Version 2.78

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

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]

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

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

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) during assessment period [CMS Assessment]

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

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

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

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?

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]

69328-3 Deprecated Patient history and diagnosis - transfer to facility, discharge from agency [OASIS-C]

Fully-Specified Name

Component
Patient history and diagnosis - transfer to facility, discharge from agency
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

LOINC Long Common Name
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility

57208-1 Influenza vaccination received in Reporting Period [CMS Assessment]

Term Description

Identifies whether the patient received an influenza vaccine for this year's flu season
Source: Regenstrief LOINC

Observation ID in Form

M1040

Skip Logic

If "1 - Yes", then go to M1050. If "NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season", then go to M1050.

Form Context

Influenza Vaccine: Did the patient receive the influenza vaccine from your agency for this year's influenza season (October 1 through March 31) during this episode of care?

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Influenza virus vaccination received
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 2.67
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; Added "vaccination received" to the Component for consistent modeling across LOINC vaccination terms.; Added "virus" to Component to be consistent with other "Influenza virus" terms
Order vs. Observation
Observation

Normative Answer List LL780-8

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. NA LA12150-1

Member of these Panels

LOINC Long Common Name
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility
86264-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [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]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency 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]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency 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]

Member of these Groups Get Info

LOINC Group Group Name
LG32757-3 Influenza virus

55020-2 Reason influenza virus vaccine not received during assessment period [CMS Assessment]

Fully-Specified Name

Component
Reason influenza virus vaccine not received
Property
Find
Time
RptPeriod
System
^Patient
Scale
Nom
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: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG
Order vs. Observation
Observation

Example Answer List LL676-8

Answer Code Score Answer ID
Resident not in facility during this year's flu season 1 LA12666-6
Received outside of this facility 2 LA184-4
Not eligible - medical contraindication 3 LA11091-8
Offered and declined 4 LA186-9
Not offered 5 LA187-7
Inability to obtain vaccine due to declared shortage 6 LA12156-8
None of the above 9 LA9-3

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
85645-0 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2 Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
45981-8 Deprecated MDS full assessment form - version 2.0
46104-6 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III 1997 update
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0
46076-6 Deprecated Minimum Data Set (MDS) supplemental items section - version 2.0
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 during assessment period [CMS Assessment]
87506-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 4.00 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]

57210-7 Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?

Observation ID in Form

M1050

Skip Logic

If "1 - Yes", then go to M1500 at TRN, go to M1230 at DC.

Fully-Specified Name

Component
Pneumococcal vaccine
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method
OASIS-C

Basic Attributes

Class
SURVEY.OASIS
Type
Surveys
First Released
Version 2.29
Last Updated
Version 2.44

Survey Question

Text
Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?
Source
OASIS-C.M1050

Normative Answer List LL251-0

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6

Member of these Panels

LOINC Long Common Name
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility

57211-5 Reason PPV not received:

Observation ID in Form

M1055

Fully-Specified Name

Component
Reason pneumococcal vaccine not given
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 2.48

Normative Answer List LL782-4

Answer Code Score Answer ID
Patient has received PPV in the past 1 LA12158-4
Offered and declined 2 LA186-9
Assessed and determined to have medical contraindication(s) 3 LA12154-3
Not indicated; patient does not meet age/condition guidelines for PPV 4 LA12161-8
None of the above 5 LA9-3

Member of these Panels

LOINC Long Common Name
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility

57045-7 Cardiac status

Fully-Specified Name

Component
Cardiac status
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.29
Last Updated
Version 2.63
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility
86264-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [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]

57239-6 Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?

Observation ID in Form

M1500

Skip Logic

If "0 - No", then go to M2004 at TRN, go to M1600 at DC. If "2 - Not assessed", then go to M2004 at TRN, go to M1600 at DC. If "NA - Patient does not have diagnoses of heart failure", then go to M2004 at TRN, go to M1600 at DC.

Fully-Specified Name

Component
Symptoms in heart failure patients
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

Survey Question

Text
Symptoms in Heart Failure Patients: If patient has been diagnosed with heart failure, did the patient exhibit symptoms indicated by clinical heart failure guidelines (including dyspnea, orthopnea, edema, or weight gain) at the time of or at any time since the most recent SOC/ROC assessment?

Normative Answer List LL799-8

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Not assessed 2 LA9348-9
Patient does not have diagnosis of heart failure NA LA12236-8

Member of these Panels

LOINC Long Common Name
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility
86264-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [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]

57240-4 Heart failure follow-up during assessment period [CMS Assessment]

Observation ID in Form

M1510

Form Coding Instructions

Mark all that apply

Source: Centers for Medicare & Medicaid Services

Form Context

If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond?

