LOINC
Version 2.67

57194-3Outcome and assessment information set (OASIS) form - version C - Discharge from agencyActive

Term Description

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

Panel Hierarchy
Details for each LOINC in Panel

LOINC Name R/O/C Cardinality Example UCUM Units
57194-3 Outcome and assessment information set (OASIS) form - version C - Discharge from agency
Indent57040-8 Clinical Record Items [CMS Assessment]
IndentIndent46500-5 Discipline of Person Completing Assessment
IndentIndent46501-3 Date Assessment Completed {mm/dd/yyyy}
IndentIndent57200-8 This Assessment is Currently Being Completed for the Following Reason:
IndentIndent57201-6 Date of Physician-ordered Start of Care (Resumption of Care) [CMS Assessment] {mm/dd/yyyy}
IndentIndent57202-4 Date of Referral {mm/dd/yyyy}
IndentIndent57203-2 Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an "early" episode or a "later" episode in the patient's current sequence of adjacent Medicare home health payment episodes?
Indent69328-3 Patient history and diagnosis
IndentIndent57208-1 Influenza vaccination received in Reporting Period [CMS Assessment]
IndentIndent57209-9 Reason influenza virus vaccine not received [OASIS-C]
IndentIndent57210-7 Pneumococcal Vaccine: Did the patient receive pneumococcal polysaccharide vaccine (PPV) from your agency during this episode of care (SOC/ROC to Transfer/Discharge)?
IndentIndent57211-5 Reason PPV not received:
Indent57042-4 Sensory status [CMS Assessment]
IndentIndent57215-6 Vision [CMS Assessment]
IndentIndent57216-4 Ability to hear [CMS Assessment]
IndentIndent57217-2 Understanding of verbal content in patient's own language (with hearing aid or device if used)
IndentIndent57218-0 Speech and oral (verbal) expression of language (in patient's own language)
IndentIndent57219-8 Has this patient had a formal Pain Assessment using a standardized, validated pain assessment tool (appropriate to the patient's ability to communicate the severity of pain)?
IndentIndent57220-6 Frequency of pain interfering with patient's activity or movement:
Indent57044-0 Integumentary status
IndentIndent57307-1 Does this patient have at lease one Unhealed Pressure Ulcer at Stage II or Higher or designated as "unstageable"
IndentIndent57222-2 Oldest non-epithelialized stage II pressure ulcer that is present at discharge
IndentIndent58052-2 Date pressure injury.oldest non-epithelialized stage 2 first identified [CMS Assessment] {mm/dd/yyyy}
IndentIndent58102-5 Current number of unhealed (non-epithelialized) pressure ulcers at each stage
IndentIndentIndent57186-9 Number currently present
IndentIndentIndentIndent55124-2 Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. {#}
IndentIndentIndentIndent55125-9 Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. {#}
IndentIndentIndentIndent55126-7 Stage IV: Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. {#}
IndentIndentIndentIndent54893-3 Unstageable: Known or likely but unstageable due to non-removable dressing or device {#}
IndentIndentIndentIndent54946-9 Unstageable: Known or likely but unstageable due to coverage of wound bed by slough and/or eschar. {#}
IndentIndentIndentIndent54950-1 Unstageable: Suspected deep tissue injury in evolution. {#}
IndentIndentIndent57187-7 Number of those listed in Column 1 that were present on admission (most recent SOC/ROC)
IndentIndentIndentIndent54886-7 Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. {#}
IndentIndentIndentIndent54887-5 Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. {#}
IndentIndentIndentIndent54890-9 Stage IV: Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. {#}
IndentIndentIndentIndent54894-1 Unstageable: Known or likely but unstageable due to non-removable dressing or device {#}
IndentIndentIndentIndent54947-7 Unstageable: Known or likely but unstageable due to coverage of wound bed by slough and/or eschar. {#}
IndentIndentIndentIndent54951-9 Unstageable: Suspected deep tissue injury in evolution. {#}
IndentIndent57188-5 Stage III and IV pressure ulcer with the largest surface dimension (length x width)
IndentIndentIndent57226-3 Pressure Ulcer Length: cm
IndentIndentIndent52729-1 Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length cm
IndentIndentIndent57228-9 Pressure Ulcer Depth: cm
IndentIndent57229-7 Status of most problematic (observable) pressure ulcer:
IndentIndent46536-9 Current Number of Stage I Pressure Ulcers: {#}
IndentIndent57231-3 Status of most problematic unhealed (observable) pressure ulcer:
IndentIndent57232-1 Does the patient have a Stasis Ulcer?
IndentIndent57233-9 Current Number of (Observable) Stasis Ulcer(s): {#}
