Version 2.78

52522-0 Overall Plan of Care/Advance Care Directives

Observation ID in Form

A

Fully-Specified Name

Component
Overall Plan of Care &or Advance Care Directives - Subheading
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

52685-5 Have the patient (or representative) and the care team (or physician) documented agreed-upon care goals and expected dates of completion or re-evaluation?

Observation ID in Form

A1

Fully-Specified Name

Component
Care goals documented
Property
Find
Time
Pt
System
^Patient
Scale
Ord
Method

Basic Attributes

Class
SURVEY.CARE
Type
Surveys
First Released
Version 2.26
Last Updated
Version 2.64
Change Reason
Method removed and Answer List Type changed to Example because this generic term can be used across contexts

Survey Question

Text
Have the patient (or representative) and the care team (or physician) documented agreed-upon care goals and expected dates of completion or re-evaluation?
Source
CARE I.a01

Example Answer List LL588-5

Answer Code Score Answer ID
No, but this work is in process 0 LA10025-7
Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) 1 LA33-6
Unclear or unknown 9 LA10109-9

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

52686-3 Which description best fits the patient's overall status?

Observation ID in Form

A2

Fully-Specified Name

Component
Overall status
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
Which description best fits the patient's overall status?
Source
CARE I.a02

Normative Answer List LL589-3

Answer Code Score Answer ID
The patient is stable with no risk for serious complications and death (beyond those typical of the patient’s age). 1 LA10098-4
The patient is temporarily facing high health risks but likely to return to being stable without risk for serious complications and death (beyond those typical of the patient's age). 2 LA10099-2
The patient is likely to remain in fragile health and have ongoing high risks of serious complications and death. 3 LA10097-6
The patient has serious progressive conditions that could lead to death within a year. 4 LA10096-8
The patient's situation is unknown or unclear to the respondent. 9 LA10100-8

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

52687-1 In anticipation of serious clinical complications, has the patient made care decisions which are documented in the medical record?

Observation ID in Form

A3

Form Coding Instructions

Check all that apply

Source: Centers for Medicare & Medicaid Services

Fully-Specified Name

Component
Decision authority documented
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
In anticipation of serious clinical complications, has the patient made care decisions which are documented in the medical record?
Source
CARE I.A3

Normative Answer List LL590-1

Answer Code Score Answer ID
The patient has designated a decision-maker (if the patient is unable to make decisions) which is documented in the medical record. 1 LA11786-3
The patient (or surrogate) has made a decision to forgo resuscitation which is documented in the medical record. 2 LA11787-1

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