Version 2.78

55762-9 Comatose

Observation ID in Form

A

Fully-Specified Name

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

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

45482-7 Persistent vegetative state/no discrenible consciousness at the time of admission

Term Description

(Persistent vegetative state/no discernible consciousness)
Source: Regenstrief LOINC

Observation ID in Form

A1

Type of Entry

Question expects user entry - requires response [Q]

Skip Logic

If Yes, skip to G6. Pain Observational Assessment.

Form Coding Instructions

Complete during the 2-day assessment period

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Comatose
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method
CMS Assessment

Basic Attributes

Class
SURVEY.MDS
Type
Surveys
First Released
Version 2.17
Last Updated
Version 2.77
Change Reason
Release 2.69: METHOD_TYP: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC Committee.;

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
69412-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
46102-0 Deprecated MDS quarterly assessment form - version 2.0
46103-8 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III
46104-6 Deprecated MDS quarterly assessment form - version 2.0 - optional version for RUG-III 1997 update

69350-7 Temporal orientation &or mental status

Observation ID in Form

B

Fully-Specified Name

Component
Temporal orientation &or mental status - acute
Property
-
Time
Pt
System
^Patient
Scale
-
Method
CARE

Basic Attributes

Class
PANEL.SURVEY.CARE
Type
Surveys
First Released
Version 2.38
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52489-2 Interview Attempted

Observation ID in Form

B1

Fully-Specified Name

Component
Interview attempted
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52594-9 Interview attempted

Observation ID in Form

B1a

Skip Logic

If Yes, skip to B2. BIMS.

Fully-Specified Name

Component
Brief interview for mental status was attempted
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52595-6 Indicate reason that the interview was not attempted

Observation ID in Form

B1b

Skip Logic

If interview not attempted, Skip to Section C. Observational Assessment of Cognitive Status:

Fully-Specified Name

Component
Reason brief interview for mental status was not attempted
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64

Normative Answer List LL558-8

Answer Code Score Answer ID
Unresponsive or minimally conscious 1 LA10112-3
Communication disorder 2 LA9950-2
No interpreter available 3 LA10023-2

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

55759-5 Temporal Orientation - CARE Acute Care

Observation ID in Form

B2

Skip Logic

Any score with an asterisk will require the completion of D. Confusion Assessment Method.

Fully-Specified Name

Component
Temporal Orientation - CARE Acute Care
Property
-
Time
Pt
System
^Patient
Scale
-
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care

52732-5 Temporal orientation - current year [BIMS]

Observation ID in Form

B2a

Skip Logic

If answered 1. Missed by 2 to 5 years, or 0. Missed by more than 5 years or no answer, complete D. Confusion Assessment Method.

Fully-Specified Name

Component
Temporal orientation - current year
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method
BIMS

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.63
Order vs. Observation
Observation

Normative Answer List LL643-8

Answer Code Score Answer ID
Correct 3 LA9960-1
Missed by 1 year 2 LA10008-3
Missed by 2-5 years 1 LA10966-2
Missed by > 5 years or no answer 0 LA10965-4

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
86870-3 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88279-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0

52733-3 Temporal orientation - current month [BIMS]

Observation ID in Form

B2b

Skip Logic

If answered 1. Missed by 6 days to 1 month, or 0. Missed by more than 1 month or no answer, complete D. Confusion Assessment Method.

Fully-Specified Name

Component
Temporal orientation - current month
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method
BIMS

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.63
Change Reason
Removed "Observed." from method to follow convention of other survey terms
Order vs. Observation
Observation

Normative Answer List LL644-6

Answer Code Score Answer ID
Accurate within 5 days 2 LA9927-0
Missed by 6 days to 1 month 1 LA10010-9
Missed by > 1 month or no answer 0 LA10969-6

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission
83265-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
87414-9 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.5 [CMS Assessment]
88329-8 Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 2.0 [CMS Assessment]
86870-3 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home and Swing bed OMRA (NO/SO) item set [CMS Assessment]
86522-0 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
86872-9 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
86871-1 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
86873-7 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
86856-2 Deprecated MDS v3.0 - RAI v1.14.1 - Nursing home PPS (NP) and Nursing home quarterly (NQ) item set [CMS Assessment]
86876-0 Deprecated MDS v3.0 - RAI v1.14.1 - Swing bed PPS (SP) item set [CMS Assessment]
88279-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88282-9 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88283-7 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88284-5 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88285-2 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88287-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home PPS (NP) item set [CMS Assessment]
88292-8 Deprecated MDS v3.0 - RAI v1.15.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88288-6 Deprecated MDS v3.0 - RAI v1.15.1 - Swing bed PPS (SP) item set [CMS Assessment]
88951-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home and Swing bed OMRA (NO and SO) item set [CMS Assessment]
88954-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
88945-1 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home discharge (ND) and Swing bed discharge (SD) item set [CMS Assessment]
88946-9 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA start of therapy and discharge (NSD) and Swing bed OMRA start of therapy and discharge (SSD) item set [CMS Assessment]
88947-7 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home OMRA-discharge (NOD) and Swing bed OMRA-discharge (SOD) item set [CMS Assessment]
88949-3 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home PPS (NP) item set [CMS Assessment]
88955-0 Deprecated MDS v3.0 - RAI v1.16.1 - Nursing home quarterly (NQ) item set [CMS Assessment]
88950-1 Deprecated MDS v3.0 - RAI v1.16.1 - Swing bed PPS (SP) item set [CMS Assessment]
54580-6 Deprecated Minimum Data Set - version 3.0

52494-2 Observational Assessment of Cognitive Status

Observation ID in Form

C

Skip Logic

Complete this section only if patient could not be interviewed.

