIndent54722-4 Resident prefers snacks between meals [MDSv3]
IndentIndentIndent54723-2 Resident prefers staying up past 8:00 p.m. [MDSv3]
IndentIndentIndent54724-0 Resident prefers family or significant other involvement in care discussions [MDSv3]
IndentIndentIndent54725-7 Resident prefers use of phone in private [MDSv3]
IndentIndentIndent54726-5 Resident prefers place to lock personal belongings [MDSv3]
IndentIndentIndent54727-3 Resident prefers reading books, newspapers, magazines [MDSv3]
IndentIndentIndent54728-1 Resident prefers listening to music [MDSv3]
IndentIndentIndent54729-9 Resident prefers being around animals such as pets [MDSv3]
IndentIndentIndent54730-7 Resident prefers keeping up with the news [MDSv3]
IndentIndentIndent54731-5 Resident prefers doing things with groups of people [MDSv3]
IndentIndentIndent54732-3 Resident prefers participating in favorite activities [MDSv3]
IndentIndentIndent54733-1 Resident prefers spending time away from the nursing home [MDSv3]
IndentIndentIndent54734-9 Resident prefers spending time outdoors [MDSv3]
IndentIndentIndent54735-6 Resident prefers participating in religious activities or practices [MDSv3]
IndentIndentIndent54736-4 Resident prefers none of the above [MDSv3]
Indent54522-8 Functional status
IndentIndent54523-6 Activities of Daily Living (ADL) Assistance
IndentIndentIndent45588-1 Bed mobility - self-performance during 7 day assessment period [CMS Assessment]
IndentIndentIndent45589-9 Bed mobility - support provided during 7 day assessment period [CMS Assessment]
IndentIndentIndent45590-7 Transfer - self-performance during 7 day assessment period [CMS Assessment]
IndentIndentIndent45591-5 Transfer - support provided during 7 day assessment period [CMS Assessment]
IndentIndentIndent45592-3 Walk in room - self-performance during 7 day assessment period [CMS Assessment]
IndentIndentIndent45593-1 Walk in room - support provided during 7 day assessment period [CMS Assessment]
IndentIndentIndent45594-9 Walk in corridor - self-performance during 7 day assessment period [CMS Assessment]
IndentIndentIndent45595-6 Walk in corridor - support provided during 7 day assessment period [CMS Assessment]
IndentIndentIndent45596-4 Locomotion on unit - self-performance during 7 day assessment period [CMS Assessment]
IndentIndentIndent45597-2 Locomotion on unit - support provided during 7 day assessment period [CMS Assessment]
IndentIndentIndent45598-0 Locomotion off unit - self-performance during 7 day assessment period [CMS Assessment]
IndentIndentIndent45599-8 Locomotion off unit - support provided during 7 day assessment period [CMS Assessment]
IndentIndentIndent45600-4 Dressing - self-performance during 7 day assessment period [CMS Assessment]
IndentIndentIndent45601-2 Dressing - support provided during 7 day assessment period [CMS Assessment]
IndentIndentIndent45602-0 Eating - self-performance during 7 day assessment period [CMS Assessment]
IndentIndentIndent45603-8 Eating - support provided during 7 day assessment period [CMS Assessment]
IndentIndentIndent45604-6 Toilet use - self-performance during 7 day assessment period [CMS Assessment]
IndentIndentIndent45605-3 Toilet use - support provided during 7 day assessment period [CMS Assessment]
IndentIndentIndent45606-1 Personal hygiene - self-performance during 7 day assessment period [CMS Assessment]
IndentIndentIndent45607-9 Personal hygiene - support provided during 7 day assessment period [CMS Assessment]
IndentIndent46008-9 Bathing [CMS Assessment]
IndentIndentIndent45608-7 Bathing - self-performance during 7 day assessment period [CMS Assessment]
IndentIndentIndent45609-5 Bathing - support provided during 7 day assessment period [CMS Assessment]
IndentIndent54524-4 Balance during transitions and walking [CMS Assessment]
IndentIndentIndent54749-7 Moving from seated to standing position
IndentIndentIndent54750-5 Walking (with assistive device if used)
IndentIndentIndent54751-3 Turning around and facing the opposite direction while walking
IndentIndentIndent54752-1 Moving on and off toilet
IndentIndentIndent54753-9 Surface-to-surface transfer
IndentIndent54525-1 Functional limitation in range of motion [CMS Assessment]
IndentIndentIndent54754-7 Upper extremity (shoulder, elbow, wrist, hand)
IndentIndentIndent54755-4 Lower extremity (hip, knee, ankle, foot)
IndentIndent54526-9 Mobility devices
IndentIndentIndent54756-2 Cane/crutch
IndentIndentIndent54757-0 Walker
IndentIndentIndent54758-8 Wheelchair (manual or electric)
IndentIndentIndent54759-6 Limb prosthesis
IndentIndentIndent54760-4 None of the above were used
IndentIndent54527-7 Functional rehabilitation potential [CMS Assessment]
IndentIndentIndent55123-4 Resident believes he or she is capable of increased independence in at least some ADLs [CMS Assessment]
IndentIndentIndent45613-7 Direct care staff believe resident is capable of increased independence in at least some ADLs [CMS Assessment]
Indent54528-5 Bladder and bowel
IndentIndent54529-3 Appliances
IndentIndentIndent54762-0 Indwelling catheter
IndentIndentIndent54763-8 External catheter
IndentIndentIndent54764-6 Ostomy (including suprapubic catheter, ileostomy, and colostomy)
IndentIndentIndent54765-3 Intermittent catheterization
IndentIndentIndent54766-1 None of the above
IndentIndent54530-1 Urinary toileting program [CMS Assessment]
IndentIndentIndent54767-9 Has a trial of a toileting program (e.g. scheduled toileting, prompted voiding, or bladder training) been attempted on admission/reentry or since urinary incontinence was noted in this facility?
