85907-4
Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
Deprecated
Status Information
- Status
- DEPRECATED
Term Description
This panel should be used for CMS OASIS-C2 Start of Care assessments performed between January 1, 2017 and December 31, 2018.
Source: Regenstrief LOINC
Panel Hierarchy
Details for each LOINC in Panel LHC-Forms
LOINC | Name | R/O/C | Cardinality | Example UCUM Units |
---|---|---|---|---|
85907-4 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment] | |||
Indent85908-2 | Home Health Patient Tracking Sheet | |||
Indent Indent69417-4 | CMS Certification Number | |||
Indent Indent46494-1 | Branch State | |||
Indent Indent46495-8 | Branch ID Number | |||
Indent Indent68468-8 | National Provider Identifier (NPI) for the attending physician who has signed the plan of care | |||
Indent Indent46496-6 | Patient ID Number | |||
Indent Indent46497-4 | Start of Care Date | {mm/dd/yyyy} | ||
Indent Indent54503-8 | Patient Name | |||
Indent Indent Indent45392-8 | (First) | |||
Indent Indent Indent45393-6 | (MI) | |||
Indent Indent Indent45394-4 | (Last) | |||
Indent Indent Indent45395-1 | (Suffix) | |||
Indent Indent46499-0 | Patient State of Residence | |||
Indent Indent45401-7 | Patient ZIP Code | |||
Indent Indent45397-7 | Medicare Number | |||
Indent Indent45396-9 | Social Security Number | |||
Indent Indent45400-9 | Medicaid Number | |||
Indent Indent21112-8 | Birth Date | {mm/dd/yyyy} | ||
Indent Indent46098-0 | Gender | |||
Indent Indent59362-4 | Race/Ethnicity | 1..6 | ||
Indent Indent57199-2 | Current Payment Sources for Home Care | 1..11 | ||
Indent57040-8 | CLINICAL RECORD ITEMS | |||
Indent Indent46500-5 | Discipline of Person Completing Assessment | |||
Indent Indent46501-3 | Date Assessment Completed | {mm/dd/yyyy} | ||
Indent Indent57200-8 | This Assessment is Currently Being Completed for the Following Reason | |||
Indent Indent57201-6 | Date of Physician-ordered Start of Care (Resumption of Care) | {mm/dd/yyyy} | ||
Indent Indent57202-4 | Date of Referral | {mm/dd/yyyy} | ||
Indent Indent57203-2 | Episode Timing: Is the Medicare home health payment episode for which this assessment will define a case mix group an "early" episode or a "later" episode in the patient's current sequence of adjacent Medicare home health payment episodes? | |||
Indent85909-0 | PATIENT HISTORY AND DIAGNOSES | |||
Indent Indent57204-0 | From which of the following Inpatient Facilities was the patient discharged within the past 14 days? | 1..7 | ||
Indent Indent86470-2 | Inpatient Discharge Date (most recent) | {mm/dd/yyyy} | ||
Indent Indent46504-7 | Inpatient Facility Diagnosis: ICD-10-CM Code | 1..6 | ||
Indent Indent46507-0 | Diagnosis Requiring Medical or Treatment Regimen Change Within Past 14 Days | 1..6 | ||
Indent Indent86469-4 | Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days | 1..6 | ||
Indent Indent85911-6 | Diagnoses, Symptom Control, and Optional Diagnoses | |||
Indent Indent Indent85912-4 | Primary Diagnosis | |||
Indent Indent Indent Indent86255-7 | Primary Diagnosis: ICD-10-code | |||
Indent Indent Indent Indent85920-7 | Primary Diagnosis Symptom Control Rating | |||
Indent Indent Indent Indent85914-0 | Optional Diagnosis: ICD-10-CM | |||
Indent Indent Indent Indent86254-0 | Optional Diagnosis: ICD-10-CM - multiple coding | |||
Indent Indent Indent85913-2 | Other Diagnoses | 0..5 | ||
Indent Indent Indent Indent81885-6 | Other Diagnoses: ICD-10-CM | |||
Indent Indent Indent Indent85920-7 | Other Diagnoses Symptom Control Rating | |||
Indent Indent Indent Indent85914-0 | Optional Diagnosis: ICD-10-CM | |||
Indent Indent Indent Indent86254-0 | Optional Diagnosis: ICD-10-CM - multiple coding | |||
Indent Indent83243-6 | Active Diagnoses-Comorbidities and Co-existing Conditions | 0..2 | ||
Indent Indent46466-9 | Therapies the patient receives at home | 1..3 | ||
Indent Indent57319-6 | Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? | 1..9 | ||
Indent Indent57206-5 | Overall Status: Which description best fits the patient's overall status? | |||
Indent Indent57207-3 | Risk factors, either present or past, likely to affect health status and/or outcome | 1..4 | ||
Indent Indent54567-3 | Height and weight | |||
Indent Indent Indent3137-7 | Height (in inches) | [in_us];cm;m | ||
Indent Indent Indent3141-9 | Weight (in pounds) | [lb_av];kg | ||
Indent85951-2 | Living Arrangements | |||
Indent Indent85950-4 | Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? | |||
Indent57042-4 | SENSORY STATUS | |||
Indent Indent57215-6 | Vision (with corrective lenses if the patient usually wears them) | |||
Indent Indent57216-4 | Ability to Hear (with hearing aid or hearing appliance if normally used) | |||
Indent Indent57217-2 | Understanding of Verbal Content in patient's own language (with hearing aid or device if used) | |||
Indent Indent57218-0 | Speech and Oral (Verbal) Expression of Language (in patient's own language) | |||