Form Coding Instructions

Complete during the 2-day assessment period

Source: Centers for Medicare & Medicaid Services

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Observational Assessment of Cognitive Status at 2D Assessment Period
Property
-
Time
2D
System
^Patient
Scale
-
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52596-4 Memory/recall ability

Observation ID in Form

C1

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Memory &or recall ability during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Nom
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64

Normative Answer List LL566-1

Answer Code Score Answer ID
Current season a LA9962-7
Location of own room b LA9998-1
Staff names and faces c LA10085-1
That he or she is in a hospital, nursing home, or home d LA10093-5
None of the above are recalled e LA10031-5
Unable to assess. Specify reason f LA10106-5

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52597-2 Specify reason

Observation ID in Form

C1f

Fully-Specified Name

Component
Unable to assess memory &or recall ability during 2D assessment period .specified reason
Property
Find
Time
2D
System
^Patient
Scale
Nom
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.27
Last Updated
Version 2.64

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52495-9 Confusion Assessment Method (CAM)

Reference Information

Type Source Reference
Article NCBI PubMed Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Link to PubMed

Observation ID in Form

D

Skip Logic

Complete this section only if patient scored 0 or 1 on B2a. Or B2b. Code the following behaviors during the 2-day assessment period. Indicate the status regardless of cause.

Fully-Specified Name

Component
Confusion Assessment Method (CAM)
Property
-
Time
Pt
System
^Patient
Scale
-
Method
Observed.CAM.CARE

Basic Attributes

Class
PANEL.SURVEY.CAM
Type
Surveys
First Released
Version 2.24
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52738-2 Inattention

Term Description

The patient has difficulty focusing attention (e.g., easily distracted, out of touch, or difficulty keeping track of what is said).
Source: Regenstrief LOINC

Reference Information

Type Source Reference
Article NCBI PubMed Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Link to PubMed

Observation ID in Form

D1

Fully-Specified Name

Component
Inattention during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
Observed.CAM.CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.29
Last Updated
Version 2.54

Normative Answer List LL567-9

Answer Code Score Answer ID
Behavior is not present. 0 LA9938-7
Behavior continuously present does not fluctuate. 1 LA9937-9
Behavior present, fluctuates (e.g., comes and goes, changes in severity). 2 LA9939-5

Member of these Panels

LOINC Long Common Name
52495-9 Confusion Assessment Method (CAM)
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52739-0 Disorganized thinking

Term Description

The patient's thinking is disorganized or incoherent (e.g., rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching of topics or ideas).
Source: Regenstrief LOINC

Reference Information

Type Source Reference
Article NCBI PubMed Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Link to PubMed

Observation ID in Form

D2

Fully-Specified Name

Component
Disorganized thinking during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
Observed.CAM.CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.29
Last Updated
Version 2.54

Normative Answer List LL567-9

Answer Code Score Answer ID
Behavior is not present. 0 LA9938-7
Behavior continuously present does not fluctuate. 1 LA9937-9
Behavior present, fluctuates (e.g., comes and goes, changes in severity). 2 LA9939-5

Member of these Panels

LOINC Long Common Name
52495-9 Confusion Assessment Method (CAM)
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52740-8 Altered level of consciousness/alertness

Term Description

The patient has an altered level of consciousness: vigilant (e.g., startles easily to any sound or touch), lethargic (e.g., repeatedly dozes off when asked questions, but responds to voice or touch), stuporous (e.g., very difficult to arouse and keep arou
Source: Regenstrief LOINC

Reference Information

Type Source Reference
Article NCBI PubMed Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Link to PubMed

Observation ID in Form

D3

Fully-Specified Name

Component
Altered level of consciousness &or alertness during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
Observed.CAM.CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.29
Last Updated
Version 2.54

Normative Answer List LL567-9

Answer Code Score Answer ID
Behavior is not present. 0 LA9938-7
Behavior continuously present does not fluctuate. 1 LA9937-9
Behavior present, fluctuates (e.g., comes and goes, changes in severity). 2 LA9939-5

Member of these Panels

LOINC Long Common Name
52495-9 Confusion Assessment Method (CAM)
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52741-6 Psychomotor retardation

Term Description

Patient has an unusually decreased level of activity (e.g., sluggishness, staring into space, staying in one position, moving very slowly).
Source: Regenstrief LOINC

