57040-8
CLINICAL RECORD ITEMS
Active
46500-5 Discipline of Person Completing Assessment
Term Description
Identifies the discipline of the clinician completing the comprehensive assessment at the specified time points or the clinician reporting the transfer to an inpatient facility, death at home, or discharge (no further visits after start of care).
Source: Regenstrief LOINC
Observation ID in Form
M0080
Fully-Specified Name
- Component
- Discipline of person completing assessment
- Property
- Type
- Time
- RptPeriod
- System
- Provider
- Scale
- Nom
- Method
- CMS Assessment
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.19
- Last Updated
- Version 2.77
- Change Reason
- Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee
- Order vs. Observation
- Observation
Normative Answer List LL245-2
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| RN | 1 | LA6367-2 | |
| PT | 2 | LA6353-2 | |
| SLP/ST | 3 | LA6378-9 | |
| OT | 4 | LA6309-4 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 69412-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0 |
| 46462-8 | Deprecated Outcome and assessment information set (OASIS) form - version B1 |
| 57039-0 | Deprecated Outcome and assessment information set (OASIS) form - version C |
| 57459-0 | Deprecated Outcome and assessment information set (OASIS) form - version C - Death at home |
| 57194-3 | Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency |
| 57192-7 | Deprecated Outcome and assessment information set (OASIS) form - version C - Follow-Up |
| 57191-9 | Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care |
| 57190-1 | Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care |
| 57193-5 | Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility |
| 86261-5 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency - death at home [CMS Assessment] |
| 86264-9 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment] |
| 86244-1 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment] |
| 86189-8 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] |
| 85907-4 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] |
| 86259-9 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [CMS Assessment] |
| 88369-4 | Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment] |
| 88370-2 | Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency - death at home during assessment period [CMS Assessment] |
| 88371-0 | Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment] |
| 88368-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment] |
| 88373-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment] |
| 88367-8 | Outcome and assessment information set (OASIS) form - version D, D1 - Transfer to inpatient facility - patient discharged or not discharged during assessment period [CMS Assessment] |
| 93058-6 | Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment] |
| 99158-8 | Outcome and assessment information set (OASIS) form - version E - Death at Home during assessment period [CMS Assessment] |
| 99178-6 | Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment] |
| 99153-9 | Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment] |
| 99160-4 | Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment] |
| 99131-5 | Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment] |
| 99174-5 | Outcome and assessment information set (OASIS) form - version E - Transfer to an Inpatient Facility during assessment period [CMS Assessment] |
46501-3 Date Assessment Completed
Term Description
The actual date the assessment is completed, except if agency policy allows assessments to be performed over more than one visit date, in which case the last date (when the assessment is finished) is the appropriate date to record.
Source: Regenstrief LOINC
Observation ID in Form
M0090
Fully-Specified Name
- Component
- Date assessment information completed
- Property
- Date
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Qn
- Method
- CMS Assessment
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.19
- Last Updated
- Version 2.77
- Change Reason
- Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 46462-8 | Deprecated Outcome and assessment information set (OASIS) form - version B1 |
| 57039-0 | Deprecated Outcome and assessment information set (OASIS) form - version C |
| 57459-0 | Deprecated Outcome and assessment information set (OASIS) form - version C - Death at home |
| 57194-3 | Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency |
| 57192-7 | Deprecated Outcome and assessment information set (OASIS) form - version C - Follow-Up |
| 57191-9 | Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care |
| 57190-1 | Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care |
| 57193-5 | Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility |
| 86261-5 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency - death at home [CMS Assessment] |
| 86264-9 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment] |
| 86244-1 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment] |
| 86189-8 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] |
| 85907-4 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] |
| 86259-9 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [CMS Assessment] |
| 88369-4 | Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment] |
| 88370-2 | Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency - death at home during assessment period [CMS Assessment] |
| 88371-0 | Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment] |
| 88368-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment] |
| 88373-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment] |
| 88367-8 | Outcome and assessment information set (OASIS) form - version D, D1 - Transfer to inpatient facility - patient discharged or not discharged during assessment period [CMS Assessment] |
| 93058-6 | Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment] |
| 99158-8 | Outcome and assessment information set (OASIS) form - version E - Death at Home during assessment period [CMS Assessment] |
| 99178-6 | Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment] |
| 99153-9 | Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment] |
