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

Fully-Specified Name

Component

Clinical record items

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

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

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

46500-5 Discipline of Person Completing Assessment

Term Description

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

Observation ID in Form

M0080

Fully-Specified Name

Component

Discipline of person completing assessment

Property

Type

Time

RptPeriod

System

Provider

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.77

Change Reason

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

Order vs. Observation

Observation

Normative Answer List LL245-2

Member of these Panels

Related Names

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

Related Codes

46501-3 Date Assessment Completed

Term Description

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

Observation ID in Form

M0090

Fully-Specified Name

Component

Date assessment information completed

Property

Date

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.77

Change Reason

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

Order vs. Observation

Observation

Member of these Panels

Related Names

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

Example Units

Related Codes

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

Observation ID in Form

M0100

Skip Logic

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

Fully-Specified Name

Component

Reason for assessment

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

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

Order vs. Observation

Observation

Normative Answer List LL773-3

Member of these Panels

Related Names

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

Related Codes

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

Fully-Specified Name

Component

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

Property

Date

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

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

Order vs. Observation

Observation

Member of these Panels

Related Names

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

Example Units

Related Codes

57202-4 Date of Referral

Fully-Specified Name

Component

Date of Referral

Property

Date

Time

Pt

System

^Patient

Scale

Qn

Method

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.63

Change Reason

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

Order vs. Observation

Observation

Member of these Panels

Related Names

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

Example Units

Related Codes

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

Fully-Specified Name

Component

Episode Timing

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

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

Order vs. Observation

Observation

Normative Answer List LL774-1

Member of these Panels

Related Names

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

Related Codes

Third Party Copyright

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

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

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

69328-3 Patient history and diagnosis

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

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 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?

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

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 http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

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

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

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

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 http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

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

Member of these Panels

Related Names

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

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

Fully-Specified Name

Component

Sensory status

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

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

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

57215-6 Vision during assessment period [CMS Assessment]

Fully-Specified Name

Component

Vision

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

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

Order vs. Observation

Observation

Normative Answer List LL784-0

Member of these Panels

Related Names

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

Related Codes

57216-4 Ability to hear during assessment period [CMS Assessment]

Fully-Specified Name

Component

Ability to hear

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

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

Order vs. Observation

Observation

Normative Answer List LL785-7

Member of these Panels

Related Names

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

Related Codes

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

Fully-Specified Name

Component

Understanding of verbal content

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

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

Order vs. Observation

Observation

Normative Answer List LL786-5

Member of these Panels

Related Names

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

Related Codes

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

Observation ID in Form

M1230

Fully-Specified Name

Component

Speech and oral expression of language

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

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

Order vs. Observation

Observation

Normative Answer List LL787-3

Member of these Panels

Related Names

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

Related Codes

57219-8 Has this patient had a formal Pain Assessment using a standardized, validated pain assessment tool (appropriate to the patient's ability to communicate the severity of pain)?

Fully-Specified Name

Component

Formal pain assessment using standardized tool

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

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

Order vs. Observation

Observation

Normative Answer List LL788-1

Member of these Panels

Related Names

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

Related Codes

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

Observation ID in Form

M1242

Fully-Specified Name

Component

Frequency of pain interfering with activity or movement

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed Property to NRat because this is a frequency term; Changed Property from NRat to Find because the answer list does not reflect Nrat

Order vs. Observation

Observation

Normative Answer List LL789-9

Member of these Panels

Related Names

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

Related Codes

57044-0 Integumentary status

Fully-Specified Name

Component

Integumentary status

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

PANEL.SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.68

Panel Type

Panel

Member of these Panels

Related Names

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

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

Observation ID in Form

M1306

Skip Logic

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

Fully-Specified Name

Component

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

Property

Find

Time

Pt

System

^Patient

Scale

Nom

Method

OASIS-C

Basic Attributes

Class

SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.64

Change Reason

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

Survey Question

Text

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

Source

OASIS-C.M1306

Normative Answer List LL251-0

Member of these Panels

Related Names

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

Third Party Copyright

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

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

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

57222-2 Oldest non-epithelialized stage II pressure ulcer that is present at discharge

Observation ID in Form

M1307

Fully-Specified Name

Component

Oldest non-epithelialized stage 2 pressure injury present at discharge

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

Order vs. Observation

Observation

Normative Answer List LL828-5

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Disch
• Finding
• Findings
• II
• Nominal
• pressure injury
• Pressure ulcer
• Pressure Ulcers
• Report period
• Survey
• Ulcer