IndentIndentIndent54768-7 Response. What was the resident's response to the trial program?
IndentIndentIndent54769-5 Current toileting program or trial. Is a toileting program (e.g. scheduled toileting, prompted voiding, or bladder training) currently being used to manage the resident's urinary continence?
IndentIndent54770-3 Urinary continence. Select the one category that best describes the resident
IndentIndent54771-1 Bowel continence. Select the one category that best describes the resident
IndentIndent54772-9 Bowel Toileting Program. Is a toileting program currently being used to manage the resident's bowel continence?
IndentIndent54773-7 Bowel Patterns. Constipation present?
Indent54531-9 Active disease diagnosis
IndentIndent54532-7 Cancer
IndentIndentIndent54774-5 Cancer
IndentIndent54533-5 Heart/Circulation
IndentIndentIndent54775-2 Anemia
IndentIndentIndent54776-0 Atrial Fibrillation and Other Dysrhythmias
IndentIndentIndent54777-8 Coronary Artery Disease (CAD)
IndentIndentIndent54778-6 Deep Venous Thrombosis (DVT), Pulmonary Embolus (PE), or Pulmonary Thrombo-Embolism (PTE)
IndentIndentIndent54779-4 Heart Failure
IndentIndentIndent54780-2 Hypertension
IndentIndentIndent54781-0 Orthostatic hypotension
IndentIndentIndent54782-8 Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
IndentIndent54534-3 Gastrointestinal
IndentIndentIndent54783-6 Cirrhosis
IndentIndentIndent54784-4 Gastroesophageal Reflux Disease (GERD) or Ulcer
IndentIndentIndent54785-1 Ulcerative Colitis, Chrohn's Disease or Inflammatory Bowel Disease
IndentIndent54535-0 Genitourinary
IndentIndentIndent54786-9 Benign prostatic hyperplasia (BPH)
IndentIndentIndent54787-7 Renal Insufficiency or Renal Failure, or End-Stage Renal Disease (ESRD)
IndentIndentIndent58111-6 Neurogenic Bladder
IndentIndentIndent58112-4 Obstructive Uropathy
IndentIndent54536-8 Infections
IndentIndentIndent58109-0 Multidrug-resistant organism (MDRO)
IndentIndentIndent54790-1 Pneumonia
IndentIndentIndent54791-9 Septicemia
IndentIndentIndent54792-7 Tuberculosis
IndentIndentIndent45689-7 Urinary tract infection (UTI) (LAST 30 DAYS)
IndentIndentIndent54794-3 Viral Hepatitis
IndentIndentIndent58110-8 Wound infection (other than foot)
IndentIndent54537-6 Metabolic
IndentIndentIndent54795-0 Diabetes Mellitus (DM)
IndentIndentIndent54796-8 Hyponatremia
IndentIndentIndent54797-6 Hyperkalemia
IndentIndentIndent54798-4 Hyperlipidemia
IndentIndentIndent54799-2 Thyroid Disorder
IndentIndent54538-4 Musculoskeletal
IndentIndentIndent54800-8 Arthritis
IndentIndentIndent54801-6 Osteoporosis
IndentIndentIndent54802-4 Hip Fracture
IndentIndentIndent54803-2 Other Fracture
IndentIndent54539-2 Neurological
IndentIndentIndent54804-0 Alzheimer's Disease
IndentIndentIndent54805-7 Aphasia
IndentIndentIndent54806-5 Cerebral Palsy
IndentIndentIndent54807-3 Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke
IndentIndentIndent54808-1 Dementia
IndentIndentIndent54809-9 Hemiplegia or Hemiparesis
IndentIndentIndent54810-7 Paraplegia
IndentIndentIndent54811-5 Quadriplegia
IndentIndentIndent54812-3 Multiple Sclerosis (MS)
IndentIndentIndent58113-2 Huntington's Disease
IndentIndentIndent54813-1 Parkinson's Disease
IndentIndentIndent58114-0 Tourette's Syndrome
IndentIndentIndent54814-9 Seizure Disorder or Epilepsy
IndentIndentIndent54815-6 Traumatic Brain Injury (TBI)
IndentIndent54540-0 Nutritional
IndentIndentIndent54816-4 Malnutrition (protein or calorie) or at risk for malnutrition
IndentIndent54541-8 Psychiatric/Mood Disorder
IndentIndentIndent54817-2 Anxiety Disorder
IndentIndentIndent54818-0 Depression (other than Bipolar)
IndentIndentIndent54819-8 Manic Depression (bipolar Disease)
IndentIndentIndent58115-7 Psychotic Disorder (other than schizophrenia)
IndentIndentIndent54820-6 Schizophrenia
IndentIndentIndent54821-4 Post-Traumatic Stress Disorder (PTSD)
IndentIndent54542-6 Pulmonary
IndentIndentIndent54822-2 Asthma,Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease
IndentIndentIndent58116-5 Respiratory Failure
IndentIndent54543-4 Vision
IndentIndentIndent54823-0 Cataracts, Glaucoma, or Macular Degeneration
IndentIndent54544-2 None of Above
IndentIndentIndent54824-8 None of the above active diagnoses within the last 7 days
IndentIndent54898-2 Other
IndentIndentIndent54545-9 Additional diagnoses
IndentIndentIndentIndent54546-7 Additional Diagnosis A
IndentIndentIndentIndent54547-5 Additional Diagnosis B
IndentIndentIndentIndent54548-3 Additional Diagnosis C
IndentIndentIndentIndent54549-1 Additional Diagnosis D
IndentIndentIndentIndent54550-9 Additional Diagnosis E
IndentIndentIndentIndent54551-7 Additional Diagnosis F
IndentIndentIndentIndent54552-5 Additional Diagnosis G
IndentIndentIndentIndent54553-3 Additional Diagnosis H
IndentIndentIndentIndent54554-1 Additional Diagnosis I
IndentIndentIndentIndent54555-8 Additional Diagnosis J
Indent54556-6 Health conditions
IndentIndent54557-4 Pain Management. Complete for all residents, regardless of current pain level. At any time in the last 7 days, has the resident:
IndentIndentIndent71447-7 Received scheduled pain medication regimen?
