LOINC
Version 2.67

88282-9MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]Active

Term Description

This panel should be used for CMS MDS3.0 v1.15.1 NC assessments performed between October 1, 2017 and September 30, 2018.
Source: Regenstrief LOINC

Panel Hierarchy
Details for each LOINC in Panel

LOINC Name R/O/C Cardinality Example UCUM Units
88282-9 MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set [CMS Assessment]
Indent86523-8 Identification Information
IndentIndent58198-3 Type of Record
IndentIndent54581-4 Facility Provider Numbers
IndentIndentIndent76468-8 National Provider Identifier (NPI)
IndentIndentIndent69417-4 CMS Certification Number (CCN)
IndentIndentIndent45398-5 State Provider Number
IndentIndent85632-8 Type of Provider
IndentIndent86524-6 Type of Assessment
IndentIndentIndent54583-0 Federal OBRA Reason for Assessment
IndentIndentIndent54584-8 PPS Assessment
IndentIndentIndent54585-5 PPS Other Medicare Required Assessment - OMRA
IndentIndentIndent58107-4 Is this a Swing Bed clinical change assessment?
IndentIndentIndent54587-1 Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry?
IndentIndentIndent58108-2 Entry/discharge reporting
IndentIndentIndent71440-2 Type of discharge
IndentIndentIndent86525-3 Is this a SNF Part A PPS Discharge Assessment?
IndentIndent86526-1 Unit Certification or Licensure Designation
IndentIndent54503-8 Legal Name of Resident
IndentIndentIndent45392-8 First name
IndentIndentIndent45393-6 Middle initial
IndentIndentIndent45394-4 Last name
IndentIndentIndent45395-1 Suffix
IndentIndent45966-9 Social Security and Medicare Numbers
IndentIndentIndent45396-9 Social Security Number
IndentIndentIndent45397-7 Medicare number (or comparable railroad insurance number)
IndentIndent45400-9 Medicaid Number
IndentIndent46098-0 Gender
IndentIndent21112-8 Birth Date {mm/dd/yyyy}
IndentIndent59362-4 Race/Ethnicity 1..6
IndentIndent54505-3 Language
IndentIndentIndent54588-9 Does the resident need or want an interpreter to communicate with a doctor or health care staff?
IndentIndentIndent54899-0 Preferred language
IndentIndent45404-1 Marital Status
IndentIndent54506-1 Optional Resident Items
IndentIndentIndent46106-1 Medical record number
IndentIndentIndent45403-3 Room number
IndentIndentIndent52462-9 Name by which resident prefers to be addressed
IndentIndentIndent21843-8 Lifetime occupation(s)
IndentIndent54589-7 Preadmission Screening and Resident Review (PASRR). Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability ("mental retardation" in federal regulation) or a related condition?
IndentIndent71441-0 Level II Preadmission Screening and Resident Review (PASRR) Conditions 1..3
IndentIndent86527-9 Conditions Related to ID/DD Status 1..4
IndentIndent86528-7 Most Recent Admission/Entry or Reentry into this Facility
IndentIndentIndent50786-3 Entry Date {mm/dd/yyyy}
IndentIndentIndent54590-5 Type of Entry
IndentIndentIndent85398-6 Entered From
IndentIndent52455-3 Admission Date (Date this episode of care in this facility began) {mm/dd/yyyy}
IndentIndent52525-3 Discharge Date {mm/dd/yyyy}
IndentIndent55128-3 Discharge Status
IndentIndent54592-1 Previous Assessment Reference Date for Significant Correction {mm/dd/yyyy}
IndentIndent54593-9 Assessment Reference Date. Observation end date {mm/dd/yyyy}
IndentIndent54507-9 Medicare Stay
IndentIndentIndent54594-7 Has the resident had a Medicare-covered stay since the most recent entry?
IndentIndentIndent54595-4 Start date of most recent Medicare stay {mm/dd/yyyy}
IndentIndentIndent54596-2 End date of most recent Medicare stay {mm/dd/yyyy}
Indent54508-7 Hearing, Speech, and Vision
IndentIndent54597-0 Comatose. Persistent vegetative state/no discernible consciousness
IndentIndent54598-8 Hearing. Ability to hear (with hearing aid or hearing appliances if normally used)
IndentIndent54599-6 Hearing Aid. Hearing aid or other hearing appliance used in completing B0200, Hearing
IndentIndent54600-2 Speech Clarity. Select best description of speech pattern
IndentIndent54601-0 Makes Self Understood. Ability to express ideas and wants, consider both verbal and non-verbal expression
IndentIndent54602-8 Ability to Understand Others. Understanding verbal content, however able (with hearing aid or device if used)
IndentIndent54603-6 Vision. Ability to see in adequate light (with glasses or other visual appliances)
IndentIndent54604-4 Corrective Lenses. Corrective lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision
Indent86529-5 Cognitive Patterns
IndentIndent54605-1 Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
IndentIndent52491-8 Brief Interview for Mental Status (BIMS)
IndentIndentIndent52731-7 Repetition of Three Words. Number of words repeated after first attempt
IndentIndentIndent54510-3 Temporal Orientation (orientation to year, month, and day)
IndentIndentIndentIndent52732-5 Able to report correct year
IndentIndentIndentIndent52733-3 Able to report correct month
IndentIndentIndentIndent54609-3 Able to report correct day of the week
IndentIndentIndent52493-4 Recall
IndentIndentIndentIndent52735-8 Able to recall "sock"
IndentIndentIndentIndent52736-6 Able to recall "blue"
IndentIndentIndentIndent52737-4 Able to recall "bed"
IndentIndentIndent54614-3 BIMS Summary Score {score}
IndentIndent54615-0 Should the Staff Assessment for Mental Status (C0700-C1000) be Conducted?