Indent Indent57219-8 | Has this patient had a formal Pain Assessment using a standardized, validated pain assessment tool (appropriate to the patient's ability to communicate the severity of pain)? | |||
Indent Indent57220-6 | Frequency of pain interfering with patient's activity or movement | |||
Indent85917-3 | INTEGUMENTARY STATUS | |||
Indent Indent57221-4 | Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers? | |||
Indent Indent57280-0 | Does this patient have a Risk of Developing Pressure Ulcers? | |||
Indent Indent85918-1 | Does this patient have at least one Unhealed Pressure Ulcer at Stage 2 or Higher or designated as Unstageable? | |||
Indent Indent85919-9 | Current Number of Unhealed Pressure Ulcers at Each Stage | |||
Indent Indent Indent55124-2 | Number of Stage 2 pressure ulcers | {#} | ||
Indent Indent Indent55125-9 | Number of Stage 3 pressure ulcers | {#} | ||
Indent Indent Indent55126-7 | Number of Stage 4 pressure ulcers | {#} | ||
Indent Indent Indent54893-3 | Number of unstageable pressure ulcers due to non-removable dressing/device | {#} | ||
Indent Indent Indent54946-9 | Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar | {#} | ||
Indent Indent Indent54950-1 | Number of unstageable pressure ulcers with suspected deep tissue injury in evolution | {#} | ||
Indent Indent57229-7 | Status of Most Problematic Pressure Ulcer that is Observable | |||
Indent Indent46536-9 | Current Number of Stage 1 Pressure Ulcers | {#} | ||
Indent Indent57231-3 | Stage of Most Problematic Unhealed Pressure Ulcer that is Stageable | |||
Indent Indent57232-1 | Does this patient have a Stasis Ulcer? | |||
Indent Indent57233-9 | Current Number of Stasis Ulcer(s) that are Observable | {#} | ||
Indent Indent57234-7 | Status of Most Problematic Stasis Ulcer that is Observable | |||
Indent Indent57235-4 | Does this patient have a Surgical Wound? | |||
Indent Indent57236-2 | Status of Most Problematic Surgical Wound that is Observable | |||
Indent Indent46534-4 | Does this patient have a Skin Lesion or Open Wound (excluding bowel ostomy), other than those described above, that is receiving intervention by the home health agency? | |||
Indent85921-5 | RESPIRATORY STATUS | |||
Indent Indent57237-0 | When is the patient dyspneic or noticeably Short of Breath? | |||
Indent Indent57238-8 | Respiratory Treatments utilized at home | 1..3 | ||
Indent85922-3 | ELIMINATION STATUS | |||
Indent Indent46552-6 | Has this patient been treated for a Urinary Tract Infection in the past 14 days? | |||
Indent Indent46553-4 | Urinary Incontinence or Urinary Catheter Presence | |||
Indent Indent57241-2 | When does Urinary Incontinence occur? | |||
Indent Indent46587-2 | Bowel Incontinence Frequency | |||
Indent Indent86471-0 | Ostomy for Bowel Elimination: Does this patient have an ostomy for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay; or b) necessitated a change in medical or treatment regimen? | |||
Indent57047-3 | NEURO/EMOTIONAL/BEHAVIORAL STATUS | |||
Indent Indent46589-8 | Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands. | |||
Indent Indent58104-1 | When Confused (Reported or Observed Within the Last 14 Days) | |||
Indent Indent86495-9 | When Anxious (Reported or Observed Within the Last 14 Days) | |||
Indent Indent57242-0 | Depression Screening: Has the patient been screened for depression, using a standardized, validated depression screening tool? | |||
Indent Indent Indent58120-7 | PHQ-2© | |||
Indent Indent Indent Indent44250-9 | Little interest or pleasure in doing things | |||
Indent Indent Indent Indent44255-8 | Feeling down, depressed, or hopeless? | |||
Indent Indent46473-5 | Cognitive, behavorial, and psychiatric symptoms that are demonstrated at least once a week (Reported or Observed) | |||
Indent Indent46592-2 | Frequency of Disruptive Behavior Symptoms (Reported or Observed): Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety. | |||
Indent Indent46593-0 | Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse? | |||
Indent85923-1 | ADL & IADLs | |||
Indent Indent46595-5 | Grooming: Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or make up, teeth or denture care, or fingernail care). | |||
Indent Indent46597-1 | Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps. | |||
Indent Indent46599-7 | Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes. | |||
Indent Indent57243-8 | Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair). | |||
Indent Indent57244-6 | Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode. | |||
Indent Indent57245-3 | Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, includes cleaning area around stoma, but not managing equipment. | |||
Indent Indent57246-1 | Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast. | |||
Indent Indent85924-9 | FUNCTIONAL ABILITIES and GOALS - SOC/ROC | |||
Indent Indent Indent85925-6 | Mobility | |||
Indent Indent Indent Indent85926-4 | Lying to Sitting on Side of Bed - SOC Performance | |||