| 99160-4 | Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment] |
| 99131-5 | Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment] |
| 99174-5 | Outcome and assessment information set (OASIS) form - version E - Transfer to an Inpatient Facility during assessment period [CMS Assessment] |
| 62863-6 | PhenX domain - Infectious diseases and immunity |
| 62812-3 | PhenX domain - Physical activity and physical fitness |
Example Units
| Unit | Source |
|---|---|
| {mm/dd/yyyy} | Example UCUM Units |
57200-8 This Assessment is Currently Being Completed for the Following Reason:
Observation ID in Form
M0100
Fully-Specified Name
- Component
- Reason for assessment
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Nom
- Method
- CMS Assessment
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.29
- Last Updated
- Version 2.77
- Change Reason
- Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee
- Order vs. Observation
- Observation
Normative Answer List LL773-3
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Start of care - further visits planned | 1 | LA6390-4 | |
| Resumption of care (after inpatient stay) | 3 | LA6366-4 | |
| Recertification (follow-up) reassessment | 4 | LA6355-7 | |
| Other follow-up | 5 | LA6312-8 | |
| Transferred to an inpatient facility - patient not discharged from agency | 6 | LA6402-7 | |
| Transferred to an inpatient facility - patient discharged from agency | 7 | LA6401-9 | |
| Death at home | 8 | LA6179-1 | |
| Discharge from agency | 9 | LA6184-1 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 57039-0 | Deprecated Outcome and assessment information set (OASIS) form - version C |
| 57459-0 | Deprecated Outcome and assessment information set (OASIS) form - version C - Death at home |
| 57194-3 | Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency |
| 57192-7 | Deprecated Outcome and assessment information set (OASIS) form - version C - Follow-Up |
| 57191-9 | Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care |
| 57190-1 | Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care |
| 57193-5 | Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility |
| 86261-5 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency - death at home [CMS Assessment] |
| 86264-9 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [CMS Assessment] |
| 86244-1 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment] |
| 86189-8 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] |
| 85907-4 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] |
| 86259-9 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [CMS Assessment] |
| 88369-4 | Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment] |
| 88370-2 | Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency - death at home during assessment period [CMS Assessment] |
| 88371-0 | Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment] |
| 88368-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment] |
| 88373-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment] |
| 88367-8 | Outcome and assessment information set (OASIS) form - version D, D1 - Transfer to inpatient facility - patient discharged or not discharged during assessment period [CMS Assessment] |
| 93058-6 | Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment] |
| 99158-8 | Outcome and assessment information set (OASIS) form - version E - Death at Home during assessment period [CMS Assessment] |
| 99178-6 | Outcome and assessment information set (OASIS) form - version E - Discharge from Agency during assessment period [CMS Assessment] |
| 99153-9 | Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment] |
| 99160-4 | Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment] |
| 99131-5 | Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment] |
| 99174-5 | Outcome and assessment information set (OASIS) form - version E - Transfer to an Inpatient Facility during assessment period [CMS Assessment] |
57201-6 Date of Physician-ordered Start of Care (Resumption of Care)
Observation ID in Form
M0102
Skip Logic
Go to M0110, if date entered
Form Coding Instructions
If the physician indicated a specific start of care (resumption of care) date when the patient was referred for home health services, record the date specified
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Date of Physician-ordered Start of Care (Resumption of Care)
- Property
- Date
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Qn
- Method
- CMS Assessment
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.29
- Last Updated
- Version 2.77
- Change Reason
- Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 57039-0 | Deprecated Outcome and assessment information set (OASIS) form - version C |
| 57459-0 | Deprecated Outcome and assessment information set (OASIS) form - version C - Death at home |
| 57194-3 | Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency |
| 57192-7 | Deprecated Outcome and assessment information set (OASIS) form - version C - Follow-Up |
| 57191-9 | Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care |
| 57190-1 | Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care |
| 57193-5 | Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility |
| 86189-8 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] |
| 85907-4 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] |
| 88368-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment] |
| 88373-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment] |
| 99160-4 | Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment] |
| 99131-5 | Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment] |
Example Units
| Unit | Source |
|---|---|
| {mm/dd/yyyy} | Example UCUM Units |
57202-4 Date of Referral
Observation ID in Form
M0104
Form Coding Instructions
Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Date of Referral
- Property
- Date
- Time
- Pt
- System
- ^Patient
- Scale
- Qn
- Method
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.29
- Last Updated
- Version 2.63
- Change Reason
- Updated METHOD from CMS assessment to method-less since this is a general concept and not specific to CMS assessments.
