Version 2.77

Term Description

This panel should be used for CMS OASIS-D Discharged from agency assessments performed between January 1, 2019 and December 31, 2019 and CMS OASIS-D1 Discharged from agency assessments performed after January 1, 2020.
Source: Regenstrief LOINC

Panel Hierarchy

Details for each LOINC in Panel LHC-Forms

LOINC Name R/O/C Cardinality Example UCUM Units
88371-0 Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency during assessment period [CMS Assessment]
IndentIndent46500-5 Discipline of Person Completing Assessment
IndentIndent46501-3 Date Assessment Completed {mm/dd/yyyy}
IndentIndent57200-8 This Assessment is Currently Being Completed for the Following Reason
IndentIndent85915-7 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?
IndentIndent57208-1 Influenza Vaccine Received: Did the patient receive the influenza vaccine for this year's flu season
IndentIndent72057-3 Pneumococcal vaccination been received
IndentIndent45956-0 Reason Pneumococcal Vaccine not received: If patient has never received the pneumococcal vaccination (for example, pneumovax), state reason
Indent88507-9 SENSORY STATUS
IndentIndent57220-6 Frequency of Pain Interfering with patient's activity or movement
IndentIndent85918-1 Does this patient have at least one Unhealed Pressure Ulcer/Injury at Stage 2 or Higher or designated as Unstageable?
IndentIndent57222-2 The Oldest Stage 2 pressure ulcer that is present at discharge
IndentIndent58052-2 Record date pressure ulcer first identified {mm/dd/yyyy}
IndentIndent88508-7 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
IndentIndentIndent55124-2 Number of Stage 2 pressure ulcers {#}
IndentIndentIndent54886-7 Number of these Stage 2 pressure ulcers that were present at most recent SOC/ROC {#}
IndentIndentIndent55125-9 Number of Stage 3 pressure ulcers {#}
IndentIndentIndent54887-5 Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC {#}
IndentIndentIndent55126-7 Number of Stage 4 pressure ulcers {#}
IndentIndentIndent54890-9 Number of these Stage 4 pressure ulcers that were present at most recent SOC/ROC {#}
IndentIndentIndent54893-3 Number of unstageable pressure ulcers/injuries due to non-removable dressing/device {#}
IndentIndentIndent54894-1 Number of these unstageable pressure ulcers/injuries that were present at most recent SOC/ROC {#}
IndentIndentIndent54946-9 Number of unstageable pressure ulcers/injuries due to coverage of wound bed by slough and/or eschar {#}
IndentIndentIndent54947-7 Number of these unstageable pressure ulcers that were present at most recent SOC/ROC {#}
IndentIndentIndent54950-1 Number of unstageable pressure injuries presenting as deep tissue injury {#}
IndentIndentIndent54951-9 Number of these unstageable pressure ulcers that were present at most recent SOC/ROC {#}
IndentIndent57231-3 Stage of Most Problematic Unhealed Pressure Ulcer/Injury that is Stageable
IndentIndent57232-1 Does this patient have a Stasis Ulcer?
IndentIndent57233-9 Current Number of Stasis Ulcer(s) that are Observable {#}
IndentIndent57234-7 Status of Most Problematic Stasis Ulcer that is Observable
IndentIndent57235-4 Does this patient have a Surgical Wound?
IndentIndent57236-2 Status of Most Problematic Surgical Wound that is Observable
IndentIndent57237-0 When is the patient dyspneic or noticeably Short of Breath?
IndentIndent46552-6 Has this patient been treated for a Urinary Tract Infection in the past 14 days?
IndentIndent46587-2 Bowel Incontinence Frequency
IndentIndent46589-8 Cognitive Functioning: Patient's current (day of assessment) level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands.
IndentIndent58104-1 When Confused (Reported or Observed Within the Last 14 Days)
IndentIndent86495-9 When Anxious (Reported or Observed Within the Last 14 Days)
IndentIndent46473-5 Cognitive, behavorial, and psychiatric symptoms that are demonstrated at least once a week (Reported or Observed): 1..6
IndentIndent46592-2 Frequency of Disruptive Behavior Symptoms (Reported or Observed): Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety.
Indent88500-4 ADL/IADLs
IndentIndent46595-5 Grooming: Current ability to tend safely to personal hygiene needs (specifically: washing face and hands, hair care, shaving or make up, teeth or denture care, or fingernail care).
IndentIndent46597-1 Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps.
IndentIndent46599-7 Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes.
