Form Coding Instructions

Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical record

Source: Centers for Medicare & Medicaid Services

Webcontent

Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990 Dec 15;113(12):941-8.

Source: National Library of Medicine

54628-3 Inattention. Did the resident have difficulty focusing attention (easily distracted, out of touch or difficulty following what was said)?

Reference Information

TypeSourceReference
ArticleNCBI PubMedInouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Link to PubMed

Observation ID in Form

C1300A

Fully-Specified Name

Component
Inattention in last 7D
Property
Find
Time
7D
System
^Patient
Scale
Nom
Method
CAM.CMS

Long Common Name

Inattention in last 7 days [CAM.CMS]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.29
Last Updated
Version 2.67 (MAJ)
Change Reason
Release 2.67: METHOD_TYP: Method updated to reflect that this item is from the CMS adaption of the Confusion Assessment Method (CAM); SURVEY_QUEST_TEXT: Survey question from the Confusion Assessment Method (CAM) added to clarify the source of this term; SURVEY_QUEST_SRC: Survey question from the Confusion Assessment Method (CAM) added to clarify the source of this term; 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.; Scale changed from Ord to Nom because answers cannot be ordered
Order vs. Observation
Observation

Normative Answer List LL652-9

AnswerCodeScoreAnswer ID
Behavior not present0LA61-7
Behavior continuously present, does not fluctuate1LA10992-8
Behavior present, fluctuates (comes and goes, changes in severity)2LA10993-6

Member of these Panels

LOINCLong Common Name
86522-0Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86856-2Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88282-9Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88287-8Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88954-3Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6Deprecated Minimum Data Set - version 3.0

54629-1 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)?

Reference Information

TypeSourceReference
ArticleNCBI PubMedInouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Link to PubMed

Observation ID in Form

C1300B

Fully-Specified Name

Component
Disorganized thinking in last 7D
Property
Find
Time
7D
System
^Patient
Scale
Ord
Method
CAM.CMS

Long Common Name

Disorganized thinking in last 7 days [CAM.CMS]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.29
Last Updated
Version 2.67 (MAJ)
Change Reason
Release 2.67: METHOD_TYP: Method updated to reflect that this item is from the CMS adaption of the Confusion Assessment Method (CAM); SURVEY_QUEST_TEXT: Survey question from the Confusion Assessment Method (CAM) added to clarify the source of this term; SURVEY_QUEST_SRC: Survey question from the Confusion Assessment Method (CAM) added to clarify the source of this term; 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 LL652-9

AnswerCodeScoreAnswer ID
Behavior not present0LA61-7
Behavior continuously present, does not fluctuate1LA10992-8
Behavior present, fluctuates (comes and goes, changes in severity)2LA10993-6

Member of these Panels

LOINCLong Common Name
86522-0Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86856-2Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88282-9Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88287-8Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88954-3Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6Deprecated Minimum Data Set - version 3.0

54630-9 Altered level of consciousness. Did the resident have altered level of consciousness?

Term Description

This term is the CMS Assessment adaption of question 4 on the Confusion Assessment Method (CAM): "[Altered level of consciousness] Overall, how would you rate this patient's level of consciousness? (Alert [normal]; Vigilant [hyperalert, overly sensitive to environmental stimuli, startled very easily], Lethargic [drowsy, easily aroused]; Stupor [difficult to arouse]; Coma; [unarousable]; Uncertain)"

Reference Information

TypeSourceReference
ArticleNCBI PubMedInouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Link to PubMed

Observation ID in Form

C1300C

Fully-Specified Name

Component
Altered level of consciousness in last 7D
Property
Find
Time
7D
System
^Patient
Scale
Ord
Method
CAM.CMS

Long Common Name

Altered level of consciousness in last 7 days [CAM.CMS]

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.29
Last Updated
Version 2.72 (MIN)
Change Reason
Release 2.67: METHOD_TYP: Method updated to reflect that this item is from the CMS adaption of the Confusion Assessment Method (CAM); 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 LL652-9

AnswerCodeScoreAnswer ID
Behavior not present0LA61-7
Behavior continuously present, does not fluctuate1LA10992-8
Behavior present, fluctuates (comes and goes, changes in severity)2LA10993-6

Member of these Panels

LOINCLong Common Name
86522-0Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86856-2Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88282-9Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88287-8Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88954-3Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6Deprecated Minimum Data Set - version 3.0

54631-7 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?

Observation ID in Form

C1300D

Fully-Specified Name

Component
Psychomotor retardation in last 7D
Property
Find
Time
7D
System
^Patient
Scale
Ord
Method
Observed.CAM.MDSv3

Long Common Name

Psychomotor retardation in last 7 days [CAM.MDSv3]

Basic Attributes

Class
SURVEY.MDS
Type
Surveys
First Released
Version 2.29
Last Updated
Version 2.54 (MAJ)

Normative Answer List LL652-9

AnswerCodeScoreAnswer ID
Behavior not present0LA61-7
Behavior continuously present, does not fluctuate1LA10992-8
Behavior present, fluctuates (comes and goes, changes in severity)2LA10993-6

Member of these Panels

LOINCLong Common Name
54580-6Deprecated Minimum Data Set - version 3.0