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 57039-0 | Deprecated Outcome and assessment information set (OASIS) form - version C |
| 57459-0 | Deprecated Outcome and assessment information set (OASIS) form - version C - Death at home |
| 57194-3 | Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency |
| 57192-7 | Deprecated Outcome and assessment information set (OASIS) form - version C - Follow-Up |
| 57191-9 | Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care |
| 57190-1 | Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care |
| 57193-5 | Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility |
| 86189-8 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] |
| 85907-4 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] |
| 86636-8 | Family planning report - FPAR 2.0 set |
| 88368-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment] |
| 88373-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment] |
| 99160-4 | Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment] |
| 99131-5 | Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment] |
Example Units
| Unit | Source |
|---|---|
| {mm/dd/yyyy} | Example UCUM Units |
57203-2 Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an "early" episode or a "later" episode in the patient's current sequence of adjacent Medicare home health payment episodes?
Observation ID in Form
M0110
Fully-Specified Name
- Component
- Episode Timing
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
- CMS Assessment
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.29
- Last Updated
- Version 2.77
- Change Reason
- Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms
- Order vs. Observation
- Observation
Normative Answer List LL774-1
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Early | 1 | LA12111-3 | |
| Later | 2 | LA12112-1 | |
| Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) | UK | LA4489-6 | |
| Not Applicable: No Medicare case mix group to be defined by this assessment. | NA | LA12114-7 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 57039-0 | Deprecated Outcome and assessment information set (OASIS) form - version C |
| 57459-0 | Deprecated Outcome and assessment information set (OASIS) form - version C - Death at home |
| 57194-3 | Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency |
| 57192-7 | Deprecated Outcome and assessment information set (OASIS) form - version C - Follow-Up |
| 57191-9 | Deprecated Outcome and assessment information set (OASIS) form - version C - Resumption of Care |
| 57190-1 | Deprecated Outcome and assessment information set (OASIS) form - version C - Start of care |
| 57193-5 | Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility |
| 86244-1 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Follow-up - recertification or other follow-up [CMS Assessment] |
| 86189-8 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] |
| 85907-4 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] |
| 88369-4 | Outcome and assessment information set (OASIS) form - version D - Follow-up - recertification or other follow-up during assessment period [CMS Assessment] |
| 88368-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Resumption of care during assessment period [CMS Assessment] |
| 88373-6 | Outcome and assessment information set (OASIS) form - version D, D1 - Start of care during assessment period [CMS Assessment] |
| 93058-6 | Outcome and assessment information set (OASIS) form - version D1 - Follow-up - recertification or other follow-up during assessment period [CMS Assessment] |
| 99153-9 | Outcome and assessment information set (OASIS) form - version E - Follow Up during assessment period [CMS Assessment] |
| 99160-4 | Outcome and assessment information set (OASIS) form - version E - Resumption of Care during assessment period [CMS Assessment] |
| 99131-5 | Outcome and assessment information set (OASIS) form - version E - Start of Care during assessment period [CMS Assessment] |
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