85814-2
Signature of Persons Completing the Assessment
Active
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 ensuring that patients receive appropriate and quality care, and 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 I may be personally subject to or may subject my organization to substantial criminal, civil, and/or administrative penalties for submitting false information
Source: Centers for Medicare & Medicaid Services85647-6 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
| 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] |
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106625-7 | Hospice Outcomes and Patient Evaluation (HOPE) Discharge v1.0 during assessment period [CMS Assessment] |
| 107631-4 | Hospice Outcomes and Patient Evaluation (HOPE) Discharge v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
| 113114-3 | Inpatient Rehabilitation Facility - Patient Assessment Instrument - version 4.4 during assessment period [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] |
| 113119-2 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.3 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] |
| 113164-8 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.3 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] |
| 113166-3 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.3 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] |
| 113165-5 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.3 during assessment period [CMS Assessment] |
| 108256-9 | Minimum 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
| 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] |
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106625-7 | Hospice Outcomes and Patient Evaluation (HOPE) Discharge v1.0 during assessment period [CMS Assessment] |
| 107631-4 | Hospice Outcomes and Patient Evaluation (HOPE) Discharge v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
| 113114-3 | Inpatient Rehabilitation Facility - Patient Assessment Instrument - version 4.4 during assessment period [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] |
| 113119-2 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.3 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] |
| 113164-8 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.3 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] |
| 113166-3 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.3 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] |
| 113165-5 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.3 during assessment period [CMS Assessment] |
| 108256-9 | Minimum Data Set (MDS) - version 3.0 - Resident Assessment Instrument (RAI) version 1.20.1 during assessment period [CMS Assessment] |
70158-1 Date Information is Provided and Time
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
| 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] |
| 106623-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.0 during assessment period [CMS Assessment] |
| 107632-2 | Hospice Outcomes and Patient Evaluation (HOPE) Admission v1.01 during assessment period [CMS Assessment] |
| 106625-7 | Hospice Outcomes and Patient Evaluation (HOPE) Discharge v1.0 during assessment period [CMS Assessment] |
| 107631-4 | Hospice Outcomes and Patient Evaluation (HOPE) Discharge v1.01 during assessment period [CMS Assessment] |
| 106933-5 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.0 [CMS Assessment] |
| 107633-0 | Hospice Outcomes and Patient Evaluation (HOPE) Update Visit v1.01 during assessment period [CMS Assessment] |
| 113114-3 | Inpatient Rehabilitation Facility - Patient Assessment Instrument - version 4.4 during assessment period [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] |
| 113119-2 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 5.3 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] |
| 113164-8 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Expired - version 5.3 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] |
| 113166-3 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Planned Discharge - version 5.3 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] |
| 113165-5 | Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Unplanned Discharge - version 5.3 during assessment period [CMS Assessment] |
| 108256-9 | Minimum Data Set (MDS) - version 3.0 - Resident Assessment Instrument (RAI) version 1.20.1 during assessment period [CMS Assessment] |