Log In

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 Services

Fully-Specified Name

Component
Signature of persons completing the assessment
Property
-
Time
RptPeriod
System
Form
Scale
-
Method
CMS Assessment

Long Common Name

Signature of persons completing the assessment during assessment period [CMS Assessment]

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.61
Last Updated
Version 2.83 (PANEL)
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

LOINCLong Common Name
103991-6CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
85645-0Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
106623-2Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment]
107632-2Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment]
106625-7Hospice Outcomes and Patient Evaluation (HOPE) Discharge v1.0 during assessment period [CMS Assessment]
107631-4Hospice Outcomes and Patient Evaluation (HOPE) Discharge v1.01 during assessment period [CMS Assessment]
106933-5Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment]
107633-0Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment]
113114-3Inpatient Rehabilitation Facility - Patient Assessment Instrument - version 4.4 during assessment period [CMS Assessment]
103949-4Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
113119-2Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.3 during assessment period [CMS Assessment]
103948-6Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment]
113164-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.3 during assessment period [CMS Assessment]
103946-0Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
113166-3Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.3 during assessment period [CMS Assessment]
103947-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment]
113165-5Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.3 during assessment period [CMS Assessment]
104608-5MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
105008-7MDS v3.0 - RAI v1.19.1 - Nursing home and Swing bed tracking (NT ST) item set during assessment period [CMS Assessment]
103564-1MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
108256-9Minimum Data Set (MDS) - version 3.0 - Resident Assessment Instrument (RAI) version 1.20.1 during assessment period [CMS Assessment]
100997-6Respiratory Allergen Panel, Area 5 - Serum

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

Long Common Name

Signature of person collecting or coordinating collection of assessment information Provider

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.61
Last Updated
Version 2.61 (ADD)
Order vs. Observation
Observation

Member of these Panels

LOINCLong Common Name
103991-6CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
83265-9Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
85645-0Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
106623-2Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment]
107632-2Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment]
106625-7Hospice Outcomes and Patient Evaluation (HOPE) Discharge v1.0 during assessment period [CMS Assessment]
107631-4Hospice Outcomes and Patient Evaluation (HOPE) Discharge v1.01 during assessment period [CMS Assessment]
106933-5Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment]
107633-0Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment]
113114-3Inpatient Rehabilitation Facility - Patient Assessment Instrument - version 4.4 during assessment period [CMS Assessment]
103949-4Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
113119-2Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.3 during assessment period [CMS Assessment]
103948-6Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment]
113164-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.3 during assessment period [CMS Assessment]
103946-0Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
113166-3Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.3 during assessment period [CMS Assessment]
103947-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment]
113165-5Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.3 during assessment period [CMS Assessment]
108256-9Minimum Data Set (MDS) - version 3.0 - Resident Assessment Instrument (RAI) version 1.20.1 during assessment period [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

Long Common Name

Title of person collecting or coordinating collection of assessment information Provider

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.61
Last Updated
Version 2.61 (ADD)
Order vs. Observation
Observation

Member of these Panels

LOINCLong Common Name
103991-6CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
83265-9Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
85645-0Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
106623-2Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment]
107632-2Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment]
106625-7Hospice Outcomes and Patient Evaluation (HOPE) Discharge v1.0 during assessment period [CMS Assessment]
107631-4Hospice Outcomes and Patient Evaluation (HOPE) Discharge v1.01 during assessment period [CMS Assessment]
106933-5Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment]
107633-0Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment]
113114-3Inpatient Rehabilitation Facility - Patient Assessment Instrument - version 4.4 during assessment period [CMS Assessment]
103949-4Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
113119-2Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.3 during assessment period [CMS Assessment]
103948-6Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment]
113164-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.3 during assessment period [CMS Assessment]
103946-0Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
113166-3Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.3 during assessment period [CMS Assessment]
103947-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment]
113165-5Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.3 during assessment period [CMS Assessment]
108256-9Minimum Data Set (MDS) - version 3.0 - Resident Assessment Instrument (RAI) version 1.20.1 during assessment period [CMS Assessment]

70157-3 Sections

Fully-Specified Name

Component
Form sections completed
Property
Type
Time
Pt
System
Provider
Scale
Nom
Method