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Heart failure follow-up
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 LL800-4

Answer Code Score Answer ID
No action taken 0 LA12237-6
Patient's physician (or other primary care practitioner) contacted the same day 1 LA12238-4
Patient advised to get emergency treatment (for example, call 911 or go to emergency room) 2 LA12239-2
Implemented physician-ordered patient-specific established parameters for treatment 3 LA12240-0
Patient education or other clinical interventions 4 LA12241-8
Obtained change in care plan orders (for example, increased monitoring by agency, change in visit frequency, telehealth, etc.) 5 LA12242-6

Member of these Panels

LOINC Long Common Name
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility
86264-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [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]

52471-0 Medications

Form Coding Instructions

List the ten most clinically relevant medications

Source: Regenstrief Help

Fully-Specified Name

Component
Medications
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
PANEL.SURVEY.MDS
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.68
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52747-3 Continuity Assessment Record and Evaluation (CARE) tool - Expired
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
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

Language Variants Get Info

Tag Language Translation
de-AT German (Austria) Synonyms: Dokumente der e-Medikation

57256-0 Medication intervention since admission/reentry during assessment period [CMS Assessment]

Term Description

Indicates whether the agency contacted and complete physician (or physician-designee) prescribed/recommended actions each time potential clinically significant medication issues were identified.
Source: Regenstrief LOINC

Observation ID in Form

M2004

Fully-Specified Name

Component
Medication intervention since admission &or reentry
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; Added "since admission/reentry" to Component to reflect the element of the question text
Order vs. Observation
Observation

Normative Answer List LL815-2

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
No clinically significant medication issues identified since the previous OASIS assessment NA LA12314-3

Member of these Panels

LOINC Long Common Name
103991-6 CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
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]
86259-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [CMS Assessment]
89963-3 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 3.0 during assessment period [CMS Assessment]
93128-7 Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.0 during assessment period [CMS Assessment]
87506-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 4.00 during assessment period [CMS Assessment]
93219-4 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.00 during assessment period [CMS Assessment]
103948-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment]
87507-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 4.00 during assessment period [CMS Assessment]
93221-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.00 during assessment period [CMS Assessment]
103946-0 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
87508-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 4.00 during assessment period [CMS Assessment]
93220-2 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.00 during assessment period [CMS Assessment]
103947-8 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment]
90473-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
90477-1 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
90478-9 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
90474-8 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
90475-5 MDS v3.0 - RAI v1.17.1, 1.17.2 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
91552-0 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
90476-3 MDS v3.0 - RAI v1.17.1, 1.17.2 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
101105-5 MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
101107-1 MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
101109-7 MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
101110-5 MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
101106-3 MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
101113-9 MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment]
101112-1 MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
103564-1 MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9 MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8 MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5 MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1 MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7 MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3 MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set 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]
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]
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]
99174-5 Outcome and assessment information set (OASIS) form - version E - Transfer to an Inpatient Facility during assessment period [CMS Assessment]

57195-0 Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?

Observation ID in Form

M2015

Fully-Specified Name

Component
Patient &or caregiver drug education intervention
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 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee
Order vs. Observation
Observation

Survey Question

Text
Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?

Normative Answer List LL817-8

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Patient not taking any drugs NA LA12320-0

Member of these Panels

LOINC Long Common Name
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility
86264-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [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]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency 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]

57052-3 Emergent care during assessment period [CMS Assessment]

Fully-Specified Name

Component
Emergent care
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

LOINC Long Common Name
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility
86264-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [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]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency 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]

57276-8 Emergent care utilized during assessment period [CMS Assessment]

Observation ID in Form

M2300

Skip Logic

If "0 - No", then go to M2400. If "UK - Unknown", then go to M2400.

Fully-Specified Name

Component
Emergent care utilized
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 Clincal LOINC committee;Added "utilized" to the Component to further clarify the term and to differeniate from the panel term 85906-6; Changed Scale to Ord because of the ordinal answer choices; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms
Order vs. Observation
Observation

Normative Answer List LL824-4

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes, used hospital emergency department WITHOUT hospital admission 1 LA12351-5
Yes, used hospital emergency department WITH hospital admission 2 LA12352-3
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) UK LA4489-6

Member of these Panels

LOINC Long Common Name
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility
86264-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [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]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency 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]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency 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]

57277-6 Reason For Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)?