IndentIndent57243-8 Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair).
IndentIndent57244-6 Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode.
IndentIndent57245-3 Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, commode, bedpan, urinal. If managing ostomy, includes cleaning area around stoma, but not managing equipment.
IndentIndent57246-1 Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast.
IndentIndent57247-9 Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.
IndentIndent57248-7 Feeding or Eating: Current ability to feed self meals and snacks safely.
Indent88520-2 MEDICATIONS
IndentIndent57256-0 Medication Intervention
IndentIndent57195-0 Patient/Caregiver Drug Education Intervention
IndentIndent57285-9 Management of Oral Medications: Patient's current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals.
IndentIndent88468-4 Types and Sources of Assistance
IndentIndentIndent57260-2 ADL assistance (for example, transfer/ ambulation, bathing, dressing, toileting, eating/feeding)
IndentIndentIndent57262-8 Medication administration (for example, oral, inhaled or injectable)
IndentIndentIndent57263-6 Medical procedures/treatments (for example, changing wound dressing, home exercise program)
IndentIndentIndent57265-1 Supervision and safety (for example, due to cognitive impairment)
Indent57052-3 EMERGENT CARE
IndentIndent57276-8 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)?
IndentIndent57277-6 Reason For Emergent Care: For what reason(s) did the patient seek and/or receive emergent care (with or without hospitalization)? 1..3
IndentIndent57198-4 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?
IndentIndentIndent57270-1 Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care
IndentIndentIndent57271-9 Falls prevention interventions
IndentIndentIndent57272-7 Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment
IndentIndentIndent57273-5 Intervention(s) to monitor and mitigate pain
IndentIndentIndent57274-3 Intervention(s) to prevent pressure ulcers
IndentIndentIndent57275-0 Pressure ulcer treatment based on principles of moist wound healing
IndentIndent46578-1 To which Inpatient Facility has the patient been admitted?
IndentIndent55128-3 Discharge disposition: Where is the patient after discharge from your agency?
IndentIndent46582-3 Discharge/Transfer/Death Date {mm/dd/yyyy}
Indent89391-7 Functional Abilities and Goals - Discharge
IndentIndent89475-8 Self-Care - Discharge Performance
IndentIndentIndent95019-6 Eating
IndentIndentIndent95018-8 Oral hygiene
IndentIndentIndent95017-0 Toileting hygiene
IndentIndentIndent95015-4 Shower/bathe self
IndentIndentIndent95014-7 Upper body dressing
IndentIndentIndent95013-9 Lower body dressing
IndentIndentIndent95012-1 Putting on/taking off footwear
IndentIndent89474-1 Mobility - Discharge Performance
IndentIndentIndent95011-3 Roll left and right
IndentIndentIndent95010-5 Sit to lying
IndentIndentIndent95009-7 Lying to sitting on side of bed
IndentIndentIndent95008-9 Sit to stand
IndentIndentIndent95007-1 Chair/bed-to-chair transfer
IndentIndentIndent95006-3 Toilet transfer
IndentIndentIndent95005-5 Car transfer
IndentIndentIndent95004-8 Walk 10 feet
IndentIndentIndent95003-0 Walk 50 feet with two turns
IndentIndentIndent95002-2 Walk 150 feet
IndentIndentIndent95001-4 Walking 10 feet on uneven surfaces
IndentIndentIndent95000-6 1 step (curb)
IndentIndentIndent94999-0 4 steps
IndentIndentIndent94998-2 12 steps
IndentIndentIndent94997-4 Picking up object
IndentIndentIndent95738-1 Does the patient use a wheelchair and/or scooter?
IndentIndentIndent94992-5 Wheel 50 feet with two turns
IndentIndentIndent95739-9 Indicate the type of wheelchair or scooter used
IndentIndentIndent94991-7 Wheel 150 feet
IndentIndentIndent95739-9 Indicate the type of wheelchair or scooter used
Indent83279-0 Health Conditions
IndentIndent83280-8 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?
IndentIndent54854-5 Number of Falls Since SOC/ROC, whichever is more recent
IndentIndentIndent54855-2 No injury
IndentIndentIndent54856-0 Injury (except major)
IndentIndentIndent54857-8 Major injury

Fully-Specified Name

Outcome and assessment information set (OASIS) form - version D, D1 - Discharged from agency
CMS Assessment

Basic Attributes

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; Release 2.67: COMPONENT: Assessment version updated to reflect must recent version
Order vs. Observation
Panel Type

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