46496-6 Patient Identification

Term Description

Agency-specific patient identifier. This is the identification code the agency assigns to the patient and uses for record keeping purposes for this episode of care.

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Agency patient number

Property

ID

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Long Common Name

Agency patient number 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: Added "Agency" to COMPONENT to indicate that this ID is assigned by the CMS agency; Updated METHOD from OASIS to CMS Assessment to use term 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
• Ident
• Identifier
• No
• Nominal
• Num
• Patient #
• Report period
• Survey

Related Codes

21112-8 Birth date

Type of Entry

Question expects user entry - requires response [Q]

Fully-Specified Name

Component

Birth date

Property

TmStp

Time

Pt

System

^Patient

Scale

Qn

Method

Basic Attributes

Class

MISC

Type

Laboratory

First Released

Version 1.0m

Last Updated

Version 2.73 (MIN)

Order vs. Observation

Observation

Common Test Rank Get Info

1746

HL7^® Attributes

HL7^® Field ID

PID-7.1

Member of these Panels

Language Variants Get Info

Related Names

• Birthdate
• Date and time
• Date of birth
• DOB
• MISC
• Point in time
• QNT
• Quan
• Quant
• Quantitative
• Random
• Time stamp
• Timestamp

Example Units

Related Codes

58237-9 Hospital

Fully-Specified Name

Component

Name

Property

ID

Time

Pt

System

Hospital

Scale

Nom

Method

Long Common Name

Hospital Name

Basic Attributes

Class

PHENX

Type

Clinical

First Released

Version 2.30

Last Updated

Version 2.64 (MIN)

Change Reason

Changed Long Common Name from "Name [Identifier] Hospital" to "Hospital Name" for clarity

Member of these Panels

Language Variants Get Info

Related Names

• Hosp
• Ident
• Identifier
• Inpatient
• Nominal
• PhenX
• Point in time
• Random

Related Codes

65844-3 Date of exam

Fully-Specified Name

Component

Date of observation

Property

Date

Time

Pt

System

XXX

Scale

Qn

Method

Long Common Name

Date of observation (non-patient)

Basic Attributes

Class

MISC

Type

Laboratory

First Released

Version 2.36

Last Updated

Version 2.73 (MIN)

Order vs. Observation

Observation

Common Test Rank Get Info

18194

HL7^® Attributes

HL7^® Field ID

OBX-14

Member of these Panels

Language Variants Get Info

Related Names

• Misc
• Miscellaneous
• Observation date
• Other
• Point in time
• QNT
• Quan
• Quant
• Quantitative
• Random
• Spec
• To be specified in another part of the message
• Unspecified

70183-9 Interval

Fully-Specified Name

Component

NIH stroke scale interval

Property

Find

Time

Pt

System

^Patient

Scale

Nom

Method

NIHSS

Long Common Name

NIH stroke scale interval [NIH Stroke Scale]

Basic Attributes

Class

SURVEY.NEURO

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.44 (MIN)

Normative Answer List LL2023-1

Member of these Panels

Related Names

• Finding
• Findings
• NEURO
• NIHSS
• NIHSS interval
• Nominal
• Point in time
• Random
• Survey
• SURVEY.NEURO

70184-7 Level of consciousness [NIH Stroke Scale]

Term Description

Tests stimulation and is graded from 0-3

Observation ID in Form

1a

Form Coding Instructions

The investigator must choose a response if a full evaluation is prevented by such obstacles as an endotracheal tube, language barrier, orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement (other than reflexive posturing) in response to noxious stimulation

Fully-Specified Name

Component

Level of consciousness

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

NIHSS

Basic Attributes

Class

SURVEY.NEURO

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.44 (MIN)

Normative Answer List LL2024-9

Member of these Panels

Related Names

• Finding
• Findings
• Levels
• Levl
• LV
• LVL
• NEURO
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.NEURO

70185-4 LOC questions [NIH Stroke Scale]