IndentIndentIndent71448-5 Received PRN pain medications or was offered and declined?
IndentIndentIndent71449-3 Received non-medication intervention for pain?
IndentIndent54828-9 Should Pain Assessment Interview be Conducted?
IndentIndent54558-2 Pain assessment interview [CMS Assessment]
IndentIndentIndent54829-7 Pain Presence. Ask resident: "Have you had pain or hurting any time in the last 5 days?"
IndentIndentIndent54830-5 Pain Frequency. Ask resident: "How much of the time have you experienced pain or hurting over the last 5 days?"
IndentIndentIndent54559-0 Pain effect on function [CMS Assessment]
IndentIndentIndentIndent54831-3 Ask resident: "Over the past 5 days, has pain made it hard for you to sleep at night?"
IndentIndentIndentIndent54832-1 Ask resident: "Over the past 7 days, have you limited your day-to-day activities because of pain?"
IndentIndentIndent54560-8 Pain intensity [CMS Assessment]
IndentIndentIndentIndent54833-9 Numeric Rating Scale (00-10). Ask resident: "Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine." (Show resident 00-10 pain scale.)
IndentIndentIndentIndent54834-7 Verbal Descriptor Scale. Ask resident: " Please rate the intensity of your worst pain over the last 5 days." (Show resident verbal scale.)
IndentIndent58117-3 Should the Staff Assessment for Pain be Conducted?
IndentIndent54561-6 Staff assessment for pain
IndentIndentIndent54562-4 Indicators of pain or possible pain
IndentIndentIndentIndent54835-4 Non-verbal sounds (crying, whining, gasping, moaning, or groaning).
IndentIndentIndentIndent54836-2 Vocal complaints of pain (that hurts, ouch, stop).
IndentIndentIndentIndent54837-0 Facial expressions (grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw).
IndentIndentIndentIndent54838-8 Protective body movements or postures (bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement).
IndentIndentIndentIndent54839-6 None of these signs observed or documented
IndentIndentIndent58118-1 Frequency of indicator of pain or possible pain in last 5 days [CMS Assessment] d/(5.d)
IndentIndent54563-2 Other health conditions
IndentIndentIndent54564-0 Shortness of Breath (dyspnea)
IndentIndentIndentIndent54841-2 Shortness of breath or trouble breathing with exertion (e.g., walking, bathing, transferring).
IndentIndentIndentIndent54842-0 Shortness of breath or trouble breathing when sitting at rest
IndentIndentIndentIndent54843-8 Shortness of breath or trouble breathing when lying flat
IndentIndentIndentIndent54844-6 None of the above
IndentIndentIndent54845-3 Tobacco Use
IndentIndentIndent54846-1 Prognosis
IndentIndentIndent54847-9 Problem conditions [MDSv3]
IndentIndentIndentIndent45701-0 Fever [Minimum Data Set]
IndentIndentIndentIndent45708-5 Vomiting [Minimum Data Set]
IndentIndentIndentIndent45696-2 Dehydrated
IndentIndentIndentIndent45703-6 Internal bleeding [Minimum Data Set]
IndentIndentIndentIndent54848-7 None of the above
IndentIndentIndent54849-5 Fall history on admission [CMS Assessment]
IndentIndentIndentIndent54850-3 Did the resident fall one or more times in the last month prior to admission?
IndentIndentIndentIndent54851-1 Did the resident fall one or more times in the last 2 - 6 months prior to admission?
IndentIndentIndentIndent54852-9 Did the resident have any fracture related to a fall in the 6 months prior to admission?
IndentIndentIndent54853-7 Has the resident had any falls since admission or the prior assessment (OBRA or PPS), whichever is more recent?
