46498-2 Resumption of care date during assessment period [CMS Assessment]

Term Description

Date care resumed (e.g. the date of the first visit following an inpatient stay by a patient currently receiving service from a home health agency).
Source: Regenstrief LOINC

Observation ID in Form

M0032

Fully-Specified Name

Component

Resumption of care date

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

Related Names

• Centers for Medicare and Medicaid Assessment
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

57040-8 Clinical Record Items during assessment period [CMS Assessment]

Fully-Specified Name

Component

Clinical record items

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.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: Added METHOD of CMS Assessments because this unique panel originates from CMS instruments

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

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

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Nominal
• Persons
• Report period
• Survey
• Typ

Related Codes

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

Related Names

• Centers for Medicare and Medicaid Assessment
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

57200-8 This Assessment is Currently Being Completed for the Following Reason:

Observation ID in Form

M0100

Skip Logic

If Yes to "4 - Recertification (follow-up reassessment" , then go to M0110. If Yes to "5 - Other follow-up", then go to M0110. If Yes to "6 - Transferred to an inpatient facility - patient not discharged from agency", then go to M1040. If Yes to"7 - Transferred to an inpatient facility - patient discharged from agency", then go to M1040. If "Yes to 8 - Death at home", then go to M0903. If " Yes to 9 - Discharge from agency", then go to M1040.

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

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Nominal
• Report period
• Survey

Related Codes

57201-6 Date of Physician-ordered Start of Care (Resumption of Care) during assessment period [CMS Assessment]

Observation ID in Form

M0102

Skip Logic

Go to M0110, if date entered. If NA, No specific SOC date ordered by physican.

Form Coding Instructions

Date of Physician-ordered Start of Care (Resumption of Care): 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

Fully-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

Related Names

• Centers for Medicare and Medicaid Assessment
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Started
• Survey

Example Units

Related Codes

57202-4 Date of Referral

Observation ID in Form

M0104

Form Coding Instructions

Date of Referral: Indicate the date that the written or verbal referral for initiation or resumption of care was received by the HHA

Fully-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

Related Names

• Point in time
• QNT
• Quan
• Quant
• Quantitative
• Random
• Survey

Example Units

Related Codes

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

Member of these Panels

Related Names

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

Related Codes

Third Party Copyright

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

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

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

69324-2 Patient history and diagnosis

Fully-Specified Name

Component

Patient history and diagnosis - start of care, resumption of care

Property

-

Time

Pt

System

^Patient

Scale

-

Method

OASIS-C

Basic Attributes

Class

PANEL.SURVEY.OASIS

Type

Surveys

First Released

Version 2.38

Last Updated

Version 2.73

Change Reason

Release 2.73: Status: LOINC will keep most current version and one prior version of CMS assessments active and discourage all older versions.;

Panel Type

Panel

Member of these Panels

Related Names

• Dx
• Hx
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.OASIS
• Panl
• Patient Hx
• Patient hx & Dx - start, resumption care
• Pnl
• Point in time
• Random
• Started
• Survey
• Survey.OASIS

57204-0 From which of the following Inpatient Facilities was the patient discharged during the past 14 days?

Observation ID in Form

M1000

Skip Logic

If Yes to "NA - Patient was not discharged from an inpatient facility", then go to M1016.

Fully-Specified Name

Component

Inpatient discharge facility within the past 14D

Property

Type

Time

14D

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.63

Change Reason

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; Changed TIME from Pt to 14D to reflect the term definition "within the past 14 days"; Added timing to the Component to follow LOINC convention

Order vs. Observation

Observation

Normative Answer List LL775-8

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Disch
• Last
• Nominal
• Survey
• Typ

Related Codes

58106-6 Other (specify)

Fully-Specified Name

Component

Inpatient discharge facility.other specified

Property

Type

Time

Pt

System

^Patient

Scale

Nom

Method

OASIS-C

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.44

Member of these Panels

Related Names

• Disch
• Nominal
• Othr
• Outcome and assessment information set
• Point in time
• Random
• Survey
• Survey.OASIS
• Typ

86470-2 Inpatient Discharge Date (most recent)