IndentIndent86595-6 Staff Assessment for Mental Status
IndentIndentIndent54616-8 Short-term Memory OK. Seems or appears to recall after 5 minutes
IndentIndentIndent54617-6 Long-term Memory OK. Seems or appears to recall long past
IndentIndentIndent86583-2 Memory/Recall Ability 1..4
IndentIndentIndent54624-2 Cognitive Skills for Daily Decision Making. Made decisions regarding tasks of daily life
IndentIndent86584-0 Delirium
IndentIndentIndent86585-7 Signs and Symptoms of Delirium (from CAM)
IndentIndentIndentIndent54632-5 Acute Onset Mental Status Change. Is there evidence of an acute change in mental status from the resident's baseline?
IndentIndentIndentIndent54628-3 Inattention - Did the resident have difficulty focusing attention, for example being easily distractible, or having difficulty keeping track of what was being said?
IndentIndentIndentIndent54629-1 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)?
IndentIndentIndentIndent54630-9 Altered level of consciousness - Did the resident have altered level of consciousness as indicated by any of the following criteria?
Indent54633-3 Mood
IndentIndent54634-1 Should Resident Mood Interview be Conducted?
IndentIndent54635-8 Resident Mood Interview (PHQ-9)
IndentIndentIndent86843-0 Symptom Presence
IndentIndentIndentIndent54636-6 Little interest or pleasure in doing things
IndentIndentIndentIndent54638-2 Feeling down, depressed or hopeless
IndentIndentIndentIndent54640-8 Trouble falling or staying asleep, or sleeping too much
IndentIndentIndentIndent54642-4 Feeling tired or having little energy
IndentIndentIndentIndent54644-0 Poor appetite or overeating
IndentIndentIndentIndent54646-5 Feeling bad about yourself - or that you are a failure or have let yourself or your family down
IndentIndentIndentIndent54648-1 Trouble concentrating on things, such as reading the newspaper or watching television
IndentIndentIndentIndent54650-7 Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
IndentIndentIndentIndent54652-3 Thoughts that you would be better off dead, or of hurting yourself in some way
IndentIndentIndent86844-8 Symptom Frequency
IndentIndentIndentIndent54637-4 Little interest or pleasure in doing things
IndentIndentIndentIndent54639-0 Feeling down, depressed or hopeless
IndentIndentIndentIndent54641-6 Trouble falling or staying asleep, or sleeping too much
IndentIndentIndentIndent54643-2 Feeling tired or having little energy
IndentIndentIndentIndent54645-7 Poor appetite or overeating
IndentIndentIndentIndent54647-3 Feeling bad about yourself - or that you are a failure or have let yourself or your family down
IndentIndentIndentIndent54649-9 Trouble concentrating on things, such as reading the newspaper or watching television
IndentIndentIndentIndent54651-5 Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
IndentIndentIndentIndent54653-1 Thoughts that you would be better off dead, or of hurting yourself in some way
IndentIndent54654-9 Total Severity Score {score}
IndentIndent54655-6 Safety Notification. Was responsible staff or provider informed that there is a potential for resident self harm?
IndentIndent54657-2 Staff Assessment of Resident Mood (PHQ-9-OV)
IndentIndentIndent86833-1 Symptom Presence
IndentIndentIndentIndent54658-0 Little interest or pleasure in doing things
IndentIndentIndentIndent54660-6 Feeling or appearing down, depressed, or hopeless
IndentIndentIndentIndent54662-2 Trouble falling or staying asleep, or sleeping too much
IndentIndentIndentIndent54664-8 Feeling tired or having little energy
IndentIndentIndentIndent54666-3 Poor appetite or overeating
IndentIndentIndentIndent54668-9 Indicating that s/he feels bad about self, is a failure, or has let self or family down
IndentIndentIndentIndent54670-5 Trouble concentrating on things, such as reading the newspaper or watching television
IndentIndentIndentIndent54672-1 Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that s/he has been moving around a lot more than usual
IndentIndentIndentIndent54673-9 States that life isn't worth living, wishes for death, or attempts to harm self
IndentIndentIndentIndent54675-4 Being short-tempered, easily annoyed
IndentIndentIndent86891-9 Symptom Frequency
IndentIndentIndentIndent54659-8 Little interest or pleasure in doing things
IndentIndentIndentIndent54661-4 Feeling or appearing down, depressed, or hopeless
IndentIndentIndentIndent54663-0 Trouble falling or staying asleep, or sleeping too much
IndentIndentIndentIndent54665-5 Feeling tired or having little energy
IndentIndentIndentIndent54667-1 Poor appetite or overeating
IndentIndentIndentIndent54669-7 Indicating that s/he feels bad about self, is a failure, or has let self or family down
IndentIndentIndentIndent54671-3 Trouble concentrating on things, such as reading the newspaper or watching television
IndentIndentIndentIndent54904-8 Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that s/he has been moving around a lot more than usual
IndentIndentIndentIndent54674-7 States that life isn't worth living, wishes for death, or attempts to harm self
IndentIndentIndentIndent54676-2 Being short-tempered, easily annoyed
IndentIndent54677-0 Total Severity Score {score}
IndentIndent54655-6 Safety Notification. Was responsible staff or provider informed that there is a potential for resident self harm?