IndentIndentIndent54854-5 Number of Falls Since Admission or Prior Assessment (OBRA or PPS), Whichever is More Recent
IndentIndentIndentIndent54855-2 No injury
IndentIndentIndentIndent54856-0 Injury (except major)
IndentIndentIndentIndent54857-8 Major injury
Indent54565-7 Swallowing/Nutritional Status
IndentIndent54566-5 Swallowing disorder
IndentIndentIndent54858-6 Loss of liquids/solids from mouth when eating or drinking
IndentIndentIndent54859-4 Holding food in mouth/cheeks or residual food in mouth after meals
IndentIndentIndent54860-2 Coughing or choking during meals or when swallowing medications
IndentIndentIndent54861-0 Complaints of difficulty or pain with swallowing
IndentIndentIndent54862-8 None of the above
IndentIndent54567-3 Height and weight
IndentIndentIndent3137-7 Height (in inches). [in_us];cm
IndentIndentIndent3141-9 Weight (in pounds). [lb_av];kg
IndentIndent54863-6 Weight loss of 5% or more in the last month or loss of 10% or more in last 6 months [CMS Assessment]
IndentIndent71442-8 Weight gain [MDSv3]
IndentIndent54568-1 Nutritional approaches panel [CMS Assessment]
IndentIndentIndent71444-4 Nutritional Approaches. While NOT a Resident 1..5
IndentIndentIndent71445-1 Nutritional Approaches. While a Resident 1..4
IndentIndent54569-9 Percent intake by artificial route
IndentIndentIndent54897-4 Proportion of total calories the resident received through parenteral or tube feedings %
IndentIndentIndent54869-3 Average fluid intake per day by parenteral or tube feedings mL/(7.d)
Indent54570-7 Oral/Dental Status
IndentIndent54571-5 Dental
IndentIndentIndent54871-9 Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose)
IndentIndentIndent54872-7 No natural teeth or tooth fragment(s) (edentulous)
IndentIndentIndent54873-5 Abnormal mouth tissue (ulcers, masses, oral lesions, including under denture or partial if one is worn)
IndentIndentIndent54874-3 Obvious or likely cavity or broken natural teeth
IndentIndentIndent54875-0 Inflamed or bleeding gums or loose natural teeth
IndentIndentIndent54876-8 Mouth or facial pain, discomfort or difficulty with chewing
IndentIndentIndent58119-9 Unable to examine
IndentIndentIndent54877-6 None of the above were present
Indent54572-3 Skin conditions
IndentIndent54573-1 Determination of pressure injury risk
IndentIndentIndent54878-4 Resident has a stage 1 or greater, a scar over bony prominence, or a non-removable dressing/device
IndentIndentIndent54879-2 Formal assessment/tool (e.g., Braden, Norton, or other)
IndentIndentIndent54880-0 Clinical assessment
IndentIndentIndent54881-8 None of the above
IndentIndent54882-6 Risk of Developing Pressure Ulcers. Is resident at risk of developing pressure ulcers?
IndentIndent58214-8 Unhealed Pressure Ulcer(s). Does this patient have one or more unhealed pressure ulcer(s) at Stage 1 or higher?
IndentIndent54575-6 Current number of unhealed (non-epithelialized) pressure injuries at each stage
IndentIndentIndent58215-5 Stage 1 [MDSv3]
IndentIndentIndentIndent54884-2 Number of pressure injuries - stage 1 [CMS Assessment] {#}
IndentIndentIndent54576-4 Stage 2
IndentIndentIndentIndent55124-2 Number of Stage 2 pressure ulcers {#}
IndentIndentIndentIndent54886-7 Number of these Stage 2 pressure ulcers that were present upon admission/reentry {#}
IndentIndentIndentIndent58123-1 Date of Pressure injury.oldest non-epithelialized stage 2 [CMS Assessment] {mm/dd/yyyy}
IndentIndentIndent54577-2 Stage 3
IndentIndentIndentIndent55125-9 Number of Stage 3 pressure ulcers {#}
IndentIndentIndentIndent54887-5 Number of these Stage 3 pressure ulcers that were present upon admission/reentry {#}
IndentIndentIndent54578-0 Stage 4
IndentIndentIndentIndent55126-7 Number of Stage 4 pressure ulcers {#}
IndentIndentIndentIndent54890-9 Number of these Stage 4 pressure ulcers that were present upon admission/reentry {#}
IndentIndentIndent54579-8 Unstageable: Known or likely but not stageable due to non-removable dressing/device
IndentIndentIndentIndent54893-3 Number of unstageable pressure ulcers due to non-removable dressing/device {#}
IndentIndentIndentIndent54894-1 Number of these unstageable pressure ulcers that were present upon admission/reentry {#}
IndentIndentIndent55089-7 Unstageable: Known or likely but not stageable due to coverage of wound bed by slough and/or eschar
IndentIndentIndentIndent54946-9 Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar {#}
IndentIndentIndentIndent54947-7 Number of these unstageable pressure ulcers that were present upon admission/reentry {#}
IndentIndentIndent55088-9 Pressure injuries - unstageable with suspected deep tissue injury in evolution
IndentIndentIndentIndent54950-1 Number of unstageable pressure ulcers with suspected deep tissue injury in evolution {#}
IndentIndentIndentIndent54951-9 Number of these unstageable ulcers that were present upon admission/reentry {#}
IndentIndentIndent52477-7 Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers Or Eschar
IndentIndentIndentIndent52728-3 Pressure ulcer length cm
IndentIndentIndentIndent52729-1 Pressure ulcer width cm
IndentIndentIndentIndent57228-9 Pressure ulcer depth cm
IndentIndentIndent55073-1 Most Severe Tissue Type for Any Pressure Ulcer
IndentIndentIndent54952-7 Worsening in pressure injury status since last assessment (OBRA, PPS, or Discharge)
IndentIndentIndentIndent54953-5 Stage 2 {#}
IndentIndentIndentIndent54954-3 Stage 3 {#}
IndentIndentIndentIndent54955-0 Stage 4 {#}
IndentIndentIndent54956-8 Healed pressure injuries [CMS Assessment]
IndentIndentIndentIndent54957-6 Were pressure ulcers present on the prior assessment (OBRA or PPS)?