Observation ID in Form

M1005

Fully-Specified Name

Component

Most recent inpatient discharge date in the last 14D

Property

Date

Time

14D

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.63

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Disch
• Past
• QNT
• Quan
• Quant
• Quantitative
• Survey

Example Units

Related Codes

46458-6 Inpatient Diagnosis

Fully-Specified Name

Component

Inpatient facililty diagnoses

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.61

Panel Type

Panel

Member of these Panels

Related Names

• Outcome and assessment information set
• Point in time
• Random
• Survey
• Survey.OASIS

46504-7 Inpatient Facility Diagnosis : ICD-9-CM Code

Term Description

Identifies diagnosis(es) for which patient was receiving treatment in an inpatient facility within the past 14 days. (Past 14 days encompasses the two-week period immediately preceding the start/resumption of care.)
Source: Regenstrief LOINC

Observation ID in Form

M1010

Observation Required in Panel

Required

Fully-Specified Name

Component

Inpatient stay within last 14D - ICD code

Property

Prid

Time

14D

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.61

Change Reason

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 LL343-5

Externally Defined

Yes

Code System

I9C

Code System OID

1.3.6.1.4.1.12009.10.1.2173

Link to External List

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Identity or presence
• International Classification of Diseases
• Nominal
• Past
• Survey

Related Codes

57183-6 Inpatient Procedure

Fully-Specified Name

Component

Inpatient procedure relevant to plan 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 2.68

Panel Type

Panel

Member of these Panels

Related Names

• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.OASIS
• Panl
• Pnl
• Point in time
• Random
• Survey
• Survey.OASIS

58050-6 Inpatient Procedure : Procedure Code

Observation ID in Form

M1012

Observation Required in Panel

Required

Fully-Specified Name

Component

Inpatient procedure relevant to plan of care

Property

Type

Time

Pt

System

^Patient

Scale

Nom

Method

OASIS-C

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.44

Normative Answer List LL842-6

Externally Defined

Yes

Code System

I9C

Code System OID

1.3.6.1.4.1.12009.10.1.3275

Link to External List

Member of these Panels

Related Names

• Nominal
• Outcome and assessment information set
• Point in time
• Random
• Survey
• Survey.OASIS
• Typ

46459-4 Diagnoses Requiring Medical or Treatment Change Within Past 14 Days

Fully-Specified Name

Component

Changed medical regimen diagnoses

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.61

Change Reason

Changed SCALE from "Set" to "-" to match current conventions for the panel terms

Panel Type

Panel

Member of these Panels

Related Names

• Outcome and assessment information set
• Point in time
• Random
• Survey
• Survey.OASIS

46507-0 Changed Medical Regimen Diagnosis : ICD-9-CM Code

Term Description

Identifies the diagnosis(es) that have caused an addition or change to the patient's treatment, regimen, health care services received, or medication within the past 14 days. (Past 14 days encompasses the two-week period immediately preceding the start/resumption of care [or the date of the follow-up/discharge visit].)
Source: Regenstrief LOINC

Observation ID in Form

M1016

Observation Required in Panel

Required

Fully-Specified Name

Component

Regimen change in past 14D - ICD code

Property

Prid

Time

14D

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.61

Change Reason

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 LL343-5

Externally Defined

Yes

Code System

I9C

Code System OID

1.3.6.1.4.1.12009.10.1.2173

Link to External List

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Exchange
• Identity or presence
• International Classification of Diseases
• Last
• Nominal
• Replace
• Survey

Related Codes

46465-1 Conditions prior to medical or treatment regimen change or inpatient stay within past 14 days [OASIS]

Term Description

Identifies existence of condition(s) prior to medical regimen change or inpatient stay within 14 days of start of care. (Past 14 days encompasses the two-week period immediately preceding the start/resumption of care [or the date of the follow-up/discharge visit].)
Source: Regenstrief LOINC

Observation ID in Form

M1018

Fully-Specified Name

Component

Conditions prior to medical or treatment regimen change or inpatient stay within past 14D

Property

Find

Time

14D

System

^Patient

Scale

Nom

Method

OASIS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.61

Order vs. Observation

Observation

Normative Answer List LL252-8

Member of these Panels

Related Names

• Exchange
• Finding
• Findings
• Last
• Nominal
• Outcome and assessment information set
• Replace
• Survey
• Tx