Term Description

Tests patient's ability to answer questions correctly and is graded from 0-2

Observation ID in Form

1b

Form Coding Instructions

The patient is asked the month and his/her age. The answer must be correct - there is no partial credit for being close. Aphasic and stuporous patients who do not comprehend the questions will score 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from any cause, language barrier, or any other problem not secondary to aphasia are given a 1. It is important that only the initial answer be graded and that the examiner not "help" the patient with verbal or non-verbal cues

Fully-Specified Name

Component

LOC questions

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

NIHSS

Basic Attributes

Class

SURVEY.NEURO

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.44 (MIN)

Normative Answer List LL2025-6

Member of these Panels

Related Names

• Finding
• Findings
• NEURO
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.NEURO

70186-2 LOC commands [NIH Stroke Scale]

Term Description

Tests patient's ability to perform tasks correctly and is graded from 0-2

Observation ID in Form

1c

Form Coding Instructions

The patient is asked to open and close the eyes and then to grip and release the non-paretic hand. Substitute another one step command if the hands cannot be used. Credit is given if an unequivocal attempt is made but not completed due to weakness. If the patient does not respond to command, the task should be demonstrated to him or her (pantomime), and the result scored (i.e., follows none, one or two commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. Only the first attempt is scored

Fully-Specified Name

Component

LOC commands

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

NIHSS

Basic Attributes

Class

SURVEY.NEURO

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.44 (MIN)

Normative Answer List LL2026-4

Member of these Panels

Related Names

• Finding
• Findings
• NEURO
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.NEURO

70187-0 Best gaze [NIH Stroke Scale]

Term Description

Tests horizontal eye movement and is graded from 0-2

Observation ID in Form

2

Form Coding Instructions

Only horizontal eye movements will be tested. Voluntary or reflexive (oculocephalic) eye movements will be scored, but caloric testing is not done. If the patient has a conjugate deviation of the eyes that can be overcome by voluntary or reflexive activity, the score will be 1. If a patient has an isolated peripheral nerve paresis (CN III, IV or VI), score a 1. Gaze is testable in all aphasic patients. Patients with ocular trauma, bandages, pre-existing blindness, or other disorder of visual acuity or fields should be tested with reflexive movements, and a choice made by the investigator. Establishing eye contact and then moving about the patient from side to side will occasionally clarify the presence of a partial gaze palsy

Fully-Specified Name

Component

Best gaze

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

NIHSS

Basic Attributes

Class

SURVEY.NEURO

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.44 (MIN)

Normative Answer List LL2027-2

Member of these Panels

Related Names

• Finding
• Findings
• NEURO
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.NEURO

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.

70188-8 Visual [NIH Stroke Scale]

Term Description

Tests visual fields and is graded from 0-3

Observation ID in Form

3

Form Coding Instructions

Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or visual threat, as appropriate. Patients may be encouraged, but if they look at the side of the moving fingers appropriately, this can be scored as normal. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. Score 1 only if a clear-cut asymmetry, including quadrantanopia, is found. If patient is blind from any cause, score 3. Double simultaneous stimulation is performed at this point. If there is extinction, patient receives a 1, and the results are used to respond to item 11

Fully-Specified Name

Component

Visual

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

NIHSS

Basic Attributes

Class

SURVEY.NEURO

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.44 (MIN)

Normative Answer List LL2028-0

Member of these Panels

Related Names

• Finding
• Findings
• NEURO
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.NEURO

70189-6 Facial palsy [NIH Stroke Scale]

Term Description

Tests the patient's ability to move facial muscles and is graded from 0-3

Observation ID in Form

4

Form Coding Instructions

Ask - or use pantomime to encourage - the patient to show teeth or raise eyebrows and close eyes. Score symmetry of grimace in response to noxious stimuli in the poorly responsive or non-comprehending patient. If facial trauma/bandages, orotracheal tube, tape or other physical barriers obscure the face, these should be removed to the extent possible

Fully-Specified Name

Component

Facial palsy

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

NIHSS

Basic Attributes

Class

SURVEY.NEURO

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.44 (MIN)