IndentIndentIndentIndent54958-4 Stage 2 {#}
IndentIndentIndentIndent54959-2 Stage 3 {#}
IndentIndentIndentIndent54960-0 Stage 4 {#}
IndentIndentIndent54970-9 Number of venous and arterial ulcers. Enter the total number of venous and arterial ulcers present. {#}
IndentIndentIndent54961-8 Other ulcers, wounds and skin problems
IndentIndentIndentIndent58228-8 Infection of the foot [MDSv3]
IndentIndentIndentIndent54963-4 Diabetic foot ulcer(s)
IndentIndentIndentIndent58125-6 Other open lesion(s) on the foot [MDSv3]
IndentIndentIndentIndent54967-5 Open lesion(s) other than ulcers, rashes, cuts
IndentIndentIndentIndent54966-7 Surgical wound(s)
IndentIndentIndentIndent54968-3 Burn(s) (second or third degree)
IndentIndentIndentIndent71450-1 Skin tear(s) [MDSv3]
IndentIndentIndentIndent71451-9 Moisture associated skin damage (MASD) [MDSv3]
IndentIndentIndentIndent54969-1 None of the above were present
IndentIndentIndent54971-7 Skin and Ulcer Treatments
IndentIndentIndentIndent54972-5 Pressure reducing device for chair
IndentIndentIndentIndent54973-3 Pressure reducing device for bed
IndentIndentIndentIndent54974-1 Turning/repositioning program
IndentIndentIndentIndent54975-8 Nutrition or hydration intervention to manage skin problems
IndentIndentIndentIndent54976-6 Pressure ulcer care
IndentIndentIndentIndent54977-4 Surgical wound care
IndentIndentIndentIndent54978-2 Application of nonsurgical dressings (with or without topical medications) other than to feet
IndentIndentIndentIndent54979-0 Applications of ointments/medications other than to feet
IndentIndentIndentIndent54980-8 Application of dressings to feet (with or without topical medications)
IndentIndentIndentIndent54981-6 None of the above were provided
Indent55094-7 Medications [MDSv3]
IndentIndent54982-4 Injections d/(7.d)
IndentIndent58217-1 Insulin [CMS Assessment]
IndentIndentIndent58127-2 Insulin injections d/(7.d)
IndentIndentIndent58128-0 Orders for insulin d/(7.d)
IndentIndent54983-2 Medications Received
IndentIndentIndent54984-0 Antipsychotic received in last 7D
IndentIndentIndent54985-7 Antianxiety received in last 7D
IndentIndentIndent54986-5 Antidepressant received in last 7D
IndentIndentIndent54987-3 Hypnotic received in last 7D
IndentIndentIndent54988-1 Anticoagulant received in last 7D
IndentIndentIndent58129-8 Antibiotic recieved in last 7D
IndentIndentIndent58130-6 Diuretic received in last 7D
Indent54990-7 Special treatments and procedures
IndentIndent54991-5 Special Treatments and Programs
IndentIndentIndent55086-3 Cancer Treatments
IndentIndentIndentIndent54992-3 Chemotherapy ‐ while NOT a resident
IndentIndentIndentIndent54993-1 Chemotherapy ‐ while a resident
IndentIndentIndentIndent54994-9 Radiation ‐ while NOT a resident
IndentIndentIndentIndent54995-6 Radiation ‐ while a resident
IndentIndentIndent55085-5 Respiratory Treatments
IndentIndentIndentIndent54996-4 Oxygen therapy ‐ while NOT a resident
IndentIndentIndentIndent54997-2 Oxygen therapy ‐ while a resident
IndentIndentIndentIndent54998-0 Suctioning ‐ while NOT a resident
IndentIndentIndentIndent54999-8 Suctioning ‐ while a resident
IndentIndentIndentIndent55000-4 Tracheostomy care ‐ while NOT a resident
IndentIndentIndentIndent55001-2 Tracheostomy care ‐ while a resident
IndentIndentIndentIndent55002-0 Ventilator or respirator ‐ while NOT a resident
IndentIndentIndentIndent55003-8 Ventilator or respirator ‐ while a resident
IndentIndentIndentIndent55004-6 BIPAP/CPAP machine ‐ while NOT a resident
IndentIndentIndentIndent55005-3 BIPAP/CPAP machine ‐ while a resident
IndentIndentIndent55084-8 Other
IndentIndentIndentIndent55006-1 IV medications ‐ while NOT a resident
IndentIndentIndentIndent55007-9 IV medications ‐ while a resident
IndentIndentIndentIndent55008-7 Transfusions ‐ while NOT a resident
IndentIndentIndentIndent55009-5 Transfusions ‐ while a resident
IndentIndentIndentIndent55010-3 Dialysis ‐ while NOT a resident
IndentIndentIndentIndent55011-1 Dialysis ‐ while a resident
IndentIndentIndentIndent55012-9 Hospice care ‐ while NOT a resident
IndentIndentIndentIndent55013-7 Hospice care ‐ while a resident
IndentIndentIndentIndent55015-2 Respite care in last 14 days - while a resident [MDSv3]
IndentIndentIndentIndent55016-0 Isolation or quarantine for active infectious disease ‐ while NOT a resident
IndentIndentIndentIndent55017-8 Isolation or quarantine for active infectious disease ‐ while a resident
IndentIndentIndent75795-5 None of the above
IndentIndentIndentIndent59374-9 None of above - while NOT a resident
IndentIndentIndentIndent59373-1 None of above - while a resident
IndentIndent55018-6 Influenza vaccine
IndentIndentIndent55019-4 Influenza virus vaccine received in facility [CMS Assessment]
IndentIndentIndent58131-4 Date of influenza vaccination {mm/dd/yyyy}
IndentIndentIndent55020-2 If influenza vaccine not received, state reason
IndentIndent55021-0 Pneumococcal vaccine
IndentIndentIndent55022-8 Is the resident's Pneumococcal Vaccination up to date?
