Version 2.67

85907-4Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]Active

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

LOINC Name R/O/C Cardinality Example UCUM Units
85907-4 Outcome and assessment information set (OASIS) form - version C2 - Start of care [CMS Assessment]
Indent85908-2 Home Health Patient Tracking Sheet
IndentIndent69417-4 CMS Certification Number
IndentIndent46494-1 Branch State
IndentIndent46495-8 Branch ID Number
IndentIndent68468-8 National Provider Identifier (NPI) for the attending physician who has signed the plan of care
IndentIndent46496-6 Patient ID Number
IndentIndent46497-4 Start of Care Date {mm/dd/yyyy}
IndentIndent54503-8 Patient Name
IndentIndentIndent45392-8 (First)
IndentIndentIndent45393-6 (MI)
IndentIndentIndent45394-4 (Last)
IndentIndentIndent45395-1 (Suffix)
IndentIndent46499-0 Patient State of Residence
IndentIndent45401-7 Patient ZIP Code
IndentIndent45397-7 Medicare Number
IndentIndent45396-9 Social Security Number
IndentIndent45400-9 Medicaid Number
IndentIndent21112-8 Birth Date {mm/dd/yyyy}
IndentIndent46098-0 Gender
IndentIndent59362-4 Race/Ethnicity 1..6
IndentIndent57199-2 Current Payment Sources for Home Care 1..11
IndentIndent46500-5 Discipline of Person Completing Assessment
IndentIndent46501-3 Date Assessment Completed {mm/dd/yyyy}
IndentIndent57200-8 This Assessment is Currently Being Completed for the Following Reason
IndentIndent57201-6 Date of Physician-ordered Start of Care (Resumption of Care) {mm/dd/yyyy}
IndentIndent57202-4 Date of Referral {mm/dd/yyyy}
IndentIndent57203-2 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?
IndentIndent57204-0 From which of the following Inpatient Facilities was the patient discharged within the past 14 days? 1..7
IndentIndent86470-2 Inpatient Discharge Date (most recent) {mm/dd/yyyy}
IndentIndent46504-7 Inpatient Facility Diagnosis: ICD-10-CM Code 1..6
IndentIndent46507-0 Diagnosis Requiring Medical or Treatment Regimen Change Within Past 14 Days 1..6
IndentIndent86469-4 Conditions Prior to Medical or Treatment Regimen Change or Inpatient Stay Within Past 14 Days 1..6
IndentIndent85911-6 Diagnoses, Symptom Control, and Optional Diagnoses
IndentIndentIndent85912-4 Primary Diagnosis
IndentIndentIndentIndent86255-7 Primary Diagnosis: ICD-10-code
IndentIndentIndentIndent85920-7 Primary Diagnosis Symptom Control Rating
IndentIndentIndentIndent85914-0 Optional Diagnosis: ICD-10-CM
IndentIndentIndentIndent86254-0 Optional Diagnosis: ICD-10-CM - multiple coding
IndentIndentIndent85913-2 Other Diagnoses 0..5
IndentIndentIndentIndent81885-6 Other Diagnoses: ICD-10-CM
IndentIndentIndentIndent85920-7 Other Diagnoses Symptom Control Rating
IndentIndentIndentIndent85914-0 Optional Diagnosis: ICD-10-CM
IndentIndentIndentIndent86254-0 Optional Diagnosis: ICD-10-CM - multiple coding
IndentIndent83243-6 Active Diagnoses-Comorbidities and Co-existing Conditions 0..2
IndentIndent46466-9 Therapies the patient receives at home 1..3
IndentIndent57319-6 Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? 1..9
IndentIndent57206-5 Overall Status: Which description best fits the patient's overall status?
IndentIndent57207-3 Risk factors, either present or past, likely to affect health status and/or outcome 1..4
IndentIndent54567-3 Height and weight
IndentIndentIndent3137-7 Height (in inches) [in_us];cm
IndentIndentIndent3141-9 Weight (in pounds) [lb_av];kg
Indent85951-2 Living Arrangements
IndentIndent85950-4 Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance?
Indent57042-4 SENSORY STATUS
IndentIndent57215-6 Vision (with corrective lenses if the patient usually wears them)
IndentIndent57216-4 Ability to Hear (with hearing aid or hearing appliance if normally used)
IndentIndent57217-2 Understanding of Verbal Content in patient's own language (with hearing aid or device if used)
IndentIndent57218-0 Speech and Oral (Verbal) Expression of Language (in patient's own language)
IndentIndent57219-8 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)?
IndentIndent57220-6 Frequency of pain interfering with patient's activity or movement
IndentIndent57221-4 Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers?
IndentIndent57280-0 Does this patient have a Risk of Developing Pressure Ulcers?
IndentIndent85918-1 Does this patient have at least one Unhealed Pressure Ulcer at Stage 2 or Higher or designated as Unstageable?
IndentIndent85919-9 Current Number of Unhealed Pressure Ulcers at Each Stage
IndentIndentIndent55124-2 Number of Stage 2 pressure ulcers {#}
IndentIndentIndent55125-9 Number of Stage 3 pressure ulcers {#}
IndentIndentIndent55126-7 Number of Stage 4 pressure ulcers {#}
IndentIndentIndent54893-3 Number of unstageable pressure ulcers due to non-removable dressing/device {#}
IndentIndentIndent54946-9 Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar {#}
IndentIndentIndent54950-1 Number of unstageable pressure ulcers with suspected deep tissue injury in evolution {#}
IndentIndent57229-7 Status of Most Problematic Pressure Ulcer that is Observable
IndentIndent46536-9 Current Number of Stage 1 Pressure Ulcers {#}
IndentIndent57231-3 Stage of Most Problematic Unhealed Pressure Ulcer that is Stageable
IndentIndent57232-1 Does this patient have a Stasis Ulcer?
IndentIndent57233-9 Current Number of Stasis Ulcer(s) that are Observable {#}
IndentIndent57234-7 Status of Most Problematic Stasis Ulcer that is Observable
IndentIndent57235-4 Does this patient have a Surgical Wound?
IndentIndent57236-2 Status of Most Problematic Surgical Wound that is Observable
IndentIndent46534-4 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?
