85637-7
Assessment Administration
Active
85648-4 Signature of Persons Completing the Assessment
Observation ID in Form
Z0400A-Z0400L
Form Context
I certify that the accompanying information accurately reflects patient assessment information for this patient and that I collected or coordinated collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable Medicare and Medicaid requirements. I understand that this information is used as a basis for payment from federal funds. I further understand that payment of such federal funds and continued participation in the government-funded health care programs is conditioned on the accuracy and truthfulness of this information, and that submitting false information may subject my organization to a 2% reduction in the Fiscal Year payment determination. I also certify that I am authorized to submit this information by this facility on its behalf
Source: Centers for Medicare & Medicaid ServicesFully-Specified Name
- Component
- Signature of persons completing the assessment
- Property
- -
- Time
- RptPeriod
- System
- Form
- Scale
- -
- Method
- CMS Assessment
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.61
- 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;
- Order vs. Observation
- Subset
- Panel Type
- Organizer
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 85645-0 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment] |
| 85671-6 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment] |
| 85662-5 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment] |
| 85668-2 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment] |
| 103949-4 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment] |
| 103948-6 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment] |
| 103946-0 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment] |
| 103947-8 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment] |
| 101111-3 | MDS v3.0 - RAI v1.18.11 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment] |
| 101108-9 | MDS v3.0 - RAI v1.18.11 - Nursing home and Swing bed tracking (NT and ST) item set [CMS Assessment] |
| 101105-5 | MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment] |
| 101107-1 | MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment] |
| 101109-7 | MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment] |
| 101110-5 | MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment] |
| 101106-3 | MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment] |
| 101113-9 | MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment] |
| 101112-1 | MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment] |
| 104608-5 | MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment] |
| 105008-7 | MDS v3.0 - RAI v1.19.1 - Nursing home and Swing bed tracking (NT ST) item set during assessment period [CMS Assessment] |
| 103564-1 | MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment] |
| 104606-9 | MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment] |
| 105201-8 | MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment] |
| 104552-5 | MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment] |
| 104554-1 | MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment] |
| 104607-7 | MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment] |
| 104609-3 | MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment] |
85647-6 Signature
Fully-Specified Name
- Component
- Signature of person collecting or coordinating collection of assessment information
- Property
- Pn
- Time
- Pt
- System
- Provider
- Scale
- Nar
- Method
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.61
- Last Updated
- Version 2.61
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 103991-6 | CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment] |
| 83265-9 | Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment] |
| 85645-0 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment] |
| 85671-6 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment] |
| 85662-5 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment] |
| 85668-2 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment] |
85650-0 Title
Fully-Specified Name
- Component
- Title of person collecting or coordinating collection of assessment information
- Property
- Type
- Time
- Pt
- System
- Provider
- Scale
- Nom
- Method
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.61
- Last Updated
- Version 2.61
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 103991-6 | CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment] |
| 83265-9 | Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment] |
| 85645-0 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment] |
| 85671-6 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment] |
| 85662-5 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment] |
| 85668-2 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment] |
70157-3 Sections
Fully-Specified Name
- Component
- Form sections completed
- Property
- Type
- Time
- Pt
- System
- Provider
- Scale
- Nom
- Method
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.40
- Last Updated
- Version 2.63
- Change Reason
- Removed METHOD because this term is generic; Corrected Property and System
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 69412-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0 |
| 85645-0 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment] |
| 85671-6 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment] |
| 85662-5 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment] |
| 85668-2 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment] |
70158-1 Date sections completed
Fully-Specified Name
- Component
- Date sections completed
- Property
- TmStp
- Time
- Pt
- System
- Provider
- Scale
- Qn
- Method
Basic Attributes
- Class
- SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.40
- Last Updated
- Version 2.63
- Change Reason
- Removed METHOD because this term is generic;Updated PROPERTY from Date to TmStp include electronic signature in which all time information is stored.; Corrected System
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 103991-6 | CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment] |
| 69412-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0 |
| 83265-9 | Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment] |
| 85645-0 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment] |
| 85671-6 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment] |
| 85662-5 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment] |
| 85668-2 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment] |
70127-6 Signature of Person Verifying Assessment Completion
Observation ID in Form
Z0500A
Fully-Specified Name
- Component
- Signature verifying assessment completion
- Property
- Pn
- Time
- Pt
- System
- ^Patient
- Scale
- Nom
- Method