IndentIndentIndent45956-0 Reason pneumococcal vaccine not received [CMS Assessment]
IndentIndent55024-4 Therapies
IndentIndentIndent58132-2 Speech-language pathology and audiology services [MDSv3]
IndentIndentIndentIndent58218-9 Speech-language pathology and audiology services - individual minutes in the last 7 days [CMS Assessment] min
IndentIndentIndentIndent58133-0 Speech-language pathology and audiology services - concurrent minutes in the last 7 days [CMS Assessment] min
IndentIndentIndentIndent58134-8 Speech-language pathology and audiology services - group minutes in the last 7 days [CMS Assessment] min
IndentIndentIndentIndent45760-6 Speech/language pathology and audiology services - Days d/(7.d)
IndentIndentIndentIndent55025-1 Speech/language pathology and audiology services - Therapy Start Date {mm/dd/yyyy}
IndentIndentIndentIndent55026-9 Speech/language pathology and audiology services - Therapy End Date {mm/dd/yyyy}
IndentIndentIndent58135-5 Occupational therapy [MDSv3]
IndentIndentIndentIndent58219-7 Occupational therapy - individual minutes in the last 7 days [CMS Assessment] min
IndentIndentIndentIndent58136-3 Occupational therapy - concurrent minutes in the last 7 days [CMS Assessment] min
IndentIndentIndentIndent58137-1 Occupational therapy - group minutes in the last 7 days [CMS Assessment] min
IndentIndentIndentIndent45762-2 Occupational Therapy - Days d/(7.d)
IndentIndentIndentIndent55027-7 Occupational Therapy - Therapy Start Date {mm/dd/yyyy}
IndentIndentIndentIndent55028-5 Occupational Therapy - Therapy End Date {mm/dd/yyyy}
IndentIndentIndent58138-9 Physical therapy [MDSv3]
IndentIndentIndentIndent58220-5 Physical therapy - individual minutes in the last 7 days [CMS Assessment] min
IndentIndentIndentIndent58139-7 Physical therapy - concurrent minutes in the last 7 days [CMS Assessment] min
IndentIndentIndentIndent58140-5 Physical therapy - group minutes in the last 7 days [CMS Assessment] min
IndentIndentIndentIndent45764-8 Physical Therapy - Days d/(7.d)
IndentIndentIndentIndent55029-3 Physical Therapy - Therapy Start Date {mm/dd/yyyy}
IndentIndentIndentIndent55030-1 Physical Therapy - Therapy End Date {mm/dd/yyyy}
IndentIndentIndent58141-3 Respiratory therapy [CMS Assessment]
IndentIndentIndentIndent45767-1 Respiratory Therapy - Minutes min
IndentIndentIndentIndent45766-3 Respiratory Therapy - Days d/(7.d)
IndentIndentIndent58142-1 Psychological therapy [CMS Assessment]
IndentIndentIndentIndent45852-1 Psychological Therapy (by any licensed mental health professional) - Minutes min
IndentIndentIndentIndent45768-9 Psychological Therapy (by any licensed mental health professional) - Days d/(7.d)
IndentIndentIndent58143-9 Recreational therapy [CMS Assessment]
IndentIndentIndentIndent55035-0 Recreational Therapy (includes recreational and music therapy) - Minutes min
IndentIndentIndentIndent55036-8 Recreational Therapy (includes recreational and music therapy) - Days d/(7.d)
IndentIndent55039-2 Restorative Nursing Programs
IndentIndentIndent55131-7 Technique
IndentIndentIndentIndent45859-6 Range of motion (passive) d
IndentIndentIndentIndent45860-4 Technique. Range of motion (active) d
IndentIndentIndentIndent45861-2 Splint or brace assistance d
IndentIndentIndent55132-5 Training and skill practice in
IndentIndentIndentIndent45862-0 Bed mobility d
IndentIndentIndentIndent45863-8 Transfer d
IndentIndentIndentIndent45864-6 Walking d
IndentIndentIndentIndent45865-3 Dressing and/or grooming d
IndentIndentIndentIndent45866-1 Eating and/or swallowing d
IndentIndentIndentIndent45867-9 Amputation/prostheses care d
IndentIndentIndentIndent45868-7 Communication d
IndentIndent55040-0 Physician Examinations. Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) examine the resident? d/(14.d)
IndentIndent55041-8 Physician Orders. Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) change the resident's orders? d/(14.d)
Indent55042-6 Restraints
IndentIndent55043-4 Physical restraints
IndentIndentIndent55129-1 Used in Bed
IndentIndentIndentIndent55044-2 Bed rail
IndentIndentIndentIndent55045-9 Trunk restraint
IndentIndentIndentIndent55046-7 Limb restraint
IndentIndentIndentIndent55047-5 Other
IndentIndentIndent55130-9 Used in Chair or Out of Bed
IndentIndentIndentIndent55048-3 Trunk restraint
IndentIndentIndentIndent55049-1 Limb restraint
IndentIndentIndentIndent55050-9 Chair prevents rising
IndentIndentIndentIndent55051-7 Other
Indent55052-5 Participation in assessment and goal setting
IndentIndent55053-3 Participation in assessment
IndentIndentIndent55054-1 Resident participated in assessment
IndentIndentIndent55074-9 Family or significant other participated in assessment
IndentIndentIndent58221-3 Guardian or legally authorized representative participated in assessment
IndentIndent55056-6 Resident's Overall Expectation
IndentIndentIndent55057-4 Resident's overall goal established during assessment process
IndentIndentIndent55058-2 Indicate information source for Q0300A
IndentIndent58222-1 Discharge plan
IndentIndentIndent58146-2 Active discharge planning already occurring for the resident to return to the community
IndentIndentIndent58147-0 What determination was made by the resident and the care planning team regarding discharge to the community?
