LOINC
Version 2.66

86189-8Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]Active

Component
Outcome and assessment information set (OASIS) form - version C2 - Resumption of care
Property
-
Time
Pt
System
^Patient
Scale
-
Method
CMS Assessment

Panel Hierarchy
Details for each LOINC in Panel

LOINC Name R/O/C Cardinality Example UCUM Units
86189-8 Outcome and assessment information set (OASIS) form - version C2 - Resumption of care [CMS Assessment]
Indent85906-6 Home health patient tracking sheet
IndentIndent46498-2 Resumption of Care Date {mm/dd/yyyy}
Indent57040-8 CLINICAL RECORD ITEMS
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?
Indent85909-0 PATIENT HISTORY AND DIAGNOSES
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
Indent85917-3 INTEGUMENTARY STATUS
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?
Indent85921-5 RESPIRATORY STATUS
IndentIndent57237-0 When is the patient dyspneic or noticeably Short of Breath?
IndentIndent57238-8 Respiratory Treatments utilized at home 1..3
Indent85922-3 ELIMINATION STATUS
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?
Indent57047-3 NEURO/EMOTIONAL/BEHAVIORAL STATUS
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) 1..6
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.
IndentIndent85924-9 FUNCTIONAL ABILITIES and GOALS - SOC/ROC
IndentIndentIndent85925-6 Mobility
IndentIndentIndentIndent85926-4 Lying to Sitting on Side of Bed - ROC 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
Indent57049-9 CARE MANAGEMENT
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)?
Indent57050-7 THERAPY NEED AND PLAN OF CARE
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

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

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.63
Last Updated
Version 2.66
Order vs. Observation
Order
Panel Type
Panel

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