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.40
- Last Updated
- Version 2.75
- Change Reason
- Release 2.75: PanelType: changed from Observation to Subset Organizer; ORDER_OBS: changed from Observation to Subset Organizer; Previous Releases: Removed METHOD because this term is generic;Changed PROPERTY from Arb to Pn
- Order vs. Observation
- Subset
- Panel Type
- Organizer
Survey Question
- Text
- Signature of assessment coordinator verifying assessment completion
- Source
- LTCH-Z0500
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 97887-4 | Core Outcome Measures Index for the Back [COMI] |
| 97327-1 | Core Outcome Measures Index for the Neck [COMI] |
| 69412-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0 |
| 85645-0 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment] |
| 85671-6 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment] |
| 85662-5 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment] |
| 85668-2 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment] |
| 103949-4 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment] |
| 103948-6 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment] |
| 103946-0 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment] |
| 103947-8 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment] |
| 101111-3 | MDS v3.0 - RAI v1.18.11 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment] |
| 101105-5 | MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment] |
| 101107-1 | MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment] |
| 101109-7 | MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment] |
| 101110-5 | MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment] |
| 101106-3 | MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment] |
| 101113-9 | MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment] |
| 101112-1 | MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment] |
| 104608-5 | MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment] |
| 105008-7 | MDS v3.0 - RAI v1.19.1 - Nursing home and Swing bed tracking (NT ST) item set during assessment period [CMS Assessment] |
| 103564-1 | MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment] |
| 104606-9 | MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment] |
| 105201-8 | MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment] |
| 104552-5 | MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment] |
| 104554-1 | MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment] |
| 104607-7 | MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment] |
| 104609-3 | MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment] |
30947-6 LTCH CARE Data Set completion date
Observation ID in Form
Z0500B
Fully-Specified Name
- Component
- Date form completed
- Property
- Date
- Time
- Pt
- System
- Form
- Scale
- Qn
- Method
Additional Names
- Short Name
- Date form completed
Basic Attributes
- Class
- ADMIN
- Type
- Clinical
- First Released
- Version 2.04
- Last Updated
- Version 2.61
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 97887-4 | Core Outcome Measures Index for the Back [COMI] |
| 97327-1 | Core Outcome Measures Index for the Neck [COMI] |
| 69412-5 | Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0 |
| 85645-0 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment] |
| 85671-6 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment] |
| 85662-5 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment] |
| 85668-2 | Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment] |
| 100203-9 | Knee Society Score post-op panel [Knee Society Score] |
| 100159-3 | Knee Society Score pre-op panel [Knee Society Score] |
| 103949-4 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment] |
| 103948-6 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment] |
| 103946-0 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment] |
| 103947-8 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment] |
| 101111-3 | MDS v3.0 - RAI v1.18.11 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment] |
| 101105-5 | MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment] |
| 101107-1 | MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set during assessment period [CMS Assessment] |
| 101109-7 | MDS v3.0 - RAI v1.18.11 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment] |
| 101110-5 | MDS v3.0 - RAI v1.18.11 - Nursing home PPS (NP) item set during assessment period [CMS Assessment] |
| 101106-3 | MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment] |
| 101113-9 | MDS v3.0 - RAI v1.18.11 - Swing bed discharge (SD) item set during assessment period [CMS Assessment] |
| 101112-1 | MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set during assessment period [CMS Assessment] |
| 104608-5 | MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment] |
| 103564-1 | MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment] |
| 104606-9 | MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment] |
| 105201-8 | MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment] |
| 104552-5 | MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment] |
| 104554-1 | MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment] |
| 104607-7 | MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment] |
| 104609-3 | MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment] |
| 46611-0 | Mental residual functional capacity (RFC) assessment form |
| 74725-3 | Patient safety event report - hospital - device or medical AndOr surgical supply, including health information technology (HIT) - version 1.2 [AHRQ] |
| 74495-3 | Patient safety event report - hospital - healthcare event reporting form (HERF) - version 1.2 [AHRQ] |
| 74080-3 | Patient safety event report - hospital - medication or other substance - version 1.2 [AHRQ] |
| 74502-6 | Patient safety event report - hospital - patient information form (PIF) - version 1.2 [AHRQ] |
| 74501-8 | Patient safety event report - hospital - summary of initial report (SIR) - version 1.2 [AHRQ] |
| 105485-7 | PhenX - healthcare communications protocol 281101 |
| 60687-1 | Test of Infant Motor Performance Version 5.1 |
| 55140-8 | Vaccine Adverse Event Reporting System (VAERS) panel |
Language Variants Get Info
| Tag | Language | Translation |
|---|---|---|
| es-AR | Spanish (Argentina) | fecha de formulario completo: |
| es-MX | Spanish (Mexico) | Formulario de fecha completado: |
| it-IT | Italian (Italy) | Data completamento form: Synonyms: Amministrativo Punto nel tempo (episodio) |
| pt-BR | Portuguese (Brazil) | Data formulário preenchido: Synonyms: Time stamp; |
| ru-RU | Russian (Russian Federation) | Дата форма заполнение: Synonyms: Дата заполнения формы Количественный Точка во времени; |
| zh-CN | Chinese (China) | 表单完成日期: Synonyms: 可用数量表示的; |
Example Units
| Unit | Source |
|---|---|
| {mm/dd/yyyy} | Example UCUM Units |