Reference Information

Type Source Reference
Article NCBI PubMed Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Link to PubMed

Observation ID in Form

D4

Fully-Specified Name

Component
Psychomotor retardation during 2D assessment period
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
Observed.CAM.CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.29
Last Updated
Version 2.54

Normative Answer List LL567-9

Answer Code Score Answer ID
Behavior is not present. 0 LA9938-7
Behavior continuously present does not fluctuate. 1 LA9937-9
Behavior present, fluctuates (e.g., comes and goes, changes in severity). 2 LA9939-5

Member of these Panels

LOINC Long Common Name
52495-9 Confusion Assessment Method (CAM)
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52500-6 Pain

Observation ID in Form

G

Form Coding Instructions

Complete during the 2-day assessment period

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

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

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Panel Type
Panel

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52603-8 Pain Interview Attempted?

Observation ID in Form

G1

Skip Logic

If No, skip to G6. Pain Observational Assessment.

Fully-Specified Name

Component
Pain interview was attempted
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Survey Question

Text
Pain Interview Attempted?
Source
CARE I.g01

Normative Answer List LL251-0

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

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52604-6 Pain Presence. Ask patient: "Have you had pain or hurting at any time during the last 2 days?"

Observation ID in Form

G2

Skip Logic

If No, skip to Section V. Impairments. If Unable, skip to G6. Pain Observational Assessment.

Fully-Specified Name

Component
Pain presence during last 2D
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Survey Question

Text
Pain Presence. Ask patient: "Have you had pain or hurting at any time during the last 2 days?"
Source
CARE I.g02

Normative Answer List LL569-5

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Unable to answer or no response 8 LA10104-0

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52742-4 Pain Severity. Ask patient: "Please rate your worst pain during the last 2 days on a zero to 10 scale, with zero being no pain and 10 as the worst pain you can imagine."

Observation ID in Form

G3

Skip Logic

If patient does not answer or is unable to respond and skip to G6. Pain Observational Assessment.

Form Coding Instructions

Enter 88 if patient does not answer or is unable to respond

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Pain severity during last 2D
Property
Score
Time
2D
System
^Patient
Scale
Ord
Method
Reported

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.52

Survey Question

Text
Please rate your worst pain during the last 2 days on a zero to 10 scale, with zero being no pain and 10 as the worst pain you can imagine.
Source
CARE I.g03

Preferred Answer List LL571-1

Answer Code Score Answer ID
0 0 LA6111-4
1 1 LA6112-2
2 or more 2 LA6113-0
3 3 LA6114-8
4 4 LA6115-5
5 5 LA10137-0
6 6 LA10138-8
7 7 LA10139-6
8 8 LA10140-4
9 9 LA10141-2
10 10 LA13942-0
Patient does not answer or is unable to respond 88 LA10056-2

Member of these Panels

LOINC Long Common Name
76464-7 American Physical Therapy Association registry panel
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52605-3 Pain Effect on Sleep. Ask patient: "During the past 2 days, has pain made it hard for you to sleep?"

Observation ID in Form

G4

Fully-Specified Name

Component
Pain has made it hard to sleep during last 2D
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Survey Question

Text
Pain Effect on Sleep. Ask patient: "During the past 2 days, has pain made it hard for you to sleep?"
Source
CARE I.g04

Normative Answer List LL569-5

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Unable to answer or no response 8 LA10104-0

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52606-1 Pain Effect on Activities. Ask patient: "During the past 2 days, have you limited your activities because of pain?"

Observation ID in Form

G5

Fully-Specified Name

Component
Limited activities because of pain during last 2D
Property
Find
Time
2D
System
^Patient
Scale
Ord
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Survey Question

Text
Pain Effect on Activities. Ask patient: "During the past 2 days, have you limited your activities because of pain?"
Source
CARE I.g05

Normative Answer List LL569-5

Answer Code Score Answer ID
No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) 0 LA32-8
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Unable to answer or no response 8 LA10104-0

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission

52607-9 Pain Observational Assessment. If the patient could not be interviewed for pain assessment, check all indicators of of pain or possible pain

Observation ID in Form

G6

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Form Coding Instructions

Pain Observational Assessment. If patient could not be interviewed for pain assessment, check all indicators of pain or possible pain Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Pain Observational Assessment
Property
Find
Time
Pt
System
^Patient
Scale
Nom
Method
CARE

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64

Normative Answer List LL572-9

Answer Code Score Answer ID
Non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning) A LA10034-9
Vocal complaints of pain (e.g., that hurts, ouch, stop) B LA10116-4
Facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) C LA9968-4
Protective body movements or postures (e.g., bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement) D LA10063-8
None of these signs observed or documented E LA10032-3

Member of these Panels

LOINC Long Common Name
52745-7 Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Discharge
52743-2 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Acute Care
52748-1 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Home Health Admission
52746-5 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Interim
52744-0 Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Post Acute Care (PAC) - Admission