IndentIndent57237-0 When is the patient dyspneic or noticeably Short of Breath?
IndentIndent57238-8 Respiratory Treatments utilized at home 1..3
IndentIndent46552-6 Has this patient been treated for a Urinary Tract Infection in the past 14 days?
IndentIndent46553-4 Urinary Incontinence or Urinary Catheter Presence
IndentIndent57241-2 When does Urinary Incontinence occur?
IndentIndent46587-2 Bowel Incontinence Frequency
IndentIndent86471-0 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?
IndentIndent46589-8 Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.
IndentIndent58104-1 When Confused (Reported or Observed Within the Last 14 Days)
IndentIndent86495-9 When Anxious (Reported or Observed Within the Last 14 Days)
IndentIndent57242-0 Depression Screening: Has the patient been screened for depression, using a standardized, validated depression screening tool?
IndentIndentIndent58120-7 PHQ-2©
IndentIndentIndentIndent44250-9 Little interest or pleasure in doing things
IndentIndentIndentIndent44255-8 Feeling down, depressed, or hopeless?
IndentIndent46473-5 Cognitive, behavorial, and psychiatric symptoms that are demonstrated at least once a week (Reported or Observed)
IndentIndent46592-2 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.
IndentIndent46593-0 Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse?
Indent85923-1 ADL & IADLs
IndentIndent46595-5 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).
IndentIndent46597-1 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.
IndentIndent46599-7 Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes.
IndentIndent57243-8 Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair).
IndentIndent57244-6 Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.
IndentIndent57245-3 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.
IndentIndent57246-1 Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.
IndentIndentIndent85925-6 Mobility
IndentIndentIndentIndent85926-4 Lying to Sitting on Side of Bed - SOC Performance
IndentIndentIndentIndent85927-2 Lying to Sitting on Side of Bed - Discharge Goal
IndentIndent57247-9 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.
IndentIndent57248-7 Feeding or Eating: Current ability to feed self meals and snacks safely.
IndentIndent57249-5 Current Ability to Plan and Prepare Light Meals (for example, cereal, sandwich) or reheat delivered meals safely.
IndentIndent46569-0 Ability to Use Telephone: Current ability to answer the phone safely, including dialing numbers, and effectively using the telephone to communicate.
IndentIndent58121-5 Prior Functioning ADL/IADL
IndentIndentIndent85070-1 Self-Care (specifically: grooming, dressing, bathing, and toileting hygiene)
IndentIndentIndent86185-6 Ambulation
IndentIndentIndent86186-4 Transfer
IndentIndentIndent86187-2 Household tasks (specifically: light meal preparation, laundry, shopping, and phone use.)
IndentIndent57254-5 Has this patient had a multi-factor Falls Risk Assessment using a standardized, validated assessment tool?
Indent85928-0 MEDICATIONS
IndentIndent57255-2 Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?
IndentIndent57281-8 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?
IndentIndent57257-8 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?
IndentIndent57285-9 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.
IndentIndent57284-2 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.
IndentIndent57196-8 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.
IndentIndentIndent57258-6 Oral medications
IndentIndentIndent57259-4 Injectable medications
IndentIndent57306-3 Types and Sources of Assistance
IndentIndentIndent57260-2 ADL assistance (for example, transfer/ ambulation, bathing, dressing, toileting, eating/feeding)
IndentIndentIndent57261-0 IADL assistance (for example, meals, housekeeping, laundry, telephone, shopping, finances)
IndentIndentIndent57262-8 Medication administration (for example, oral, inhaled or injectable)
IndentIndentIndent57263-6 Medical procedures/treatments (for example, changing wound dressing, home exercise program)
IndentIndentIndent57264-4 Management of equipment (for example, oxygen, IV/infusion equipment, enteral/parenteral nutrition, ventilator therapy equipment or supplies)
IndentIndentIndent57265-1 Supervision and safety (for example, due to cognitive impairment)
IndentIndentIndent57266-9 Advocacy or facilitation of patient's participation in appropriate medical care (for example, transportation to or from appointments)
IndentIndent57267-7 How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?
IndentIndent57268-5 Therapy need: Number of therapy visits indicated (total of physical, occupational and speech-language pathology combined). {#}
IndentIndent57197-6 Plan of Care Synopsis
IndentIndentIndent57269-3 Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings
IndentIndentIndent57270-1 Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care
IndentIndentIndent57271-9 Fall prevention interventions
IndentIndentIndent57272-7 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
IndentIndentIndent57273-5 Intervention(s) to monitor and mitigate pain
IndentIndentIndent57274-3 Intervention(s) to prevent pressure ulcers
IndentIndentIndent57275-0 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

Outcome and assessment information set (OASIS) form - version C2 - Start of care
CMS Assessment

Basic Attributes

First Released
Version 2.63
Last Updated
Version 2.66
Order vs. Observation
Panel Type

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