57040-8 Clinical record items

Fully-Specified Name

Component

Clinical record items

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Long Common Name

Clinical Record Items during assessment period [CMS Assessment]

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Added METHOD of CMS Assessments because this unique panel originates from CMS instruments

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

46500-5 Discipline of Person Completing Assessment

Term Description

Identifies the discipline of the clinician completing the comprehensive assessment at the specified time points or the clinician reporting the transfer to an inpatient facility, death at home, or discharge (no further visits after start of care).

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

Long Common Name

Discipline of Person Completing Assessment during assessment period [CMS Assessment] Provider

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Normative Answer List LL245-2

Member of these Panels

Related Names

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

Related Codes

46501-3 Date Assessment Completed

Term Description

The actual date the assessment is completed, except if agency policy allows assessments to be performed over more than one visit date, in which case the last date (when the assessment is finished) is the appropriate date to record.

Observation ID in Form

M0090

Fully-Specified Name

Component

Date assessment information completed

Property

Date

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Date assessment information completed during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Member of these Panels

Related Names

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

Example Units

Related Codes

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

Observation ID in Form

M0100

Skip Logic

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

Fully-Specified Name

Component

Reason for assessment

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Long Common Name

Reason for assessment during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Normative Answer List LL773-3

Member of these Panels

Related Names

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

Related Codes

57201-6 Date of Physician-ordered Start of Care (Resumption of Care)

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

Long Common Name

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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Member of these Panels

Related Names

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

Example Units

Related Codes

57202-4 Date of Referral

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 (MAJ)

Change Reason

Updated METHOD from CMS assessment to method-less since this is a general concept and not specific to CMS assessments.

Order vs. Observation

Observation

Member of these Panels

Related Names

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

Example Units

Related Codes

57203-2 Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an "early" episode or a "later" episode in the patient's current sequence of adjacent Medicare home health payment episodes?

Fully-Specified Name

Component

Episode Timing

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Episode Timing during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms

Order vs. Observation

Observation

Normative Answer List LL774-1

Member of these Panels

Related Names

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

Related Codes

Third Party Copyright

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

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

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

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 (DEL)

Change Reason

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

Panel Type

Panel

Member of these Panels

Related Names

• Disch
• Dx
• Hx
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.OASIS
• Panl
• Patient Hx
• Patient hx & Dx - transfer to facility, d/c
• Pnl
• Point in time
• Random
• Survey
• Survey.OASIS

57208-1 Influenza virus vaccination received

Term Description

Identifies whether the patient received an influenza vaccine for this year's flu season

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?

Fully-Specified Name

Component

Influenza virus vaccination received

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Influenza vaccination received in Reporting Period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.67 (MIN)

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

Member of these Panels

Member of these Groups Get Info

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• FLUV
• ID
• Immunizations
• Infectious Disease
• InfectiousDisease
• Influ
• Influenza vacc received
• Ordinal
• QL
• Qual
• Qualitative
• Report period
• Screen
• Survey
• Vaccine

Related Codes

Third Party Copyright

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

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

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

55020-2 Reason influenza virus vaccine not received

Fully-Specified Name

Component

Reason influenza virus vaccine not received

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Long Common Name

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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77 (MAJ)

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

Member of these Panels

Related Names

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

Related Codes

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

Long Common Name

Pneumococcal vaccine [OASIS-C]

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.44 (MIN)

Normative Answer List LL251-0

Member of these Panels

Related Names

• Finding
• Findings
• Ordinal
• Outcome and assessment information set
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• Survey.OASIS

Third Party Copyright

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

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

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

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

Long Common Name

Reason pneumococcal vaccine not given [OASIS-C]

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.48 (MIN)

Normative Answer List LL782-4

Member of these Panels

Related Names

• Finding
• Findings
• Gvn
• Nominal
• Outcome and assessment information set
• Point in time
• Random
• Survey
• Survey.OASIS

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 (MIN)

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Point in time
• Random
• Survey

57239-6 Symptoms in heart failure patients

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

Long Common Name

Symptoms in heart failure patients during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

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 LL799-8

Member of these Panels

Related Names

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

Related Codes

Third Party Copyright

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

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

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

57240-4 Heart failure follow-up

Observation ID in Form

M1510

Form Coding Instructions

Mark all that apply

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?

Fully-Specified Name

Component

Heart failure follow-up

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Long Common Name

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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

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

Member of these Panels

Related Names

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

Related Codes

52471-0 Medications

Form Coding Instructions

List the ten most clinically relevant medications

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 (MIN)

Panel Type

Panel

Member of these Panels

Language Variants Get Info

Related Names

• Pan
• Panel
• Panl
• Pnl
• Point in time
• Random
• Survey
• SURVEY.MDS

57256-0 Medication intervention since admission &or reentry

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.