Third Party Copyright

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

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

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

46609-4 Diagnosis and severity index

Fully-Specified Name

Component

Diagnosis and severity index

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.73

Panel Type

Panel

Member of these Panels

Related Names

• Dx
• Dx and severity index
• Outcome and assessment information set
• Point in time
• Random
• Survey
• Survey.OASIS

Copyright

Organization

Center for Health Policy Research, UCHSC, Denver, CO

Copyright

Copyright © 2002 Center for Health Services Research, UCHSC, Denver, CO.

Terms of Use

Used with permission.

86255-7 Primary diagnosis ICD code

Term Description

The condition that is the chief reason for providing care.
Source: Regenstrief LOINC

Fully-Specified Name

Component

Primary diagnosis ICD code

Property

Type

Time

Pt

System

^Patient

Scale

Nom

Method

Additional Names

Short Name

Primary Dx ICD code

Basic Attributes

Class

CLIN

Type

Clinical

First Released

Version 2.63

Last Updated

Version 2.73

Order vs. Observation

Both

Common Test Rank Get Info

17680

Example Answer List LL4547-7

Externally Defined

Yes

Code System

Code System OID

1.3.6.1.4.1.12009.10.1.3459

Link to External List

http://www.cdc.gov/nchs/icd.htm

Member of these Panels

Language Variants Get Info

Related Names

• CLIN
• Dx
• Dx ICD code
• International Classification of Diseases
• Nominal
• Point in time
• Primary Dx ICD code
• Random
• Typ

Related Codes

46512-0 Primary Diagnosis Symptom Control Rating

Term Description

Severity category for diagnosis.
Source: Regenstrief LOINC

Observation ID in Form

M1020

Fully-Specified Name

Component

Primary diagnosis severity rating

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

OASIS

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.50

Normative Answer List LL253-6

Member of these Panels

Related Names

• Dx
• Finding
• Findings
• Ordinal
• Outcome and assessment information set
• Point in time
• Primary Dx severity rating
• Ql
• Qual
• Qualitative
• Random
• Screen
• Survey
• Survey.OASIS

Copyright

Organization

Center for Health Policy Research, UCHSC, Denver, CO

Copyright

Copyright © 2002 Center for Health Services Research, UCHSC, Denver, CO.

Terms of Use

Used with permission.

46513-8 Other diagnosis 1 - ICD code [OASIS]

Term Description

Identifies diagnosis for which the patient is receiving care and its ICD-9-CM code.
Source: Regenstrief LOINC

Observation ID in Form

M1022

Fully-Specified Name

Component

Other diagnosis 1 - ICD code

Property

Prid

Time

Pt

System

^Patient

Scale

Nom

Method

OASIS

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.54

Normative Answer List LL343-5

Externally Defined

Yes

Code System

I9C

Code System OID

1.3.6.1.4.1.12009.10.1.2173

Link to External List

Member of these Panels

Related Names

• Dx
• i
• Identity or presence
• International Classification of Diseases
• Nominal
• Other Dx 1- ICD code
• Othr
• Outcome and assessment information set
• Point in time
• Random
• Survey
• Survey.OASIS

Copyright

Organization

Center for Health Policy Research, UCHSC, Denver, CO

Copyright

Copyright © 2002 Center for Health Services Research, UCHSC, Denver, CO.

Terms of Use

Used with permission.

46514-6 Other diagnosis 1: Symptom Control Rating

Term Description

Severity category for diagnosis.
Source: Regenstrief LOINC

Observation ID in Form

M1022

Fully-Specified Name

Component

Other diagnosis 1 - severity rating

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

OASIS

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.54

Normative Answer List LL253-6

Member of these Panels

Related Names

• Dx
• Finding
• Findings
• i
• Ordinal
• Other Dx 1- severity rating
• Othr
• Outcome and assessment information set
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• Survey.OASIS

Copyright

Organization

Center for Health Policy Research, UCHSC, Denver, CO

Copyright

Copyright © 2002 Center for Health Services Research, UCHSC, Denver, CO.