IndentIndent58223-9 Return to community
IndentIndentIndent58148-8 Has the resident been asked about returning to the community?
IndentIndentIndent58149-6 Ask the resident (or family or significant other if resident is unable to respond): "Do you want to talk to someone about the possibility of returning to the community?"
IndentIndent58150-4 Referral. Has a referral been made to the Local Contact Agency?
Indent58154-6 Care Area Assessment (CAA) Summary [MDSv3]
IndentIndent58224-7 Items from most recent prior OBRA or scheduled PPS assessment
IndentIndentIndent54583-0 Prior Assessment Federal OBRA Reason for Assessment
IndentIndentIndent54584-8 Prior Assessment PPS Reason for Assessment
IndentIndentIndent54593-9 Prior Assessment Reference Date {mm/dd/yyyy}
IndentIndentIndent58151-2 Prior assessment Brief Interview for Mental Status (BIMS) summary score [MDSv3] {score}
IndentIndentIndent58152-0 Prior assessment resident mood interview (PHQ-9) total severity score [MDSv3] {score}
IndentIndentIndent58153-8 Prior assessment staff assessment of resident mood interview (PHQ-9) total severity score [MDSv3] {score}
IndentIndent58155-3 CAAs and Care Planning
IndentIndentIndent58156-1 CAA Results
IndentIndentIndentIndent58157-9 Delirium - care area triggered [MDSv3]
IndentIndentIndentIndent58158-7 Delirium - addressed in care plan [MDSv3]
IndentIndentIndentIndent58159-5 Cognitive loss/dementia - care area triggered
IndentIndentIndentIndent58160-3 Cognitive loss/dementia - addressed in care plan
IndentIndentIndentIndent58226-2 Visual function - care area triggered [MDSv3]
IndentIndentIndentIndent58225-4 Visual function - addressed in care plan [MDSv3]
IndentIndentIndentIndent58161-1 Communication - care area triggered [MDSv3]
IndentIndentIndentIndent58162-9 Communication - addressed in care plan [MDSv3]
IndentIndentIndentIndent58163-7 ADL functional/rehabilitation potential - care area triggered
IndentIndentIndentIndent58164-5 ADL functional/rehabilitation potential - addressed in care plan
IndentIndentIndentIndent58165-2 Urinary incontinence and indwelling catheter - care area triggered [MDSv3]
IndentIndentIndentIndent58166-0 Urinary incontinence and indwelling catheter - addressed in care plan [MDSv3]
IndentIndentIndentIndent58167-8 Psychosocial well-being - care area triggered [MDSv3]
IndentIndentIndentIndent58168-6 Psychosocial well-being - addressed in care plan [MDSv3]
IndentIndentIndentIndent58169-4 Mood state - care area triggered [MDSv3]
IndentIndentIndentIndent58170-2 Mood state - addressed in care plan [MDSv3]
IndentIndentIndentIndent58171-0 Behavioral symptoms - care area triggered [MDSv3]
IndentIndentIndentIndent58172-8 Behavioral symptoms - addressed in care plan [MDSv3]
IndentIndentIndentIndent58173-6 Activities - care area triggered [MDSv3]
IndentIndentIndentIndent58174-4 Activities - addressed in care plan [MDSv3]
IndentIndentIndentIndent58175-1 Falls - care area triggered [MDSv3]
IndentIndentIndentIndent58176-9 Falls - addressed in care plan [MDSv3]
IndentIndentIndentIndent58177-7 Nutritional status - care area triggered [MDSv3]
IndentIndentIndentIndent58178-5 Nutritional status - addressed in care plan [MDSv3]
IndentIndentIndentIndent58179-3 Feeding tube - care area triggered [MDSv3]
IndentIndentIndentIndent58180-1 Feeding tube - addressed in care plan [MDSv3]
IndentIndentIndentIndent58181-9 Dehydration/fluid maintenance - care area triggered
IndentIndentIndentIndent58182-7 Dehydration/fluid maintenance - addressed in care plan
IndentIndentIndentIndent58183-5 Dental care - care area triggered [MDSv3]
IndentIndentIndentIndent58184-3 Dental care - addressed in care plan [MDSv3]
IndentIndentIndentIndent58185-0 Pressure injury - care area triggered [MDSv3]
IndentIndentIndentIndent58186-8 Pressure injury - addressed in care plan [MDSv3]
IndentIndentIndentIndent58187-6 Psychotropic drug use - care area triggered [MDSv3]
IndentIndentIndentIndent58188-4 Psychotropic drug use - addressed in care plan [MDSv3]
IndentIndentIndentIndent58189-2 Physical restraints - care area triggered [MDSv3]
IndentIndentIndentIndent58190-0 Physical restraints - addressed in care plan [MDSv3]
IndentIndentIndentIndent58191-8 Pain - care area triggered [MDSv3]
IndentIndentIndentIndent58192-6 Pain - addressed in care plan [MDSv3]