Observation ID in Form

M2310

Form Coding Instructions

Mark all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Reason for emergent care
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 to account for variation across CMS forms
Order vs. Observation
Observation

Normative Answer List LL825-1

Answer Code Score Answer ID
Improper medication administration, adverse drug reactions, medication side effects, toxicity, anaphylaxis 1 LA27773-3
Injury caused by fall 2 LA12355-6
Respiratory infection (for example, pneumonia, bronchitis) 3 LA12356-4
Other respiratory problem 4 LA12357-2
Heart failure (for example, fluid overload) 5 LA12358-0
Cardiac dysrhythmia (irregular heartbeat) 6 LA12359-8
Myocardial infarction or chest pain 7 LA12360-6
Other heart disease 8 LA12361-4
Stroke (CVA) or TIA 9 LA12362-2
Hypo/hyperglycemia, diabetes out of control 10 LA6223-7
GI bleeding, obstruction, constipation, impaction 11 LA12364-8
Dehydration, malnutrition 12 LA12365-5
Urinary tract infection 13 LA6437-3
IV catheter-related infection or complication 14 LA12367-1
Wound infection or deterioration 15 LA12368-9
Uncontrolled pain 16 LA6430-8
Acute mental/behavioral health problem 17 LA12370-5
Deep vein thrombosis, pulmonary embolus 18 LA6180-9
Other than above reasons 19 LA6315-1
Reason unknown UK LA4394-8

Member of these Panels

LOINC Long Common Name
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility
86264-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [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]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency 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]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency 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]

69330-9 Data items collected at inpatient facility admission or agency discharge only

Fully-Specified Name

Component
Data items collected at inpatient facility admission or agency discharge only - transfer to facility
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 2.44
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility

57198-4 Intervention Synopsis:

Observation ID in Form

M2400

Fully-Specified Name

Component
Intervention synopsis
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.29
Last Updated
Version 2.67
Order vs. Observation
Subset
Panel Type
Organizer

Member of these Panels

LOINC Long Common Name
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility
86264-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [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]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency 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]

57270-1 Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care

Observation ID in Form

M2400a

Form Coding Instructions

NA - Patient is not diabetic or is bilateral amputee

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Plan of care includes diabetic foot care
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 Clincal LOINC committee; Added "Plan of care includes" to COMPONENT to match form text
Order vs. Observation
Observation

Example Answer List LL823-6

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Not applicable na LA4720-4

Member of these Panels

LOINC Long Common Name
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
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
86264-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [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]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency 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]

57271-9 Falls prevention interventions

Observation ID in Form

M2400b

Form Coding Instructions

NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since the last OASIS assessment

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Plan of care includes fall prevention interventions
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 Clincal LOINC committee; Added "Plan of care includes" to COMPONENT to match form text
Order vs. Observation
Observation

Normative Answer List LL823-6

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Not applicable na LA4720-4

Member of these Panels

LOINC Long Common Name
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
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
86264-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [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]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency 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]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency 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]

57272-7 Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment

Observation ID in Form

M2400c

Form Coding Instructions

NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not have diagnosis of depression since the last OASIS assessment

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Plan of care includes depression intervention
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 Clincal LOINC committee;Added "Plan of care includes" to COMPONENT to match form text
Order vs. Observation
Observation

Example Answer List LL823-6

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Not applicable na LA4720-4

Member of these Panels

LOINC Long Common Name
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
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
86264-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [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]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency 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]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency 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]

57273-5 Intervention(s) to monitor and mitigate pain

Observation ID in Form

M2400d

Form Coding Instructions

NA - Formal assessment did not indicate pain since the last OASIS assessment

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Plan of care includes intervention to monitor and mitigate pain
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; Added "Plan of care includes" to COMPONENT to match form text
Order vs. Observation
Observation

Example Answer List LL823-6

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Not applicable na LA4720-4

Member of these Panels

LOINC Long Common Name
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
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
86264-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [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]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency 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]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency 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]

57274-3 Plan of care includes intervention to prevent pressure injuries during assessment period [CMS Assessment]

Observation ID in Form

M2400e

Form Coding Instructions

NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Plan of care includes intervention to prevent 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; Added "Plan of care includes" to COMPONENT to match form text; "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

Example Answer List LL823-6

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Not applicable na LA4720-4

Member of these Panels

LOINC Long Common Name
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
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
86264-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [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]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency 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]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency 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]

57275-0 Pressure ulcer treatment based on principles of moist wound healing

Observation ID in Form

M2400f

Form Coding Instructions

NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Plan of care includes pressure injury treatment - moist healing
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; Added "Plan of care includes" to COMPONENT to match form text; "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

Example Answer List LL823-6

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Not applicable na LA4720-4

Member of these Panels

LOINC Long Common Name
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
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
86264-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [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]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency 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]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency 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]

46578-1 To which Inpatient Facility has the patient been admitted?

Term Description

Identifies the type of inpatient facility to which the patient was admitted.
Source: Regenstrief LOINC

Observation ID in Form

M2410

Skip Logic

If "1 - Hospital", then go to M2430. If "2 - Rehabilitation facility", then go to M0903. If "3 - Nursing home", then go to M2440. If "4 - Hospice", then go to M0903. If "NA - No inpatient facility admission, omit "NA" option on TRN.