Terms of Use

Used with permission.

46515-3 Other diagnosis 2 - ICD code [OASIS]

Term Description

Identifies diagnosis for which the patient is receiving care and its ICD-9-CM code.
Source: Regenstrief LOINC

Observation ID in Form

M1022

Fully-Specified Name

Component

Other diagnosis 2 - ICD code

Property

Prid

Time

Pt

System

^Patient

Scale

Nom

Method

OASIS

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.54

Normative Answer List LL343-5

Externally Defined

Yes

Code System

I9C

Code System OID

1.3.6.1.4.1.12009.10.1.2173

Link to External List

Member of these Panels

Related Names

• Dx
• Identity or presence
• II
• International Classification of Diseases
• Nominal
• Other Dx 2- ICD code
• Othr
• Outcome and assessment information set
• Point in time
• Random
• Survey
• Survey.OASIS

Copyright

Organization

Center for Health Policy Research, UCHSC, Denver, CO

Copyright

Copyright © 2002 Center for Health Services Research, UCHSC, Denver, CO.

Terms of Use

Used with permission.

46516-1 Other diagnosis 2: Symptom Control Rating

Term Description

Severity category for diagnosis.
Source: Regenstrief LOINC

Fully-Specified Name

Component

Other diagnosis 2 - severity rating

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

OASIS

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.54

Normative Answer List LL253-6

Member of these Panels

Related Names

• Dx
• Finding
• Findings
• II
• Ordinal
• Other Dx 2- severity rating
• Othr
• Outcome and assessment information set
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• Survey.OASIS

Copyright

Organization

Center for Health Policy Research, UCHSC, Denver, CO

Copyright

Copyright © 2002 Center for Health Services Research, UCHSC, Denver, CO.

Terms of Use

Used with permission.

46517-9 Other diagnosis 3 - ICD code [OASIS]

Term Description

Identifies diagnosis for which the patient is receiving care and its ICD-9-CM code.
Source: Regenstrief LOINC

Observation ID in Form

M1022

Fully-Specified Name

Component

Other diagnosis 3 - ICD code

Property

Prid

Time

Pt

System

^Patient

Scale

Nom

Method

OASIS

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.54

Normative Answer List LL343-5

Externally Defined

Yes

Code System

I9C

Code System OID

1.3.6.1.4.1.12009.10.1.2173

Link to External List

Member of these Panels

Related Names

• Dx
• Identity or presence
• III
• International Classification of Diseases
• Nominal
• Other Dx 3- ICD code
• Othr
• Outcome and assessment information set
• Point in time
• Random
• Survey
• Survey.OASIS

Copyright

Organization

Center for Health Policy Research, UCHSC, Denver, CO

Copyright

Copyright © 2002 Center for Health Services Research, UCHSC, Denver, CO.

Terms of Use

Used with permission.

46518-7 Other diagnosis 3: Symptom Control Rating

Term Description

Severity category for diagnosis.
Source: Regenstrief LOINC

Observation ID in Form

M1022

Fully-Specified Name

Component

Other diagnosis 3 - severity rating

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

OASIS

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.54

Normative Answer List LL253-6

Member of these Panels

Related Names

• Dx
• Finding
• Findings
• III
• Ordinal
• Other Dx 3- severity rating
• Othr
• Outcome and assessment information set
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• Survey.OASIS

Copyright

Organization

Center for Health Policy Research, UCHSC, Denver, CO

Copyright

Copyright © 2002 Center for Health Services Research, UCHSC, Denver, CO.

Terms of Use

Used with permission.

46519-5 Other diagnosis 4 - ICD code [OASIS]

Term Description

Identifies diagnosis for which the patient is receiving care and its ICD-9-CM code.
Source: Regenstrief LOINC

Observation ID in Form

M1022

Fully-Specified Name

Component

Other diagnosis 4 - ICD code

Property

Prid

Time

Pt

System

^Patient

Scale

Nom

Method

OASIS

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.54

Normative Answer List LL343-5

Externally Defined

Yes

Code System

I9C

Code System OID

1.3.6.1.4.1.12009.10.1.2173

Link to External List

Member of these Panels

Related Names

• Dx
• Identity or presence
• International Classification of Diseases
• Nominal
• Other Dx 4- ICD code
• Othr
• Outcome and assessment information set
• Point in time
• Random
• Survey
• Survey.OASIS

Copyright

Organization

Center for Health Policy Research, UCHSC, Denver, CO

Copyright

Copyright © 2002 Center for Health Services Research, UCHSC, Denver, CO.