Indent86596-4 Behavior
IndentIndent86597-2 Potential Indicators of Psychosis 1..2
IndentIndent54514-5 Behavioral Symptom - Presence & Frequency
IndentIndentIndent54682-0 Physical behavioral symptoms directed toward others d/(7.d)
IndentIndentIndent54683-8 Verbal behavioral symptoms directed toward others d/(7.d)
IndentIndentIndent54684-6 Other behavioral symptoms not directed toward others d/(7.d)
IndentIndent54685-3 Overall Presence of Behavioral Symptoms.Were any behavioral symptoms in questions E0200 coded 1, 2, or 3?
IndentIndent54515-2 Impact on Resident
IndentIndentIndent54686-1 Did any of the identified symptom(s): Put the resident at significant risk for physical illness or injury?
IndentIndentIndent54687-9 Did any of the identified symptom(s): Significantly interfere with the resident's care?
IndentIndentIndent54688-7 Did any of the identified symptom(s): Significantly interfere with the resident's participation in activities or social interactions?
IndentIndent54516-0 Impact on Others
IndentIndentIndent54689-5 Did any of the identified symptom(s): Put others at significant risk for physical injury?
IndentIndentIndent54690-3 Did any of the identified symptom(s): Significantly intrude on the privacy or activity of others?
IndentIndentIndent54691-1 Did any of the identified symptom(s): Significantly disrupt care or living environment?
IndentIndent54692-9 Rejection of Care - Presence & Frequency. Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? d/(7.d)
IndentIndent54693-7 Wandering - Presence & Frequency. Has the resident wandered? d/(7.d)
IndentIndent54517-8 Wandering - Impact
IndentIndentIndent54694-5 Does the wandering place the resident at significant risk of getting to a potentially dangerous place?
IndentIndentIndent54695-2 Does the wandering significantly intrude on the privacy or activities of others?
IndentIndent54696-0 Change in Behavior or Other Symptoms.How does resident's current behavior status, care rejection, or wandering compare to prior assessment (OBRA or Scheduled PPS)?
Indent86600-4 Preferences for Customary Routine and Activities
IndentIndent54697-8 Should Interview for Daily and Activity Preferences be Conducted?
IndentIndent54519-4 Interview for Daily Preferences
IndentIndentIndent54698-6 While you are in this facility how important is it to you to choose what clothes to wear?
IndentIndentIndent54699-4 While you are in this facility how important is it to you to take care of your personal belongings or things?
IndentIndentIndent54700-0 While you are in this facility how important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?
IndentIndentIndent54701-8 While you are in this facility how important is it to you to have snacks available between meals?
IndentIndentIndent54702-6 While you are in this facility how important is it to you to choose your own bedtime?
IndentIndentIndent54703-4 While you are in this facility how important is it to you to have your family or a close friend involved in discussions about your care?
IndentIndentIndent54704-2 While you are in this facility how important is it to you to be able to use the phone in private?
IndentIndentIndent54705-9 While you are in this facility how important is it to you to have a place to lock your things to keep them safe?
IndentIndent54520-2 Interview for Activity Preferences
IndentIndentIndent54706-7 While you are in this facility how important is it to you to have books, newspapers, and magazines to read?
IndentIndentIndent54707-5 While you are in this facility how important is it to you to listen to music you like?
IndentIndentIndent54708-3 While you are in this facility how important is it to you to be around animals such as pets?
IndentIndentIndent54709-1 While you are in this facility how important is it to you to keep up with the news?
IndentIndentIndent54710-9 While you are in this facility how important is it to you to do things with groups of people?
IndentIndentIndent54711-7 While you are in this facility how important is it to you to do your favorite activities?
IndentIndentIndent54712-5 While you are in this facility how important is it to you to go outside to get fresh air when the weather is good?
IndentIndentIndent54713-3 While you are in this facility how important is it to you to participate in religious services or practices?
IndentIndent54714-1 Daily and Activity Preferences Primary Respondent. Indicate primary respondent for Daily and Activity Preferences (F0400 and F0500)
IndentIndent54715-8 Should the Staff Assessment of Daily and Activity Preferences be Conducted?
IndentIndent86599-8 Staff Assessment of Daily and Activity Preferences. Resident Prefers:
Indent86601-2 Functional Status
IndentIndent86880-2 Activities of Daily Living (ADL) Assistance. Self-Performance
IndentIndentIndent45588-1 Bed mobility
IndentIndentIndent45590-7 Transfer
IndentIndentIndent45592-3 Walk in room
IndentIndentIndent45594-9 Walk in corridor
IndentIndentIndent45596-4 Locomotion on unit
IndentIndentIndent45598-0 Locomotion off unit
IndentIndentIndent45600-4 Dressing
IndentIndentIndent45602-0 Eating
IndentIndentIndent45604-6 Toilet use
IndentIndentIndent45606-1 Personal hygiene
IndentIndent86881-0 Activities of Daily Living (ADL) Assistance. Support Provided
IndentIndentIndent45589-9 Bed mobility
IndentIndentIndent45591-5 Transfer
IndentIndentIndent45593-1 Walk in room
IndentIndentIndent45595-6 Walk in corridor
IndentIndentIndent45597-2 Locomotion on unit
IndentIndentIndent45599-8 Locomotion off unit
IndentIndentIndent45601-2 Dressing
IndentIndentIndent45603-8 Eating
IndentIndentIndent45605-3 Toilet use
IndentIndentIndent45607-9 Personal hygiene
IndentIndent46008-9 Bathing
IndentIndentIndent45608-7 Self-performance
IndentIndentIndent45609-5 Support provided
IndentIndent54524-4 Balance During Transitions and Walking
IndentIndentIndent54749-7 Moving from seated to standing position
IndentIndentIndent54750-5 Walking (with assistive device if used)
IndentIndentIndent54751-3 Turning around and facing the opposite direction while walking
IndentIndentIndent54752-1 Moving on and off toilet
IndentIndentIndent54753-9 Surface-to-surface transfer (transfer between bed and chair or wheelchair)
IndentIndent92908-3 Functional Limitation in Range of Motion
IndentIndentIndent92850-7 Upper extremity (shoulder, elbow, wrist, hand)
IndentIndentIndent92851-5 Lower extremity (hip, knee, ankle, foot)
IndentIndent86602-0 Mobility Devices 1..4
IndentIndent54527-7 Functional Rehabilitation Potential
IndentIndentIndent55123-4 Resident believes he or she is capable of increased independence in at least some ADLs.
