86257-3 CLINICAL RECORD ITEMS

Fully-Specified Name

Component

Clinical record items - transfer or discharge

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 2.77

Change Reason

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

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Disch
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Report period
• Survey

46500-5 Discipline of Person Completing Assessment

Term Description

Identifies the discipline of the clinician completing the comprehensive assessment at the specified time points or the clinician reporting the transfer to an inpatient facility, death at home, or discharge (no further visits after start of care).
Source: Regenstrief LOINC

Observation ID in Form

M0080

Fully-Specified Name

Component

Discipline of person completing assessment

Property

Type

Time

RptPeriod

System

Provider

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

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 from OASIS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Normative Answer List LL245-2

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Nominal
• Persons
• Report period
• Survey
• Typ

Related Codes

46501-3 Date Assessment Completed

Term Description

The actual date the assessment is completed, except if agency policy allows assessments to be performed over more than one visit date, in which case the last date (when the assessment is finished) is the appropriate date to record.
Source: Regenstrief LOINC

Observation ID in Form

M0090

Fully-Specified Name

Component

Date assessment information completed

Property

Date

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

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 from OASIS to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

57200-8 This Assessment is Currently Being Completed for the Following Reason

Observation ID in Form

M0100

Skip Logic

If 6, go to M1041. If 7, go to M1041.

Fully-Specified Name

Component

Reason for assessment

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

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 from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Normative Answer List LL773-3

Member of these Panels

Related Names

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

Related Codes

86256-5 PATIENT HISTORY AND DIAGNOSIS

Fully-Specified Name

Component

Patient history and diagnoses - transfer or discharge from agency

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 2.77

Change Reason

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

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Disch
• Hx
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Patient Hx
• Pnl
• Report period
• Survey

85915-7 InfluenzaVaccine Data Collection Period: Does this episode of care (SOC/ROC to Transfer/Discharge) include any dates on or between October 1 and March 31?

Term Description

Episode of care (defined as SOC/ROC to Transfer/Discharge) includes any dates on or between October 1 and March 31
Source: Regenstrief LOINC

Observation ID in Form

M1041

Skip Logic

If 0, go to M1051

Fully-Specified Name

Component

Episode of care includes influenza vaccination season

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

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;

Order vs. Observation

Observation

Normative Answer List LL4256-5

Member of these Panels

Related Names

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

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.

57208-1 Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year's flu season

Term Description

Identifies whether the patient received an influenza vaccine for this year's flu season
Source: Regenstrief LOINC

Observation ID in Form

M1046

Fully-Specified Name

Component

Influenza virus vaccination received

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.67

Change Reason

Updated METHOD from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms; Added "vaccination received" to the Component for consistent modeling across LOINC vaccination terms.; Added "virus" to Component to be consistent with other "Influenza virus" terms

Order vs. Observation

Observation

Normative Answer List LL4495-9

Member of these Panels

Member of these Groups Get Info

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• FLUV
• ID
• Immunizations
• Infectious Disease
• InfectiousDisease
• Influ
• Influenza vacc received
• Ordinal
• QL
• Qual
• Qualitative
• Report period
• Screen
• Survey
• Vaccine

Related Codes

72057-3 Pneumococcal vaccination been received

Term Description

Indicates whether a patient received a pneumococcal vaccination.
Source: Regenstrief LOINC

Fully-Specified Name

Component

Pneumococcal vaccination been received

Property

Find

Time

Pt

System

^Patient

Scale

Nom

Method

Basic Attributes

Class

SURVEY.ESRD

Type

Surveys

First Released

Version 2.40

Last Updated

Version 2.67

Order vs. Observation

Observation

Survey Question

Source

RQMT_1278

Member of these Panels

Related Names

• ESRD
• ESRD survey
• Finding
• Findings
• Immunizations
• Nominal
• Pneumococcal vacc received
• Point in time
• Random
• Survey
• Vaccine

45956-0 Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example, pneumovax), state reason

Observation ID in Form

M1056

Fully-Specified Name

Component

Reason pneumococcal vaccine not received

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.17

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 from MDS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Normative Answer List LL4497-5