Long Common Name

Form sections completed Provider

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.40
Last Updated
Version 2.63 (MAJ)
Change Reason
Removed METHOD because this term is generic; Corrected Property and System
Order vs. Observation
Observation

Member of these Panels

LOINCLong Common Name
69412-5Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
85645-0Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2Deprecated 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

Long Common Name

Date sections completed Provider

Basic Attributes

Class
SURVEY.CMS
Type
Surveys
First Released
Version 2.40
Last Updated
Version 2.63 (MAJ)
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

LOINCLong Common Name
103991-6CMS - Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 4.2 during assessment period [CMS Assessment]
69412-5Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
83265-9Deprecated Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) - version 1.4 [CMS Assessment]
85645-0Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
106623-2Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment]
107632-2Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment]
106625-7Hospice Outcomes and Patient Evaluation (HOPE) Discharge v1.0 during assessment period [CMS Assessment]
107631-4Hospice Outcomes and Patient Evaluation (HOPE) Discharge v1.01 during assessment period [CMS Assessment]
106933-5Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment]
107633-0Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment]
113114-3Inpatient Rehabilitation Facility - Patient Assessment Instrument - version 4.4 during assessment period [CMS Assessment]
103949-4Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
113119-2Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.3 during assessment period [CMS Assessment]
103948-6Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment]
113164-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.3 during assessment period [CMS Assessment]
103946-0Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
113166-3Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.3 during assessment period [CMS Assessment]
103947-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment]
113165-5Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.3 during assessment period [CMS Assessment]
108256-9Minimum Data Set (MDS) - version 3.0 - Resident Assessment Instrument (RAI) version 1.20.1 during assessment period [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
RptPeriod
System
^Patient
Scale
Nom
Method
CMS Assessment

Long Common Name

Signature verifying assessment completion during assessment period [CMS Assessment]

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.40
Last Updated
Version 2.83 (PANEL)
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

Member of these Panels

LOINCLong Common Name
97887-4Core Outcome Measures Index for the Back [COMI]
97327-1Core Outcome Measures Index for the Neck [COMI]
69412-5Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
85645-0Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
106623-2Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment]
107632-2Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment]
106625-7Hospice Outcomes and Patient Evaluation (HOPE) Discharge v1.0 during assessment period [CMS Assessment]
107631-4Hospice Outcomes and Patient Evaluation (HOPE) Discharge v1.01 during assessment period [CMS Assessment]
106933-5Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment]
107633-0Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment]
103949-4Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
113119-2Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.3 during assessment period [CMS Assessment]
103948-6Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment]
113164-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.3 during assessment period [CMS Assessment]
103946-0Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
113166-3Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.3 during assessment period [CMS Assessment]
103947-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment]
113165-5Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.3 during assessment period [CMS Assessment]
104608-5MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
105008-7MDS v3.0 - RAI v1.19.1 - Nursing home and Swing bed tracking (NT ST) item set during assessment period [CMS Assessment]
103564-1MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
108256-9Minimum Data Set (MDS) - version 3.0 - Resident Assessment Instrument (RAI) version 1.20.1 during assessment period [CMS Assessment]
100997-6Respiratory Allergen Panel, Area 5 - Serum

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

Long Common Name

Date form completed

Basic Attributes

Class
ADMIN
Type
Clinical
First Released
Version 2.04
Last Updated
Version 2.61 (MIN)
Order vs. Observation
Observation