Terms of Use

Used with permission.

46520-3 Other diagnosis 4: Symptom Control Rating

Term Description

Severity category for diagnosis.
Source: Regenstrief LOINC

Observation ID in Form

M1022

Fully-Specified Name

Component

Other diagnosis 4 - severity rating

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

OASIS

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.54

Normative Answer List LL253-6

Member of these Panels

Related Names

• Dx
• Finding
• Findings
• Ordinal
• Other Dx 4- severity rating
• Othr
• Outcome and assessment information set
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• Survey.OASIS

Copyright

Organization

Center for Health Policy Research, UCHSC, Denver, CO

Copyright

Copyright © 2002 Center for Health Services Research, UCHSC, Denver, CO.

Terms of Use

Used with permission.

46521-1 Other diagnosis 5 - ICD code [OASIS]

Term Description

Identifies diagnosis for which the patient is receiving care and its ICD-9-CM code.
Source: Regenstrief LOINC

Observation ID in Form

M1022

Fully-Specified Name

Component

Other diagnosis 5 - ICD code

Property

Prid

Time

Pt

System

^Patient

Scale

Nom

Method

OASIS

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.54

Normative Answer List LL343-5

Externally Defined

Yes

Code System

I9C

Code System OID

1.3.6.1.4.1.12009.10.1.2173

Link to External List

Member of these Panels

Related Names

• Dx
• Identity or presence
• International Classification of Diseases
• Nominal
• Other Dx 5- ICD code
• Othr
• Outcome and assessment information set
• Point in time
• Random
• Survey
• Survey.OASIS

Copyright

Organization

Center for Health Policy Research, UCHSC, Denver, CO

Copyright

Copyright © 2002 Center for Health Services Research, UCHSC, Denver, CO.

Terms of Use

Used with permission.

46522-9 Other diagnosis 5: Symptom Control Rating

Term Description

Severity category for diagnosis.
Source: Regenstrief LOINC

Observation ID in Form

M1022

Fully-Specified Name

Component

Other diagnosis 5 - severity rating

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

OASIS

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.54

Normative Answer List LL253-6

Member of these Panels

Related Names

• Dx
• Finding
• Findings
• Ordinal
• Other Dx 5- severity rating
• Othr
• Outcome and assessment information set
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• Survey.OASIS

Copyright

Organization

Center for Health Policy Research, UCHSC, Denver, CO

Copyright

Copyright © 2002 Center for Health Services Research, UCHSC, Denver, CO.

Terms of Use

Used with permission.

58051-4 Payment diagnosis [OASIS-C]

Observation Required in Panel

Required

Fully-Specified Name

Component

Payment diagnosis

Property

-

Time

Pt

System

^Patient

Scale

-

Method

OASIS-C

Basic Attributes

Class

PANEL.SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.68

Panel Type

Panel

Member of these Panels

Related Names

• Dx
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.OASIS
• Panl
• Payment Dx
• Pnl
• Point in time
• Random
• Survey
• Survey.OASIS

49561-4 Payment diagnosis [identifier]

Observation ID in Form

M1024

Observation Required in Panel

Required

Fully-Specified Name

Component

Payment diagnosis

Property

Prid

Time

Pt

System

^Patient

Scale

Nom

Method

Additional Names

Short Name

Payment Dx

Basic Attributes

Class

CLIN

Type

Clinical

First Released

Version 2.22

Last Updated

Version 2.40

Example Answer List LL343-5

Externally Defined

Yes

Code System

I9C

Code System OID

1.3.6.1.4.1.12009.10.1.2173

Link to External List

Member of these Panels

Language Variants Get Info

Related Names

• CLIN
• Dx
• Identity or presence
• Nominal
• Payment Dx
• Point in time
• Random

46466-9 Therapies the patient receives at home

Term Description

Identifies whether the patient is receiving intravenous, parenteral nutrition, or enteral nutrition therapy at home.
Source: Regenstrief LOINC

Observation ID in Form

M1030

Fully-Specified Name

Component

Therapeutic substance administered at home

Property

Find

Time

RptPeriod

System

^Patient

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; Added to the Component to clarify the concept

Order vs. Observation

Observation

Normative Answer List LL254-4

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Nominal
• Report period
• Subs
• Survey
• Ther

Related Codes

57319-6 Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization?