Member of these Panels

Related Names

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

Related Codes

86258-1 MEDICATIONS

Fully-Specified Name

Component

OASIS C2, D - Medications - transfer to inpatient facility

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 2.77

Change Reason

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; Previous Releases: Added "D" to Component to indicate the use of this term OASIS D

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

57256-0 Medication Intervention

Term Description

Indicates whether the agency contacted and complete physician (or physician-designee) prescribed/recommended actions each time potential clinically significant medication issues were identified.
Source: Regenstrief LOINC

Observation ID in Form

M2005

Fully-Specified Name

Component

Medication intervention since admission &or reentry

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

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 from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms; Added "since admission/reentry" to Component to reflect the element of the question text

Order vs. Observation

Observation

Normative Answer List LL4520-4

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.

57195-0 Patient/Caregiver Drug Education Intervention

Observation ID in Form

M2016

Fully-Specified Name

Component

Patient &or caregiver drug education intervention

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

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 from OASIS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Survey Question

Text

Patient/Caregiver Drug Education Intervention: At the time of, or at any time since the most recent SOC/ROC assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, adverse drug reactions, and significant side effects, and how and when to report problems that may occur?

Normative Answer List LL817-8

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Drugs
• Finding
• Findings
• Ordinal
• Patient/caregiver drug education intervention
• 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.

57052-3 EMERGENT CARE

Fully-Specified Name

Component

Emergent care

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.29

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: Added METHOD of CMS Assessments because this unique panel originates from CMS instruments

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

57276-8 Emergent Care: At the time of or at any time since the most recent SOC/ROC assessment has the patient utilized a hospital emergency department (includes holding/observation status)?

Observation ID in Form

M2301

Skip Logic

If 0, go to M2401. If UK, go to M2401.

Fully-Specified Name

Component

Emergent care utilized

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

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 from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clincal LOINC committee;Added "utilized" to the Component to further clarify the term and to differeniate from the panel term 85906-6; Changed Scale to Ord because of the ordinal answer choices; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms

Order vs. Observation

Observation

Normative Answer List LL824-4

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.

57277-6 Reason For Emergent Care: For what reason(s) did the patient seek and/or receive emergent care (with or without hospitalization)?

Observation ID in Form

M2310

Form Coding Instructions

Mark all that apply

Fully-Specified Name

Component

Reason for emergent care

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

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 from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee;Moved Survey Question Text to Override Display Name to account for variation across CMS forms

Order vs. Observation

Observation

Normative Answer List LL4874-5

Member of these Panels

Related Names

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

Related Codes

88504-6 DATA ITEMS COLLECTED AT INPATIENT FACILITY ADMISSION OR AGENCY DISCHARGE ONLY

Fully-Specified Name

Component

OASIS D - Data items collected at inpatient facility admission or agency discharge only - transfer

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.64

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;

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

57198-4 Intervention Synopsis: At the time of or at any time since the most recent SOC/ROC assessment, were the following interventions BOTH included in the physician-ordered plan or care AND implemented?

Observation ID in Form

M2401

Form Coding Instructions

Check only one box in each row

Fully-Specified Name

Component

Intervention synopsis

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.67

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Point in time
• Random
• Survey

Related Codes

57270-1 Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care

Observation ID in Form

M2401a

Fully-Specified Name

Component

Plan of care includes diabetic foot care

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

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 from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clincal LOINC committee; Added "Plan of care includes" to COMPONENT to match form text

Order vs. Observation

Observation

Normative Answer List LL4502-2

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Lower extremity
• 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.

57271-9 Falls prevention interventions

Observation ID in Form

M2401b

Fully-Specified Name

Component

Plan of care includes fall prevention interventions

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

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 from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clincal LOINC committee; Added "Plan of care includes" to COMPONENT to match form text

Order vs. Observation

Observation

Normative Answer List LL4522-0

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.