Indent Indent Indent Indent85927-2 | Lying to Sitting on Side of Bed - Discharge Goal | |||
Indent Indent57247-9 | Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces. | |||
Indent Indent57248-7 | Feeding or Eating: Current ability to feed self meals and snacks safely | |||
Indent Indent57249-5 | Current Ability to Plan and Prepare Light Meals (for example, cereal, sandwich) or reheat delivered meals safely. | |||
Indent Indent46569-0 | Ability to Use Telephone: Current ability to answer the phone safely, including dialing numbers, and effectively using the telephone to communicate. | |||
Indent Indent58121-5 | Prior Functioning ADL/IADL | |||
Indent Indent Indent85070-1 | Self-Care (specifically: grooming, dressing, bathing, and toileting hygiene) | |||
Indent Indent Indent86185-6 | Ambulation | |||
Indent Indent Indent86186-4 | Transfer | |||
Indent Indent Indent86187-2 | Household tasks (specifically: light meal preparation, laundry, shopping, and phone use.) | |||
Indent Indent57254-5 | Has this patient had a multi-factor Falls Risk Assessment using a standardized, validated assessment tool? | |||
Indent85928-0 | MEDICATIONS | |||
Indent Indent57255-2 | Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues? | |||
Indent Indent57281-8 | Medication Follow-up: Did the agency contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues? | |||
Indent Indent57257-8 | Patient/Caregiver High-Risk Drug Education: Has the patient/caregiver received instruction on special precautions for all high-risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur? | |||
Indent Indent57285-9 | Management of Oral Medications: Patient's current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals | |||
Indent Indent57284-2 | Management of Injectable Medications: Patient's current ability to prepare and take all prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals | |||
Indent Indent57196-8 | Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to his/her most recent illness, exacerbation or injury. | |||
Indent Indent Indent57258-6 | Oral medications | |||
Indent Indent Indent57259-4 | Injectable medications | |||
Indent57049-9 | CARE MANAGEMENT | |||
Indent Indent57306-3 | Types and Sources of Assistance | |||
Indent Indent Indent57260-2 | ADL assistance (for example, transfer/ ambulation, bathing, dressing, toileting, eating/feeding) | |||
Indent Indent Indent57261-0 | IADL assistance (for example, meals, housekeeping, laundry, telephone, shopping, finances) | |||
Indent Indent Indent57262-8 | Medication administration (for example, oral, inhaled or injectable) | |||
Indent Indent Indent57263-6 | Medical procedures/treatments (for example, changing wound dressing, home exercise program) | |||
Indent Indent Indent57264-4 | Management of equipment (for example, oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies) | |||
Indent Indent Indent57265-1 | Supervision and safety (for example, due to cognitive impairment) | |||
Indent Indent Indent57266-9 | Advocacy or facilitation of patient's participation in appropriate medical care (for example, transportation to or from appointments) | |||
Indent Indent57267-7 | How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)? | |||
Indent57050-7 | THERAPY NEED AND PLAN OF CARE | |||
Indent Indent57268-5 | Therapy need: Number of therapy visits indicated (total of physical, occupational and speech-language pathology combined) | {#} | ||
Indent Indent57197-6 | Plan of Care Synopsis | |||
Indent Indent Indent57269-3 | Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings | |||
Indent Indent Indent57270-1 | Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care | |||
Indent Indent Indent57271-9 | Fall prevention interventions | |||
Indent Indent Indent57272-7 | Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment and/or physician notified that patient screened positive for depression | |||
Indent Indent Indent57273-5 | Intervention(s) to monitor and mitigate pain | |||
Indent Indent Indent57274-3 | Intervention(s) to prevent pressure ulcers | |||
Indent Indent Indent57275-0 | Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician |
Fully-Specified Name
- Component
- Outcome and assessment information set (OASIS) form - version C2 - Start of care
- Property
- -
- Time
- Pt
- System
- ^Patient
- Scale
- -
- Method
- CMS Assessment
Basic Attributes
- Class
- PANEL.SURVEY.CMS
- Type
- Surveys
- First Released
- Version 2.63
- Last Updated
- Version 2.73
- Change Reason
- Release 2.73: Status: LOINC will keep most current version and one prior version of CMS assessments active and discourage all older versions.;
- Order vs. Observation
- Order
- Panel Type
- Panel
LOINC Terminology Service (API) using HL7® FHIR® Get Info
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- CodeSystem lookup
- https:
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Copyright © 2024 Regenstrief Institute, Inc. All Rights Reserved. To the extent included herein, the LOINC table and LOINC codes are copyright