Observation ID in Form

M1032

Fully-Specified Name

Component

Risk for hospitalization

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; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms

Order vs. Observation

Observation

Normative Answer List LL777-4

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Hospitalization hx
• Nominal
• Report period
• Survey

Related Codes

57206-5 Overall Status:Which description best fits the patient's overall status?

Observation ID in Form

M1034

Fully-Specified Name

Component

Overall status

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; Changed Scale from Nom to Ord because the Answer List is ordinal

Order vs. Observation

Observation

Normative Answer List LL778-2

Member of these Panels

Related Names

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

Related Codes

57207-3 Risk factors, either present or past, likely to affect current health status and/or outcome

Observation ID in Form

M1036

Fully-Specified Name

Component

Risk factors affecting health status and or outcome

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; Removed "past or present" from the Component because that is implied

Order vs. Observation

Observation

Common Test Rank Get Info

16958

Normative Answer List LL779-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Nominal
• Report period
• Risk factors present or past affecting health status and or outcome
• Survey

Related Codes

Third Party Copyright

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

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

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

57043-2 Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance?

Observation ID in Form

M1100

Form Coding Instructions

Check one option only

Fully-Specified Name

Component

Living arrangements

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

PANEL.SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.68

Panel Type

Panel

Survey Question

Text

Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance?

Source

OASIS-C.M1100

Member of these Panels

Related Names

• Housing
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.OASIS
• Panl
• Pnl
• Point in time
• Random
• Survey
• Survey.OASIS

57212-3 Patient lives alone during assessment period [CMS Assessment]

Observation ID in Form

M1100a

Fully-Specified Name

Component

Patient lives alone

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 LL783-2

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Nominal
• Report period
• Survey

57213-1 Patient lives with other person during assessment period [CMS Assessment]

Observation ID in Form

M1100b

Fully-Specified Name

Component

Patient lives with other person

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 LL845-9

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Nominal
• Othr
• Persons
• Report period
• Survey

57214-9 Patient lives in congregated situtation during assessment period [CMS Assessment]

Observation ID in Form

M1100c

Form Coding Instructions

e.g., assisted living

Fully-Specified Name

Component

Patient lives in congregated situtation

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 LL848-3

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Nominal
• Report period
• Survey

57042-4 Sensory status during assessment period [CMS Assessment]

Fully-Specified Name

Component

Sensory status

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.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: Added METHOD of CMS Assessments because this unique panel originates from CMS instruments

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

57215-6 Vision

Observation ID in Form

M1200

Fully-Specified Name

Component

Vision

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

Order vs. Observation

Observation

Normative Answer List LL784-0

Member of these Panels

Related Names

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

Related Codes

57216-4 Ability to hear

Observation ID in Form

M1210

Fully-Specified Name

Component

Ability to hear

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 across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Normative Answer List LL785-7

Member of these Panels

Related Names

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

Related Codes

57217-2 Understanding of verbal content in patient's own language (with hearing aid or device if used)

Observation ID in Form

M1220

Fully-Specified Name

Component

Understanding of verbal content

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

Order vs. Observation

Observation

Normative Answer List LL786-5

Member of these Panels

Related Names

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

Related Codes

57218-0 Speech and oral (verbal) expression of language (in patient's own language)

Observation ID in Form

M1230

Fully-Specified Name

Component

Speech and oral expression of language

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

Order vs. Observation

Observation

Normative Answer List LL787-3

Member of these Panels

Related Names

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

Related Codes

57219-8 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)?