57272-7 Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment

Observation ID in Form

M2401c

Fully-Specified Name

Component

Plan of care includes depression intervention

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

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 from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clincal LOINC committee;Added "Plan of care includes" to COMPONENT to match form text

Order vs. Observation

Observation

Normative Answer List LL4523-8

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.

57273-5 Intervention(s) to monitor and mitigate pain

Observation ID in Form

M2401d

Fully-Specified Name

Component

Plan of care includes intervention to monitor and mitigate pain

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

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 from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Added "Plan of care includes" to COMPONENT to match form text

Order vs. Observation

Observation

Normative Answer List LL4524-6

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.

57274-3 Intervention(s) to prevent pressure ulcers

Observation ID in Form

M2401e

Fully-Specified Name

Component

Plan of care includes intervention to prevent pressure injuries

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

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 from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Added "Plan of care includes" to COMPONENT to match form text; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Normative Answer List LL4525-3

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• Pressure ulcer
• Pressure Ulcers
• 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.

57275-0 Pressure ulcer treatment based on principles of moist wound healing

Observation ID in Form

M2401f

Fully-Specified Name

Component

Plan of care includes pressure injury treatment - moist healing

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

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 from OASIS-C to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Added "Plan of care includes" to COMPONENT to match form text; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Normative Answer List LL4510-5

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Ordinal
• pressure injury
• Pressure ulcer
• Pressure Ulcers
• QL
• Qual
• Qualitative
• Report period
• Screen
• Survey
• Tx
• 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.

46578-1 To which Inpatient Facility has the patient been admitted?

Term Description

Identifies the type of inpatient facility to which the patient was admitted.
Source: Regenstrief LOINC

Observation ID in Form

M2410

Fully-Specified Name

Component

Admitted to

Property

Type

Time

RptPeriod

System

Inpatient facility

Scale

Nom

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

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 from OASIS to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Moved Survey Question text to Override Display Name for consistent modeling across CMS forms; Changed Component to "Admitted to" and System to "Inpatient facility" to match LOINC convention for terms about facilities

Order vs. Observation

Observation

Normative Answer List LL4546-9

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• IP
• Nominal
• Report period
• Survey
• Transferred
• Typ

Related Codes

46582-3 Discharge/Transfer/Death Date

Term Description

Identifies the actual date of discharge, transfer, or death.
Source: Regenstrief LOINC

Observation ID in Form

M0906

Form Coding Instructions

Enter the date of the discharge, transfer, or death (at home) of the patient

Fully-Specified Name

Component

Discharge, transfer, death date

Property

Date

Time

Pt

System

^Patient

Scale

Qn

Method

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.19

Last Updated

Version 2.71

Change Reason

Release 2.71: METHOD_TYP: Removed Method because this concept is not specific to CMS; Previous Releases: Updated METHOD from OASIS to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee

Order vs. Observation

Observation

Member of these Panels

Related Names

• Disch
• Point in time
• QNT
• Quan
• Quant
• Quantitative
• Random
• Survey

Example Units

Related Codes

83279-0 Health Conditions

Observation ID in Form

J

Fully-Specified Name

Component

IRF-PAI v3.0, LCDS v4.00, OASIS E - Health conditions - discharge or expired or transfer

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.61

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; Release 2.72: COMPONENT: Updated to include current version of OASIS that uses this panel; Release 2.69: COMPONENT: Updated to state the current active versions of each form that use this panel.; Release 2.67: COMPONENT: Assessment and assessment versions added to Component to distinguish this panel from similar panels in other versions of these assessments.; Previous Releases: Added "transfer" to the Component because this panel is also included in OASIS D Transfer form

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

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

Related Codes

83280-8 Any falls since SOC/ROC. Has the patient had any falls since SOC/ROC, whichever is more recent? Has the patient had any falls since SOC/ROC, whichever is more recent?

Observation ID in Form

J1800

Skip Logic

If 0, Skip to J1900. If 1, Continue to J1900. Number of Falls Since Admission.

Fully-Specified Name

Component

Has the patient had any falls since admission

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.61

Last Updated

Version 2.61

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 SOC/ROC, 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 patient; no change in the patient'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 patient 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.