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

Long Common Name

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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

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

Member of these Panels

Related Names

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

Related Codes

Third Party Copyright

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

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

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

57195-0 Patient &or caregiver drug education intervention

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

Long Common Name

Patient/caregiver drug education intervention during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

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 LL817-8

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Drugs
• Finding
• Findings
• Ordinal
• Patient/caregiver drug education intervention
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

Third Party Copyright

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

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

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

57052-3 Emergent care

Fully-Specified Name

Component

Emergent care

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Long Common Name

Emergent care during assessment period [CMS Assessment]

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Added METHOD of CMS Assessments because this unique panel originates from CMS instruments

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

57276-8 Emergent care utilized

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

Long Common Name

Emergent care utilized during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

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

Member of these Panels

Related Names

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

Related Codes

Third Party Copyright

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

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

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

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

Fully-Specified Name

Component

Reason for emergent care

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Long Common Name

Reason for emergent care during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

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

Member of these Panels

Related Names

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

Related Codes

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

Long Common Name

Data items collected at inpatient facility admission or agency discharge only - OASIS-C - transfer to facility [OASIS-C]

Basic Attributes

Class

PANEL.SURVEY.OASIS

Type

Surveys

First Released

Version 2.38

Last Updated

Version 2.44 (MIN)

Panel Type

Panel

Member of these Panels

Related Names

• Disch
• Inpatient admission agency discharge items - transfer to facility
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.OASIS
• Panl
• Pnl
• Point in time
• Random
• Survey
• Survey.OASIS

57198-4 Intervention Synopsis:

Observation ID in Form

M2400

Fully-Specified Name

Component

Intervention synopsis

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Long Common Name

Intervention synopsis

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.67 (PANEL)

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Point in time
• Random
• Survey

Related Codes

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

Fully-Specified Name

Component

Plan of care includes diabetic foot care

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Plan of care includes diabetic foot care during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

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

Member of these Panels

Related Names

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

Related Codes

Third Party Copyright

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

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

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

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

Fully-Specified Name

Component

Plan of care includes fall prevention interventions

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Plan of care includes fall prevention interventions during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

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

Member of these Panels

Related Names

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

Related Codes

Third Party Copyright

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

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

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

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

Fully-Specified Name

Component

Plan of care includes depression intervention

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Plan of care includes depression intervention during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

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

Member of these Panels

Related Names

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

Related Codes

Third Party Copyright

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

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

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

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

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

Long Common Name

Plan of care includes intervention to monitor and mitigate pain during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

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

Member of these Panels

Related Names

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

Related Codes

Third Party Copyright

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

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

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

57274-3 Plan of care includes intervention to prevent pressure injuries

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

Fully-Specified Name

Component

Plan of care includes intervention to prevent pressure injuries

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

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

Member of these Panels

Related Names

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

Related Codes

Third Party Copyright

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

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

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

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

Fully-Specified Name

Component

Plan of care includes pressure injury treatment - moist healing

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

Plan of care includes pressure injury treatment - moist healing during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

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

Member of these Panels

Related Names

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

Related Codes

Third Party Copyright

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

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

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

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.

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

Long Common Name

Admitted to during assessment period [CMS Assessment] Inpatient facility

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.77 (MAJ)

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

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Fclty
• IP
• Nominal
• Report period
• Survey
• Transferred
• Typ

Related Codes

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

Fully-Specified Name

Component

Reason for hospitalization

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Long Common Name

Reason for hospitalization during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

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

Member of these Panels

Related Names

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

Related Codes

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.

Observation ID in Form

M2440

Skip Logic

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

Form Coding Instructions

Mark all that apply

Fully-Specified Name

Component

Reason for nursing home admission

Property

Find

Time

Pt

System

^Patient

Scale

Nom

Method

OASIS

Long Common Name

Reason for nursing home admission [OASIS]

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.50 (MIN)

Normative Answer List LL331-0

Member of these Panels

Related Names

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

Copyright

Organization

Center for Health Policy Research, UCHSC, Denver, CO

Copyright

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

Terms of Use

Used with permission.

Third Party Copyright

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

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

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

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.

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

Long Common Name

Date of last home visit during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Member of these Panels

Related Names

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

Example Units

Related Codes

46582-3 Discharge/Transfer/Death Date:

Term Description

Identifies the actual date of discharge, transfer, or death.

Observation ID in Form

M0906

Form Coding Instructions

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

Fully-Specified Name

Component

Discharge, transfer, death date

Property

Date

Time

Pt

System

^Patient

Scale

Qn

Method

Long Common Name

Discharge, transfer, death date

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.71 (MAJ)

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

Related Names

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

Example Units

Related Codes