IndentIndentIndent45613-7 Direct care staff believe resident is capable of increased independence in at least some ADLs
Indent86612-9 Functional Abilities and Goals - Admission (Start of SNF PPS Stay)
IndentIndent86613-7 Self-care - Admission Performance
IndentIndentIndent83232-9 Eating
IndentIndentIndent83230-3 Oral hygiene
IndentIndentIndent83228-7 Toileting hygiene
IndentIndent86618-6 Self-Care - Discharge Goal
IndentIndentIndent83231-1 Eating
IndentIndentIndent83229-5 Oral hygiene
IndentIndentIndent83227-9 Toileting hygiene
IndentIndent86614-5 Mobility - Admission Performance
IndentIndentIndent83216-2 Sit to lying
IndentIndentIndent83214-7 Lying to sitting on side of bed
IndentIndentIndent83212-1 Sit to stand
IndentIndentIndent83210-5 Chair/bed-to-chair transfer
IndentIndentIndent83208-9 Toilet transfer
IndentIndentIndent83270-9 Does the resident walk?
IndentIndentIndent83202-2 Walk 50 feet with two turns
IndentIndentIndent83200-6 Walk 150 feet
IndentIndentIndent83271-7 Does the resident use a wheelchair/scooter?
IndentIndentIndent83188-3 Wheel 50 feet with two turns
IndentIndentIndent83272-5 Indicate the type of wheelchair/scooter used
IndentIndentIndent83235-2 Wheel 150 feet
IndentIndentIndent83272-5 Indicate the type of wheelchair/scooter used
IndentIndent86619-4 Mobility - discharge goal
IndentIndentIndent83215-4 Sit to lying
IndentIndentIndent83213-9 Lying to sitting on side of bed
IndentIndentIndent83211-3 Sit to stand
IndentIndentIndent83209-7 Chair/Bed-to-chair transfer
IndentIndentIndent83207-1 Toilet transfer
IndentIndentIndent83201-4 Walk 50 feet with two turns
IndentIndentIndent83199-0 Walk 150 feet
IndentIndentIndent83187-5 Wheel 50 feet with two turns
IndentIndentIndent83236-0 Wheel 150 feet
Indent86615-2 Functional Abilities and Goals - Discharge (End of SNF PPS Stay)
IndentIndent86616-0 Self-Care - Discharge Performance
IndentIndentIndent83232-9 Eating
IndentIndentIndent83230-3 Oral hygiene
IndentIndentIndent83228-7 Toileting hygiene
IndentIndent86617-8 Mobility - Discharge Performance
IndentIndentIndent83216-2 Sit to lying
IndentIndentIndent83214-7 Lying to sitting on side of bed
IndentIndentIndent83212-1 Sit to stand
IndentIndentIndent83210-5 Chair/bed-to-chair transfer
IndentIndentIndent83208-9 Toilet transfer
IndentIndentIndent83278-2 Does the resident walk?
IndentIndentIndent83202-2 Walk 50 feet with two turns
IndentIndentIndent83200-6 Walk 150 feet
IndentIndentIndent83271-7 Does the resident use a wheelchair/scooter?
IndentIndentIndent83188-3 Wheel 50 feet with two turns
IndentIndentIndent83272-5 Indicate the type of wheelchair/scooter used
IndentIndentIndent83235-2 Wheel 150 feet
IndentIndentIndent83272-5 Indicate the type of wheelchair/scooter used
Indent89048-3 Bladder and Bowel
IndentIndent86624-4 Appliances 1..4
IndentIndent54530-1 Urinary Toileting Program
IndentIndentIndent54767-9 Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility?
IndentIndentIndent54768-7 Response - What was the resident's response to the trial program?
IndentIndentIndent54769-5 Current toileting program or trial - Is a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) currently being used to manage the resident's urinary continence?
IndentIndent54770-3 Urinary Continence 1..1
IndentIndent54771-1 Bowel Continence 1..1
IndentIndent88695-2 Bowel Toileting Program. Is a toileting program currently being used to manage the resident's bowel continence?
IndentIndent54773-7 Bowel Patterns. Constipation present?