IndentIndentIndentIndent58193-4 Return to community referral - care area triggered [MDSv3]
IndentIndentIndentIndent58194-2 Return to community referral - addressed in care plan [MDSv3]
IndentIndentIndentIndent58195-9 Date of Care Area Assessment (CAA) information [MDSv3] R 0..20
IndentIndentIndentIndent58196-7 Location of Care Area Assessment (CAA) information [MDSv3] R 0..20
Indent58197-5 Correction request [MDSv3]
IndentIndent54582-2 Provider type [MDSv3]
IndentIndent54503-8 Name of Resident on existing record to be modified/inactivated
IndentIndentIndent45392-8 First name
IndentIndentIndent45394-4 Last name
IndentIndent46098-0 Gender on existing record to be modified/inactivated
IndentIndent21112-8 Birth Date on existing record to be modified/inactived {mm/dd/yyyy}
IndentIndent45966-9 Social Security Number on existing record to be modified/inactivated
IndentIndent54502-0 Type of Assessment on existing record to be modified/inactivated
IndentIndentIndent54583-0 Federal OBRA reason for assessment [CMS Assessment]
IndentIndentIndent54584-8 PPS Assessment [CMS Assessment]
IndentIndentIndent54585-5 PPS Other Medicare Required Assessment - OMRA [CMS Assessment]
IndentIndentIndent58107-4 Is this a Swing Bed clinical change assessment?
IndentIndentIndent54587-1 Is this assessment the first assessment (OBRA, PPS, or Discharge) since the most recent admission?
IndentIndentIndent58108-2 Entry/discharge reporting
IndentIndentIndent71440-2 Type of discharge
IndentIndent75794-8 Date on existing record to be modified/inactivated
IndentIndentIndent54593-9 Assessment reference date - observation end date [CMS Assessment] {mm/dd/yyyy}
IndentIndentIndent52525-3 Discharge date {mm/dd/yyyy}
IndentIndentIndent50786-3 Entry Date {mm/dd/yyyy}
IndentIndent58200-7 Correction number [CMS Assessment] {#}
IndentIndent58199-1 Reasons for modification [MDSv3]
IndentIndentIndent58201-5 Transcription error [MDSv3]
IndentIndentIndent58202-3 Data entry error [MDSv3]
IndentIndentIndent58203-1 Item coding error [MDSv3]
IndentIndentIndent58227-0 Software product error [MDSv3]
IndentIndentIndent58204-9 Other error requiring modification [MDSv3]
IndentIndentIndent58205-6 Other error requiring modification.other specified [MDSv3]
IndentIndent58206-4 Reasons for inactivation [MDSv3]
IndentIndentIndent58207-2 Reasons for inactivation - event did not occur [MDSv3]
IndentIndentIndent58208-0 Other error requiring error requiring inactivation [MDSv3]
IndentIndentIndent58209-8 Other error requiring error requiring inactivation.other specified [MDSv3]
Indent55063-2 Assessment administration
IndentIndent55064-0 Medicare part A billing
IndentIndentIndent55065-7 Medicare part A - HIPPS code for billing
IndentIndentIndent55066-5 RUG version code
IndentIndentIndent58421-9 Medicare short stay assessment [CMS Assessment]
IndentIndent59375-6 Medicare non-therapy Part A billing [CMS Assessment]
IndentIndentIndent58210-6 Medicare non-therapy Part A HIPPS code [CMS Assessment]
IndentIndentIndent58211-4 RUG version code
IndentIndent55067-3 State Medicaid billing
IndentIndentIndent55068-1 RUG Case Mix group
IndentIndentIndent55069-9 RUG version code
IndentIndent58422-7 Alternate state Medicaid billing
IndentIndentIndent58212-2 RUG Case Mix Group
IndentIndentIndent58213-0 RUG version code
IndentIndent55070-7 Insurance billing
IndentIndentIndent55071-5 RUG Case Mix group
IndentIndentIndent55072-3 RUG version code
IndentIndent55083-0 Item subset code
IndentIndent55075-6 Version code Specifications
IndentIndent55082-2 Transaction code Transaction [MDSv3]
IndentIndent55076-4 Production or test indicator Submission [MDSv3]
IndentIndent55077-2 State assigned facility submission ID
IndentIndent55078-0 Federal employer tax ID Software vendor
IndentIndent55079-8 Vendor company name Software
IndentIndent55093-9 Vendor email address Software
IndentIndent55080-6 Product name Software
IndentIndent55081-4 Product version code Software

Fully-Specified Name

Component
Minimum Data Set - version 3.0
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
PANEL.SURVEY.MDS
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.29
Panel Type
Panel

LOINC FHIR® API Example - CodeSystem Request Get Info

https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=54580-6