Related Codes

58052-2 Date pressure injury.oldest non-epithelialized stage 2 first identified [CMS Assessment]

Fully-Specified Name

Component

Date pressure injury first identified

Property

Date

Time

RptPeriod

System

Pressure injury.oldest non-epithelialized stage 2

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

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• II
• Isolated
• pressure injury
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey
• Ulcer

Example Units

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

Observation ID in Form

M1308

Form Coding Instructions

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

Fully-Specified Name

Component

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

Property

-

Time

Pt

System

^Patient

Scale

-

Method

OASIS-C

Basic Attributes

Class

PANEL.SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.68

Change Reason

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

Panel Type

Panel

Member of these Panels

Related Names

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

57186-9 Number currently present

Observation ID in Form

M1308.1

Form Coding Instructions

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

Fully-Specified Name

Component

Number of pressure injuries at each stage

Property

-

Time

Pt

System

^Patient

Scale

Set

Method

Basic Attributes

Class

PANEL.SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.68

Change Reason

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

Panel Type

Panel

Member of these Panels

Related Names

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

55124-2 Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister

Term Description

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

Observation ID in Form

M1308.1a

Form Context

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

Fully-Specified Name

Component

Number of pressure injuries - stage 2

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

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

Example Units

Related Codes

55125-9 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

Term Description

A stage 3 pressure ulcer is defined as full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M1308.1b

Skip Logic

If 0, skip to M0400C, Stage 4.

Form Context

Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling

Fully-Specified Name

Component

Number of pressure injuries - stage 3

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

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

Example Units

Related Codes

55126-7 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

Term Description

A stage 4 pressure ulcer is defined as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M1308.1c

Form Context

Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling

Fully-Specified Name

Component

Number of pressure injuries - stage 4

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

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

Example Units

Related Codes

54893-3 Unstageable: Known or likely but unstageable due to non-removable dressing or device

Term Description

A pressure ulcer that is unstageable due to a non-removable dressing is defined as a known pressure ulcer that is covered by a non-removable dressing or device, such as a surgical dressing, cast, other orthopedic device, or dressing not to be removed per physician's order.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M1308.1d1

Description

Unstageable: Known or likely but unstageable due to non-removable dressing or device

Fully-Specified Name

Component

Number of pressure injuries - unstageable due to non-removable dressing or device

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Removed "at assessment" from COMPONENT because it is implied by TIMING of "Pt".; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

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

Example Units

Related Codes

54946-9 Unstageable: Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.

Term Description

Slough tissue is defined as non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Eschar tissue is defined as dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scablike.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M1308.1d2

Description

Unstageable: Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.

Fully-Specified Name

Component

Number of pressure injuries - unstageable due to coverage of wound bed by slough &or eschar

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Removed "at assessment" from COMPONENT because it is implied by TIMING of "Pt";Updated COMPONENT from "and or" to "&or" to match convention; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

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

Example Units

Related Codes

54950-1 Unstageable: Suspected deep tissue injury in evolution

Term Description

A pressure ulcer that is unstageable due to deep tissue injury has purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M1308.1d3

Form Context

Unstageable: Suspected deep tissue injury in evolution

Fully-Specified Name

Component

Number of pressure injuries - unstageable with suspected deep tissue injury in evolution

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Removed "at assessment" from COMPONENT because it is implied by TIMING of "Pt"; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

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

Example Units

Related Codes

57187-7 Number of those listed in Column 1 that were present on admission (most recent SOC/ROC)

Observation ID in Form

M1308.2

Form Coding Instructions

Column 2 Complete at FU & D/C. Number of those listed in Column 1 that were present on admission (most recent SOC/ROC)

Fully-Specified Name

Component

Number of pressure injuries present at admission

Property

-

Time

Pt

System

^Patient

Scale

Set

Method

Basic Attributes

Class

PANEL.SURVEY.OASIS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.68

Change Reason

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

Panel Type

Panel

Member of these Panels

Related Names

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

54886-7 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

Observation ID in Form

M1308.2a

Form Coding Instructions

Enter how many were noted at the time of admission

Fully-Specified Name

Component

Number of pressure injuries present upon admission &or reentry - stage 2

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

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

Example Units

Related Codes

54887-5 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

Observation ID in Form

M1308.2b

Form Coding Instructions

Enter how many were noted at the time of admission

Fully-Specified Name

Component

Number of pressure injuries present upon admission &or reentry - stage 3

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

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

Example Units

Related Codes