86189-8
Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
Deprecated
Status Information
- Status
- DEPRECATED
Term Description
This information is collected at Resumption of Care in addition to M0032 Resumption of Care Date on the Patient Tracking Sheet. This panel should be used for CMS OASIS-C2 Resumption 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 |
---|---|---|---|---|
86189-8 | Deprecated Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment] | |||
Indent85906-6 | Home health patient tracking sheet | |||
Indent Indent46498-2 | Resumption of Care Date | {mm/dd/yyyy} | ||
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) | 1..6 | ||
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 - ROC 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 - Resumption 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
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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