Indent86670-7 Active Diagnoses
IndentIndent86671-5 Active Diagnoses in the last 7 days 1..*
IndentIndent52797-8 Additional active diagnoses 0..10
Indent86686-3 Health Conditions
IndentIndent54557-4 Pain Management
IndentIndentIndent71447-7 At any time in the last 5 days, has the resident: Received scheduled pain medication regimen?
IndentIndentIndent71448-5 At any time in the last 5 days, has the resident: Received PRN pain medications OR was offered and declined?
IndentIndentIndent71449-3 At any time in the last 5 days, has the resident: Received non-medication intervention for pain?
IndentIndent54828-9 Should Pain Assessment Interview be Conducted?
IndentIndent54558-2 Pain Assessment Interview
IndentIndentIndent54829-7 Pain Presence. Have you had pain or hurting at any time in the last 5 days?
IndentIndentIndent54830-5 Pain Frequency. How much of the time have you experienced pain or hurting over the last 5 days?
IndentIndentIndent54559-0 Pain Effect on Function
IndentIndentIndentIndent54831-3 Over the past 5 days, has pain made it hard for you to sleep at night?
IndentIndentIndentIndent54832-1 Over the past 5 days, have you limited your day-to-day activities because of pain?
IndentIndentIndent54560-8 Pain Intensity
IndentIndentIndentIndent54833-9 Numeric Rating Scale (00-10)
IndentIndentIndentIndent54834-7 Verbal Descriptor Scale
IndentIndent58117-3 Should the Staff Assessment for Pain be Conducted?
IndentIndent86672-3 Staff Assessment for Pain
IndentIndentIndent86673-1 Indicators of Pain or Possible Pain in the last 5 days 1..4
IndentIndentIndent58118-1 Frequency of Indicator of Pain or Possible Pain in the last 5 days. Frequency with which resident complains or shows evidence of pain or possible pain d/(5.d)
IndentIndent86674-9 Other Health Conditions
IndentIndentIndent86675-6 Shortness of Breath (dyspnea) 1..3
IndentIndentIndent54845-3 Current Tobacco Use
IndentIndentIndent54846-1 Prognosis. Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months?
IndentIndentIndent86676-4 Problem Conditions 1..4
IndentIndentIndent54849-5 Fall History on Admission/Entry or Reentry
IndentIndentIndentIndent54850-3 Did the resident have a fall any time in the last month prior to admission/entry or reentry?
IndentIndentIndentIndent54851-1 Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry?
IndentIndentIndentIndent54852-9 Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry?
IndentIndentIndent54853-7 Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent?
IndentIndentIndent54854-5 Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is more recent
IndentIndentIndentIndent54855-2 No injury
IndentIndentIndentIndent54856-0 Injury (except major)
IndentIndentIndentIndent54857-8 Major injury
Indent86625-1 Swallowing/Nutritional Status
IndentIndent86677-2 Swallowing Disorder. Signs and symptoms of possible swallowing disorder 1..4
IndentIndent54567-3 Height and Weight
IndentIndentIndent3137-7 Height (in inches) [in_us];cm
IndentIndentIndent3141-9 Weight (in pounds) [lb_av];kg
IndentIndent54863-6 Weight Loss. Loss of 5% or more in the last month or loss of 10% or more in last 6 months
IndentIndent86678-0 Weight Gain. Gain of 5% or more in the last month or gain of 10% or more in last 6 months
IndentIndent54568-1 Nutritional Approaches
IndentIndentIndent71444-4 Nutritional Approaches. While NOT a Resident 1..4
IndentIndentIndent71445-1 Nutritional Approaches. While a Resident 1..4
IndentIndent86679-8 Percent Intake by Artificial Route
IndentIndentIndent86680-6 Proportion of total calories the resident received through parenteral or tube feeding. While NOT a Resident
IndentIndentIndent86681-4 Proportion of total calories the resident received through parenteral or tube feeding. While a Resident
IndentIndentIndent86687-1 Proportion of total calories the resident received through parenteral or tube feeding. During Entire 7 Days
IndentIndentIndent86682-2 Average fluid intake per day by IV or tube feeding. While NOT a Resident
IndentIndentIndent86683-0 Average fluid intake per day by IV or tube feeding. While a Resident
IndentIndentIndent86684-8 Average fluid intake per day by IV or tube feeding. During Entire 7 Days
Indent86685-5 Oral/Dental Status
IndentIndent86706-9 Dental 1..7
Indent89052-5 Skin Conditions
IndentIndent86708-5 Determination of Pressure Ulcer Risk 1..3
IndentIndent57280-0 Risk of Pressure Ulcers. Is this resident at risk of developing pressure ulcers?
IndentIndent58214-8 Unhealed Pressure Ulcer(s). Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher?