Observation ID in Form

M1240

Fully-Specified Name

Component

Formal pain assessment using standardized tool

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 LL788-1

Member of these Panels

Related Names

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

Related Codes

57220-6 Frequency of pain interfering with patient's activity or movement:

Observation ID in Form

M1242

Fully-Specified Name

Component

Frequency of pain interfering with activity or movement

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; Changed Property to NRat because this is a frequency term; Changed Property from NRat to Find because the answer list does not reflect Nrat

Order vs. Observation

Observation

Normative Answer List LL789-9

Member of these Panels

Related Names

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

Related Codes

57044-0 Integumentary status

Fully-Specified Name

Component

Integumentary status

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

PANEL.SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.68

Panel Type

Panel

Member of these Panels

Related Names

• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.OASIS
• Panl
• Pnl
• Point in time
• Random
• Survey
• Survey.OASIS

57221-4 Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?

Observation ID in Form

M1300

Skip Logic

If "0 - No", then go to M1306.

Fully-Specified Name

Component

Pressure injury assessment was conducted

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; Changed Scale from Nom to Ord because the Answer List is ordinal; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Normative Answer List LL790-7

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• pressure injury
• Pressure ulcer
• Pressure Ulcers
• QL
• Qual
• Qualitative
• Report period
• Screen
• Survey
• Ulcer

Related Codes

57280-0 Does this patient have a Risk of Developing Pressure Ulcers?

Observation ID in Form

M1302

Fully-Specified Name

Component

Risk of developing pressure injuries

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; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Normative Answer List LL251-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Pressure ulcer
• Pressure Ulcers
• QL
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

Third Party Copyright

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

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

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

57307-1 Does this patient have at lease one Unhealed Pressure Ulcer at Stage II or Higher or designated as "unstageable"

Observation ID in Form

M1306

Skip Logic

If "0 - No", then go to M1322.

Fully-Specified Name

Component

Unhealed pressure injury at Stage 2 or higher or designated as unstageable

Property

Find

Time

Pt

System

^Patient

Scale

Nom

Method

OASIS-C

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.64

Change Reason

"Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

Survey Question

Text

Does this patient have at lease one Unhealed Pressure Ulcer at Stage II or Higher or designated as "unstageable"

Source

OASIS-C.M1306

Normative Answer List LL251-0

Member of these Panels

Related Names

• Arterial Stenosis
• Finding
• Findings
• II
• Nominal
• Outcome and assessment information set
• Point in time
• pressure injury
• Pressure ulcer
• Pressure Ulcers
• Random
• Survey
• Survey.OASIS
• Ulcer

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58102-5 Current number of unhealed (non-epithelialized) pressure ulcers at each stage

Observation ID in Form

M1308

Form Coding Instructions

Enter "0" if none; excludes Stage I pressure ulcers

Fully-Specified Name

Component

Current number of unhealed (non-epithelialized) pressure injuries at each stage

Property

-

Time

Pt

System

^Patient

Scale

-

Method

OASIS-C

Basic Attributes

Class

PANEL.SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.68

Change Reason

"Pressure ulcers" has been updated to "pressure injuries" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

Panel Type

Panel

Member of these Panels

Related Names

• No
• Num
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.OASIS
• Panl
• Pnl
• Point in time
• Pressure ulcer
• Pressure Ulcers
• Random
• Survey
• Survey.OASIS

57186-9 Number currently present

Observation ID in Form

M1308.1

Form Coding Instructions

Column 1 Complete at SOC/ROC/FU & D/C

Fully-Specified Name

Component

Number of pressure injuries at each stage

Property

-

Time

Pt

System

^Patient

Scale

Set

Method

Basic Attributes

Class

PANEL.SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.68

Change Reason

"Pressure ulcers" has been updated to "pressure injuries" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

Panel Type

Panel

Member of these Panels

Related Names

• No
• Num
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.OASIS
• Panl
• Pnl
• Point in time
• Pressure ulcer
• Pressure Ulcers
• Random
• Survey
• Survey.OASIS

55124-2 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

Term Description

A stage 2 pressure ulcer is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M1308.1a

Form Context

Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister

Fully-Specified Name

Component

Number of pressure injuries - stage 2

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

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 MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• II
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes