LOINC
Version 2.67

57190-1Outcome and assessment information set (OASIS) form - version C - Start of careActive

Term Description

The OASIS is a core set of screening and assessment elements, including standardized definitions and coding categories that form the foundation of the comprehensive assessment for all clients of home health agencies certified to participate in the Medicare or Medicaid program. OASIS-C is a modification to the Outcome and Assessment Information Set (OASIS) that Home Health Agencies (HHAs) must collect in order to participate in the Medicare program. Implementation of OASIS-C, OMB #0938-0760, is required effective January1, 2010.
Source: Regenstrief LOINC

Panel Hierarchy
Details for each LOINC in Panel

LOINC Name R/O/C Cardinality Example UCUM Units
57190-1 Outcome and assessment information set (OASIS) form - version C - Start of care
Indent46456-0 CMS certification number (CCN) Agency [OASIS]
Indent46494-1 Branch State
Indent46495-8 Branch ID Number
Indent44954-6 National Provider Identifier (NPI)
Indent46496-6 Patient ID Number
Indent46497-4 Start of care date [CMS Assessment] {mm/dd/yyyy}
Indent45965-1 Patient Name
IndentIndent45392-8 First name
IndentIndent45393-6 Middle initial
IndentIndent45394-4 Last name
IndentIndent45395-1 Name suffix
Indent46499-0 Patient State of Residence
Indent45401-7 Patient Zip Code
Indent45397-7 Medicare Number
Indent45396-9 Social Security number [Identifier]
Indent45400-9 Medicaid number
Indent21112-8 Birth date {mm/dd/yyyy}
Indent46098-0 Gender
Indent57199-2 Current payment sources for home care [CMS Assessment]
Indent58105-8 Other (specify)
Indent57040-8 Clinical Record Items [CMS Assessment]
IndentIndent46500-5 Discipline of Person Completing Assessment
IndentIndent46501-3 Date Assessment Completed {mm/dd/yyyy}
IndentIndent57200-8 This Assessment is Currently Being Completed for the Following Reason:
IndentIndent57201-6 Date of Physician-ordered Start of Care (Resumption of Care) [CMS Assessment] {mm/dd/yyyy}
IndentIndent57202-4 Date of Referral {mm/dd/yyyy}
IndentIndent57203-2 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?
Indent69324-2 Patient history and diagnosis
IndentIndent57204-0 From which of the following Inpatient Facilities was the patient discharged during the past 14 days? 1..7
IndentIndent58106-6 Other (specify)
IndentIndent86470-2 Inpatient Discharge Date (most recent) {mm/dd/yyyy}
IndentIndent46458-6 Inpatient Diagnosis
IndentIndentIndent46504-7 Inpatient Facility Diagnosis : ICD-9-CM Code R 1..6
IndentIndent57183-6 Inpatient Procedure
IndentIndentIndent58050-6 Inpatient Procedure : Procedure Code R 0..4
IndentIndent46459-4 Diagnoses Requiring Medical or Treatment Change Within Past 14 Days
IndentIndentIndent46507-0 Changed Medical Regimen Diagnosis : ICD-9-CM Code R
IndentIndent46465-1 Conditions prior to medical or treatment regimen change or inpatient stay within past 14 days [OASIS]
IndentIndent46609-4 Diagnosis and severity index
IndentIndentIndent46511-2 Primary diagnosis
IndentIndentIndent46512-0 Primary Diagnosis Symptom Control Rating
IndentIndentIndent46513-8 Other diagnosis 1 - ICD code [OASIS]
IndentIndentIndent46514-6 Other diagnosis 1: Symptom Control Rating
IndentIndentIndent46515-3 Other diagnosis 2 - ICD code [OASIS]
IndentIndentIndent46516-1 Other diagnosis 2: Symptom Control Rating
IndentIndentIndent46517-9 Other diagnosis 3 - ICD code [OASIS]
IndentIndentIndent46518-7 Other diagnosis 3: Symptom Control Rating
IndentIndentIndent46519-5 Other diagnosis 4 - ICD code [OASIS]
IndentIndentIndent46520-3 Other diagnosis 4: Symptom Control Rating
IndentIndentIndent46521-1 Other diagnosis 5 - ICD code [OASIS]
IndentIndentIndent46522-9 Other diagnosis 5: Symptom Control Rating
IndentIndent58051-4 Payment diagnosis [OASIS-C] R 1..12
IndentIndentIndent49561-4 Payment diagnosis [identifier] R 0..12
IndentIndent46466-9 Therapies the patient receives at home 1..3
IndentIndent57319-6 Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization?
IndentIndent57206-5 Overall Status:Which description best fits the patient's overall status?
IndentIndent57207-3 Risk factors, either present or past, likely to affect current health status and/or outcome
Indent57043-2 Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance?
IndentIndent57212-3 Patient lives alone [CMS Assessment]
IndentIndent57213-1 Patient lives with other person [CMS Assessment]
IndentIndent57214-9 Patient lives in congregated situtation [CMS Assessment]
Indent57042-4 Sensory status [CMS Assessment]
IndentIndent57215-6 Vision
IndentIndent57216-4 Ability to hear (with hearing aid or hearing appliance if normally used):
IndentIndent57217-2 Understanding of verbal content in patient's own language (with hearing aid or device if used)
IndentIndent57218-0 Speech and oral (verbal) expression of language (in patient's own language)
IndentIndent57219-8 Has this patient had a formal Pain Assessment using a standardized, validated pain assessment tool (appropriate to the patient's ability to communicate the severity of pain)?
IndentIndent57220-6 Frequency of pain interfering with patient's activity or movement:
Indent57044-0 Integumentary status
IndentIndent57221-4 Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?
IndentIndent57280-0 Does this patient have a Risk of Developing Pressure Ulcers?
IndentIndent57307-1 Does this patient have at lease one Unhealed Pressure Ulcer at Stage II or Higher or designated as "unstageable"
IndentIndent58102-5 Current number of unhealed (non-epithelialized) pressure ulcers at each stage
IndentIndentIndent57186-9 Number currently present
IndentIndentIndentIndent55124-2 Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. {#}
IndentIndentIndentIndent55125-9 Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling {#}
IndentIndentIndentIndent55126-7 Stage IV: Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. {#}
IndentIndentIndentIndent54893-3 Unstageable: Known or likely but unstageable due to non-removable dressing or device {#}
IndentIndentIndentIndent54946-9 Unstageable: Known or likely but unstageable due to coverage of wound bed by slough and/or escha {#}
IndentIndentIndentIndent54950-1 Unstageable: Suspected deep tissue injury in evolution {#}
IndentIndentIndent57187-7 Number of those listed in Column 1 that were present on admission (most recent SOC/ROC)
IndentIndentIndentIndent54886-7 Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. {#}
IndentIndentIndentIndent54887-5 Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. {#}
IndentIndentIndentIndent54890-9 Stage IV: Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. {#}
IndentIndentIndentIndent54894-1 Unstageable: Known or likely but unstageable due to non-removable dressing or device {#}
IndentIndentIndentIndent54947-7 Unstageable: Known or likely but unstageable due to coverage of wound bed by slough and/or eschar. {#}
IndentIndentIndentIndent54951-9 Unstageable: Suspected deep tissue injury in evolution. {#}
IndentIndent57188-5 Stage III and IV pressure ulcer with the largest surface dimension (length x width)
IndentIndentIndent57226-3 Pressure Ulcer Length: cm
IndentIndentIndent52729-1 Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length cm
IndentIndentIndent57228-9 Pressure Ulcer Depth: cm
IndentIndent57229-7 Status of most problematic (observable) pressure ulcer:
IndentIndent46536-9 Current Number of Stage I Pressure Ulcers: {#}
IndentIndent57231-3 Status of most problematic unhealed (observable) pressure ulcer:
IndentIndent57232-1 Does the patient have a Stasis Ulcer?
IndentIndent57233-9 Current Number of (Observable) Stasis Ulcer(s): {#}
IndentIndent57234-7 Status of most problematic (observable) stasis ulcer:
IndentIndent57235-4 Does this patient have a Surgical Wound?
IndentIndent57236-2 Status of most problematic (observable) surgical wound:
IndentIndent46534-4 Does this patient have a Skin Lesion or Open Wound (excluding bowel ostomy), other than those described above, that is receiving intervention by the home health agency?
Indent52510-5 Respiratory status
IndentIndent57237-0 When is the patient dyspneic or noticeably Short of Breath?
IndentIndent57238-8 Respiratory treatments utilized at home: 1..3
Indent57046-5 Elimination status
IndentIndent46553-4 Urinary incontinence or urinary catheter present [CMS Assessment]
IndentIndent46587-2 Bowel incontinence frequency [CMS Assessment]
IndentIndent46588-0 Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, or b) necessitated a change in medical or treatment regimen?
Indent69334-1 Neuro & emotional & behavioral status
IndentIndent46589-8 Cognitive functioning [CMS Assessment]
IndentIndent58104-1 When confused (reported or observed within the last 14 days):
IndentIndent86495-9 When Anxious (Reported or Observed Within the Last 14 Days)
IndentIndent57242-0 Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?
IndentIndentIndent58120-7 Patient Health Questionnaire 2 item (PHQ-2) [PHQ.CMS]
IndentIndentIndentIndent44250-9 Little interest or pleasure in doing things
IndentIndentIndentIndent44255-8 Feeling down, depressed, or hopeless
IndentIndent46473-5 Cognitive, behavorial, and psychiatric symptoms that are demonstrated at least once a week (Reported or Observed):
IndentIndent46592-2 Frequency of disruptive behavior symptoms (reported or observed)
IndentIndent46593-0 Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?
Indent57048-1 ADL and IADLs
IndentIndent46595-5 Grooming:
IndentIndent46597-1 Ability to dress upper body:
IndentIndent46599-7 Ability to dress lower body:
IndentIndent57243-8 Bathing:
IndentIndent57244-6 Toileting transferring:
IndentIndent57245-3 Toileting hygiene:
IndentIndent57246-1 Transferring:
IndentIndent57247-9 Ambulation/Locomotion:
IndentIndent57248-7 Feeding or eating:
IndentIndent57249-5 Ability to plan or prepare light meals
IndentIndent46569-0 Ability to use telephone:
IndentIndent58121-5 Prior Functioning ADL/IADL [CMS Assessment]
IndentIndentIndent85070-1 Self-care (specifically: grooming, dressing, bathing, and toileting hygiene)
IndentIndentIndent86185-6 Ambulation
IndentIndentIndent86186-4 Transfer
IndentIndentIndent86187-2 Household tasks (specifically: light meal preparation, laundry, shopping, and phone use.)
IndentIndent57254-5 Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency, general mobility/transferring impairment, environmental hazards)?
Indent52471-0 Medications
IndentIndent57255-2 Drug regimen review identified potential medication issues [CMS Assessment]
IndentIndent57281-8 Medication follow-up [CMS Assessment]
IndentIndent57257-8 Patient/caregiver received high risk drug education [CMS Assessment]
IndentIndent57285-9 Management of oral medications:
IndentIndent57284-2 Management of injectable medications:
IndentIndent57196-8 Prior medication management [CMS Assessment]
IndentIndentIndent57258-6 Oral medications
IndentIndentIndent57259-4 Injectable medications
Indent57049-9 Care management [CMS Assessment]
IndentIndent57306-3 Types and sources of assistance [CMS Assessment]
IndentIndentIndent57260-2 Non-agency caregiver ability and willingness to assist with ADL [CMS Assessment]
IndentIndentIndent57261-0 Non-agency caregiver ability and willingness to assist with IADL [CMS Assessment]
IndentIndentIndent57262-8 Non-agency caregiver ability and willingness to assist with medication administration [CMS Assessment]
IndentIndentIndent57263-6 Medical procedures/treatments
IndentIndentIndent57264-4 Non-agency caregiver ability and willingness to assist with management of equipment [CMS Assessment]
IndentIndentIndent57265-1 Non-agency caregiver ability and willingness to assist with supervision and safety [CMS Assessment]
IndentIndentIndent57266-9 Advocacy or facilitation
IndentIndent57267-7 How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?
Indent57050-7 Therapy need and plan of care [CMS Assessment]
IndentIndent57268-5 Therapy need # [CMS Assessment] {#}
IndentIndent57197-6 Plan of Care Synopsis:
IndentIndentIndent57269-3 Plan of care includes patient-specific parameters for notifying physician of changes [CMS Assessment]
IndentIndentIndent57270-1 Plan of care includes diabetic foot care [CMS Assessment]
IndentIndentIndent57271-9 Plan of care includes fall prevention interventions [CMS Assessment]
IndentIndentIndent57272-7 Depression intervention(s)
IndentIndentIndent57273-5 Intervention(s) to monitor and mitigate pain
IndentIndentIndent57274-3 Intervention(s) to prevent pressure ulcers
IndentIndentIndent57275-0 Plan of care includes pressure injury treatment - moist healing [CMS Assessment]

Fully-Specified Name

Component
Outcome and assessment information set (OASIS) form - version C - Start of care
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
PANEL.SURVEY.OASIS
Type
Surveys
First Released
Version 2.29
Last Updated
Version 2.40
Panel Type
Panel

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