IndentIndent86745-7 Current Number of Unhealed Pressure Ulcers at Each Stage
IndentIndentIndent54884-2 Number of Stage 1 pressure ulcers {#}
IndentIndentIndent55124-2 Number of Stage 2 pressure ulcers {#}
IndentIndentIndent54886-7 Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry {#}
IndentIndentIndent58123-1 Date of oldest Stage 2 pressure ulcer {mm/dd/yyyy}
IndentIndentIndent55125-9 Number of Stage 3 pressure ulcers {#}
IndentIndentIndent54887-5 Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry {#}
IndentIndentIndent55126-7 Number of Stage 4 pressure ulcers {#}
IndentIndentIndent54890-9 Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry {#}
IndentIndentIndent54893-3 Number of unstageable pressure ulcers due to non-removable dressing/device {#}
IndentIndentIndent54894-1 Number of these unstageable pressure ulcers that were present upon admission/entry or reentry {#}
IndentIndentIndent54946-9 Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar {#}
IndentIndentIndent54947-7 Number of these unstageable pressure ulcers that were present upon admission/entry or reentry {#}
IndentIndentIndent54950-1 Number of unstageable pressure ulcers with suspected deep tissue injury in evolution {#}
IndentIndentIndent54951-9 Number of these unstageable pressure ulcers that were present upon admission/entry or reentry {#}
IndentIndent86746-5 Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar
IndentIndentIndent86901-6 Pressure ulcer length: Longest length from head to toe cm
IndentIndentIndent86902-4 Pressure ulcer width: Widest width of the same pressure ulcer, side-to-side perpendicular (90-degree angle) to length cm
IndentIndentIndent57228-9 Pressure ulcer depth: Depth of the same pressure ulcer from the visible surface to the deepest area cm
IndentIndent86903-2 Most Severe Tissue Type for Any Pressure Ulcer
IndentIndent54952-7 Worsening in Pressure Ulcer Status Since Prior Assessment (OBRA or Scheduled PPS) or Last Admission/Entry or Reentry
IndentIndentIndent54953-5 Stage 2 {#}
IndentIndentIndent54954-3 Stage 3 {#}
IndentIndentIndent54955-0 Stage 4 {#}
IndentIndent54956-8 Healed Pressure Ulcers
IndentIndentIndent54957-6 Were pressure ulcers present on the prior assessment (OBRA or scheduled PPS)?
IndentIndentIndent54958-4 Stage 2 {#}
IndentIndentIndent54959-2 Stage 3 {#}
IndentIndentIndent54960-0 Stage 4 {#}
IndentIndent54970-9 Number of Venous and Arterial Ulcers {#}
IndentIndent88696-0 Other Ulcers, Wounds and Skin Problems 1..8
IndentIndent86748-1 Skin and Ulcer Treatments 1..9
Indent88289-4 Medications
IndentIndent54982-4 Injections. Record the number of days that injections of any type were received during the last 7 days or since admission/entry or reentry if less than 7 days. d/(7.d)
IndentIndent58217-1 Insulin
IndentIndentIndent58127-2 Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if less than 7 days d/(7.d)
IndentIndentIndent58128-0 Orders for insulin - Record the number of days the physician (or authorized assistant or practitioner) changed the resident's insulin orders during the last 7 days or since admission/entry or reentry if less than 7 days d/(7.d)
IndentIndent88290-2 Medications Received
IndentIndentIndent86751-5 Antipsychotic d/(7.d)
IndentIndentIndent86752-3 Antianxiety d/(7.d)
IndentIndentIndent86753-1 Antidepressant d/(7.d)
IndentIndentIndent86754-9 Hypnotic d/(7.d)
IndentIndentIndent86755-6 Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin) d/(7.d)
IndentIndentIndent86756-4 Antibiotic d/(7.d)
IndentIndentIndent86757-2 Diuretic d/(7.d)
IndentIndentIndent88291-0 Opiod d/(7.d)
IndentIndent88295-1 Antipsychotic Medication Review
IndentIndentIndent88296-9 Did the resident receive antipsychotic medications since admission/entry or reentry or the prior OBRA assessment, whichever is more recent?
IndentIndentIndent88297-7 Has a gradual dose reduction (GDR) been attempted?
IndentIndentIndent88298-5 Date of last attempted GDR {mm/dd/yyyy}
IndentIndentIndent88299-3 Physician documented GDR as clinically contraindicated
IndentIndentIndent88300-9 Date physician documented GDR as clinically contraindicated {mm/dd/yyyy}
Indent86758-0 Special Treatments, Procedures, and Programs
IndentIndent86759-8 Special Treatments, Procedures, and Programs
IndentIndentIndent86760-6 While NOT a Resident 1..12
IndentIndentIndent86761-4 While a Resident 1..13
IndentIndent69339-0 Influenza Vaccine
IndentIndentIndent55019-4 Did the resident receive the influenza vaccine in this facility for this year's influenza vaccination season?
IndentIndentIndent58131-4 Date influenza vaccine received {mm/dd/yyyy}
IndentIndentIndent55020-2 If influenza vaccine not received, state reason:
IndentIndent55021-0 Pneumococcal Vaccine
IndentIndentIndent55022-8 Is the resident's Pneumococcal vaccination up to date?