Normative Answer List LL2029-8

Member of these Panels

Related Names

• Finding
• Findings
• NEURO
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.NEURO

70190-4 Motor arm Left arm [NIH Stroke Scale]

Term Description

Tests motor abilities of the arms and is graded from 0-4

Observation ID in Form

5a

Form Coding Instructions

The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic arm. Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice

Fully-Specified Name

Component

Motor arm

Property

Find

Time

Pt

System

Arm.left

Scale

Ord

Method

NIHSS

Basic Attributes

Class

SURVEY.NEURO

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.44 (MIN)

Normative Answer List LL2030-6

Member of these Panels

Related Names

• Arm.lft
• Finding
• Findings
• L
• LT
• NEURO
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.NEURO
• Upper extremity

70967-5 Motor arm Right arm [NIH Stroke Scale]

Observation ID in Form

5b

Fully-Specified Name

Component

Motor arm

Property

Find

Time

Pt

System

Arm.right

Scale

Ord

Method

NIHSS

Basic Attributes

Class

SURVEY.NEURO

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.67 (MIN)

Order vs. Observation

Observation

Normative Answer List LL2030-6

Member of these Panels

Related Names

• Arm.rght
• Finding
• Findings
• NEURO
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• R
• Random
• RT
• Screen
• Survey
• SURVEY.NEURO
• Upper extremity

70191-2 Motor leg Leg - left [NIH Stroke Scale]

Term Description

Tests motor abilites of the legs and is graded from 0-4

Observation ID in Form

6a

Form Coding Instructions

The limb is placed in the appropriate position: hold the leg at 30 degrees (always tested supine). Drift is scored if the leg falls before 5 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic leg. Only in the case of amputation or joint fusion at the hip, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice

Fully-Specified Name

Component

Motor leg

Property

Find

Time

Pt

System

Leg.left

Scale

Ord

Method

NIHSS

Basic Attributes

Class

SURVEY.NEURO

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.44 (MIN)

Normative Answer List LL2031-4

Member of these Panels

Related Names

• Finding
• Findings
• L
• Leg-L
• Lower extremity
• LT
• NEURO
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.NEURO

70968-3 Motor leg Leg - right [NIH Stroke Scale]

Observation ID in Form

6b

Fully-Specified Name

Component

Motor leg

Property

Find

Time

Pt

System

Leg.right

Scale

Ord

Method

NIHSS

Basic Attributes

Class

SURVEY.NEURO

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.67 (MIN)

Order vs. Observation

Observation

Normative Answer List LL2031-4

Member of these Panels

Related Names

• Finding
• Findings
• Leg-R
• Lower extremity
• NEURO
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• R
• Random
• RT
• Screen
• Survey
• SURVEY.NEURO

70192-0 Limb ataxia [NIH Stroke Scale]

Term Description

Tests coordination of muscle movements and is graded from 0-2

Observation ID in Form

7

Form Coding Instructions

This item is aimed at finding evidence of a unilateral cerebellar lesion. Test with eyes open. In case of visual defect, ensure testing is done in intact visual field. The finger-nose-finger and heel-shin tests are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is absent in the patient who cannot understand or is paralyzed. Only in the case of amputation or joint fusion, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice. In case of blindness, test by having the patient touch nose from extended arm position

Fully-Specified Name

Component

Limb ataxia

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

NIHSS

Basic Attributes

Class

SURVEY.NEURO

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.44 (MIN)

Normative Answer List LL2032-2

Member of these Panels

Related Names

• Finding
• Findings
• NEURO
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.NEURO

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.