IndentIndent57234-7 Status of most problematic (observable) stasis ulcer:
IndentIndent57235-4 Does this patient have a Surgical Wound?
IndentIndent57236-2 Status of most problematic (observable) surgical wound:
IndentIndent46534-4 Does this patient have a Skin Lesion or Open Wound (excluding bowel ostomy), other than those described above, that is receiving intervention by the home health agency?
Indent52510-5 Respiratory status
IndentIndent57237-0 When is the patient dyspneic or noticeably Short of Breath?
IndentIndent57238-8 Respiratory treatments utilized at home: 1..3
Indent57045-7 Cardiac status
IndentIndent57239-6 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?
IndentIndent57240-4 Heart failure follow-up [CMS Assessment] 1..5
Indent57046-5 Elimination status
IndentIndent46553-4 Urinary incontinence or urinary catheter present [CMS Assessment]
IndentIndent46587-2 Bowel incontinence frequency [CMS Assessment]
IndentIndent46588-0 Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, or b) necessitated a change in medical or treatment regimen?
Indent69332-5 Neuro & emotional & behavioral status
IndentIndent46589-8 Cognitive functioning [CMS Assessment]
IndentIndent58104-1 When confused (reported or observed within the last 14 days):
IndentIndent86495-9 When Anxious (Reported or Observed Within the Last 14 Days)
IndentIndent46473-5 Cognitive, behavorial, and psychiatric symptoms that are demonstrated at least once a week (Reported or Observed):
IndentIndent46592-2 Frequency of disruptive behavior symptoms (reported or observed)
Indent69337-4 ADL/IADLs
IndentIndent46595-5 Grooming:
IndentIndent46597-1 Ability to dress upper body:
IndentIndent46599-7 Ability to dress lower body:
IndentIndent57243-8 Bathing:
IndentIndent57244-6 Toileting transferring:
IndentIndent57245-3 Toileting hygiene:
IndentIndent57246-1 Transferring:
IndentIndent57247-9 Ambulation/Locomotion:
IndentIndent57248-7 Feeding or eating:
IndentIndent57249-5 Ability to plan or prepare light meals
IndentIndent46569-0 Ability to use telephone:
Indent52471-0 Medications
IndentIndent57256-0 Medication intervention since admission/reentry [CMS Assessment]
IndentIndent57195-0 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?
IndentIndent57285-9 Management of oral medications:
IndentIndent57284-2 Management of injectable medications:
Indent57049-9 Care management [CMS Assessment]
IndentIndent57306-3 Types and sources of assistance [CMS Assessment]
IndentIndentIndent57260-2 Non-agency caregiver ability and willingness to assist with ADL [CMS Assessment]
IndentIndentIndent57261-0 Non-agency caregiver ability and willingness to assist with IADL [CMS Assessment]
IndentIndentIndent57262-8 Non-agency caregiver ability and willingness to assist with medication administration [CMS Assessment]
IndentIndentIndent57263-6 Medical procedures/treatments
IndentIndentIndent57264-4 Non-agency caregiver ability and willingness to assist with management of equipment [CMS Assessment]
IndentIndentIndent57265-1 Non-agency caregiver ability and willingness to assist with supervision and safety [CMS Assessment]
IndentIndentIndent57266-9 Advocacy or facilitation
IndentIndent57267-7 How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?
Indent57052-3 Emergent care [CMS Assessment]
IndentIndent57276-8 Emergent care utilized [CMS Assessment]
IndentIndent57277-6 Reason For Emergent Care: For what reason(s) did the patient receive emergent care (with or without hospitalization)? 1..19
Indent69331-7 Data items collected at inpatient facility admission or agency discharge only
IndentIndent57198-4 Intervention Synopsis:
IndentIndentIndent57270-1 Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care
IndentIndentIndent57271-9 Falls prevention interventions
IndentIndentIndent57272-7 Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment
IndentIndentIndent57273-5 Intervention(s) to monitor and mitigate pain
IndentIndentIndent57274-3 Plan of care includes intervention to prevent pressure injuries [CMS Assessment]
IndentIndentIndent57275-0 Pressure ulcer treatment based on principles of moist wound healing
IndentIndent46578-1 To which Inpatient Facility has the patient been admitted?
IndentIndent55128-3 Discharge disposition
IndentIndent46581-5 Date of last (most recent) home visit: {mm/dd/yyyy}
IndentIndent46582-3 Discharge/Transfer/Death Date: {mm/dd/yyyy}

Fully-Specified Name

Component
Outcome and assessment information set (OASIS) form - version C - Discharge from agency
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

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

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