IndentIndentIndent45956-0 If Pneumococcal vaccine not received, state reason:
IndentIndent86762-2 Therapies
IndentIndentIndent86763-0 Speech-Language Pathology and Audiology Services
IndentIndentIndentIndent58218-9 Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the last 7 days min
IndentIndentIndentIndent58133-0 Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the last 7 days min
IndentIndentIndentIndent58134-8 Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days min
IndentIndentIndentIndent86765-5 Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment sessions in the last 7 days min
IndentIndentIndentIndent45760-6 Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days d/(7.d)
IndentIndentIndentIndent55025-1 Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started {mm/dd/yyyy}
IndentIndentIndentIndent55026-9 Therapy end date - record the date the most recent therapy regimen (since the most recent entry) ended {mm/dd/yyyy}
IndentIndentIndent86767-1 Occupational Therapy
IndentIndentIndentIndent58219-7 Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the last 7 days min
IndentIndentIndentIndent58136-3 Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the last 7 days min
IndentIndentIndentIndent58137-1 Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days min
IndentIndentIndentIndent86764-8 Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment sessions in the last 7 days min
IndentIndentIndentIndent45762-2 Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days d/(7.d)
IndentIndentIndentIndent55027-7 Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started {mm/dd/yyyy}
IndentIndentIndentIndent55028-5 Therapy end date - record the date the most recent therapy regimen (since the most recent entry) ended {mm/dd/yyyy}
IndentIndentIndent86768-9 Physical Therapy
IndentIndentIndentIndent58220-5 Individual minutes - record the total number of minutes this therapy was administered to the resident individually in the last 7 days min
IndentIndentIndentIndent58139-7 Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently with one other resident in the last 7 days min
IndentIndentIndentIndent58140-5 Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of residents in the last 7 days min
IndentIndentIndentIndent86766-3 Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment sessions in the last 7 days min
IndentIndentIndentIndent45764-8 Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days d/(7.d)
IndentIndentIndentIndent55029-3 Therapy start date - record the date the most recent therapy regimen (since the most recent entry) started {mm/dd/yyyy}
IndentIndentIndentIndent55030-1 Therapy end date - record the date the most recent therapy regimen (since the most recent entry) ended {mm/dd/yyyy}
IndentIndentIndent58141-3 Respiratory Therapy
IndentIndentIndentIndent45767-1 Total minutes - record the total number of minutes this therapy was administered to the resident in the last 7 days min
IndentIndentIndentIndent45766-3 Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days d/(7.d)
IndentIndentIndent58142-1 Psychological Therapy (by any licensed mental health professional)
IndentIndentIndentIndent45852-1 Total minutes - record the total number of minutes this therapy was administered to the resident in the last 7 days min
IndentIndentIndentIndent45768-9 Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days. d/(7.d)
IndentIndentIndent58143-9 Recreational Therapy (includes recreational and music therapy)
IndentIndentIndentIndent55035-0 Total minutes - record the total number of minutes this therapy was administered to the resident in the last 7 days min
IndentIndentIndentIndent55036-8 Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days d/(7.d)
IndentIndent86769-7 Distinct Calendar Days of Therapy. Record the number of calendar days that the resident received Speech-Language Pathology and Audiology Services, Occupational Therapy, or Physical Therapy for at least 15 minutes in the past 7 days. d
IndentIndent86770-5 Resumption of Therapy
IndentIndentIndent86772-1 Has a previous rehabilitation therapy regimen (speech, occupational, and/or physical therapy) ended, as reported on this End of Therapy OMRA, and has this regimen now resumed at exactly the same level for each discipline?
IndentIndentIndent86771-3 Date on which therapy regimen resumed {mm/dd/yyyy}
IndentIndent86773-9 Restorative Nursing Programs
IndentIndentIndent86774-7 Technique. Range of motion (passive) d/(7.d)
IndentIndentIndent86775-4 Technique. Range of motion (active) d/(7.d)
IndentIndentIndent86776-2 Technique. Splint or brace assistance d/(7.d)
IndentIndentIndent86777-0 Training and Skill Practice In: Bed mobility d/(7.d)
IndentIndentIndent86778-8 Training and Skill Practice In: Transfer d/(7.d)
IndentIndentIndent86779-6 Training and Skill Practice In: Walking d/(7.d)
IndentIndentIndent86780-4 Training and Skill Practice In: Dressing and/or grooming d/(7.d)
IndentIndentIndent86781-2 Training and Skill Practice In: Eating and/or swallowing d/(7.d)
IndentIndentIndent86782-0 Training and Skill Practice In: Amputation/prostheses care d/(7.d)
IndentIndentIndent86783-8 Training and Skill Practice In: Communication d/(7.d)
IndentIndent55040-0 Physician Examinations. Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) examine the resident? d/(14.d)
IndentIndent55041-8 Physician Orders. Over the last 14 days, on how many days did the physician (or authorized assistant or practitioner) change the resident's orders? d/(14.d)
Indent88307-4 Restraints and Alarms
IndentIndent86785-3 Physical Restraints
IndentIndentIndent86786-1 Used in Bed. Bed rail d/(7.d)
IndentIndentIndent86787-9 Used in Bed. Trunk restraint d/(7.d)
IndentIndentIndent86788-7 Used in Bed. Limb restraint d/(7.d)
IndentIndentIndent86789-5 Used in Bed. Other d/(7.d)
IndentIndentIndent86790-3 Used in Chair or Out of Bed. Trunk restraint d/(7.d)
IndentIndentIndent86791-1 Used in Chair or Out of Bed. Limb restraint d/(7.d)
IndentIndentIndent86792-9 Used in Chair or Out of Bed. Chair prevents rising d/(7.d)
IndentIndentIndent86793-7 Used in Chair or Out of Bed. Other d/(7.d)
IndentIndent88309-0 Alarms
IndentIndentIndent88310-8 Bed alarm
IndentIndentIndent88311-6 Chair alarm
IndentIndentIndent88312-4 Floor mat alarm
IndentIndentIndent88313-2 Motion sensor alarm
IndentIndentIndent88314-0 Wander/elopement alarm
IndentIndentIndent88308-2 Other alarm
Indent86794-5 Participation in Assessment and Goal Setting
IndentIndent55053-3 Participation in Assessment
IndentIndentIndent55054-1 Resident participated in assessment
IndentIndentIndent55074-9 Family or significant other participated in assessment
IndentIndentIndent58221-3 Guardian or legally authorized representative participated in assessment
IndentIndent55056-6 Resident's Overall Expectation
IndentIndentIndent55057-4 Select one for resident's overall goal established during assessment process
IndentIndentIndent55058-2 Indicate information source for Q0300A
IndentIndent58146-2 Discharge Plan. Is active discharge planning already occurring for the resident to return to the community?