Member of these Panels

LOINCLong Common Name
97887-4Core Outcome Measures Index for the Back [COMI]
97327-1Core Outcome Measures Index for the Neck [COMI]
69412-5Deprecated Continuity Assessment Record and Evaluation (CARE) tool - Long term care hospital (LTCH) - version 1.0
85645-0Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 3.00 [CMS Assessment]
85671-6Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 3.00 [CMS Assessment]
85662-5Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 3.00 [CMS Assessment]
85668-2Deprecated Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 3.00 [CMS Assessment]
106623-2Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment]
107632-2Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment]
106625-7Hospice Outcomes and Patient Evaluation (HOPE) Discharge v1.0 during assessment period [CMS Assessment]
107631-4Hospice Outcomes and Patient Evaluation (HOPE) Discharge v1.01 during assessment period [CMS Assessment]
106933-5Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment]
107633-0Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment]
100203-9Knee Society Score post-op panel [Knee Society Score]
100159-3Knee Society Score pre-op panel [Knee Society Score]
103949-4Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.1 during assessment period [CMS Assessment]
113119-2Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.3 during assessment period [CMS Assessment]
103948-6Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.1 during assessment period [CMS Assessment]
113164-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.3 during assessment period [CMS Assessment]
103946-0Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.1 during assessment period [CMS Assessment]
113166-3Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.3 during assessment period [CMS Assessment]
103947-8Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.1 during assessment period [CMS Assessment]
113165-5Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.3 during assessment period [CMS Assessment]
104608-5MDS v3.0 - RAI v1.19.1 - Interim Payment Assessment (IPA) item set during assessment period [CMS Assessment]
103564-1MDS v3.0 - RAI v1.19.1 - Nursing home comprehensive (NC) item set during assessment period [CMS Assessment]
104606-9MDS v3.0 - RAI v1.19.1 - Nursing home discharge (ND) item set during assessment period [CMS Assessment]
105201-8MDS v3.0 - RAI v1.19.1 - Nursing home part A PPS discharge (NPE) item set during assessment period [CMS Assessment]
104552-5MDS v3.0 - RAI v1.19.1 - Nursing home PPS (NP) item set during assessment period [CMS Assessment]
104554-1MDS v3.0 - RAI v1.19.1 - Nursing home quarterly (NQ) item set during assessment period [CMS Assessment]
104607-7MDS v3.0 - RAI v1.19.1 - Swing Bed discharge (SD) item set during assessment period [CMS Assessment]
104609-3MDS v3.0 - RAI v1.19.1 - Swing bed PPS (SP) item set during assessment period [CMS Assessment]
46611-0Mental residual functional capacity (RFC) assessment form
107107-5Mini nutritional assessment MNA
108256-9Minimum Data Set (MDS) - version 3.0 - Resident Assessment Instrument (RAI) version 1.20.1 during assessment period [CMS Assessment]
74725-3Patient safety event report - hospital - device or medical AndOr surgical supply, including health information technology (HIT) - version 1.2 [AHRQ]
74495-3Patient safety event report - hospital - healthcare event reporting form (HERF) - version 1.2 [AHRQ]
74080-3Patient safety event report - hospital - medication or other substance - version 1.2 [AHRQ]
74502-6Patient safety event report - hospital - patient information form (PIF) - version 1.2 [AHRQ]
74501-8Patient safety event report - hospital - summary of initial report (SIR) - version 1.2 [AHRQ]
105485-7PhenX - healthcare communications protocol 281101
100997-6Respiratory Allergen Panel, Area 5 - Serum
60687-1Test of Infant Motor Performance Version 5.1
55140-8Vaccine Adverse Event Reporting System (VAERS) panel

Language Variants Get Info

TagLanguageTranslation
el-GRGreek (Greece)Ημερομηνία συμπλήρωσης εντύπου:Ημερομηνία:Pt:Μορφή:Qn:
Synonyms: ADMIN Pt Qn Ημερομηνία Ημερομηνία συμπλήρωσης εντύπου Μορφή
es-ARSpanish (Argentina)fecha de formulario completo:marca de tiempo:fecha y hora:punto en el tiempo:forma:cuantitativo:
es-MXSpanish (Mexico)Formulario de fecha completado:Fecha:Punto temporal:Formulario:Cuantitativo:
it-ITItalian (Italy)Data completamento form:Data:Pt:Modulo:Qn:
Synonyms: Amministrativo Punto nel tempo (episodio)
pt-BRPortuguese (Brazil)Data formulário preenchido:TmStp:Pt:Forma:Qn:
Synonyms: Time stamp; Date and time; Timestamp; Point in time; Random; Quantitative; QNT; Quant; Quan; VACCINE
ru-RURussian (Russian Federation)Дата форма заполнение:Дата:ТчкВрм:Форма:Колич:
Synonyms: Дата заполнения формы Количественный Точка во времени;Момент
zh-CNChinese (China)表单完成日期:日期:时间点:表单:定量型:
Synonyms: 可用数量表示的;定量性;数值型;数量型;连续数值型标尺 日子;几号 时刻;随机;随意;瞬间 行政;管理;施行;执行;经营 表单填写日期 表格;表;窗体

Example Units

UnitSource
{mm/dd/yyyy}Example UCUM Units