86585-7 Signs and Symptoms of Delirium (from CAM)

Observation ID in Form

C1310

Form Coding Instructions

Code after completing Brief Interview for Mental Status or Staff Assessment, and reviewing medical record

Fully-Specified Name

Component

MDS v3.0 - RAI v1.17.2, OASIS E - Signs and symptoms of delirium (from CAM)

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.78

Change Reason

Release 2.78: ORDER_OBS: CMS LTPAC Project policy: revise all existing Header LOINCs from “Order, Panels” to “Subset, Organizers”; PanelType: CMS LTPAC Project policy: revise all existing Header LOINCs from “Order, Panels” to “Subset, Organizers”; Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Release 2.72: COMPONENT: Updated to include current version of OASIS that uses this panel; Release 2.68: COMPONENT: Assessment version number was updated to reflect the most recent version.; Previous Releases: This panel is in version 1.14.1, 1.15.1, and 1.16.1. So "v1.16.1" was added to the Component; Current convention (as approved by the joint CMS LTPAC & LOINC project team) will list only the most current assessment in the Component for CMS Assessment panels.

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Outcome and assessment information set
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey
• Sx

Related Codes

54632-5 Acute Onset Mental Status Change. Is there evidence of an acute change in mental status from the resident's baseline?

Reference Information

Observation ID in Form

C1310A

Fully-Specified Name

Component

Acute onset mental status change

Property

Find

Time

Pt

System

^Patient

Scale

Ord

Method

CAM.CMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.67

Change Reason

Release 2.67: METHOD_TYP: Method updated to reflect that this item is from the CMS adaption of the Confusion Assessment Method (CAM); SURVEY_QUEST_TEXT: Survey question from the Confusion Assessment Method (CAM) added to clarify the source of this term; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Survey Question

Text

[Acute Onset] Is there evidence of an acute change in mental status from the patient's baseline?

Source

CAM.1

Normative Answer List LL251-0

Member of these Panels

Related Names

• Exchange
• Finding
• Findings
• Ordinal
• Point in time
• QL
• Qual
• Qualitative
• Random
• Replace
• Screen
• Survey

Related Codes

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to http://www.snomed.org/snomed-ct/get-snomed-ct or info@snomed.org<mailto:info@snomed.org>. This may incur a fee in SNOMED International non-Member countries.

54628-3 Inattention - Did the resident have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?

Reference Information

Observation ID in Form

C1310B

Fully-Specified Name

Component

Inattention in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Nom

Method

CAM.CMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.67

Change Reason

Release 2.67: METHOD_TYP: Method updated to reflect that this item is from the CMS adaption of the Confusion Assessment Method (CAM); SURVEY_QUEST_TEXT: Survey question from the Confusion Assessment Method (CAM) added to clarify the source of this term; SURVEY_QUEST_SRC: Survey question from the Confusion Assessment Method (CAM) added to clarify the source of this term; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.; Scale changed from Ord to Nom because answers cannot be ordered

Order vs. Observation

Observation

Survey Question

Text

[Inattention] Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?

Source

CAM.2A

Normative Answer List LL652-9

Member of these Panels

Related Names

• Finding
• Findings
• Nominal
• Past
• Survey

Related Codes

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/

54629-1 Disorganized Thinking - Was the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject)?

Reference Information

Observation ID in Form

C1310C

Fully-Specified Name

Component

Disorganized thinking in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Ord

Method

CAM.CMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.67

Change Reason

Release 2.67: METHOD_TYP: Method updated to reflect that this item is from the CMS adaption of the Confusion Assessment Method (CAM); SURVEY_QUEST_TEXT: Survey question from the Confusion Assessment Method (CAM) added to clarify the source of this term; SURVEY_QUEST_SRC: Survey question from the Confusion Assessment Method (CAM) added to clarify the source of this term; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Survey Question

Text

[Disorganized thinking] Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?

Source

CAM.3

Normative Answer List LL652-9

Member of these Panels

Related Names

• Finding
• Findings
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey

Related Codes

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/

54630-9 Altered Level of Consciousness - Did the resident have altered level of consciousness, as indicated by any of the following criteria?

Term Description

This term is the CMS Assessment adaption of question 4 on the Confusion Assessment Method (CAM): "[Altered level of consciousness] Overall, how would you rate this patient's level of consciousness? (Alert [normal]; Vigilant [hyperalert, overly sensitive to environmental stimuli, startled very easily], Lethargic [drowsy, easily aroused]; Stupor [difficult to arouse]; Coma; [unarousable]; Uncertain)"
Source: Regenstrief LOINC

Reference Information

Observation ID in Form

C1310D

Fully-Specified Name

Component

Altered level of consciousness in last 7D

Property

Find

Time

7D

System

^Patient

Scale

Ord

Method

CAM.CMS

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.72

Change Reason

Release 2.67: METHOD_TYP: Method updated to reflect that this item is from the CMS adaption of the Confusion Assessment Method (CAM); Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments. Moved Survey Question text to Display Name for Form for consistent modeling across CMS forms.

Order vs. Observation

Observation

Survey Question

Text

Altered level of consciousness. Did the resident have altered level of consciousness? (e.g., vigilant - startled easily to any sound or touch; lethargic- repeatedly dozed off when being asked questions, but responded to voice or touch; stuporous-very difficult to arouse and keep aroused for the interview; comatose - could not be aroused)

Source

CMS

Normative Answer List LL652-9

Member of these Panels

Related Names

• Finding
• Findings
• Levels
• Levl
• LV
• LVL
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey

Related Codes

Copyright

Organization

Dr. SK Inouye

Copyright

Copyright © 2003 Sharon K. Inouye, M.D., MPH. Adapted from: Inouye SK, vanDyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method: Training Manual and Coding Guide.

Terms of Use

Used with permission.

URL

https://www.hospitalelderlifeprogram.org/