Fully-Specified Name

Component
Admitted to
Property
Type
Time
RptPeriod
System
Inpatient facility
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; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms; Changed Component to "Admitted to" and System to "Inpatient facility" to match LOINC convention for terms about facilities
Order vs. Observation
Observation

Example Answer List LL326-0

Answer Code Score Answer ID
Hospital 1 LA6218-7
Rehabilitation facility 2 LA6357-3
Nursing Home 3 LA27-8
Hospice 4 LA6216-1
No inpatient facility admission NA LA6281-5

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
57194-3 Deprecated Outcome and assessment information set (OASIS) form - version C - Discharge from agency
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility
86264-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Discharged from agency [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]
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency 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]
99178-6 Outcome and assessment information set (OASIS) form - version E - Discharge from Agency 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]

57279-2 For what reason(s) did the patient require hospitalization?

Observation ID in Form

M2430

Skip Logic

If "UK - Reason unknown", then go to M0903.

Form Coding Instructions

Mark all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Reason 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 LL827-7

Answer Code Score Answer ID
Improper medication administration, adverse drug reactions, medication side effects, toxicity, anaphylaxis 1 LA27773-3
Injury caused by fall 2 LA12355-6
Respiratory infection (for example, pneumonia, bronchitis) 3 LA12356-4
Other respiratory problem 4 LA12357-2
Heart failure (for example, fluid overload) 5 LA12358-0
Cardiac dysrhythmia (irregular heartbeat) 6 LA12359-8
Myocardial infarction or chest pain 7 LA12360-6
Other heart disease 8 LA12361-4
Stroke (CVA) or TIA 9 LA12362-2
Hypo/hyperglycemia, diabetes out of control 10 LA6223-7
GI bleeding, obstruction, constipation, impaction 11 LA12364-8
Dehydration, malnutrition 12 LA12365-5
Urinary tract infection 13 LA6437-3
IV catheter-related infection or complication 14 LA12367-1
Wound infection or deterioration 15 LA12368-9
Uncontrolled pain 16 LA6430-8
Acute mental/behavioral health problem 17 LA12370-5
Deep vein thrombosis, pulmonary embolus 18 LA6180-9
Scheduled treatment or procedure 19 LA12397-8
Other than above reasons 20 LA6315-1
Reason unknown UK LA4394-8

Member of these Panels

LOINC Long Common Name
57039-0 Deprecated Outcome and assessment information set (OASIS) form - version C
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility
86259-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [CMS Assessment]

46477-6 For what Reason(s) was the patient Admitted to a Nursing Home?

Term Description

Identifies the reason(s) the patient was admitted to a nursing home.
Source: Regenstrief LOINC

Observation ID in Form

M2440

Skip Logic

If "UK - Unknown", then go to M0903.

Form Coding Instructions

Mark all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Reason for nursing home admission
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
OASIS

Basic Attributes

Class
SURVEY.OASIS
Type
Surveys
First Released
Version 2.19
Last Updated
Version 2.50

Survey Question

Text
For what Reason(s) was the patient Admitted to a Nursing Home?
Source
OASIS-C.M2440

Normative Answer List LL331-0

Answer Code Score Answer ID
Therapy services 1 LA6393-8
Respite care 2 LA6365-6
Hospice care 3 LA6217-9
Permanent placement 4 LA6345-8
Unsafe for care at home 5 LA6434-0
Other 6 LA46-8
Unknown Copyright http://snomed.info/sct ID:261665006 Unknown (qualifier value) UK LA4489-6

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
57193-5 Deprecated Outcome and assessment information set (OASIS) form - version C - Transfer to facility

46581-5 Date of last (most recent) home visit:

Term Description

Identifies the last or most recent home visit of any agency provider, including skilled providers or home health aides.
Source: Regenstrief LOINC

Observation ID in Form

M0903

Fully-Specified Name

Component
Date of last home visit
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
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]
86259-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [CMS Assessment]

Example Units

Unit Source
{mm/dd/yyyy} Example UCUM Units

46582-3 Discharge/Transfer/Death Date:

Term Description

Identifies the actual date of discharge, transfer, or death.
Source: Regenstrief LOINC

Observation ID in Form

M0906

Form Coding Instructions

Enter the date of the discharge, transfer, or death (at home) of the patient

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Discharge, transfer, death date
Property
Date
Time
Pt
System
^Patient
Scale
Qn
Method

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.19
Last Updated
Version 2.71
Change Reason
Release 2.71: METHOD_TYP: Removed Method because this concept is not specific to CMS; 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
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]
86259-9 Deprecated Outcome and assessment information set (OASIS) form - version C2 - Transfer To inpatient facility - patient discharged or not discharged [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]
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]
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]
99174-5 Outcome and assessment information set (OASIS) form - version E - Transfer to an Inpatient Facility during assessment period [CMS Assessment]

Example Units

Unit Source
{mm/dd/yyyy} Example UCUM Units