70193-8 Sensory [NIH Stroke Scale]

Term Description

Tests sensation of the face, arms. And legs and is graded from 0-2

Observation ID in Form

8

Form Coding Instructions

Sensation or grimace to pinprick when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient. Only sensory loss attributed to stroke is scored as abnormal and the examiner should test as many body areas (arms [not hands], legs, trunk, face) as needed to accurately check for hemisensory loss

Fully-Specified Name

Component

Sensory

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

NIHSS

Basic Attributes

Class

SURVEY.NEURO

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.44 (MIN)

Normative Answer List LL2033-0

Member of these Panels

Related Names

• Finding
• Findings
• NEURO
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.NEURO

70194-6 Best language [NIH Stroke Scale]

Term Description

Tests the patient's comprehension and communication and is graded from 0-3

Reference Information

Type	Source	Reference
Image	National Institutes of Health	NIHSS Image for Best Language
Image	National Institutes of Health	NIHSS Image for Best Language
Image	National Institutes of Health	NIHSS Image for Best Language

Observation ID in Form

9

Form Coding Instructions

A great deal of information about comprehension will be obtained during the preceding sections of the examination. For this scale item, the patient is asked to describe what is happening in the attached picture, to name the items on the attached naming sheet and to read from the attached list of sentences. Comprehension is judged from responses here, as well as to all of the commands in the preceding general neurological exam. If visual loss interferes with the tests, ask the patient to identify objects placed in the hand, repeat, and produce speech. The intubated patient should be asked to write. The patient in a coma (item 1a=3) will automatically score 3 on this item. The examiner must choose a score for the patient with stupor or limited cooperation, but a score of 3 should be used only if the patient is mute and follows no one-step commands

Fully-Specified Name

Component

Best language

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

NIHSS

Basic Attributes

Class

SURVEY.NEURO

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.44 (MIN)

Normative Answer List LL2034-8

Member of these Panels

Related Names

• Finding
• Findings
• NEURO
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.NEURO

70195-3 Dysarthria [NIH Stroke Scale]

Term Description

Tests patient's speech and is graded from 0-2

Reference Information

Type	Source	Reference
Image	National Institutes of Health	NIHSS Image for Dysarthria

Observation ID in Form

10

Form Coding Instructions

If patient is thought to be normal, an adequate sample of speech must be obtained by asking patient to read or repeat words from the attached list. If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be rated. Only if the patient is intubated or has other physical barriers to producing speech, the examiner should record the score as untestable (UN), and clearly write an explanation for this choice. Do not tell the patient why he or she is being tested

Fully-Specified Name

Component

Dysarthria

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

NIHSS

Basic Attributes

Class

SURVEY.NEURO

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.44 (MIN)

Normative Answer List LL2035-5

Member of these Panels

Related Names

• Finding
• Findings
• NEURO
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.NEURO

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.

70196-1 Extinction and inattention [NIH Stroke Scale]

Term Description

Tests patient's recognition of self and is graded from 0-2

Observation ID in Form

11

Form Coding Instructions

Sufficient information to identify neglect may be obtained during the prior testing. If the patient has a severe visual loss preventing visual double simultaneous stimulation, and the cutaneous stimuli are normal, the score is normal. If the patient has aphasia but does appear to attend to both sides, the score is normal. The presence of visual spatial neglect or anosagnosia may also be taken as evidence of abnormality. Since the abnormality is scored only if present, the item is never untestable

Fully-Specified Name

Component

Extinction and inattention

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

NIHSS

Basic Attributes

Class

SURVEY.NEURO

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.44 (MIN)

Normative Answer List LL2036-3

Member of these Panels

Related Names

• Extinction - inattention
• Finding
• Findings
• NEURO
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Screen
• Survey
• SURVEY.NEURO

72089-6 Total score [NIH Stroke Scale]

Term Description

Used to gauge the severity of a stroke. Patients are given more points for greater deficiencies. A score of 0 indicates that the test is normal.

Fully-Specified Name

Component

Total score

Property

Score

Time

Pt

System

^Patient

Scale

Qn

Method

NIHSS

Basic Attributes

Class

SURVEY.NEURO

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.67 (MIN)

Order vs. Observation

Observation

Member of these Panels

Related Names

• NEURO
• Point in time
• QNT
• Quan
• Quant
• Quantitative
• Random
• Scale
• Scre
• Survey
• SURVEY.NEURO
• Tot
• Totl

Example Units