IndentIndent86795-2 Resident's Preference to Avoid Being Asked Question Q0500B. Does the resident's clinical record document a request that this question be asked only on comprehensive assessments?
IndentIndent58149-6 Return to Community. Do you want to talk to someone about the possiblity of leaving this facility and returning to live and receive services in the community?
IndentIndent86796-0 Resident's Preference to Avoid Being Asked Question Q0500B Again
IndentIndentIndent86797-8 Does the resident (or family or significant other or guardian or legally authorized representative if resident is unable to understand or respond) want to be asked about returning to the community on all assessments?
IndentIndentIndent86798-6 Indicate information source for Q0550A
IndentIndent58150-4 Referral. Has a referral been made to the Local Contact Agency?
Indent87207-7 Care Area Assessment (CAA) Summary
IndentIndent87208-5 Items From the Most Recent Prior OBRA or Scheduled PPS Assessment
IndentIndentIndent54583-0 Prior Assessment Federal OBRA Reason for Assessment
IndentIndentIndent54584-8 Prior Assessment PPS Reason for Assessment
IndentIndentIndent54593-9 Prior Assessment Reference Date {mm/dd/yyyy}
IndentIndentIndent54614-3 Prior Assessment Brief Interview for Mental Status (BIMS) Summary Score {score}
IndentIndentIndent54654-9 Prior Assessment Resident Mood Interview (PHQ-9©) Total Severity Score {score}
IndentIndentIndent54677-0 Prior Assessment Staff Assessment of Resident Mood (PHQ-9-OV) Total Severity Score {score}
IndentIndent87210-1 CAAs and Care Planning
IndentIndentIndent87211-9 CAA Results
IndentIndentIndentIndent87212-7 Care Area Triggered
IndentIndentIndentIndent87213-5 Care Planning Decision
Indent87224-2 Correction Request
IndentIndent85632-8 Type of Provider
IndentIndent87226-7 Name of Resident
IndentIndentIndent45392-8 First name
IndentIndentIndent45394-4 Last name
IndentIndent46098-0 Gender
IndentIndent21112-8 Birth Date {mm/dd/yyyy}
IndentIndent45396-9 Social Security Number
IndentIndent87227-5 Type of Assessment
IndentIndentIndent54583-0 Federal OBRA Reason for Assessment
IndentIndentIndent54584-8 PPS Assessment
IndentIndentIndent54585-5 PPS Other Medicare Required Assessment - OMRA
IndentIndentIndent58107-4 Is this a Swing Bed clinical change assessment?
IndentIndentIndent58108-2 Entry/discharge reporting
IndentIndentIndent86525-3 Is this a SNF Part A PPS Discharge Assessment?
IndentIndent87216-8 Date on existing record to be modified/inactivated
IndentIndentIndent54593-9 Assessment Reference Date {mm/dd/yyyy}
IndentIndentIndent52525-3 Discharge Date {mm/dd/yyyy}
IndentIndentIndent50786-3 Entry Date {mm/dd/yyyy}
IndentIndent87209-3 Correction Attestation Section
IndentIndentIndent58200-7 Correction Number {#}
IndentIndentIndent87217-6 Reasons for Modification 1..6
IndentIndentIndent87225-9 Reasons for Inactivation 1..2
IndentIndentIndent87218-4 RN Assessment Coordinator Attestation of Completion
IndentIndentIndentIndent87219-2 Attesting individual's first name
IndentIndentIndentIndent87220-0 Attesting individual's last name
IndentIndentIndentIndent87221-8 Attesting individual's title
IndentIndentIndentIndent87222-6 Attestation date {mm/dd/yyyy}
Indent87223-4 Assessment Administration
IndentIndent55064-0 Medicare Part A Billing
IndentIndentIndent55065-7 Medicare Part A HIPPS code
IndentIndentIndent55066-5 RUG version code
IndentIndentIndent58421-9 Is this a Medicare Short Stay assessment?
IndentIndent59375-6 Medicare Part A Non-Therapy Billing
IndentIndentIndent58210-6 Medicare Part A non-therapy HIPPS code
IndentIndentIndent58211-4 RUG version code
IndentIndent55067-3 State Medicaid Billing (if required by the state)
IndentIndentIndent55068-1 RUG Case Mix group
IndentIndentIndent55069-9 RUG version code
IndentIndent58422-7 Alternate State Medicaid Billing (if required by the state)
IndentIndentIndent58212-2 RUG Case Mix Group
IndentIndentIndent58213-0 RUG version code
IndentIndent55070-7 Insurance Billing
IndentIndentIndent55071-5 RUG billing code
IndentIndentIndent55072-3 RUG billing version

Fully-Specified Name

Component
MDS v3.0 - RAI v1.15.1 - Nursing home comprehensive (NC) item set
Property
-
Time
Pt
System
^Patient
Scale
-
Method
CMS Assessment

Basic Attributes

Class
PANEL.SURVEY.CMS
Type
Surveys
First Released
Version 2.64
Last Updated
Version 2.66
Order vs. Observation
Order
Panel Type
Panel

LOINC FHIR® API Example - CodeSystem Request Get Info

https://fhir.loinc.org/CodeSystem/$lookup?system=http://loinc.org&code=88282-9