86675-6 Shortness of Breath (dyspnea)

Observation ID in Form

J1100

Form Coding Instructions

Check all that apply

Fully-Specified Name

Component

Shortness of breath

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.70

Change Reason

Release 2.70: TIME_ASPCT: Updated Timing to align with the new model representing various reporting periods across CMS assessment.; COMPONENT: Removed "in last 7D"; Release 2.67: ANSWER_LIST_TYPE: Answer List Type changed to Example to accommodate Override Answer Lists

Order vs. Observation

Observation

Normative Answer List LL4606-1

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Nominal
• Report period
• Survey

Related Codes

54845-3 Current Tobacco Use

Observation ID in Form

J1300

Fully-Specified Name

Component

Tobacco use

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.70

Change Reason

Release 2.70: TIME_ASPCT: Updated Timing to align with the new model representing various reporting periods across CMS assessment.; COMPONENT: Removed "in last 7D"; Previous Releases: Removed "Current" from Component because it is does not match Timing of 7D. Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee.

Order vs. Observation

Observation

Normative Answer List LL251-0

Member of these Panels

Member of these Groups Get Info

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

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.

54846-1 Prognosis

Observation ID in Form

J1400

Form Coding Instructions

Requires physician documentation

Form Context

Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months?

Fully-Specified Name

Component

Life expectancy of less than 6M

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; 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

Normative Answer List LL251-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

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.

86676-4 Problem Conditions

Observation ID in Form

J1550

Form Coding Instructions

Check all that apply

Fully-Specified Name

Component

Problem conditions

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.70

Change Reason

Release 2.70: COMPONENT: Removed "in last 7D"; TIME_ASPCT: Updated Timing to align with the new model representing various reporting periods across CMS assessment.;

Order vs. Observation

Observation

Normative Answer List LL4571-7

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Nominal
• Report period
• Survey

Related Codes

54849-5 Fall History on Admission/Entry or Reentry

Observation ID in Form

J1700

Skip Logic

Complete only if A0310A = 01 or A0310E = 1

Fully-Specified Name

Component

Fall history on admission

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.78

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; 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.

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Fall Hx on admission
• Hx
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

Related Codes

54850-3 Did the resident have a fall any time in the last month prior to admission/entry or reentry?

Observation ID in Form

J1700A

Fully-Specified Name

Component

Fall one or more times in the last Mo prior to admission

Property

Find

Time

1Mo

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

Changed month to Mo in component based on current LOINC model. 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

Normative Answer List LL1502-5

Member of these Panels

Related Names

• 1 month
• 1 month (30 days)
• 30 days
• Centers for Medicare and Medicaid Assessment
• Fall one or more times in the last month prior to admission
• Finding
• Findings
• month
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey

Related Codes

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.

54851-1 Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry?

Observation ID in Form

J1700B

Fully-Specified Name

Component

Fall one or more times in the last 2 to 6Mo prior to admission

Property

Find

Time

6Mo

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

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

Normative Answer List LL1502-5

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Fall one or more times in the last 2 to 6 months prior to admission
• Finding
• Findings
• II
• Ordinal
• Past
• QL
• Qual
• Qualitative
• Screen
• Survey

Related Codes

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.

54852-9 Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry?

Observation ID in Form

J1700C

Fully-Specified Name

Component

Any fracture related to a fall in the 6Mo prior to admission

Property

Find

Time

6Mo

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

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

Normative Answer List LL1502-5

Member of these Panels

Related Names

• Any fracture related to a fall in the 6 months prior to admission
• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Screen
• Survey

Related Codes

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.

54853-7 Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent?

Observation ID in Form

J1800

Skip Logic

If 0, Skip to J2000 Prior Surgery. If 1, Continue to J1900, Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS).

Fully-Specified Name

Component

Has the patient had any falls since admission or prior assessment

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63

Change Reason

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

Normative Answer List LL251-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

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.

54854-5 Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent

Observation ID in Form

J1900

Fully-Specified Name

Component

Number of falls since admission or prior assessment

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.67

Change Reason

Updated METHOD from MDSv3 to CMS Assessment to use term across CMS assessments as approved by the Clinical LOINC committee; TIMING was changed from Pt to RptPeriod to accurately reflect the time interval addressed.

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• # falls since admission or prior assessment
• Centers for Medicare and Medicaid Assessment
• No
• Num
• Num of falls
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

Related Codes

54855-2 No injury

Term Description

Number of falls the patient/resident has experienced in which no evidence of any injury is noted on physical assessment by the nurse or primary care clinician, no complaints of pain or injury by the patient/resident, and no change in the patient/resident's behavior is noted after the fall.
Source: Regenstrief LOINC

Observation ID in Form

J1900A

Form Context

No evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the resident; no change in the resident's behavior is noted after the fall

Fully-Specified Name

Component

Number of falls since admission or prior assessment - no injury

Property

Num

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.67

Change Reason

Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Timing was changed from Pt to RptPeriod to accurately reflect the time interval addressed.

Order vs. Observation

Observation

Normative Answer List LL670-1

Member of these Panels

Related Names

• # falls since admission or prior assessment
• # falls since admission or prior assessment - no injury
• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Num of falls
• Number
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey
• Ulcer

Related Codes

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.

54856-0 Injury (except major)

Term Description

Number of falls the patient/resident has experienced that resulted in skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the patient to complain of pain.
Source: Regenstrief LOINC

Observation ID in Form

J1900B

Form Context

Skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the resident to complain of pain

Fully-Specified Name

Component

Number of falls since admission or prior assessment - injury except major

Property

Num

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.61

Change Reason

Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Timing was changed from Pt to RptPeriod to accurately reflect the time interval addressed.

Order vs. Observation

Observation

Normative Answer List LL670-1

Member of these Panels

Related Names

• # falls since admission or prior assessment
• # falls since admission or prior assessment - injury except major
• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Num of falls
• Number
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey
• Ulcer

Related Codes

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.

54857-8 Major injury

Term Description

Number of falls the patient has experienced that resulted in bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma.
Source: Regenstrief LOINC

Observation ID in Form

J1900C

Form Context

Bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma

Fully-Specified Name

Component

Number of falls since admission or prior assessment - major injury

Property

Num

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.61

Change Reason

Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Timing was changed from Pt to RptPeriod to accurately reflect the time interval addressed.

Order vs. Observation

Observation

Normative Answer List LL670-1

Member of these Panels

Related Names

• # falls since admission or prior assessment
• # falls since admission or prior assessment - major injury
• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Num of falls
• Number
• Ordinal
• Ql
• Qual
• Qualitative
• Report period
• Screen
• Survey
• Ulcer

Related Codes

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.